A client-centered medical home for people in rural North Carolina who are living with HIV, experiencing homelessness or unstable housing, and have substance use and/or mental health diagnoses
News about CommWell Health
CommWell Health’s NC-REACH program named outstanding program of the year by the National Rural Health Association: https://youtu.be/McjJLKDEsZs
Lisa McKeithan, project manager of the NC-REACH Program at CommWell Health, was named Outstanding Educator of the Year: https://youtu.be/KVvy5oB4wWk
CommWell Health was named Outstanding Organization of the Year: https://youtu.be/5kUtuLU0KNM
Name of Grantee Organization: CommWell Health
Project Name: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless (NC-REACH)
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.
- Improved health status: Viral load suppression—meaning viral load below limits of quantification—at last test during the measurement year
- Engagement and retention in care: At least two medical visits during the measurement year with at least 60 days in between each visit
- Linkage to stable housing: Permanent housing with supports or other stable housing Improve the experience of care
Catchment Area: Rural Southeast North Carolina: Johnston, Cumberland, Harnett, Duplin and Sampson counties
Location: Dunn, NC
Partners and Linkages: Pillar Consulting
The NC-REACH medical home model calls for the care team to develop, implement, and evaluate a culturally competent, coordinated, integrated, interdisciplinary and community-based medical model. The NC-REACH team aimed to improve timely entry, engagement and retention, and supportive services in HIV care to 80 medically underserved individuals in rural Southeast North Carolina who were living with HIV and a substance use or mental health disorder and who were experiencing homelessness or unstable housing. As a medical home intervention, the NC-REACH 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 NC-REACH 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:
- Patient-centered medical home
- Intensive care coordination
- Building sustainable partnerships
One principal investigator/project director
Two network navigators
One continuum of care coordinator
One study evaluator
One evaluation consultant
NC-REACH 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 NC-REACH’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.
Lisa McKeithan, M.S. C.R.C.
(910)576-6194 ext. 6054