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Multnomah County Health Department HIV Health Services Center

Using network navigators to connect individuals who are multiply diagnosed, homeless, and HIV-positive with a medical home in Portland, Oregon

Multnomah County Health Department logo.

Name of Grantee Organization:  Multnomah County Health Department HIV Health Services Center

Project Name: SPNS Building a Medical Home for Multiply Diagnosed HIV Positive Homeless Populations

Organization Description: 
The HIV Health Services Center (HHSC) is the largest provider of HIV medical care in the state of Oregon serving approximately 1200 patients a year.  HHSC clients have high rates of substance use (29%) and mental illness (56%). Our population is overwhelmingly low income (76 % < 100 FPL) and experience high rates of homelessness (16%). HHSC provides comprehensive, specialized medical care and support services designed to address the chronic, complex needs of low income and uninsured PLWH through the continuum of early diagnosis to advanced illness (AIDS). Services include outpatient medical care, mental health and substance use counseling, case management, peer mentoring, health education, HIV prevention and risk reduction support, nutritional counseling, and treatment adherence counseling.

Oregon Public Health logo: Prevent, Promote, Protect.For the purposes of this SPNS Initiative HHSC has contracted with Cascade AIDS Project (CAP) to provide network navigation and housing services.  Cascade AIDS Project is the oldest and largest community-based provider of HIV services, housing, education and advocacy in Oregon and Southwest Washington.

Goals/Objectives: 

  1. To expand and support a comprehensive, coordinated, culturally competent continuum of care that is able to identify and care for HIV positive homeless and unstably housed individuals with co-morbid mental health and substance use disorders
  2. To identify HIV positive homeless individuals with co-occurring substance use or mental health diagnoses and engage them in care
  3. To improve medical outcomes for PLWH/A with co-morbid mental health and substance use disorders who are homeless or at-risk for homelessness by providing them a medical home with comprehensive primary care and links to support services
  4. To assess the efficacy of the model through a local and a multi-site evaluation plan
  5. To implement a long-term sustainability plan for the SPNS Program model

Cascade AIDS Project logo.Catchment Area: The HIV Health Services Center (HHSC) serves a six-county area that includes five counties in Oregon and Clark County in Washington.

Location: Portland, OR

Partners and Linkages: HHSC has contracted with Cascade AIDS Project (CAP). Other community partners and linkages include HOPWA SPNS coordination, Central City Concern, Transition Projects, Inc., City Team Ministries, Cascadia Behavioral Health, Outside In and Home Forward.

Program Intervention/Services:
Network Navigators and Medical Case Managers will coordinate client care seamlessly. Clients will be linked to mental health and substance use services quickly and will be connected to CAP housing programs with the goal of achieving stable housing. Network Navigators will guide clients through the process of engaging with all needed services and aid in the exchange of timely and relevant information among service providers. The Medical Case Managers are the provider teams’ liaisons with the Navigators.

Program Staff:

Project Director (Jodi Davich): Oversees project implementation and integration of Network Navigators into HHSC’s medical home. Monitors subcontract with CAP and completes reporting requirements.
Project and Data Manager (Christa Black):  Assists with project implementation, contract negotiation and reporting.  Monitors data collection and evaluation components of project.
Manager of Support Services (Erin Nortrup): Provides project oversight and supervises Network Navigator Lead.
Network Navigator Lead (Adam Kutrumbos): Provides direct supervision of Network Navigators, provides intensive navigation services; coordinates with Housing and Medical Case Managers, links clients to mental health and substance use services.
Two Network Navigators (Maurice Evans & Faith Henion): Provide intensive navigation services; coordinates with Housing and Medical Case Managers, links clients to mental health and substance use services.

Consumer Involvement:
HHSC is supported by an active Client Advisory Board, as well as the Portland Ryan White Planning Council.

Contact Information: 
Jodi Davich, Project Director, Multnomah County HIV Health Services Center
426 SW Stark St, 5th Floor
Portland, OR 97204
Jodi.w.davich@multco.us
503-988-3663 x 26561
 
Christa Black, Project and Data Manager, Multomah County HIV Health Services Center
426 SW Stark St, 5th Floor
Portland, OR 97204
christa.a.black@multco.us
503-988-3663 x 23098

Erin Nortup, Manager of Support Services, Cascade AIDS Project (CAP)
208 SW 5th Ave, Suite 800
Portland, OR 97204
e.nortrup@cascadeaids.org
503-278-3830

Adam Kutrumbos, Network Navigator Lead, Cascade AIDS Project (CAP)
208 SW 5th Ave, Suite 800
Portland, OR 97204
a.kutrumbos@cascadeaids.org
adam.kutrumbos@multco.us
503-278-3835

Maurice Evans, Network Navigator, Cascade AIDS Project (CAP)
208 SW 5th Ave, Suite 800
Portland, OR 97204
m.evans@cascadeaids.org
Maurice.evans@multco.us
503-

Faith Henion, Network Navigator, Cascade AIDS Project (CAP)
208 SW 5th Ave, Suite 800
Portland, OR 97204
f.henion@cascadeaids.org
faith.henion@multco.us
503-278-3847