Models of Care: Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations

Below are links to manuals for the models of care that were developed as part of the initiative Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations. They include a multisite manual that provides an overview of the initiative and nine manuals created by each of the nine demonstration sites that outline the model of care they developed as part of the initiative. As part of this set of manuals, the Resources page includes links to the job descriptions, tools, forms, standard operating procedures and other resources that the sites found helpful in setting up and implementing their models.

Learn more about the initiative at Medical Home Evaluation and Resource Team (Med-HEART), the evaluation and technical assistance center for the initiative.

Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations.Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations: An implementation guide to achieve the goals of the HIV Care Continuum for people living with HIV who have co-occurring mental health and substance use disorders and are experiencing homelessness
Multisite implementation manual

Health, Hope and Recovery. Prism Health North Texas.Health, Hope and Recovery: Intensive care coordination to link and retain individuals who are HIV-positive, multiply diagnosed and homeless in a medical home
Prism Health North Texas, Dallas, TX

PCMH Connections for Multiply Diagnosed San Diegans Living with HIV: Creating a collaborative care navigator model that serves individuals in San Diego who are homeless, HIV-positive, and face substance use or mental health challenges
Family Health Centers of San Diego (FHCSD), San Diego, CA

Project Hi-5: Comprehensive outreach and treatment for people in Houston living with HIV who are homeless, HIV-positive and face substance use or mental health challenges
Harris Health System, Houston, TX


The Partnership for Access to Treatment and Housing (PATH).The Partnership for Access to Treatment and Housing (PATH Home): A partnership for access to HIV treatment and housing in Jacksonville, Florida
University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES), Jacksonville, FL

Building a Medical Home for Multiply Diagnosed Building a Medical Home for Multiply Diagnosed People Experiencing Homelessness and Living with HIV/AIDS: Using patient navigators to connect individuals who are multiply diagnosed, experiencing homelessness, and living with HIV with a medical home in Portland, Oregon
Multnomah County HIV Health Services Center, Portland, Oregon

PROJECT mHEALTH.PROJECT mHEALTH: Creating a medical home for people living with HIV who are experiencing homelessness in New Haven, CT
Yale University School of Medicine AIDS Program, New Haven, CT


Operation Link, City of Pasadena Public Health Department Operation Link: Providing vital care navigation and outreach to individuals who are experiencing homelessness and living with HIV in the San Gabriel Valley
City of Pasadena Public Health Department, Pasadena, CA


The Homeless HIV Outreach and Mobile Engagement (HHOME) Program The Homeless HIV Outreach and Mobile Engagement (HHOME) Program: Serving individuals who are experiencing homelessness and living with HIV through mobile integrated care: case management, navigation, HIV primary care, mental health and substance use treatment, and housing support
San Francisco Department of Public Health, San Francisco, CA


CommWell Health NC-REACH. NC-Rurally Engaging and Assisting Clients who Are HIV Positive and Homeless (NC-REACH) A client-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
CommWell Health, Dunn, NC