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CommWell Health

Patient-centered medical home for people with HIV who are homeless or unstably housed and have substance use and/or mental health diagnosis in rural North Carolina


News about CommWell Health

CommWell Health Hosts Community Housing Coalition Luncheon

Name of Grantee Organization:  CommWell Health

Project Name:  CommWell Medical Home Works (CWMH)

Organization Description: 
CommWell Health offers comprehensive, compassionate, high-quality primary medical, dental, pharmacy and behavioral health services in southeastern North Carolina. CWH is a private non-profit; federally qualified migrant community health center providing direct services to an average of 24,750 individuals on a yearly basis. CWH provides culturally competent, integrated primary medical, dental and behavioral services to racially and ethnically diverse populations including African Americans, Latinos, American Indians, and migrant/seasonal farmworkers.

CWH has provided HIV/AIDS services since 1990, when the organization first received funding from the North Carolina HIV/STD Prevention and Care Branch to become a confidential HIV counseling and testing site. In 1998, CWH was awarded Ryan White Part B funds to establish the state’s first community primary HIV care program, known as Positive Life.  Since 1998, CWH has significantly expanded the primary care program to include behavioral health and nutrition through RW Part C funds and services for women and youth through Part D funding. In addition, prevention and outreach services have been expanded via CDC HIV Prevention Project funds received since 2004.  CWH offers intensive outpatient substance use services to individuals diagnosed with addictions disorders and HIV disease.

Main goal: To promote and improve timely entry, engagement and retention in HIV care, psychosocial and supporting services for individuals who are HIV-positive and homeless or unstably housed in rural North Carolina.


  1. Improve the experience of care;
  2. Improve patient health outcomes;
  3. Improve patient’s involvement in their own care;
  4. Advance knowledge and understanding of cost containment strategies; and
  5. Evaluate the project.

Catchment Area: Rural Southeast North Carolina: Johnston, Cumberland, Harnett, Pender, Blander, Brunswick, Robeson, Duplin and Sampson counties

Location: Dunn, NC 

Partners and Linkages: Fenway Health

Program Intervention/Services:
The Medical Home Works (CWMH) model is an innovative program for improving primary health care and supporting services delivery as well as patient outcomes.  CWMH is not a healthcare facility, house or hospital, but rather an approach to providing comprehensive primary care and supporting services to homeless and unstably housed HIV positive individuals with mental health and or substance use disorders.  As a medical home intervention, the CWMH team will work in partnership with patients and, when necessary, their families to assure that all the medical and non-medical needs of the patient are met. Overall, the CWMH model addresses and integrates high quality acute and chronic disease management in a planned, coordinated, culturally competent, and patient-centered manner.

The Core Components of the model are:

  1. Personal primary care physician,
  2. Patient-centered orientation,
  3. Team-directed medical practice,
  4. Intensive care coordination,
  5. Building sustainable partnerships,
  6. Quality and Safety, and
  7. Consumer Involvement.

Program Staff:

One principal investigator/project director
One data manager
One care manager/housing specialist
One continuum of care coordinator
One network navigator
One part-time lead evaluator
One evaluation consultant

Consumer Involvement:
The CWMH Model creates ongoing opportunities for patients and their families to actively participate in decision making, including seeking feedback to ensure that patients’ expectations are being met. The CWMH Model’s staff seek continuous input from consumers to enhance access to care through systems such as open scheduling, extended hours, and new options for communication between patient and provider/staff. Consumers are involved in validating that the CWMH is indeed patient-centered through patient feedback and completion of qualification tools.

Contact Information: 
Jesus Felizzola, M.D., M.H.S.A., M.A.
(202) 904-8851