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Enhanced Patient Navigation for Women of Color with HIV
Patient navigation intervention informed and adapted from the best practice findings of a past SPNS initiative that yielded successful HIV care continuum outcomes among client participants.Resource updated 05/07/2024
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Virology FastTrack
Clinical Decision Support System (CDSS) that generates alerts in electronic medical records to notify HIV outpatient providers of suboptimal follow-up, virologic failure, and laboratory toxicity.Resource updated 09/14/2023
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Navigator Case Management
Patient navigation-enhanced case management intervention that improved linkage and retention in HIV care among people with HIV who were leaving jail to return to the community.Resource updated 09/14/2023
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The Emotional Toll Experienced by HIV Care Workers
Managing the needs of people with HIV can be difficult and intensive. The importance of caring for oneself is often overlooked by program staff and can threaten their well-being. Staff who provide non-medical case management and assistance in finding employment and housing were interviewed to determine key areas of concern.
Resource (Conference Presentation) updated 09/14/2023
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Using an Electronic Health Record to Support Non-Medical Case Management Processes, Assessments, and Program Graduation
Prism Health North Texas will share the challenges and successes of integrating non-medical case management workflow processes into an integrated electronic health record system. The presenter will discuss workflow processes, assessments that allow non-medical case managers to gather required information and determine outcomes and identify patients appropriate for program graduation.
Resource (Conference Presentation) updated 09/14/2023
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Change in Acuity Level Between Assessments among Los Angeles County Medical Care Coordination Clients
The Los Angeles County Department of Health compared change in acuity level from initial assessment to reassessment among Los Angeles County Medical Care Coordination (MCC) clients. At reassessment, 2,361 clients (50%) had a significant reduction in acuity. MCC is an effective strategy to reduce medical and psychosocial acuity in addition to improving HIV care continuum outcomes.
Resource (Conference Presentation) updated 09/14/2023
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Assessing and Providing for Needs of Ryan White Clients with Standardized, Validated Tools
Modernizing acuity scales in provision of services to clients allows for those with the greatest need to achieve improved health outcomes in a health equity approach.
Learning Objectives
- Identify appropriate standardized, validated tools to use in client assessments.
- Describe an equity-based model of care for clients.
- Create process flow maps in order to optimize procedures for increased retention.
Resource (Conference Presentation) updated 09/14/2023
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Creating and Implementing a Protocol for RWHAP Providers to Assess and Build HIV Patients' Self-Management Skills
The New York City Department of Health and Mental Hygiene designed an HIV self-management protocol for the Ryan White Part A care coordination program. Through the protocol, staff and patients systematically identify and address patient strengths and challenges, focusing activities on building patients' capacity to manage their care.
Resource (Conference Presentation) updated 09/14/2023
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Integrating a Multi-Level ART Adherence Program into HIV Care Management: Considerations for Development, Implementation, Expansion
The New York City Health Department has scaled up The Undetectables Viral Load Suppression Program, in collaboration with the program developer (Housing Works) and other stakeholders, by integrating the program into existing HIV medical case management service delivery.
Resource (Conference Presentation) updated 09/14/2023
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Using Ryan White Case Management Standards to Support Status Neutral Service Delivery to PrEP Patients
Prism Health North Texas will share the challenges and successes of adapting Ryan White case management tools and strategies to a pre-exposure prophylaxis (PrEP) program for behavioral intervention. Panelists will detail how they took lessons learned from case management to HIV prevention to become status neutral.
Resource (Conference Presentation) updated 09/14/2023
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Electronic Case Management Tracking System: A Tool for Case Managers and Managers
This session will describe the development and implementation of a web-based electronic and administrative tracking system developed for use by clinic case managers. This electronic tracking tool allows case managers to easily view patient data with the overall goal of improving retention in care and adherence to medication.
Resource (Conference Presentation) updated 09/14/2023
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Housing First to Treat and Prevent HIV
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%.
Resource from the RWHAP Best Practices Compilation updated on 05/13/2024
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A Trauma-Informed Approach to Integrating HIV Primary Care and Behavioral Health Services
To better integrate primary care with behavioral health services, providers were trained on trauma-informed care and contracts and standards of care were modified to require that medical providers conduct mental health screenings. As a result, receipt of mental health services and care retention rates improved.Resource from the RWHAP Best Practices Compilation updated on 04/17/2024
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Using a Multidisciplinary Approach to Improve Retention in HIV Care
MacGregor Infectious Diseases, a hospital-based clinic affiliated with the Hospital of the University of Pennsylvania, implemented a multidisciplinary approach to strengthen outreach to clients and improve care retention. As compared to clients in standard care, clients served with the multidisciplinary approach had higher rates of retention in care, particularly among clients who were not virally suppressed.Resource from the RWHAP Best Practices Compilation updated on 01/07/2024
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Ridesharing to Transport Clients to Medical Visits
San Joaquin County Public Health Services Department partnered with the California Department of Public Health, Office of AIDS to help clients get to medical appointments via ridesharing. Representing the first partnership between a jurisdiction and a ridesharing company, this program addresses transportation barriers, promotes engagement in medical care, and leads to cost savings.Resource from the RWHAP Best Practices Compilation updated on 04/15/2024
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Leveraging Electronic Health Records to Collect and Integrate Outcomes-Based Data in Care
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.Resource from the RWHAP Best Practices Compilation updated on 11/01/2023
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Providing HIV Services to People Who Are Incarcerated
The Maricopa Jail Project was implemented by five jails to decrease the wait time between incarceration and/or diagnosis to the start of treatment, and to better support clients to reach viral suppression. Maricopa hired a nurse practitioner to manage access and case manage across the jail system. The initiative was successful in increasing the number of clients who were virally suppressed.Resource from the RWHAP Best Practices Compilation updated on 12/12/2023
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KC Life 360
Expanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.Resource from the RWHAP Best Practices Compilation updated on 11/26/2023
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Coordinador de atención médica del Proyecto CAATCH / Manual de intervención entre pares
Plan de estudios de sesiones educativas para promover la participación y retención del cliente en la atención del VIH a fin de aumentar las tasas generales de supresión viral, con base en prácticas informadas por la evidencia, incluidas entrevistas motivacionales, para abordar las brechas identificadas en la atención.
Resource updated 09/19/2023