Intensive care coordination intervention to link and retain individuals who are HIV+, multiply diagnosed and homeless in a medical home
Name of Grantee Organization: AIDS Arms, Inc. dba Prism Health North Texas
AIDS Arms, Inc. dba Prism Health North Texas, established in 1986 is the largest community-based AIDS service organization in North Texas providing coordinated and comprehensive HIV services. Prism Health North Texas’ mission is to combat HIV/AIDS in the community by improving the lives and health of individuals living with the disease and preventing its spread. Prism Health North Texas’ programs reach out to individuals at risk, identify those who are HIV+, link them to care, provide HIV medical treatment and psychosocial support and help reduce transmission risk. Prism Health North Texas aims to help clients access medical care and promote optimal health outcomes regardless of gender, socioeconomic status, sexual orientation, age, race, culture and/or ethnicity.
The key goal for clients is improved health status evidenced by decreased viral loads and improved immune system function. Additional objectives are for clients to achieve: self-sufficiency, stability, shelter, sobriety (daily functioning is not compromised by substance use), engagement in social support, and increased safety.
Catchment Area: The Dallas Metro statistical area
Location: Dallas, TX
Partners and Linkages:
The Bridge-A Homeless Recovery Center, The City of Dallas/Shelter Plus, Legacy Counseling Center, HOPWA, The Stewpot, Austin Street Shelter, Dallas Life Foundation, ABC Behavioral Health, Metro Dallas Homeless Alliance, AIDS Services of Dallas, City Square.
The intervention draws on evidence-based practices related to engaging HIV+, homeless, mentally ill, and substance abusing populations persons in HIV medical care, using motivational enhancement within a stages of change framework, integrated mental illness and substance abuse treatment, and care coordination. Key elements of the care coordination plan include:
- Engaging clients in the care process, being proactive to maintain client engagement.
- Woking with behavioral health care staff to support clients.
- Collaborating with AAI medical and psychosocial support teams to promote treatment adherence, decrease barriers to care and promote access to critical benefits.
- Regular meetings with clients.
- Regular case conferences with providers to address client challenges.
- Building client’s “social capital” through strengths-based approaches.
- 1.0 FTE Program Director
- 3.0 FTE Care Coordinators
- 0.5 FTE Case Manager II
- 0.5 Data Manager
- Principal Investigator (Chief Program Officer)
- 0.25 FTE contractual evaluator
The Prism Health North Texas Consumer Advisory Board (CAB) meets monthly to provide guidance regarding recruitment and program activities, and is part of the Program Materials Review Panel. Project clients will be invited to serve on the agency CAB and provide feedback through comment cards and the annual client satisfaction survey.
Justin Vander and Raymond Castilleja, Jr., Program Co-Directors
Manisha Maskay, Ph.D.,Chief Program Officer
351 W. Jefferson Blvd. Suite 300
Dallas, TX 75208