Housing & Homelessness

Approaches to providing and linking to housing services and serving homeless and unstably housed clients. 

Spotlight: See resources developed by The HIV, Housing & Employment Project, a HRSA SPNS initiative.

From the Infographic: Housing and HIV-Related Health Care Outcomes Among HRSA’s Ryan White HIV/AIDS Program (RWHAP) Clients in 2021.

Resources 44

Best Practices

  • Center for Innovation and Engagement
    Collection of implementation guides on evidence-informed best practices in HIV care delivery.
  • AIDS Action Foundation

    Workbooks describing ways to help connect people living with HIV/AIDS to medical care. Estos cuadernos describen la manera de asistir a conectar personas que viven con VIH/SIDA con el sistema médico.  

  • IHIP
    Intervention using three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and Motivational Interviewing.
  • IHIP
    HHOME is a mobile care and systems intervention that helps connect vulnerable and homeless individuals in San Francisco to rapid HIV treatment.
  • IHIP
    KC Life 360 is an employment-focused intervention that utilizes the intersection between employment services, HIV care and treatment, and housing to improve health outcomes of people with HIV.
  • The HIV, Housing & Employment Project
    COVID-19 adjustments developed by Ryan White HIV/AIDS Program recipients.
  • Boston University School of Social Work Center for Innovation in Social Work and Health, The HIV, Housing & Employment Project

    Best practices (and extensive resource links) for integrating into medical care teams the non-medical staff called Navigators.

  • The HIV, Housing & Employment Project

    Review of strategies for housing vulnerable populations in tight housing markets.

  • Center for Advancing Health Policy and Practice

    Insights from a HRSA SPNS initiative on care coordinator/patient navigation interventions for vulnerable populations.

  • U.S. Department of Health and Human Services

    Study examining models of integration and coordination of housing assistance services and HIV care.

  • The HIV, Housing & Employment Project
    Avenue 360 Health & Wellness offers a medical home for patients and AIDS Foundation Houston coordinates employment training and resources. These agencies believe that coordination is the key to breaking down barriers to health care in their community.
  • The HIV, Housing & Employment Project
    SSRP is a client, provider, and system levels intervention to rapidly connect PLWH recently released from jail/prison to medical, housing, and employment services using a Peer Community Reengagement Specialist model.
  • The HIV, Housing & Employment Project
    Coordination of client services for six months and transitioning clients to the jurisdiction's case management system after completion of the program. Acuity scores determine clients’ case management paths.
  • The HIV, Housing & Employment Project
    Short-term intensive case management services to link clients to housing, employment, and health care services provided by a team comprised of a Peer Care Navigator, Housing Navigator, and an Employment Navigator.
  • The HIV, Housing & Employment Project
    Smart Care Management data-driven/IT model (e.g., patient portal, real-time dashboard for agencies) to enhance utilization of existing health, housing, and employment services.
  • Best Practices Compilation
    This intervention to rapidly re-house people with HIV was implemented at multiple New York City shelters and was associated with significant improvements in viral suppression.
  • The HIV, Housing & Employment Project
    Coordination of health care with housing and employment services through regular meetings, formal agreements, and a Linkage Coordinator.
  • The HIV, Housing & Employment Project
    Partnership between employment services and Ryan White HIV/AIDS Program providers to foster case coordination among medical care and social service providers, including a screening and referral system for housing and employment needs and services individualized for specific patient needs. 
  • The HIV, Housing & Employment Project
    Care coordination to link clients to services by assessing client needs, barriers, and stages of change, guided by electronic health records and a modified stages of change tool used to assess housing & employment stages of change.
  • Best Practices Compilation
    HHOME offers mobile HIV primary care, behavioral health care, and connection to housing services to people with HIV experiencing homelessness. A centralized HHOME team acts as a hub to meet clients where they are, refer them to housing and support services, and provide ongoing case management and HIV primary care services. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.
  • Best Practices Compilation

    Caracole, an AIDS Service Organization, uses three interconnected approaches to improve retention in HIV care: housing first, harm reduction, and motivational interviewing. Clients in permanent supportive housing had high rates of viral suppression, exceeding Caracole's goal of 75%.

