A rural health clinic’s approach to building a PCMH

Abstract

This presentation describes the program model a rural health clinic developed as part of a demonstration project funded by the Health Resources and Services Administration’s Special Projects of National Significance (HRSA/SPNS) initiative to engage and retain patients with HIV in medical care. Patients targeted for this intervention are homeless or unstably housed and have a co-occurring substance use or mental health condition in addition to being HIV-positive.

Proposal Summary

This presentation will describe how partnerships between HIV medical and housing providers, the use of network navigators, and the integration of behavioral health services into HIV care can improve retention in care and stable housing for People Living with HIV/AIDS (PLWHA). Our program model, or NC REACH, is an innovative intervention that engages and retains homeless/unstably housed PLWHA in HIV care and treatment and promotes housing stability through community partnerships. NC-REACH is a model of a medical home developed and implemented by CommWell Health in Southeastern North Carolina to improve primary health care and support services delivery as well as patient outcomes for homeless and unstably housed HIV positive individuals with mental health and or substance abuse disorders. The NC-REACH team works in partnership with patients to assure that all the medical and non-medical needs of the patient are met by providing comprehensive, accessible, patient-centered and coordinated care. A key feature in this program is having a dedicated staff, continuum of care coordinators, service linkages, and network navigators to serve as the main point of contact for PLWHA who are homeless/unstably housed. Additionally, securing stable housing is one of the main outcomes of the HRSA/SPNS initiative. Network navigators play a key role in the coordination of services between the HIV service system and the housing system, with the goal of providing seamless care for homeless/unstably housed populations. At CommWell Health, we host a series of coalition community meetings with health care and housing agencies to bridge the coordination gap between health care and housing managers. These partnership meetings assist in reducing duplication of efforts by case managers to find available housing for HIV homeless clients.

Relevance And Significance

HIV-positive, homeless clients in rural North Carolina face specific challenges securing stable housing and managing their illness. This presentation will convey the social determinants at play for this population, and disseminate knowledge about the distinctive challenges faced by clients in rural North Carolina and strategies for addressing them. This information may inform other service providers who work with rural populations, strategies for working with community leaders and policy makers, and advocacy for programs addressing HIV-related disparities, stigma, and discrimination.

Session Format

Presentation Session

Keywords

rural, rural health clinic, patient-centered medical home, HIV+, homeless, research study, HRSA, SPNS, North Carolina

Publication Type and Release Option

Presentation (Open Access)

This document is currently not available here.

Share

COinS
 
Oct 23rd, 3:30 PM Oct 23rd, 4:15 PM

A rural health clinic’s approach to building a PCMH

This presentation describes the program model a rural health clinic developed as part of a demonstration project funded by the Health Resources and Services Administration’s Special Projects of National Significance (HRSA/SPNS) initiative to engage and retain patients with HIV in medical care. Patients targeted for this intervention are homeless or unstably housed and have a co-occurring substance use or mental health condition in addition to being HIV-positive.