The IHHP notice stipulates that grantees should demonstrate “a concerted effort . . . to integrate and coordinate cross-cutting resources in providing a comprehensive approach to HIV/AIDS housing and support services.” The IHHP sites we visited created program models involving significant service coordination among housing, health care, and other support service coordinators. Key program components facilitated service integration: (1) in-depth screening of clients’ housing, health care, and other support service needs at intake; (2) development of individualized care plans tailored to the needs and circumstances of participants; and (3) frequent in-person contact between housing coordinators and peer specialists, clients, and medical providers (Table III.3).
Table III.3. Service Provision and Linkage to Care
|.||River Region Human Services||Frannie Peabody Health Center||Portland Housing Bureau||Albany CARES|
|Direct Housing Services||RRHS provides tenant-based rental assistance to FUSE clients and others||FPC provides tenant rental assistance and linkages to housing vouchers and public housing statewide||PHB provides short-term rental assistance: helping with eviction prevention, rapid re-housing, and housing retention||CARES provides tenant-based rental assistance and helps with clients’ transition to housing self-sufficiency|
|Service Coordination||FUSE service coordinator and peer specialist offer coordinated linkages and transportation to medical care and support services||FPC works with AIDS service organization (ASO) partners across the state to coordinate local case management with IHHP housing assistance||System-wide, PHB and local partners use common assessment form and “acuity scale” to rate and assess client need for housing, employment, and HIV medical care||Local partner sites (Albany and Rochester) offer both housing and employment service coordination, and closely collaborate with local medical providers|
|Health Care Linkage||Site uses a single health impact assessment tool to link to care. The FUSE service coordinator is a former RWP-funded medical case manager who works closely with the local medical case manager network||Local ASO partners coordinate referrals and engage with local health care providers. Integration of HIV housing and medical care is coordinated statewide by FPC staff||PBH coordinates all services, but linkages to medical care are made directly by partner organizations. Program has strong system connections to HIV care||New York state is moving to a Medicaid health home model for PLWHA CARES’ local partner organizations are providing linkages to medical providers and medical homes|
Source: Discussions with program staff and document review conducted by Mathematica Policy Research, 2013.
CoC = Continuum of Care; HOPWA = Housing Opportunities for Persons With AIDS; IHHP = Integrated HIV/AIDS Housing Plan; RWP = Ryan White HIV/AIDS Program.
Each program also uses an interdisciplinary team made up of internal staff and external partners with the technical knowledge, collaborative skills, and program experience to meet the multiple needs of the client population. All sites leverage existing staff resources, but they have used their IHHP grants to incorporate housing coordinator positions into their programs; such positions are deemed critical to the integration of care and housing services, which is achieved through the activities described below. Sites described using multidisciplinary teams and suggested frequent communication among core staff to help clients make and keep service appointments, address problems with rental payments and compliance with rental requirements, motivate clients to make and work toward long-term self-sufficiency goals, and handle crises that could disrupt clients’ housing stability and access to health care.
In addition, all four IHHP programs have developed policies and practices to facilitate care coordination. For example, RRHS employs an internal service coordinator/peer specialist team to maintain close personal contact with clients and with other agencies. FPC contracts with local partners to provide case management and care coordination. PHB uses a common client assessment form and “acuity scale” of clients’ housing and HIV needs. CARES uses service coordinators that offer comprehensive housing and employment service planning and collaborate closely with medical providers. Other site-specific service integration-related practices are summarized below.
RRHS FUSE staff use a program-specific intake form that is a modified version of the RRHS general housing program intake form. The FUSE form includes RWP-specific data elements, including CD4/viral load counts, Medicaid status, enrollment in RWP, and medical and provider history. At intake, FUSE staff also inquire about the client’s history of substance use and homelessness, criminal background, demographic information, income, and medications. Notably, the local CoC coalition task force is using the FUSE intake form as a model for the common intake and assessment form it is developing. If necessary, FUSE team members provide transportation and accompany clients to medical and other service appointments. The FUSE service coordinator also conducts home visits with each client at least monthly, and asks clients to provide their lab test results from each medical visit (every three to six months) to track their retention in care and clinical outcomes. The service coordinator also leverages his preexisting relationships with local medical providers and RWP medical case managers (he was previously a medical case manager himself), calling them once or twice a week to ask for verification of medical appointments and other information.
At intake, FPC staff also use a detailed screening form that is used in FPC housing programs and that FPC staff encourage AIDS service organization partners to use statewide. The screening tool is used to assess physical and mental health, oral health, financial assets, legal history, and transportation issues. The use of a universal screening form allows intake staff to ask clients about their long-term housing plans, beyond the three-year limit of the IHHP program. Physical and mental health status is assessed at intake and then annually, at a minimum. As part of the intake process, the case manager contacts the applicant’s health care providers; for some clients, the case manager may call the provider as often as once a week. The case manager also creates an individualized housing plan, linking the client to a range of medical and social services, such as the AIDS Drug Assistance Program (ADAP), RWP, Medicaid, SSI, TANF, and SNAP. At FPC, health care coordination includes setting appointments; ensuring that clients get to appointments; working with pharmacies to help clients refill prescriptions, ensuring that clients understand any medical jargon, and accompanying clients to appointments, if needed. Overall, FPC described a high level of integration between HIV housing and medical care.
PHB’s service partners, CAP and MCHD, use a “no wrong door” approach to intake. That is, they work closely together to integrate housing and care at the client level regardless of whether the initial point of contact by someone with HIV/AIDS is with the housing or the medical care system. CAP and MCHD conduct intake assessments independently. CAP collects clients’ demographic information and creates a profile in HMIS. CAP staff assess clients across a wide range of indicators, including housing stability/status, behavioral health (mental health, substance use, domestic violence), medical care, insurance, and risk indicators (unprotected sex and drug/alcohol use), then refer the client to the appropriate programs. MCHD also assesses clients’ housing needs upon intake, relies on CAP for support on most housing-related issues, but also refers clients to other non-HIV-specific housing resources in the community, as appropriate. MCHD and CAP informants reflected on the relative merits of their case management approaches. MCHD medical case managers could confer directly and immediately with clients and health care providers, offering rapid referral and care coordination; however, they have high case loads, which reduces their frequency of client contact. CAP staff work with lower case loads and a higher degree of flexibility and thus are able to accompany clients to appointments (with lawyers, landlords, or even health care providers) and facilitate assistance with overcoming a variety of barriers to care.
CARES is working to create a seamless collaborative team approach to integrate housing programs with (1) health care, (2) support services (e.g., HIV prevention, mental health, and substance abuse treatment), and (3) vocational rehabilitation and employment programs. Like PHB, CARES’ partner organizations, ADC and CCCS, use a similar in-depth intake and assessment process. Clients are referred to ADC or CCCS and assessed (using the same program assessment template) regarding their interest in employment, eligibility for HOPWA, and legal history. Clients are contacted at least once a month, but more frequently if required. Both ADC and CCCS conduct in-person visits at which they develop individualized service plans that address employment, improvement in health, and access to primary care. Clients are connected to housing, vocational training and employment services, and medical care depending on their needs and goals as detailed in their service plan. The case manager is in regular contact with medical providers to ensure that clients are complying with their recommended course of treatment and are attending primary care appointments. HIV-related documentation is also collected and includes viral loads and CD4 counts.