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Curriculum updated on 06/09/2020
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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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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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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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Test and Treat
The Test and Treat initiative, implemented by Oklahoma State University, connects people to antiretroviral therapy (ART) within 14 days of HIV diagnosis through streamlined intake and initial clinic visit protocols and 30-day medication starter packs. Participants in Test and Treat are linked to care and reach viral suppression sooner, and are more likely to be retained in care, as compared with people in standard care.Resource from the RWHAP Best Practices Compilation updated on 04/12/2024
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Expanding Oral Health Care Services for People with HIV
Extramural dental clinics implemented the medical home model, with integrated trauma-informed care, to expand oral health care services for people with HIV, and saw increases in referrals from partner organizations and the number of new clients.Resource from the RWHAP Best Practices Compilation updated on 11/22/2023
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Improving Access to Mental Health Care
The AIDS Institute is committed to promoting, monitoring, and supporting the quality of clinical services for people with HIV in New York State. The Adolescent Quality Learning Network (AQLN) is a collaborative of 16 HIV Adolescent/Young Adult Specialized Care Center (SCC) programs. In collaboration with the AIDS Institute, SCC providers selected a quality improvement project aimed to raise viral suppression rates by improving access to mental health services.Resource from the RWHAP Best Practices Compilation updated on 11/01/2023
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PACT Food Assistance Program
The University of Pittsburgh Medical Center, Center for Care of Infectious Diseases, Pittsburgh Area Center for Treatment (PACT) began implementing the Food Assistance Program in August 2017 to serve as a supplemental resource for people with HIV receiving care who experience food insecurity. The program helps bridge gaps in Supplemental Nutrition Assistance Program (SNAP) benefits and monthly food costs while promoting access to healthy foods and retention in HIV care.Resource from the RWHAP Best Practices Compilation updated on 11/14/2023
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Rapid Access Initial HIV Appointment and ART Prescription
The Virginia Commonwealth University implemented a clinical quality improvement project to increase linkage to HIV medical care within 30 days and initiation of antiretroviral therapy (ART) at the first visit by making “Rapid Access” appointments available each week for people with newly diagnosed HIV.Resource from the RWHAP Best Practices Compilation updated on 01/07/2024
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Early Intervention Services and Outreach
The Oregon Health Authority awarded contracts to local public health authorities across the state to work with community partners to integrate early intervention services and outreach services, link people to HIV care, and provide support to help clients reach viral suppression. Quick linkage to care resulted in a median of 57 days to viral suppression for Early Intervention Services and Outreach clients in 2019.Resource from the RWHAP Best Practices Compilation updated on 05/14/2024
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Project HERO
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.Resource from the RWHAP Best Practices Compilation updated on 11/26/2023
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Project CORE: Coordination of Resources and Employment
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.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Pay it Forward Transitional Care Coordination
One Stop Career Center of Puerto Rico (OSCC-PR) implemented Pay it Forward to increase workforce capacity to connect Puerto Ricans with HIV to community-based HIV care and social supports following release from jail. Pay it Forward included training of OSCC-PR staff in the Transitional Care Coordination model. Eighty percent of clients who were supported by Pay it Forward in Puerto Rico were still in HIV care 12 months after release.Resource from the RWHAP Best Practices Compilation updated on 05/07/2024
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PositiveLinks
PositiveLinks is a mobile platform deployed by clinics or community-based organizations to connect people with HIV to a digital support community. The client-facing app helps people with a new diagnosis of HIV become engaged in care and helps people at risk of being lost to care overcome barriers related to geographic or social isolation. From the app, people can access Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant patient dashboards, secure messaging, and patient lab records. People who used PositiveLinks had increased rates of retention in care and viral suppression.Resource from the RWHAP Best Practices Compilation updated on 02/02/2024
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Project ACCEPT
Project ACCEPT is designed to improve engagement and retention in medical care for youth ages 16 to 24 years with newly diagnosed HIV. The educational and skill-building intervention was deployed at four demonstration sites and increased rates of medication use and appointment adherence in comparison to a control group. Although originally developed for cisgender youth, Project ACCEPT may be adapted for gender-diverse people.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Transitional Care Coordination: From Jail Intake to Community HIV Care Intervention
Transitional Care Coordination (TCC) connects people with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails.Resource from the RWHAP Best Practices Compilation updated on 02/02/2024
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Community Health Workers: Improving Linkage and Retention in HIV Care
Ten organizations across the U.S. integrated Community Health Workers (CHWs) into their multidisciplinary care teams. Enrolled clients had statistically significant improvements in viral suppression, antiretroviral therapy prescription, and appointment attendance after six months in the program.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Patient-Centered HIV Care Model
The Patient-Centered HIV Care Model (PCHCM) integrates the services of community-based HIV specialized pharmacists and HIV medical providers to deliver patient-centered care for people with HIV. PCHCM expands upon the medication therapy management model by including information sharing between partnered pharmacy and clinic teams; collaborative medication-related action planning between pharmacists, medical providers, and patients; and quarterly follow-up pharmacy visits. Patients participating in the intervention had improved retention in care and viral suppression rates.Resource from the RWHAP Best Practices Compilation updated on 11/26/2023
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Minimize to Maximize: A Cadence of Accountability
The Utah Department of Health and Human Services collaborated with RWHAP Part B-funded medical case managers to improve care and outcomes for clients following Franklin Covey’s 4 Disciplines of Execution: 1) focus on the wildly important goal; 2) act on the lead measures; 3) keep a compelling scoreboard; and 4) create a cadence of accountability. Through intensive case management, regular monitoring, and feedback sessions, the state's RWHAP Part B program's overall viral suppression rate increased from 88.9% in 2020 to 90.4% by December 2021.Resource from the RWHAP Best Practices Compilation updated on 11/13/2023
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Louisiana Public Health Information Exchange
The Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.Resource from the RWHAP Best Practices Compilation updated on 05/20/2024