We partnered with the Boston Health Care for the Homeless Program to serve as the evaluation and technical assistance center for the initiative Building Medical Homes for Multiply Diagnosed HIV-Positive Homeless Populations. The evaluation and technical assistance center, called Med-HEART (Medical Home HIV Evaluation & Resource Team), collaborated with nine demonstration sites to evaluate models of care that link individuals living with HIV and experiencing homelessness with needed services and resources. The nine sites implemented care coordination/patient navigation interventions to:


improve retention in HIV care and treatment


increase viral load suppression


improve housing stability

The nine medical home models created partnerships between HIV and housing providers, and integrated behavioral health and HIV services They added a network navigator to the health care team who worked intensively one-on-one with clients to reduce barriers to care and improve access to HIV care, housing, and support services. The following nine sites were part of the intervention:

  • Prism Health North Texas, Dallas, TX: Intensive care coordination intervention to help clients navigate the complex system of HIV medical care and other services
  • Family Health Centers of San Diego (FHCSD), San Diego, CA: A model of care built upon a developed collaboration between FHCSD as lead program organization with People Assisting the Homeless (PATH)
  • Harris Health System, Houston, TX: A medical home delivering HIV care at the site of choice for homeless individuals in Houston
  • Multnomah County Health Department, Portland, OR: A model that integrated patient navigators and housing support into a medical home to better engage and retain clients in HIV care and provide housing services
  • City of Pasadena Public Health Department, Pasadena, CA: A model that integrated peer navigators to provide vital care navigation and outreach to individuals in the San Gabriel Valley who are experiencing homelessness and living with HIV
  • San Francisco Department of Public Health, San Francisco, CA: A mobile, team-based intervention designed to engage and retain the most severely impacted and hardest-to-serve people living with HIV/AIDS in HIV primary care, behavioral health services, and housing
  • CommWell Health, Dunn, NC: A patient-centered medical home for people in rural North Carolina who are living with HIV, experiencing homelessness or unstable housing, and have substance use and/or mental health diagnoses.
  • University of Florida-UF Cares, Jacksonville, FL: A model which partnered with River Region Human Services, a housing provider, and created a medical home with intensive case management and peer navigation in a centrally located facility in Jacksonville, FL
  • Yale University, New Haven, CT: A patient-centered medical home characterized by a mobile medical clinic that partnered with a housing provider (Liberty Community Services) and the Connecticut Department of Correction.



clients served


reached viral suppression


retained in care

Project Impact

By the end of the project, 1,338 clients had been served, and new partnerships and coalitions were created among agencies. For all clients enrolled in the multisite study who had primary care visits post 12 months (n=745), 70% reached viral suppression and 74% were retained in care. Housing stability also improved for participants. Several of the demonstration sites have been working towards sustaining and replicating the model and specifically the role of the navigators as part of the care team into their Ryan White programs.

Project Team Members

This five-year initiative was funded through the U.S. Department of Health and Human Services (HHS) under the Health Resources and Services Administration (HRSA) Division of HIV/AIDS Bureau Special Projects of National Significance (SPNS).