  • The HIV, Housing & Employment Project
    KC Life 360’s same-day intake, informed consent, and one-on-one with an Employment Career Specialist generates awareness of services and benefits across provider networks.
  • Best Practices Compilation
    Expanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
  • Best Practices Compilation
    Gay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
  • Center for Innovation and Engagement
    The Leveraging Housing Opportunities to Promote Retention in Care for People with HIV program in New York City offers three types of housing-related supportive services.
  • Best Practices Compilation
    The RWHAP Part F SPNS program funded the Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative from 2012–2017, to provide coordinated housing supports and HIV, behavioral and mental health care to people experiencing homelessness. Nine funded demonstration sites created partnerships with housing providers, integrated behavioral health and HIV care, and provided intensive patient navigator services. A multi-demonstration site evaluation found that, compared to baseline, participants were more likely to be virally suppressed after 12 months in the intervention.
  • Best Practices Compilation
    Fenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the RWHAP Part F SPNS initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.
  • The HIV, Housing & Employment Project
    Housing first model to help people with HIV address their housing instability while working towards obtaining employment and maintaining consistent medical care. Every patient completes an individual service plan, developed in partnership with their case manager.
  • The HIV, Housing & Employment Project
    Clients are enrolled into a low barrier program that provides immediate and critical housing crisis intervention, including in-housing employment services and ongoing intervention services to secure permanent housing and maintain access to HIV primary care.
  • Best Practices Compilation
    Avenue 360 Health and Wellness, a Federally Qualified Health Center, and AIDS Foundation Houston, a community-based AIDS Service Organization, implemented Project CORE. This intervention aimed to improve health outcomes for people with HIV through the coordination of supportive employment and housing services. Through Project CORE, 39% of participants were placed in housing and 39% gained employment.
  • Best Practices Compilation
    Yale Community Health Care Van and Clinic, and Liberty Community Services, Inc., empowered clients to set and achieve employment and housing goals, as well as strengthened the ability of community-based organizations to provide related services. This initiative known as Project HERO was implemented between 2017 and 2020 as part of the HIV, Housing, and Employment SPNS initiative.
  • Best Practices Compilation
    Project Vogue provided community-based care coordination, HIV care, and behavioral health services to Black men who have sex with men (MSM) within New York City’s House & Ball community to address the unique cultural barriers that Black MSM experience when trying to access care. Project Vogue participants were linked to behavioral health services as well as to non-clinical supportive services, such as food and housing assistance.
  • Best Practices Compilation
    T.W.E.E.T. aims to engage transgender women in HIV care by combining weekly peer-based education and discussion groups, leadership training, community building, and the provision of supportive services. Three sites implemented T.W.E.E.T. as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Clients had improved outcomes across the HIV care continuum 12 months after enrollment in T.W.E.E.T.
  • The HIV, Housing & Employment Project
    Housing and employment services include a Job Club to provide a supportive environment and training for participants. 

Resources

Webinars

Conference Presentations

Wayne State University
Presenters:
Evelyn Postell-Franklin
2022 National Ryan White Conference on HIV Care & Treatment
Baltimore City Health Department
Presenters:
Victoria Cargill, Omeid Heidari, Katie O'Conor, Kelly Lowensen, Jess LaRici, Derrick Hunt, Lisa Parker, Jason Farley
2022 National Ryan White Conference on HIV Care & Treatment
NYC Department of Health and Mental Hygiene
Presenters:
Scott Spiegler, Eleonora Jimenez-Levi, Giovanna Novoa, Ellen Wiewel, Guadalupe Dominguez Plummer
2022 National Ryan White Conference on HIV Care & Treatment
HRSA
Presenters:
Amy Palilonis, Deborah Noble, Rashida Hassan, Susan Robilotto, Kathie Hiers, Norman Dixon
2022 National Ryan White Conference on HIV Care & Treatment
HRSA
Presenters:
Susan Robilotto, Jorge Cestou, Linda Koenig, Amy Palilonis
2022 National Ryan White Conference on HIV Care & Treatment

Technical Assistance