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 list below includes implementation packages and toolkits from SPNS and other recent innovation projects.

  • Project START
    Using a client-focused, personalized, Incremental Risk Reduction approach, the Project START intervention improves linkage and retention in care among people with HIV who are leaving correctional facilities to return to the community. (CIE)
  • Navigator Case Management
    Case management to promote healthy behaviors among people with HIV post-incarceration. (CIE)
  • 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)
  • 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)
  • 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)
  • 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)
  • Clinic-Based Surveillance-Informed
    Combines clinic and health department surveillance data to identify and re-engage people with HIV who are out of care. (CIE)
  • Emergency Department and Hospital-Based Data Exchange
    A real-time data to care program to identify and re-engage people with HIV in care. (CIE)
  • Virology FastTrack
    A clinical decision support system that generates alerts in EMRs and improves appointment follow up. (CIE)
  • PositiveLinks
    A clinic-based mobile app to promote linkage to and engagement in HIV care by connecting clients to a virtual local community. (CIE)
  • SPNS Social Media Initiative Demonstration Site Resources
    Monographs and implementation manuals for ten effective projects focusing on engagement and retention of youth in HIV care. (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)
  • SPNS Social Media Initiative Demonstration Site Monographs
    Intervention monographs from ten demonstration sites on technology-based projects to improve engagement, retention, and outcomes in youth.
  • 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
    Collection features 11 models of care (summary fact sheets and program tools) and online multidisciplinary training modules for providers, community agency staff, and leaders. (CEBACC)
  • Well Versed
    Resources for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)
  • Project ACCEPT
    A group-based intervention for cisgender youth, 16- to 24-years old, to improve engagement in HIV care. (CIE)
  • Project STYLE
    An innovative model that links youth to the care step of the HIV care continuum. (CIE)
  • Tailored Motivational Interviewing
    Motivational Interviewing reimagined for youth with new HIV diagnoses to ultimately improve retention in HIV care. (CIE)

Guide to Sources

  • CEBACC: Center for Engaging Black MSM Across the Care Continuum. TA project ending in 2018.
  • CIE: Center for Innovation and Engagement. TA project active 2018-2021.
  • DEII: Dissemination of Evidence-Informed Interventions. SPNS project evaluating implementation packages for four interventions. Active 2015 - 2020.
  • HRSA HAB: Health Resources and Services Administration HIV/AIDS Bureau.
  • IHIP: Integrating HIV Innovative Practices - developed and disseminated replication tools derived from the SPNS program after projects were 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.