Medical Homes

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.

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

This medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.

By 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.

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.

The 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.

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.

Description 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.

Collection of webinars and tools to assist ASOs and other HIV agencies make changes in their operations.

Highlight of two programs that successfully engaged in HIV care clients who are hard-to-reach and serve via delivery of HIV primary care, behavioral health, and housing.

Learn how two successful programs are addressing homelessness and housing instability and behavioral health disorders, improving client engagement and retention in care, and observing improved rates of viral suppression.