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San Francisco Department of Public Health

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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

Program Intervention/Services:
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.

Program Staff: 

  • 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.

Contact Information: 
Dean Goodwin, HIV Health Services Administrator

John Aynsley; Quality Management Coordinator

25 Van Ness Avenue, Suite 500
San Francisco, CA 94102