This initiative supports the design, implementation, and evaluation of innovative interventions that coordinate HIV care and treatment, housing, and employment services to improve HIV health outcomes for low-income, uninsured, and underserved people living with HIV (PLWH) in racial and ethnic minority communities. The overall goal of this coordinated services intervention is to decrease the impact of the social determinants of health (such as unmet housing or employment needs) that affect long-term HIV health outcomes for PLWH impacted by employment and housing instability in racial and ethnic minority communities. To promote long-term health and stability for PLWH, this initiative supports and one Evaluation and Technical Assistance Provider (ETAP) and 12 demonstration sites across the United States that will implement, evaluate, and disseminate innovative strategies for integrating HIV care, housing, and employment services into a coordinated intervention. This Special Projects of National Significance (SPNS) initiative is supported through the Department of Health and Human Services (HHS) Secretary’s Minority AIDS Initiative Fund (SMAIF) and the SPNS Program.
Grants for this initiative have been awarded to the organizations listed below, with brief descriptions of their projects provided.
AIDS Foundation of Chicago, Chicago, IL
Safe & Sound Return Partnership (SSRP)
The Safe & Sound Return Partnership is a collaborative, multidisciplinary intervention bringing together providers of HRSA, Department of Housing and Urban Development/Housing Opportunities for Persons with AIDS (HUD/HOPWA), and Department of Labor (DOL)-funded services. The goals of the partnership are to: 1) rapidly connect 215 high-need People Living with HIV (PLWH) recently released from Cook County Jail and Illinois prisons to an expanded range of medical, housing, and employment services, along with other critical wraparound supports such as behavioral health treatment; 2) develop and deliver trainings to increase capacity of citywide housing and employment providers to deliver culturally competent services to HIV/AIDS and reentry populations; and 3) convene a cross-system SSRP Coalition to reduce systemic barriers/gaps and develop strategies to increase access to and coordination of comprehensive medical, housing, and employment resources for ex-offenders with HIV/AIDS. SSRP is a three-pronged intervention that works at the client, provider, and systems levels to ensure continuity of and retention in care and reduce structural barriers that can impede ex-offenders’ progress along the HIV care continuum.
Avenue 360 Health and Wellness (formerly Houston Area Community Services), Houston, TX
Project CORE (Coordination Of Resources and Employment Services)
This project provides a coordinated response with a comprehensive framework, description of employment needs and other supportive services within the City of Houston and Harris County, Texas. Houston Area Community Services (HACS), doing business as AVENUE 360 Health and Wellness (AVENUE 360), along with AIDS Foundation Houston (AFH), will collaborate to meet the objectives and activities of the proposed Project CORE (Coordination Of Resources and Employment Services). AVENUE 360 ensures that primary medical services are accessible throughout one of the largest urban areas in the U.S. AVENUE 360, along with AFH, is part of an advanced prevention and care system located within the City of Houston. Both AVENUE 360 and AFH will coordinate their respective programs to ensure that PLWH access all available eligible services within the HIV continuum of care and HIV-housing related services by enhancing employment and support services. AVENUE 360 in Houston’s main campus targets Hispanic and African American PLWH, and provides services to a diverse population of PLWH, along with a high number of youth in care. This project has the potential to successfully achieve the three main outcomes of housing stability, achievement of viral suppression.
Bexar County Hospital District, San Antonio, Texas
CASE (CAse HouSing and Employment) Management Initiative: Creating sustainable improvement of HIV health outcomes through coordination of medical, housing and employment services
The Case Project will support the design, implementation and evaluation of an intervention that will coordinate HIV care and treatment, housing, and employment to improve HIV health outcomes for low-income, uninsured and underinsured PLWH in racial and ethnic minority communities in the four-county San Antonio Transitional Grant Area (SATGA). The project will achieve a systematic transformation of the SATGA HIV service delivery model. BCHD proposes a unique partnership between SATGA’s public and private sectors to develop innovative strategies to: 1) integrate HIV care; 2) promote housing stability; and 3) increase employment opportunities. Goals of the program are to: 1) increase housing stability; 2) decrease rates of unemployment and underemployment; and 3) increase viral suppression. BCHD’s project will hire and integrate dedicated staff into SATGA’s Ryan White HIV/AIDS Program Parts A/B/D and HOPWA Care Continuum to coordinate housing, health care and employment services for racial and ethnic minority PLWH. The project will address the following needs: 1) unstable housing; 2) high unemployment rates and 3) low medical care adherence to maintain/achieve viral suppression. BCHD will develop an innovative program by integrating SPNS-funded CASE Coordinators into current RWHAP Parts A/B/D and HOPWA funded programs.
