Building Medical Homes for Multiply Diagnosed HIV-Positive Homeless Populations

Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations Implementation Guide is for organizations that serve people living with HIV who are experiencing homelessness and have a mental health or substance use disorder. Insights are drawn from the nine demonstration sites. Sections cover:

• Setting up a program within your agency.
• Finding and engaging people in care.
• Providing services.
• Evaluating program activities and conducting quality improvement.
• Sustaining program services.
• Resources and References.

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Manuals for models of care developed under the SPNS Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations Initiative. Included is a multisite manual (overview of the initiative) and site-specific manuals that outline their models of care.

• Dallas, TX - Prism Health North Texas
• Dunn, NC - CommWell Health NC-REACH
• Houston, TX - Project Hi-5. Harris Health System
• Jacksonville, FL - Partnership for Access to Treatment and Housing (PATH), University of Florida
• New Haven, CT - Project mHEALTH, Yale
• Pasadena, CA - Operation Link, City of Pasadena
• Portland, OR - Multnomah County HIV Health Services Center
• San Diego - Family Health Centers of San Diego
• San Francisco, CA - Homeless HIV Outreach and Mobile Engagement (HHOME) Program

In this video series, clients living with HIV who are also dealing with unstable housing, substance abuse and mental health challenges describe their work with navigators to achieve their goals for health and well-being.

Housing Process for PATH Clients (DOC, UF CARES) (DOC)

Tool: Creating Client's Housing Application Packet - Sample Checklist (DOC)

Tool: Creating Client's Housing Application Packet - Template Letter Request to Healthcare Provider to Verify Eligibility (DOC)

Tool: Creating Client's Housing Application Packet - Letter Confirming Disability and Need for Companion Pet (DOC)

Tool: Creating Client's Housing Application Packet - Sample Rental Application (DOC)

Tool: Creating Client's Housing Application Packet - Building a Housing Application Packet (DOC)

Case Staffing Form (for Care Coordinator to seek guidance from team members regarding client care) (DOC)

Follow-up Screening Form to Track Enrollment and Attempts to Contact Client After Intake (DOC)

Setting Up a Medical Home: Sample Logic Models (DOC)

HIV Continuum of Care for Homeless and Marginally Housed HIV Clients, HHOME, San Francisco (DOC)

Sample MOUs: Building Medical Homes for Multiply Diagnosed Homeless Persons Living with HIV/AIDS

Sample Frontline Job Descriptions: Staff Working with Homeless Populations Living with HIV

Peer Review Checklist (to assess client encounters with Care Coordinators) (DOC)

Navigator Manifesto (for patient navigators to keep in mind when working with clients) (DOC)

Client Consent for Services Form (DOC)

Client Community Agreement and Rules and Consequences Form (DOC)

Client Grievance Policy (DOC)

Client Peer Care Navigator/Client Contract (DOC)

Biopsychosocial Assessment Form (DOC)

Intake Referral Form (DOC)

Referral Forms: Homeless Patients to Primary Care, Case Management, Other (DOC)

Client Movement Flow Chart, Harris Health (PPTX)

Client Flow Chart, Operation Link Pasadena (PPTX)

Patient Flow Sheet, UF CARES (XLSX)

Services Flow Chart, Prism Health (DOC)

Services Flow Chart, CommWell Health, NC-REACH (DOC)

Sample Care Plans: Homeless Persons with HIV (DOC)

Disenrollment in Services Form (DOC)

Encounter Form, CommWell Health, NC-REACH (DOC)

Encounter Log, Prism Health (DOC)

Encounter Note with Acuity Worksheet, Prism Health (DOC)

Outreach Log Sheet, CommWell Health, NC-REACH (DOC)

Panel Process Template, SFDPH (DOC)

Progress Notes, CommWell Health, NC-REACH (DOC)

Receipt for Tangible Goods Form, Prism Health (DOC)

Transportation Services Form, CommWell Health, NC-REACH (DOC)

Checklists (for working with clients)

Sample Policies and Procedures in Working with Homeless Clients (e.g., Handling Mail, Crises, Home Visits)

Transition to Standard Care Forms

Acuity Tools: Samples