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Collaborative Care Management: E2i
Collaborative Care Management (CoCM) integrates mental health and primary care, with a care team of a primary care provider, behavioral health care manager, and psychiatric consultant. Together they provide comprehensive and coordinated care to people with HIV who have co-occurring depression or other psychiatric disorders. Four sites implemented CoCM as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. CoCM led to statistically significant increases in antiretroviral therapy (ART) prescription and viral suppression.Resource from the RWHAP Best Practices Compilation updated on 01/03/2024
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Integration of HCV Treatment within an HIV Clinic
The University of California San Francisco, San Francisco General Hospital HIV Clinic developed a care model to enhance access to hepatitis C virus (HCV) treatment among people with HIV by co-locating care and creating a multidisciplinary team. Developed as part of the RWHAP Part F SPNS Hepatitis C Treatment Expansion Initiative, this model of care led to a considerable decrease in the number of people with HIV who were coinfected with HCV among the patients served by San Francisco General Hospital during the 2010 and 2011 demonstration years.Resource from the RWHAP Best Practices Compilation updated on 05/15/2024
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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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Link-up Rx
Link-Up Rx is a data to care (D2C) program that aims to increase retention in care and viral suppression among people with HIV by using prescription refill information to decrease the length of time between refills and reduce antiretroviral therapy (ART) interruption.Resource updated 09/14/2023
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Maricopa County: Expanding Jail Services & Improving Health for Incarcerated People with HIV
The Maricopa County Jail Project was implemented by five jails and uses a nurse practitioner to manage service access and case management across the jail system.Resource updated 10/13/2023
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Telemedicine Implementation at a Midwestern HIV Clinic During COVID-19: One Year Outcomes
This HIV clinic evaluated effectiveness of telemedicine for selected patients during the first year of the COVID-19 pandemic, and found overall viral suppression and retention in care rates were not adversely impacted by switch to telemedicine. They also noted similar rates of telemedicine utilization across demographic criteria.
Resource (Conference Presentation) updated 09/14/2023
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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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Telehealth Strategies to Maximize HIV Care
Identify and maximize the use of telehealth strategies that are most effective in HIV care. Project period: 2022-2025.RWHAP Technical Assistance Provider updated on 09/15/2023
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An Evolution of Telemedicine: Innovative Care Approaches in Response to the COVID-19 Pandemic
Development of telehealth services to patients with SARS-CoV-2 infection, including diagnostic testing, telephone evaluation, home pulse oximetry, monoclonal antibodies, and follow-up for patients through video assessments and the contributions to successful outcomes.Resource (Conference Presentation) updated 09/14/2023
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Evolution of Telehealth and the Revenue Cycle – Lessons from UPMC and a Ryan White Clinic
Description of how the agency standardized the complicated charge capture of telemedicine visits, from scheduling to billing to payment, in a rapidly evolving environment.
Resource (Conference Presentation) updated 09/14/2023
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Ensuring Equitable Access to Smartphone-based Tele-mental Health Care to Non-urban People with HIV during the COVID-19 Pandemic
Description of telehealth implementation through a clinic-deployed smartphone application.
Resource (Conference Presentation) updated 09/14/2023
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Cultivating Growth: Home-based Behavioral Health and Supportive Housing across Oregon's Balance of State
Review of the Oregon model of integrating intensive case management, behavioral health, in-home and other wrap-around services with housing assistance and its replication potential in other jurisdictions.
Resource (Conference Presentation) updated 09/14/2023
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Telehealth in the Ryan White HIV/AIDS Program
RWHAP recipients review their telehealth innovations developed during COVID-19 while HRSA reviews a new program identify and maximize the use of telehealth strategies in the RWHAP and other telehealth initiatives across HRSA.
Resource (Conference Presentation) updated 09/14/2023
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Homeless Health Outreach Mobile Engagement (HHOME)
HHOME offers mobile HIV primary care, behavioral health care, and connection to housing services to people with HIV experiencing homelessness. A centralized HHOME team acts as a hub to meet clients where they are, refer them to housing and support services, and provide ongoing case management and HIV primary care services. Clients participating in HHOME experienced increased retention in care, viral suppression, and connection to stable housing.Resource from the RWHAP Best Practices Compilation updated on 11/27/2023
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Telehealth Implementation at a Midwest HIV Clinic
The University of Nebraska Medical Center/Nebraska Medicine (UNMC/NM) Specialty Care Center (SCC) is the largest provider of comprehensive HIV care—including primary and HIV-focused medical services as well as multiple support services—in Nebraska. In March 2020, at the onset of the COVID-19 pandemic, the clinic integrated telehealth into its care delivery model to continue serving patients beyond the clinic structure, and developed algorithms that allowed any team member to quickly identify a patient's eligibility for a telehealth visit. The algorithms include the date of the most recent office visit, stability of HIV disease, most recent viral load and CD4 count, and antiretroviral therapy (ART) refill histories as a proxy for medication adherence. Overall, viral suppression rates remained high for all patients regardless of visit type, indicating that telehealth is a successful alternative to in-person visits for providing HIV care.Resource from the RWHAP Best Practices Compilation updated on 03/23/2024
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Enhanced Patient Navigation for Women of Color
The Enhanced Patient Navigation for Women of Color with HIV intervention uses patient navigators, who are non-medical staff in clinical settings, to reduce barriers to health care and optimize care. The intervention was effective in improving linkage to and retention in care, as well as viral suppression.Resource from the RWHAP Best Practices Compilation updated on 02/28/2024
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MORE: Mobile Outreach Prevention and Engagement
MORE focuses on people who are not virally suppressed and/or who have not attended an HIV medical appointment in six months. Participants can choose from one of three MORE programs, depending on the intensity of services they want. Based on initial evaluation findings, participants who received more intensive MORE services were more likely to be virally suppressed and less likely to be lost to follow-up than those who received less intensive services.Resource from the RWHAP Best Practices Compilation updated on 04/15/2024
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Checklist for Evaluating HIV Telehealth Care
The rationale, methodology, and implementation of New York State's Checklist for Evaluating HIV Telehealth Care as used by HIV providers to assess the quality of their telehealth services.
Resource (Conference Presentation) updated 09/14/2023
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Adapting HIV Service Delivery During COVID-19: Lessons Learned
BPHC and HIV service agencies in the Boston EMA quickly adapted during the pandemic by shifting to telehealth, streamlining and enhancing processes, and expanding services to accommodate changing client needs. These changes have led to valuable lessons learned to reduce barriers to care, sustain adaptability and modernize service delivery.
Resource (Conference Presentation) updated 09/14/2023