This guide details components of a program establishing a medical-community partnership to facilitate a linkage to care program reengaging HIV clients in care and decreasing missed appointments.
A patient centered medical home (PCMH) is a health care setting that seeks to deliver care in a culturally and linguistically appropriate manner through a collection of strategies like registries, information technology, health information exchange, and other means. PCMH is an accreditation program that requires compliance with multiple criteria in order to be recognized as such under new health care reform and reimbursement policies.
Best Practices
- IHIP
- Center for Advancing Health Policy and Practice
Insights from a HRSA SPNS initiative on care coordinator/patient navigation interventions for vulnerable populations.
- Best Practices CompilationThis medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.
- Best Practices CompilationBy integrating comprehensive HIV medical care with addiction services and medication protocols for substance use disorder (SUD), clients with HIV and SUD saw improvements in retention in care and viral suppression.
- Best Practices CompilationThe 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 CompilationThe New York City HIV Care Coordination Program is a structural intervention that combines multiple strategies, including multidisciplinary care coordination, patient navigation, and personalized health education to address client medical and social needs. Multiple evaluations of the program consistently show improvements in viral suppression and engagement in care, especially for people with a new diagnosis of HIV or who are out of care.
- Best Practices CompilationYale 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.
- Center for Innovation and EngagementDescription of a communication-centered approach to service delivery that provides a compassionate and supportive environment to promote intrinsic behavior change among youth 16 to 29 with newly diagnosed HIV.
Webinars
- HRSA HIV/AIDS Bureau (HAB)
Collection of webinars and tools to assist ASOs and other HIV agencies make changes in their operations.
Conference Presentations
Drexel University Partnership for Comprehensive Care Practice
2020 National Ryan White Conference on HIV Care & Treatment
Denver Health and Hospital Authority
Adam Dworetsky, Mariah Hoffman, Tara Hixson
2020 National Ryan White Conference on HIV Care & Treatment
Denver Health and Hospital Authority
Tara Hixson, Adam Dworetsky, Mariah Hoffman
2020 National Ryan White Conference on HIV Care & Treatment
Vivent Health
Quinn Paton, Jon Martin, Kristen Grimes
2020 National Ryan White Conference on HIV Care & Treatment