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HIV Care Innovations: Replication Resources

HRSA HAB has long supported an evaluation pipeline of promising care models to identify those that deserve a wider audience. The Special Projects of National Significance (SPNS) program has been the primary vehicle for supporting, documenting, and disseminating Ryan White Community innovations. The IHIP: Integrating HIV Innovative Practices project has developed a series of robust implementation packages based on SPNS findings.

The list below includes implementation packages and toolkits from SPNS, IHIP, and other innovation projects.

Evidence-Informed Interventions for Improving HIV Care, Engagement, and Outcomes

  • Improving Health Outcomes: Moving Patients Along the HIV Care Continuum and Beyond
    Resources to help HIV care programs improve health outcomes along with HIV care continuum. Materials include a manual, case studies, pocket guides, and TA webinars and cover a broad range of approaches and audiences. (IHIP)
  • Engaging Hard-to-Reach Populations
    Tools (training manual, curriculum, webinars) for programs on how to create programs to reach clients not in HIV care via outreach, motivational interviewing, patient navigation, case management, and other models. (IHIP)
  • Social Networks Testing
    Social Networks Testing demonstrates that members of high-risk groups are often more effective at identifying and recruiting HIV-positive and at-risk individuals than traditional testing and outreach models. Overview, replication tips, and case study. (IHIP)
  • Correctional Health Linkage Interventions
    Implementation resources for an evidence-based intervention to facilitate linkage to community-based HIV care after incarceration. Includes manual, training curriculum, and tools. (IHIP)
  • Transitional Care Coordination
    Evidence-based intervention to facilitate linkage to community-based HIV care after incarceration featuring a training curriculum for agencies and implementation activities and tools. (DEII)
  • Assess, Test, Link- Achieve Success (ATLAS) Program
    Integrates jail-based case managers into the community HIV case management system to engage and subsequently link incarcerated individuals as they transition from jail to community. Overview, replication tips, and case study. (IHIP)
  • Care Coordination Intervention
    Intervention promotes HIV medication access, coverage, and pickup for individuals transitioning from correctional facilities. Overview, replication tips, and case study. (IHIP)
  • Enhancing Linkages to Care for Women Leaving Jail
    Innovative, evidence-informed intervention integrates jail-based case managers to work with jail-based discharge planners and peers to support HIV-positive women as they transition from jail to the community. Overview, replication tips, and case study. (IHIP)
  • Video Conferencing Intervention: Case Study, Overview, and Replication Tips
    This intervention allows community-based case managers to connect via video chat with incarcerated clients prior to release. Overview, replication tips, and case study. (IHIP)
  • Models of Care: Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations
    Ten implementation manuals on models of care (e.g., medical homes, patient navigation, case management) for people living with HIV who have co-occurring conditions (substance abuse, mental health, homelessness). (SPNS ETAC)
  • Finding Home: Tips and Tools for Guiding People Living with HIV Toward Stable Housing
    Toolkit on ways to increase access to housing for people with HIV and co-occurring mental illness and/or substance use disorders, along with an extensive collection of tools (acuity measures, job descriptions, sample MOUs, checklists). (SPNS ETAC)
  • Active Referral Intervention
    This intervention uses Disease Intervention Specialists (DIS) to more actively and immediately link clients to HIV care services. Overview, replication tips, and case study. (IHIP)
  • Louisiana Public Health Information Exchange
    This intervention facilitates bidirectional information exchange between hospital system records and public health surveillance data to identify and link out-of-care HIV-positive clients back to care and treatment. Overview, replication tips, and case study. (IHIP)
  • My Health Profile Continuity of Care Record Intervention
    My Health Profile is a patient portal leveraged across a regional health network containing critical health information to improve continuity of care. Overview, replication tips, and case study. (IHIP)
  • SPNS Systems Linkages Project
    Manuals and tools from five demonstration sites on how to replicate linkages across public health systems via innovative strategies (e.g., referral systems, care engagement techniques, patient navigation, electronic medical records). (SPNS ETAC)
  • Peer Linkage and Re-engagement of HIV-Positive Women of Color
    Resources to prepare women of color living with HIV to provide peer support to link/re-engage clients in HIV primary care. Includes training curriculum for peers and a manual for staff on how to implement a peer program, with extensive tips and tools in both. (DEII)
  • Enhanced Patient Navigation for HIV-Positive Women of Color
    Tools for use of patient navigators to support women of color living with HIV to optimize their engagement in care via support and patient empowerment. Includes training curriculum for navigators and manual for program staff on implementing a program. (DEII)
  • Women of Color: Enhancing Access
    Guide for ways to expand/improve services for women of color living with HIV, with planning and implementation steps based on best practices from demonstration sites, from steps on getting started to lessons learned. (IHIP)
  • Expanding Care for People Living with HIV Toolkit
    Actions that health agencies can take to either add or increase HIV care to their service offerings. Four steps are outlined, and each presents an implementation tool to guide that step. Also presents lessons learned. (SPNS ETAC)
  • Optimizing the Care Team
    Insights on operating Care Teams: multidisciplinary collection of providers who work together to meet multiple patient needs to improve care delivery and outcomes. Best practices cover: preparation, staffing, buy-in, formalization, and adaptability. (SPNS ETAC)
  • Patient Engagement and Care Coordination in HIV Health (PEACCH) Tool
    Steps for setting up an HIV care coordination program (e.g., getting buy-in, staffing, health information systems). (SPNS ETAC)
  • Building Futures: Supporting Youth Living with HIV
    Activities agencies can undertake to enhance delivery of HIV care to youth living with HIV, presented under the themes: clinical service models, infrastructure development, information program development, and wraparound services. (HRSA HAB)
  • HisHealth: Models of Care for Young, Black, Men who Have Sex with Men
    Website features 11 models of care (summary fact sheets and program tools) and online multidisciplinary training modules for both providers and community agency staff and leaders. (CEUs provided). (CEBACC)
  • Well Versed
    Website for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)

Guide to Sources

  • CEBACC: Center for Engaging Black MSM Across the Care Continuum. TA project ending in 2018.
  • DEII: Dissemination of Evidence-Informed Interventions. SPNS project evaluating implementation packages for four interventions.
  • HRSA HAB: Health Resources and Services Administration HIV/AIDS Bureau.
  • IHIP: Integrating HIV Innovative Practices - develops and disseminates replication tools derived from the SPNS program after projects have completed.
  • SPNS: Special Projects of National Significance. Program under RWHAP Part F responsible for HIV care model identification, evaluation, and dissemination.
  • SPNS ETAC: Each SPNS project has an Evaluation and TA Center (ETAC) with responsibility for compiling dissemination tools (manuals, training resources) developed under the initiative.