A partnership for access to treatment and housing in Jacksonville, Florida
Project Name: PATH HOME
The University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES) Program is recognized by the NCQA as a Level 3 Medical Home and has provided services to the disproportionately affected populations of Northeast (NE) Florida since 1998. River Region Human Services, founded in 1972, provides housing, substance use and mental health treatment to people living with HIV/AIDS (PLWHA), and has the oldest supportive housing program in NE Florida for PLWHA. In our combined 50+ years of service, we have both seen the impact of homelessness and HIV/AIDS, with mental health/substance use needs. This mosaic of needs combine to make Homeless PLWHA some of the most difficult to serve, calling for the need to innovate and unite resources.
Catchment Area: Northeast Florida and extreme Southeast Georgia
Partners and Linkages: River Region Human Services and Ability Housing of Northeast Florida
- Utilize Peer Navigators to identify and link 60 individuals who are homeless and HIV-positive to housing through a comprehensive joint plan each year.
- Use empirically demonstrated behavioral models to implement plan
- Link individuals who are homeless and HIV-positive into Mental Health/ Substance Use Treatment
- Engage individuals who are homeless and HIV-positive in a Medical Home (housing and clinic based)
- Utilize Peer Navigators and Medical Case Management models to continue engagement in care
- Open doors to the medical home through innovative social network connections (Phones and Voicemail)
- Demonstrate the impact to the community (measuring reduced hospitalizations, cost measures, increased adherence) to garner ongoing support for these targeted efforts
- We plan to serve 300 individuals who are homeless, HIV-positive, and living with co-morbidities (mental health issues and/or substance use) over the five-year demonstration project.
Principal Investigator, HIV Primary Medical Provider, Behavioral Health Provider, Program Evaluator, Executive Director, Housing Director, Program Director, Program Manager, Program Coordinator, One Data Manager, Two Case Managers and Two Peer Navigators
The Peer Navigators will serve as the bridge between identification of HIV+ homeless and linkage to housing, mental health services and/or substance use services, as well as the medical home; they will also follow up systematically with clients during the first year of enrollment, and quarterly review care plans after the first year, with clients, under the PATH Home model program.
Kendall Guthrie, Program Director
653-1 West 8th Street, LRC, L-13
Jacksonville, FL 32209
Telephone: (904) 244-4424