An innovative mobile care project, providing vital care navigation and outreach to individuals who are homeless and HIV-positive in the San Gabriel Valley
Name of grantee organization: City of Pasadena Public Health Department
Project name: Operation Link
The City of Pasadena Public Health Department (PPHD) is dedicated to promoting the physical, social, and mental well-being of all who live, work, worship, learn, and play in Pasadena. PPHD is committed to building trusting relationships with the community we serve, providing high quality services, making health services accessible, instilling the value of public health, and creating opportunities that foster health professional excellence.
Operation Link seeks to implement a Mobile Care Unit that proactively outreaches to and takes project services into the community. This will allow Operation Link staff to coordinate, formalize, and streamline a Provider Network that focuses on the needs of the target population.
Service Provider Area (SPA) 3 of Los Angeles County is situated between the San Gabriel Mountains to the north and the Whittier Hills to the south. The SPA’s western border is defined by the western boundaries of the cities of Pasadena, South Pasadena, Alhambra, and Monterey Park. Its eastern boundary is the San Bernardino County line, contiguous with the city boundaries of Claremont, Pomona, and Diamond Bar. SPA 3’s southern border runs below a series of unincorporated areas (the Whittier Narrows Recreation Area, Hacienda Heights, Rowland Heights) and the Orange County line.
Location: Pasadena, California
Partners and Linkages: When possible, PPHD will link individuals who are homeless and HIV+ to case management services through PPHD’s own HIV/AIDS programs, which includes an outpatient medical clinic, dental clinic, mental health (psychotherapy and psychiatry) services, benefits specialty, medical care coordination, food pantry, and transportation. In addition to these HIV/AIDS services, PPHD also provides other direct services, including outpatient substance use classes, prenatal clinic, and immunization clinic.
PPHD will also partner with the City of Pasadena Housing Department, as well as community organizations such as the Serra Project, for housing referrals. PPHD plans to work with various homeless shelters in order to provide HIV testing to better target the key population for this project. PPHD has already begun these activities by outreaching at two different homeless shelters in the Pasadena area. HIV testing and counseling is conducted either in a private room inside the homeless shelter or in a separated area inside PPHD’s mobile unit. Identified eligible clients will then be connected to services most appropriate to them. If it is not possible to link them to care within PPHD’s system, the care navigators will research resources more convenient to the client.
The program, Operation Link, will focus on three validated interventions: Critical Time Intervention; 2) Seeking Safety; and 3) Illness Management and Recovery. This approach together includes care management, mental health and substance use counseling, housing services, and other service linkages to create a new and innovative mobile, patient-centered medical home approach.
Project Director (in-kind): Angélica Palmeros, MSW
1.0 FTE Case Manager: Jennifer Mejia, MSW
3.0 FTE Care Navigator/Peer Counselor: Precious Jackson; Veronica Brown; Edwin Cockrell
0.20 FTE Evaluator: Matthew Feaster, MPH
Clinical staff (in-kind): Vivan Yeh, MD; Ellen Machikawa, MD
Support staff (in-kind): Gary Iem (Management Analyst IV), Erika Davies (Contract Management)
PPHD is committed to receiving feedback from clients and implementing processes to improve service delivery. PPHD’s HIV/AIDS Programs has a Client Advisory Board, which meets monthly to discuss current issues. It also serves as a forum for clients a to voice concerns or needs and to make suggestions for improvement.
Angélica Palmeros, MSW – Program Coordinator
1845 N. Fair Oaks Ave.
Pasadena, CA 91103