City of Kansas City, Kansas City, MO
KC-Life-360 Project: KC TGA Supportive Employment & Housing Services to Advance the HIV Care Continuum Demonstration Project
The KC-Life-360 Project will consist of an integrated delivery system for housing, employment, and HIV care services to holistically meet client needs. The Kansas City TGA includes 7 Missouri and 4 Kansas counties. This program will include adding employment assistance and access to stable housing for PLWH, co-locating project staff within housing provider sites, case conferencing, and cross training between employment, other service providers and partners. The City of Kansas City will collaborate with Catholic Charities of Kansas City – St. Joseph, reStart, and other stakeholders in this initiative, using the intersection of employment services, HIV care and treatment, and housing to improve health outcomes for PLWH.
The City of Pasadena Public Health Department, Pasadena, CA
Operation Link II
Operation Link II, a community-based demonstration program, will coordinate health care, housing, and employment navigation for racial and ethnic minority PLWH at high risk for poor HIV health outcomes living in the San Gabriel Valley of California. The project will connect PLWH with immediate Ryan White HIV/AIDS Program (RWHAP) health care providers; appropriate Housing Opportunities for Persons with AIDS (HOPWA) housing; and employment navigation, through the development of a coordinated system among partners to support clients successfully achieving economic independence and overall well-being. The project will be a partnership of the City of Pasadena’s employment and workforce resource, Foothill Workforce Development Board, the Wesley Health Centers (a RWHAP provider), and Union Station Homeless Services (a HOPWA provider). Two dedicated, full-time staff members, a Housing Navigator and an Employment Navigator, will facilitate the coordinated care response for clients. Operation Link II builds upon the successful implementation of Operation Link, a five-year demonstration program under the HRSA RWHAP SPNS Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations initiative. Clients will be recruited through partner agency and other referrals and will be linked to health care, housing, and employment service components, with Operation Link II staff providing guidance, support, and advocacy. The proposed project will ensure efficiency in identifying unmet needs and service coordination, helping to remove barriers to care and independent living, and addressing the social stigma that exists for PLWH and racial and ethnic minorities, including potential job discrimination.
City of Paterson, Paterson, NJ
The City of Paterson is a Ryan White HIV/AIDS Program Part A recipient and HOPWA recipient serving the Bergen-Passaic Transitional Grant Area (TGA) in New Jersey. In partnership with the Paterson Free Public Library and Bergen One-Stop Career Center, this project will augment an existing coordinated services intervention that integrates HIV care, housing, and employment services. The proposed Project will improve the coordination of HIV care services, housing services and employment services through: 1) the development and implementation of standardized procedures for referrals for employment and housing services; and 2) enhancements to existing health information technology (HIT). The HIT enhancements will: 1) optimize efficiency of referrals among RWHAP and HOPWA sub-recipients and organizations providing employment services; 2) improve the coordination of RWHAP, HOPWA and employment services; 3) enable users to quantify, track and evaluate the effect of homelessness or unstable housing and unemployment on linkage to care, retention in care and clinical outcomes; and 4) automate Consolidated Annual Performance and Evaluation Report (CAPER) reporting for HOPWA/RWHAP sub-recipients. The Project seeks to achieve better coordination of services and improve the TGA’s ability to collect and analyze data relating to the housing and employment needs of PLWH, thereby improving HIV care and services, and ultimately leading to improvement in the rate of viral suppression for PLWH in the Bergen-Passaic region.
Family Health Centers of San Diego, San Diego, CA
Family Health Centers of San Diego will improve long-term health outcomes of racial/ethnic minority PLWH who have fallen out of care through innovative system-level changes that will improve regional capacity to reduce the impact of unmet housing and employment needs. A Coordinated Services Intervention (CSI) will build upon HUD’s and DOL’s Getting to Work initiative and the client-focused Considering Work Model. The CSI will streamline intake and assessment forms across programs to increase efficiencies to better identify unmet needs and create person-centered coordinated services for clients seeking housing and employment. The CSI will also provide intensive case management, follow-up, and peer support through a dedicated Linkage Coordinator, peer discussion groups, and additional leveraged resources. Patient experiences will be enhanced through linked data systems, housing and employment services linked to clients’ medical homes, interdisciplinary team-based care, and facilitated referrals. The CSI will consist of the joint management and delivery of a consortium of RWHAP, DOL, and HOPWA providers, leveraged with a rich array of social services resources and evidenced-based programs. The goal of project is to improve long-term health outcomes for racial and ethnic minority PLWH by reducing the impact of unmet housing and employment needs.
Fenway Community Health Center, Boston, MA
Housing and Employment Improves Health Outcomes (HEI-HO)
Fenway Health proposes to partner with Jewish Vocational Services (JVS), Greater Boston’s largest workforce development provider, to provide coordinated employment, housing and medical case management services to recipients of Fenway Health’s HIV case management services. The specific target population will be case management clients with incomes below 400% of federal poverty level who have unmet housing and/or employment needs, with a special focus on members of racial and ethnic minority communities. Fenway Health anticipates leveraging the education and training assets of The Fenway Institute, including its HRSA-funded centers, to integrate project findings into its widely distributed issue briefs, webinars, and in-person technical assistance offerings.
