A collaborative peer navigator model for serving individuals in San Diego who are homeless, HIV-positive, and dually diagnosed
Name of Grantee Organization: Family Health Centers of San Diego (FHCSD)
Family Health Centers of San Diego (FHCSD), one of the first federally qualified health centers to be recognized as a Primary Care Medical Home (PCMH), and People Assisting The Homeless (PATH), one of the most innovative organizations serving the needs of people on the West Coast who are homeless, will pilot a model for supporting San Diegans who are homeless or unstably housed, HIV-positive, and living with co-occurring mental health/or substance use disorders.
FHCSD and PATH have an integrated coordination model through Connections Housing, a “one-stop” shopping resource for social services and FHCSD clinic co-located under one roof. Peer Navigators at both organizations will work to braid services together to best meet the needs of identified San Diegans.
- Provide case management services, HIV medical care, substance use outpatient care/resources and mental health therapy
- Retain individuals in care and coordinate with PATH for supportive housing
- Assist homeless individuals to rebuild their lives and secure permanent housing
This will be done by the FHCSD/PATH collaboration to provide “one-stop shopping resources” for social service, housing (permanent, interim, special needs beds) and a co-located clinic facility.
Catchment Area: Central San Diego County
Location: San Diego, CA
Partners and Linkages:
PATH/Connections Housing is FHCSD’s core partner. In addition to PATH, FHCSD is the county’s largest provider of comprehensive HIV prevention, care and support services that maintain memoranda of understanding with over twenty community based organizations that specialize in serving low-income and underserved Persons Living with HIV/AIDS.
Program Intervention/Services: From the mountaintop, FHCSD’s care integration and coordination proposed looks like this (click to view enlarged diagram [PDF]):
A portion of the Program Director, Associate Director and Program Manager oversees the day to day operations. A full time Program Navigator, a part time MFT, Psychiatrist and Patient Services Representative support the program. Institute for Public Health, SDSU are the Program Evaluators.
FHCSD encourages and solicits consumer involvement in a variety of ways and at various junctures within its Ryan White funded programs. Consumer involvement is incorporated through; surveys, focus groups, Community Advisory Boards (CAB), and the San Diego County HIV Planning Council.
Verna Gant, Program Manager
Family Health Centers of San Diego
4040 30th Street
San Diego, CA. 92104