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News Article updated on 10/01/2021
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Peer Engagement to Improve Linkage to Care and Retention in Care for Women and Youth
University Health uses peers and patient navigators to provide support, reduce barriers, and improve linkage and retention to care for women and youth with HIV. Two peers with lived experience were hired as Outreach Specialists to spearhead the program, encourage medication adherence and use of services, and provide mentoring. The intervention was successful in moderately improving the numbers of clients linked to care, retained in care, and virally suppressed.Resource from the RWHAP Best Practices Compilation updated on 11/14/2023
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City of Pasadena: Operation Link
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.Resource updated 09/14/2023
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City of Paterson: Coordination of Supportive Employment and Housing Services
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.Resource updated 09/14/2023
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Family Health Centers of San Diego: Coordinated Services Integration Intervention
Coordination of health care with housing and employment services through regular meetings, formal agreements, and a Linkage Coordinator.Resource updated 09/14/2023
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Fenway Health: 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.Resource updated 09/14/2023
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GMHC: Project HEALTH
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.Resource updated 09/14/2023
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Positive Impact Health Centers: H.O.M.E.S.
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.Resource updated 09/14/2023
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PRC: Integrative Health Analysis
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.Resource updated 09/14/2023
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Bexar County: The CASE Management Initiative
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.Resource updated 09/14/2023
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Yale, Liberty Community Services: Project HERO
Housing and employment services include a Job Club to provide a supportive environment and training for participants.Resource updated 09/14/2023
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HIV, Housing & Employment Project Demonstration Sites
Follow the links below to access intervention manuals, summaries, and other intervention resources from the participating demonstration sites.
Organization updated 04/02/2024
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About the HIV, Housing & Employment Project
Documentation of the overall project over its course with a focus on evaluation and technical assistance.Organization updated 09/14/2023
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Initiative Products and Resources
Webinars and briefs on delivery of HIV care to persons with unstable housing.Resource updated 09/14/2023
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Medical Monitoring Project 2019-2020 Data on HIV Care Access and Health Outcomes
In the U.S., almost all people with HIV have some type of health insurance coverage (pub
News Article updated on 08/09/2021 -
Innovation and Resilience: How Ryan White HIV/AIDS Program Recipients Leverage Telehealth during the COVID-19 Pandemic
Recap of changes made in telehealth laws, regulations, and policies and corresponding efforts of healthcare systems, payers, and providers to modify their services to keep clients with HIV engaged in care provided by HRSA's Ryan White HIV/AIDS Program.Resource updated 06/09/2022
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Transgender Women Engagement and Entry to Care (T.W.E.E.T): E2i
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.Resource from the RWHAP Best Practices Compilation updated on 02/09/2024
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Bilingual and Bicultural Care Team
Hispanic and Latino clients served by the team received culturally responsive care and linkages to external community resources, with resulting greater retention in care and improved viral suppression rates.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Integration of Oral Health and Primary Care in Seattle-King County
This referral-based oral health model used dental navigators to connect clients to a large network of dentists, which facilitated scheduling of appointments.Resource from the RWHAP Best Practices Compilation updated on 11/02/2023
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Peer Linkage and Re-engagement of Women of Color with HIV
From 2016 through 2019, three clinics—AIDS Care Group, Howard Brown Health, and Meharry Medical College—participated in a RWHAP Part F SPNS DEII initiative to implement peer linkage and re-engagement interventions for women of color with HIV. Integrating peers into HIV primary care teams has been effective in better engaging women of color in care.Resource from the RWHAP Best Practices Compilation updated on 02/28/2024