Yale University

mHEALTH: Medical Home Engagement and Aligning Lifestyles and Transition from Homelessness

Principle Investigator(s):

Funder: Health Resources and Services Administration
Project period: 09/01/2012 - 08/31/2017
Grant Type: Research
Further Detail

Abstract Text:

Despite more than three decades of HIV/AIDS and two decades since the Ryan White Care Act provided additional and necessary funding to meet the comprehensive needs of people living with HIV/AIDS (PLWHA), innovative services that meet the needs of the epidemic’s most socially and medically marginalized PLWHA have been unable to successfully meet the comprehensive needs of homeless PLWHA who cycle into and out of the criminal justice system (CJS), whose lives are repeatedly disrupted through loss of housing and who experience a disproportionate amount of medical and psychiatric comorbidity, including the chronic and relapsing nature of substance use disorders and mental illness. As a result, homeless and unstably housed PLWHA experience poor HIV treatment outcomes compared to their housed counterparts, including decreased: 1) linkage to and retention in HIV care; 2) access to life-saving antiretroviral therapy (ART); 3) adherence to ART once prescribed; and 4) viral suppression. The target population for this demonstration project is homeless PLWHA who are primarily transitioning from the CJS (the most common pre-shelter residing site in the U.S.) and those that are not retained in HIV care in New Haven, CT -- the 4th poorest city in the U.S. for its size and with disproportionate levels of HIV/AIDS, substance abuse, mental illness, homelessness and poverty. mHEALTH, the proposed intervention in this application, seeks to expand and enhance the existing New Haven Ryan White Continuum (NHRWC) to ensure the creation of a patient-centered medical home for homeless PLWHA by adding increased coordination and referral between the CJS and the Early Intervention Services (EIS) provided through an innovative mobile health program and the city’s largest housing provider for PLWHA. The EIS program will medically stabilize CJS clients through screening and provision of onsite HIV care (including directly administered antiretroviral therapy), substance abuse treatment (including buprenorphine or extended release naltrexone + counseling) and psychiatric services (including medications and counseling). Moreover, the city-wide database of PLWHA (CareWare) that is operated by the NHRWC will be reconfigured to create an Early Alert System (EAS) that will identify anyone who has been lost to HIV care and invoke the EIS program to deploy community outreach to stabilize and re-engage them. Thus, homeless PLWHA from the CJS and the community will be served. The EIS program will be enhanced through the provision of a Network and Peer Navigator that will deploy intensive case management (ICM) strategies based on evidence-based Assertive Community Treatment (ACT) and ACCESS programs used to retain individuals with mental illness and chronic homelessness, respectively, in care and to actively transition clients to urgent, transitional and ultimately stable housing through coordination with the EIS program and the patient-centered medical home created in New Haven as part of mHEALTH’s proposed expanded NHRWC. The likelihood of success is based on 10 years of previous SPNS activities, strong community support, the use of evidence-based interventions, a skilled group of collaborators who have a track record of evaluation and dissemination of finding and an extensive and long-standing history working with and providing innovative services for the target population.


SPNS Initiative: Building Medical Homes for Multiply Diagnosed HIV-Positive Homeless Populations