The HOME Project: Building a medical home for people who are multiply diagnosed, HIV-positive, and homeless
Name of Grantee Organization: San Francisco Department of Public Health - HIV Health Services in partnership with the Tom Waddell Health Center and the Asian & Pacific Islander Wellness Center
Project Name: HIV Homeless Outreach Mobile Engagement (HOME) Project
Organization Description: A division of the San Francisco Department of Public Health
Key outcomes of the project include:
- Linking at least 90% of project clients to a patient-centered, culturally competent HIV medical home within one month of engagement in the program;
- Transitioning at least 65% of project clients to long term and supportive housing over the course of the program;
- Ensuring that at least 75% of clients with a psychiatric diagnosis will have seen a psychiatrist and will be on a monitored psychotropic regimen within three months of engagement with the multidisciplinary team;
- Ensuring that at least 50% of chronic substance users will be enrolled in a medical substance abuse treatment plan within three months of engagement with the multidisciplinary team.
Catchment Area: San Francisco, California
Partners and Linkages:
Asian & Pacific Islander Wellness Center, Tom Waddell Health Center, Project Homeless Connect, Forensic AIDS Project, Centerforce, Behavioral Health Access Center, SFFirst, Homeless Outreach Team
The HOME Project will target homeless individuals who are the most difficult to engage and retain in care: those facing complex, multiple co-morbidities and barriers who have thus far resisted attempts to engage them in housing and/or HIV treatment, with the goal of getting individuals into medical care.
The project will deploy a mobile multidisciplinary, multi-agency team that will serve a caseload of 20 - 25 of the hardest to serve indivuals who are HIV-infected and homeless in San Francisco at any one time. The HOME Project team will consist of a variety of providers including peer and outreach workers.
This team will form intense, one-on-one relationships with their client population, and will maintain close contact with the individuals they serve, including delivery of HIV medications and conducting in-the-field medication adherence assessments, though the goal of the project is to get individuals established at a medical home.
- In-Kind Principal Investigator
- Psychiatric RN
- Homeless Outreach Worker
- Project Director
- Evaluation Coordinator
- Medical Social Worker
- Homeless Peer Navigator
Consumer Involvement: Consumer involvement will take place at partner agencies (APIWC & TWHC), not at HIV Health Services.
Dean Goodwin, HIV Health Services Administrator
John Aynsley; Quality Management Coordinator
25 Van Ness Avenue, Suite 500
San Francisco, CA 94102