The HOME Project: Building a medical home for people who are multiply diagnosed, HIV-positive, and homeless
Name of Grantee Organization: San Francisco Department of Public Health – HIV Health Services in partnership with the Tom Waddell Health Center and the Asian & Pacific Islander Wellness Center
Project Name: HIV Homeless Outreach Mobile Engagement (HOME) Project
Organization Description: A division of the San Francisco Department of Public Health
Goals/Objectives:
Key outcomes of the project include:
- Linking at least 90% of project clients to a patient-centered, culturally competent HIV medical home within one month of engagement in the program;
- Transitioning at least 65% of project clients to long term and supportive housing over the course of the program;
- Ensuring that at least 75% of clients with a psychiatric diagnosis will have seen a psychiatrist and will be on a monitored psychotropic regimen within three months of engagement with the multidisciplinary team;
- Ensuring that at least 50% of chronic substance users will be enrolled in a medical substance abuse treatment plan within three months of engagement with the multidisciplinary team.
Catchment Area: San Francisco, California
Partners and Linkages:
Asian & Pacific Islander Wellness Center, Tom Waddell Health Center, Project Homeless Connect, Forensic AIDS Project, Centerforce, Behavioral Health Access Center, SFFirst, Homeless Outreach Team
Program Intervention/Services:
The HOME Project will target homeless individuals who are the most difficult to engage and retain in care: those facing complex, multiple co-morbidities and barriers who have thus far resisted attempts to engage them in housing and/or HIV treatment, with the goal of getting individuals into medical care.
The project will deploy a mobile multidisciplinary, multi-agency team that will serve a caseload of 20 – 25 of the hardest to serve indivuals who are HIV-infected and homeless in San Francisco at any one time. The HOME Project team will consist of a variety of providers including peer and outreach workers.
This team will form intense, one-on-one relationships with their client population, and will maintain close contact with the individuals they serve, including delivery of HIV medications and conducting in-the-field medication adherence assessments, though the goal of the project is to get individuals established at a medical home.
Program Staff:
- In-Kind Principal Investigator
- Psychiatric RN
- Homeless Outreach Worker
- Project Director
- Evaluation Coordinator
- Medical Social Worker
- Homeless Peer Navigator
Consumer Involvement: Consumer involvement will take place at partner agencies (APIWC & TWHC), not at HIV Health Services.
Contact Information:
Dean Goodwin, HIV Health Services Administrator
[email protected]
415-554-9054
John Aynsley; Quality Management Coordinator
[email protected]
415-554-9499
25 Van Ness Avenue, Suite 500
San Francisco, CA 94102