Gay Men’s Health Crisis, New York, NY
Project Housing and Employment Access Lead to Health (Project HEALTH)
Gay Men’s Health Crisis (GMHC) will implement an innovative care coordination program that will foster improved health outcomes by addressing barriers to engagement in housing, employment, and Ryan White HIV/AIDS Program (RWHAP) services among African American and Hispanic PLWH in New York City. GMHC’s Project HEALTH will: 1) hire an interdisciplinary team to coordinate HIV care, employment, and housing services for PLWH with unsuppressed viral loads; 2) expand GMHC’s technology infrastructure to support service coordination; and 3) augment the agency’s existing service programs with a suite of social work-informed support services that address emotional, practical, and clinical factors that impact clients’ ability to make changes in their lives. Project HEALTH will use evidence-based social work modalities to address social determinants of health and facilitate access to and engagement in care. Project HEALTH will be embedded in GMHC’s integrated program environment and leverage a vast array of onsite and partner-based services to meet client needs. Project HEALTH will focus on African American and Hispanic PLWH living throughout NYC who are not virally-suppressed and who are unemployed, unstably-housed, or both.
Positive Impact Health Centers, Inc., Duluth, GA
HOMES-DS: The HIV Housing Options, Medical, and Employment Services
HOMES-DS is a program that seeks to improve HIV-related health outcomes through coordinated strategies to connect PLWH from the most impacted communities with HIV care, housing, and employment services. The project will establishing new partnerships with vocational services providers; obtaining staff certification in supplemental security income/social security disability income work incentive benefits counseling; and providing non-medical case management (NMCM) services to PLWH. This project will also directly address gaps in housing and employment services for homeless and unemployed PLWH enrolled in PIHC’s intensive outpatient substance abuse treatment programs by providing Life Skills in a group format. It will also include altering program schedules to allow for appointments with employment services job search, and providing clients enrolled in the first phase of treatment with short-term housing support. HOMES-DS will also be supported by the RWHAP, HOPWA and Client Services team that includes Housing Coordinators, Medical Case Managers, Linkage Coordinators and Community Health Workers.
Positive Resources Center, San Francisco, CA
Integrative Health Analysis (IHA)
Positive Resource Center (PRC) will coordinate primary care, housing, and employment services in racial/ethnic minority communities in the City of San Francisco by increasing collaborative efforts between the agency’s Employment Services program, HOPWA-funded providers, HIV primary care clinics, and other community partners. PRC’s new program is called Integrative Health Analysis (IHA), which screens targeted individuals for detrimental social determinants, and improves them via social services offered internally by PRC or through partner agencies. The project will evaluate a host of social determinants, but focus mainly on employment and housing status. Activities will take place mainly at two HOPWA-funded housing sites in San Francisco. IHA will coordinate client access to HIV primary care and ensure continuity of care as residents exit these HOPWA-funded housing programs. Client access to additional supportive services will also be provided. The program will increase data sharing between agencies to track the impact of social services on identified health outcomes, while building greater efficiencies into the San Francisco system of HIV care coordination.
Yale University, New Haven, CT
Project HERO: Housing and Employment Resources to Improve HIV Outcomes
Project HERO is an augmentation of current work that uses evidence-based interventions to provide HIV treatment, behavioral health services, and housing to PLWH in the New Haven area. Project HERO will build on mHEALTH (Medical Home Engagement and Aligning Lifestyles and Transitions from Homelessness), a demonstration project of the previous Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations SPNS initiative. The project will build on this community based patient-centered medical home and continue to enhance a community relationship with Liberty Community Services, the largest HUD and HOPWA service provider in the area. It will also implement the Getting to Work Technical Assistance modules; train HERO staff in the Getting to Work initiative to increase the competence of all disciplines on employment and training opportunities for clients; facilitate maximum access to mainstream, disability and income-specific employment and occupational training services; and facilitate access to affordable and subsidized safe, decent and accessible housing.
Boston University, Boston, MA
Evaluation and Technical Assistance Provider (ETAP)
Boston University, in collaboration with Boston Health Care for the Homeless Program
(BHCHP) and its consulting partners, will serve as the Evaluation and Technical Assistance Provider (ETAP) for this initiative. The ETAP will: 1) develop and implement the mixed methods multi-site evaluation of the demonstration sites; 2) provide training and technical assistance to implement housing and employment supports that achieve quality HIV and behavioral health care; and 3) produce and disseminate tools, products, and models to expand housing and employment services for PLWH that may be replicated in other Ryan White HIV/AIDS Program, HOPWA, Department of Labor and community partners. In collaboration with HRSA’s RWHAP Part F SPNS, the ETAP will support the demonstration sites in developing, evaluating, and disseminating interventions that coordinate health, housing, and employment services to reduce barriers to HIV care and improve health outcomes.