1. HRSA/SPNS Initiative: Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations Verna Gant Programs Manager
Good morning. It is a pleasure to be here today and share the work of our initiative in finding engaging and working with people living with HIV/AIDS who are homeless. I have had the privilege over the past 4.5 years to work with a dedicated group of individuals and organizations with expertise in HIV care, housing, substance use treatment and mental health care to implement models and test strategies that could reach people living with HIV who at the highest risk for being lost to care by our care system.
I also want to applaud HRSA for in my experience in working with SPNS for the last decade or so they designed the first of a project to examine the social determinants of health specifically housing. We know from the literature that homelessness impact HIV health care access and health status. However, this SPNS initiative sheds light on best practices and models of care of how to improve housing stability and retention in care and viral suppression.
I’m going to share in the next 10 minutes some of our preliminary overall findings from these models. And in the over the next 3 hours you will the details hear from providers, navigators about how these models worked and from SPNS clients about these how their participation in the program impacted their lives.

2. Model Description
In 2012, with funding support from the Health Resources and Services Administration (HRSA), HIV/AIDS Bureau through its Ryan White HIV/AIDS Program Part F Special Projects of National Significance (SPNS), Family Health Centers of San Diego (FHCSD) built a Primary Care Medical Home (PCMH) collaborative care model that serves homeless individuals living with HIV in San Diego County who face substance use and/or mental health challenges.
The FHCSD model of care is built upon a developed collaboration between FHCSD as lead program organization in formalized partnership with People Assisting the Homeless (PATH). Family Health Centers of San Diego (FHCSD) is a private, non-profit federally qualified healthcare center with a mission to provide high-quality, affordable health care to individuals and families. PATH is a non-profit organization that provides services for homeless or unstably housed individuals in San Diego County.

3. Programmatic Goals
Improve housing stability among the target population.
Increase client engagement and retention in HIV care and treatment, resulting in viral suppression.
Build and sustain linkages to mental health and substance abuse.
Create a bridge to other supportive services such as case management and care navigation.

4. So first who are we—nine demonstration sites from across the country were funded under this initiative. I’m from BU which served as the Evaluation and technical assistance center.
The nine sites include various organization settings:
3 public health department
2 Federally qualified community health centers
2 comprehensive HIV/AIDS care centers
2 large outpatient affiliated HIV care systems.
Operated in 8 urban areas and 1 rural setting
Goal: To engage people who are experiencing homelessness/unstably housed and living with HIV who have mental illness and/or substance use disorders in HIV and behavioral health care and obtain stable housing

5. Focus Population
People living with HIV who are 18 years of age or older;
And are experiencing homelessness or are unstably housed
Literally homeless
Unstably housed
Fleeing domestic violence
And/or have one or more co-occurring mental health or substance use disorders
Our focus population for the initiative included the following criteria---
Adults living with HIV
AND
Experiencing homelessness or unstable housing due to one or more of the following:
Literally homeless-residing in a place not meant for human habitation in a shelter, in a public space
Unstably housed—moving in the last 60 days, no rent or lease
Fleeing domestic violence
Have one or more co-occurring mental health and/or substance use disorder
Individual sites also focused on other criteria
Such as being released from jail/prison
Having a detectable viral load
Being out of care for at least 6 months

6. Implementation Model
Network navigators (aka, care coordinators, peer navigators, specialized case managers)
Not traditional HIV medical case managers
Key member of the health care team
“My understanding is SPNS kind of really tries to keep people engaged in the medical piece, but they also, kind of feel like the glue that really connects the medical piece to the housing piece.” MCHD Case Manager
Integrated behavioral health integration & HIV primary care
Team communication/huddles
Partnering with housing providers & landlords
System level coordination (housing, health, mental health, substance use treatment providers)
“Move beyond the clinic walls”
“The ultimate goal is for people to be in a four-walls health center, which is the optimal best place for any human to be to get their primary care. ..But for clients who cannot get their care in a four-walls clinic, how do we take the meat without the walls out of the clinic and create a clinic? And that’s been the goal of the project”. –Deborah Borne, MD PI HHOME-SFDPH
This was not a randomized clinical trial where all the sites followed the same intervention protocol. However there were similar key components across the nine sites:
1) Every site employed a Network Navigators (aka, care coordinators, peer navigators, Specialized Case Managers). There were various titles across the sites but their function was similar to engage and retain a person in care and find stable housing
Not traditional HIV RW medical case managers
.Comprised of LICSW social workers, peer navigators, community health workers. Provided the intensive contact
2) Behavioral health integration with HIV primary care (not just have the service) but facilitated walk in access to a behavioral health practitioner prescriber/counselor who a person could see immediately; Active member of the team; provide Medication assistance therapy in field
3) Partnering with housing providers & landlords
4 sites formed direct partnerships with housing agencies to establish health clinics in shelter or transitional housing facilities.
All agencies formed close MOUs with HOPWA agencies or community agencies with HOPWA or housing assistance programs to secure housing with agencies.
Regular consistent meetings
Partnering with
4)Working at system levels—part of community committees not just Ryan White council but became members of the Continuum of care committees in the area; share data results—find patients coordinate systems
5) Not in the four walls =-team physician, nurse practitioners behavioral health counselors actively finding people provide care in the field get to housing get them stabilized

