Resources for Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations

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

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

Preparing stakeholders and partners

Services referral guides

Staff recruitment and hiring

Staff training

Staff supervision

Finding and Engaging People in Care

Outreach materials


Client contact and consent forms


Acuity tools

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

Sample forms

Checklists for working with clients

Sample policies and procedures

Transitioning to standard of care

Online resources for clients

  • Liberty Job Seekers Blog:
    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:
    Unique to women served by Liberty.
  • Liberty Prevention Blog:
    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

Evaluation and Quality Improvement

Evaluation tools

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

Resources relevant to the Housing and Urban Development (HUD) HOPWA program