The nine demonstration sites that contributed to the initiative Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations have made available the resources that they found helpful in setting up and implementing their models. It is hoped that organizations will be able to leverage this work as they create a medical home for people who are homeless, living with HIV, and facing mental health or substance use challenges.
Each demonstration site has developed a manual that describes its medical home model in detail. These manuals, together with a multisite implementation manual that provides an overview of the initiative, are available at https://ciswh.org/project/medheart/models-of-care
Learn more about the initiative at Medical Home Evaluation and Resource Team (Med-HEART), the evaluation and technical assistance center for the initiative.
Setting up the medical home
Underlying theoretical models
- Logic model, City of Pasadena Public Health Department, Operation Link (.doc)
- Logic model, Yale AIDS Project, mHEALTH (.doc)
- Theoretical model, Prism Health North Texas, Health Hope and Recovery (HHR) (.doc)
Preparing stakeholders and partners
- Building a medical home presentation, Family Health Center of San Diego (FHCSD), PCMH Connections (.ppt)
- Charting memorandum of understanding, Multnomah County HIV Health Services Center, Building a Medical Home for Multiply Diagnosed Homeless People Living with HIV/AIDS (.pdf)
- HIV continuum of care, San Francisco Department of Public health (SFDPH), HHOME (.doc)
Services referral guides
- Matrix of shelters, SFDPH (.pdf)
- Services referral guide, Univeristy of Florida CARES (UF CARES) PATH Home (.xls)
- Description of community partners, Multnomah (.doc)
- Memorandum of understanding, Pasadena (.doc)
Staff recruitment and hiring
- All staff role descriptions
- Program director role description
- Care coordinator/network navigator and other “frontline” staff role description
- Care coordinator, Prism Health (.doc)
- Care navigator, FHCSD (.doc)
- Case manager, FHCSD (.doc)
- Case manager II, Prism Health (.doc)
- Comprehensive case manager, UF CARES (.doc)
- Network peer navigator, UF CARES (.doc)
- Peer navigator, UF CARES (.doc)
- SPNS navigator and housing case manager job descriptions, Multnomah (.doc)
- Data collection/management role description
- Evaluation assistant, FHCSD (.doc)
- Medical case manager, UF CARES (.doc)
- Senior evaluation specialist, FHCSD (.doc)
Staff training
- AETC training and education needs assessment, Harris Health System, Hi-5 (.pdf)
- Antiretroviral therapy training presentation, Harris Health (.pdf)
- SPNS navigator/housing case manager training tracker, Multnomah (.doc)
Staff supervision
- Case staffing form, Prism Health (.doc) used when a care coordinator wishes to solicit guidance from team members regarding a client’s care
- Peer review assignment template and review checklist, Prism Health (.doc)
Finding and Engaging People in Care
Outreach materials
- Collateral material- palm card and rack card, Prism Health (.doc) provides information to potential clients about the HHR program
- Follow up screening, Prism Health (.doc) to track enrollment status and attempts to contact client after intake
Eligibility
- Eligibility Screening Form, CommWell Health, NC-REACH (.doc)
- Navigation program eligibility, Multnomah (.doc)
Client contact and consent forms
- ARIES consent form, SFDPH (.pdf)
- A&PI community agreement, SFDPH (.doc)
- A&PI consent for services, SFDPH (.doc)
- A&PI emergency contact consent, SFDPH (.doc)
- A&PI grievance policy, SFDPH (.doc)
- A&PI HIPAA privacy notice, SFDPH (.doc)
- Client contract, Pasadena (.doc)
- HHOME first encounter checklist, SFDPH (.pdf)
- HHOME follow-up checklist, SFDPH (.pdf)
Referrals
- Biopsychosocial assessment form, Pasadena (.doc)
- Intake referral form, Prism Health (.doc)
- Monthly referral tracking sheet, UF CARES (.xls)
- Referral form, CommWell Health, NC-REACH (.doc)
- Referral form, UF CARES (.doc)
- Referral form for housing, mental health, substance use, UF CARES (.doc)
- Referral and linkage process, UF CARES (.doc)
- Referral process, UF CARES (.doc)
- Referral and screening form, FHCSD (.doc)
- Referral Process, Multnomah (.doc)
Acuity tools
- Acuity tool, FHCSD (.doc)
- Acuity tool, SFDPH (.doc)
- Transitional system acuity tool, Prism Health (.doc)
- Charting tool, Prism Health (.doc) used to track client’s acuity in areas of service need over time
- Initial risk assessment, SFDPH (.pdf)
- Mental health assessment, SFDPH (.doc)
- Montreal cognitive assessment (MoCA), SFDPH (on MoCA website)
- Patient health questionnaire, SFDPH (.pdf)
- Stability acuity scale, CommWell Health, NC-REACH (.doc)
- Substance abuse and mental illness symptoms screener, Harris Health (.pdf)
- Substance abuse and mental illness symptoms screener, SFDPH (.pdf)
- WHO disability assessment, SFDPH (webpage on WHO website)
Service Delivery
The Navigator Manifesto, multiple sites (.docx): some things patient navigators keep in mind when working with clients
Service delivery model charts and diagrams
- Client movement flow chart, Harris Health (.ppt)
- Operation link client flow chart, Pasadena (.ppt)
- Patient flow sheet, UF CARES (.xls)
- Services flow chart, Prism Health (.doc)