7. National SPNS participants
1,332 clients served
47% African-American/Black
62% literally homeless
17% Hispanic
37% unstably housed
1% fleeing domestic violence
75% Male
21% Female
4% Transgender
So in total since May 2017, 1,332 clients received SPNS services.
Majority have been literally homeless by the HUD definition

8. National SPNS participants
81% history of incarceration
75% diagnosed mental health condition (depression, anxiety, schizophrenia, PTSD)
40% experienced sexual assault
44% experienced physical injury
Illicit substance use
24% high risk (dependence)
78% moderate (problem)
59% food insecure, past 30 days
32% out of care more than 6 months
Large sample of these 1,332 enrolled in a multisite evaluation study over time...
High risk population for finding and re-engaging and retaining people in care.—these sites did an incredible job on recruiting finding gaining consent to participate in a follow up study.
Our participants on average were homeless about 6 years;
81% had history of being in prison or jail—important to note because can make people more difficult to house. Not to mention---One fo the most important and time consuming task by navigators was helping people get their IDS, birth certificates—just so they can ACCESS services for the system; This can not be underestimated.
Trauma history—approximately 40% experienced some form of sexual or physical assault and just in the year prior this proportion was about the same/ Addressing trauma is another piece sites spent time training staff and developing policies to help address trauma..
Active substance use and mental health disorders---again goal of the initiative was to connect people to these services

9. FHCSD Housing Results 254 clients served – San Diego
83 permanently housed
24 temporarily housed
31 relocated out of state
15 couch surfing
61 homeless
7 incarcerated
15 deceased
18 unknown

10. FHCSD SPNS Participants
108 study participants
77 virally suppression
24 literally homeless
8 unstably housed
5 fleeing domestic violence

11. FHCSD SPNS participants
108 clients served
94 Male
7 Female
7 Transgender
62% White
31% African-American/Black
5% American Indian/Alaska Native
2% Asian
Majority are male and minorities. Here are a few pictures of SPNS clients from our grantee at UF CARES and River Region.

12. Initiative Evaluation
Baseline Interviews
3 months
6 months
12 months
18 months
Evaluation Incentives
$25 Gift card offered to participants to complete evaluation questionnaires

13. Intervention Dose 38,760 encounters forms
40 encounters/per participant
Length of time in the intervention: 18 months
Average active case load size: clients per intervention staff

14. FHCSD & PATH Successes Creation of a Primary Care Medical Home
Expansion of Formalized Housing Partners
Increased Collaborative Organizational Relationships
Enrollment of Participants in Evaluation to Determine Efficacy
Creation of a One-Stop-Shop Comprehensive Services Model
Legal Services
Case Management
Navigation
Employment Readiness
Behavioral Health Services
Support Groups
Community Advisory Board-Involve consumers to ensure program design continues to meet changing needs.

15. SPNS Challenges Lack of Housing Options in San Diego County
Lack of permanent housing
Lack of permanent shelters and winter shelters
Shortage of affordable housing and housing supportive services
Untreated Mental Health and/or Substance Use Issues
Loss of Employment, Financial Hardship, Non-livable Wages
Immigration Status
Untreated Chronic Illness

16. Summary
Promising findings from the SPNS Initiative to engage multiply diagnosed HIV-positive populations in HIV Care to achieve viral suppression
Lowest viral suppression prior to enrollment (<200 copies/mL), 180 days prior to enrollment to 30 days post enrollment
Lowest viral suppression (<200 copies/mL) first 12 months** 30 to 395 days post enrollment
General trends in retention of care and viral suppression rates for persons still experiencing unstable housing
Reduction in unmet needs and barriers to care
Substance use treatment
Mental health care
Housing
Need for multi-level strategies to coordinate providers across the community, within the organization, and intensive one-on-one with individuals
READ slide
The SPNS sites implemented an achieved their goal of connecting people to primary care improving viral suppression rates and creating a seamless system of care using navigators to improve access and use to behavioral health services and achieve housing stability. These are descriptive trends will look more in-depth at some of the factors associated with these changes to identify the pathways to improvements examine sub-populations were the intervention was most effective and where gaps still may exist.

17. Program Outcomes Nevertheless, permanent housing alone is not enough.
Supportive services such as
medical care
mental health
substance abuse counseling
educational training
job placement
Are also paramount and necessary to successfully house this population.
Through the provision of these wrap-around services, our SPNS intervention improved
timely entry
engagement
retention in HIV care
supportive services
For homeless and unstably housed people living with HIV with co-occurring mental illness and/or substance use disorders.

18. Acknowledgments
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number H97HA24961 Special Projects of National Significance (SPNS) Initiative Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations, in the amount of $300,000 annual awarded to Family Health Centers of San Diego. No percentage of this project was financed with non- governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

19. THANK YOU