Resources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model.
HIV agencies often focus on employment services--for people with HIV as well as their staff. For patients/consumers, employment support is increasingly crucial given the disproportionate impact of HIV on lower income individuals, who are living long and hopefully productive lives given the effectiveness of HIV treatment and care. Support may include, for example, job training, hiring of peers to work with clients (e.g., peer educators, peer navigators), and support for individuals transitioning from correctional facilities.
See Program Management and the AETC NCRC Library for resources on workforce support on conducting services in new and innovative ways (e.g., via practice transformation training).
Best Practices
- Boston University School of Social Work Center for Innovation in Social Work and Health
- The HIV, Housing & Employment ProjectCOVID-19 adjustments developed by Ryan White HIV/AIDS Program recipients.
- The HIV, Housing & Employment ProjectThe goal of Project HERO is to improve HIV outcomes through an established patient-centered medical home by linking people living with HIV who are unstably housed to HIV care, housing, and employment services.
- Boston University School of Social Work Center for Innovation in Social Work and Health, The HIV, Housing & Employment Project
Best practices (and extensive resource links) for integrating into medical care teams the non-medical staff called Navigators.
- The HIV, Housing & Employment Project
Review of strategies for housing vulnerable populations in tight housing markets.
- Boston University School of Social Work Center for Innovation in Social Work and Health
SPNS innovative and replicable HIV service delivery models using HIV+ peers.
- The HIV, Housing & Employment ProjectAvenue 360 Health & Wellness offers a medical home for patients and AIDS Foundation Houston coordinates employment training and resources. These agencies believe that coordination is the key to breaking down barriers to health care in their community.
- The HIV, Housing & Employment ProjectSSRP is a client, provider, and system levels intervention to rapidly connect PLWH recently released from jail/prison to medical, housing, and employment services using a Peer Community Reengagement Specialist model.
- The HIV, Housing & Employment ProjectCoordination 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.
- The HIV, Housing & Employment ProjectShort-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.
- The HIV, Housing & Employment ProjectSmart 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.
- The HIV, Housing & Employment ProjectCoordination of health care with housing and employment services through regular meetings, formal agreements, and a Linkage Coordinator.
- The HIV, Housing & Employment ProjectPartnership 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.
- The HIV, Housing & Employment ProjectCare 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.
- The HIV, Housing & Employment ProjectKC Life 360’s same-day intake, informed consent, and one-on-one with an Employment Career Specialist generates awareness of services and benefits across provider networks.
- Best Practices CompilationExpanded housing and employment opportunities for people with HIV contributed to positive housing, earned income, and viral suppression outcomes for clients.
- Best Practices CompilationGay Men’s Health Crisis updated its data management process to better document housing and employment service outcomes. Enhancements to the Electronic Health Record contributed to positive housing, employment, and viral suppression outcomes for clients.
- Best Practices CompilationFenway Health, Fenway AIDS Action Committee, and MassHire Downtown Boston provided housing and employment supports to clients who were unstably housed and were un- or under-employed, in order to improve health outcomes as part of the RWHAP Part F SPNS initiative Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. Almost 70 percent of clients who participated in this intervention and received medical care at Fenway Health were virally suppressed, despite facing considerable barriers to care.
- Best Practices CompilationOne 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.
- The HIV, Housing & Employment ProjectHousing 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.
- The HIV, Housing & Employment ProjectClients 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.
- Best Practices CompilationAvenue 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.
- Best Practices CompilationYale 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.
- The HIV, Housing & Employment ProjectHousing and employment services include a Job Club to provide a supportive environment and training for participants.
Resources
- Boston University School of Social Work Center for Innovation in Social Work and Health, HRSA HIV/AIDS Bureau (HAB)
Training compendium for agencies seeking to develop programs that utilize peers to help engage and retain other people with HIV in care. Also en Espanol: Componentes Esenciales para la Capacitación y Éxito de los Trabajadores Pares (Peers)
- SPNS Improving Care and Treatment Coordination Black Women with HIVInnovative strategies for delivery of bundled interventions for improving health outcomes for Black women with HIV during COVID-19.
- The HIV, Housing & Employment ProjectWebinars and briefs on delivery of HIV care to persons with unstable housing.
Conference Presentations
Alliance for Positive Change
Presenters:
Sharen Duke, Ramona Cummings, Eugene Eppes
2022 National Ryan White Conference on HIV Care & Treatment