- Services flow chart, CommWell Health, NC-REACH (.doc)
- Recruitment to transition or discharge flow chart, FHCSD
Sample forms
- Care plan, Prism Health (.doc)
- Care plan, UF CARES (.doc)
- Case management care plan, FHCSD (.doc)
- Client denial of services form, UF CARES (.doc)
- Client service plan, Harris Health (.pdf)
- Client service plan, CommWell Health, NC-REACH (.doc)
- Contact form, CommWell Health, NC-REACH (.doc)
- Declined ineligible patient log sheet, UF CARES (.xls)
- Disenrollment criteria form, FHCSD (.doc)
- Encounter form, CommWell Health, NC-REACH (.doc)
- Encounter log, Prism Health (.doc)
- Encounter note with acuity worksheet, Prism Health (.doc)
- Outreach log sheet, CommWell Health, NC-REACH (.doc)
- Operation Link Individual Service Plan, Pasadena (.xls)
- Panel process template, SFDPH (.doc)
- Progress notes, CommWell Health, NC-REACH (.doc)
- Receipt for tangible goods form, Prism Health (.doc)
- Behavioral health and substance use appointment attendance log, CommWell Health, NC-REACH (.xls)
- Transportation services form, CommWell Health, NC-REACH (.doc)
Checklists for working with clients
- Housing readiness checklist, UF CARES (.doc)
- Case manager, SFPHD (pdf, SFDPH)
- Medical social worker checklist, SFDPH (.pdf)
- Peer navigator checklist, SFDPH (.pdf)
- Primary care provider checklist, SFDPH (.pdf)
- Registered nurse checklist, SFDPH (.pdf)
Sample policies and procedures
- Acceptance, safeguarding, and distributing client mail, Prism Health (.doc)
- Client complaint procedure, Prism Health (.doc)
- Clinic flow for referral and linkage, UF CARES (.doc)
- Crisis staff debrief guidelines, Multnomah (.doc)
- Crisis intervention plan, FHCSD (.doc)
- Disruptive behavior client agreement, Prism Health (.doc)
- Distribution of pre-paid cell phones and minutes, Prism Health (.doc)
- Documentation replacement assistance, Prism Health (.doc)
- Financial assistance for emergency housing, Prism Health (.doc)
- Home visit protocol, FHCSD (.doc)
- Housing referral process, UF CARES (.doc)
- Maintaining boundaries with clients and other external parties, Prism Health (.doc)
- Managing situations in which clients are disruptive/inappropriate, Prism Health (.doc)
- Outpatient process, UF CARES (.doc)
- Program outline and protocol, Prism Health (.doc)
Transitioning to standard of care
- Discharge checklist, SFDPH (.pdf)
- Graduation certificate, Pasadena (.pdf)
- Graduation template, Multnomah (.pdf)
- Program discharge form, Prism Health (.doc)
- Transition form, CommWell Health, NC-REACH (.doc)
- Transition form, UF CARES (.doc)
- Transition from PATH process, UF CARES (.doc)
- Transition letter and contact info, UF CARES (.doc)
- Transition planning policy, Yale (.pdf)
- Transition tool, FHCSD (.doc)
- Transition checklist, Yale (.doc)
Online resources for clients
- Liberty Job Seekers Blog: http://libertycsjobs.blogspot.com/
This blog provides links to resources that a job seeker may need as well as regular postings on job opportunities. There are documents guide people in writing resumes and links to online education for job seekers. Additionally, the blog includes links to transportation and basic needs. - Liberty Women’s Resource Blog: http://libertycswomen.blogspot.com/
Unique to women served by Liberty. - Liberty Prevention Blog: http://lcshivprevention.blogspot.com/
This blog will become more active as we have hired a full-time HIV Prevention Specialist. He will be providing education on PrEP, risk reduction and other germane material for the community.
Online resources for staff
- Greater New Haven Regional Supportive Housing Program Blog: http://nhregionalsupportivehousing.blogspot.com/
Information for providers and consumers alike. It is a one-stop for supportive housing information, eligibility, shelter, etc. - Library Office Hours Blog: http://libraryofficehours.blogspot.com
For frontline staff, this blog is easy access to information and referral for clients in need.
Evaluation and Quality Improvement
Evaluation tools
- Housing status tracking database, Prism Health (.doc)
- Sample dashboard report, Prism Health (.doc)
- Sample process evaluation calendar, Prism Health (.doc)
- Peer review checklist, Prism Health (.doc)
- Motivational interviewing supervisor observation, Prism Health (.doc)
- Client feedback survey, Prism Health (.doc)
- SPNS EMR smart phrases, Multnomah (.doc)
Policy resources
Policy notices and program letters relevant to the HRSA Ryan White and Global HIV/AIDS programs can be found on the HRSA website
- 16-02 Ryan White HIV/AIDS Program Services: Eligible Individuals & Allowable Uses of Funds (.pdf)
- Policy Clarification Notice 16-02: Eligible Individuals and Allowable Uses of Funds: Housing Services Frequently Asked Questions (.pdf)
- Policy Clarification Notice 16-02: Eligible Individuals and Allowable Uses of Funds: Frequently Asked Questions (.pdf)
- Program Letter from HHS and HUD re. Integrating and Using the Housing Opportunities for Persons with AIDS and Ryan White HIV/AIDS Program Data Sets August 29, 2017 (.pdf)
- Program letter from HRSA re. Using Ryan White HIV/AIDS Program Funds to Support Housing Services August 18, 2016 (.pdf)
Resources relevant to the Housing and Urban Development (HUD) HOPWA program