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Yale University

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The mHEALTH model creates a medical home for people living with HIV who are homeless in New Haven, CT.

Name of Grantee Organization:  Yale University

Project Name:  mHEALTH (Medical Home Engagement and Aligning Lifestyles and Transition from Homelessness)

Organization Description:
The Yale AIDS Program, Clinical and Community Research (YCCR) program is located within the Infectious Disease Section of Yale University School of Medicine. YCCR conducts community-based clinical research at the intersection of HIV, substance abuse, mental illness, and the criminal justice system. It houses the Community Health Care Van, a 40-foot mobile medical van, which provides testing for HIV, HCV, and sexually transmitted infections, and other primary care services in four underserved neighborhoods in New Haven. YCCR provides outreach, comprehensive social support services, and medically assisted therapy for people with HIV, substance use disorders and mental illness.

Goals/Objectives: To provide quality HIV primary care, mental health and substance use treatment, social supports, and access to stable/permanent housing for people living with HIV/AIDS (PLWHA) who are homeless and not retained in care, through enhanced partnerships with the Ryan White continuum, the Department of Correction, and the city’s largest U.S. Dept. of Housing and Urban Development (HUD) provider for housing for PLWHA.

Catchment Area:  Greater New Haven, CT

Location: New Haven, CT

Partners and Linkages:
Connecticut Department of Correction (CT DOC), Liberty Community Services, and the New Haven Ryan White Continuum of Care; Greater New Haven Coalition to End Homelessness

Program Intervention/Services:
YCCR will use the Community Health Care Van and RW Continuum agencies to conduct primary care, medical case management, mental health and substance abuse treatment, medically assisted treatment for opioid and alcohol abuse, case finding and outreach, care coordination, and adherence support.  Liberty Community Services will provide housing coordination and social support through peer and network navigation services.  The CT DOC will identify clients and provide referral and linkage to care in the community.  Our interdisciplinary team will provide support services including transportation, substance abuse and mental health counseling, linkages to entitlement programs, health insurance, AIDS Drug Assistance Program (ADAP) and medication assistance.

Program Staff: 
YCCR staff: part-time Project Manager, part-time Clinical Coordinator, part-time Research Assistant, part-time Local Evaluator, part-time Data Manager;
Liberty Community Services staff: part-time Coordinator, part-time Peer Navigator, part-time Network Navigator;
CT DOC staff: part-time Referrals Coordinator

Consumer Involvement:A Peer Navigator will be hired by Liberty Community Services to identify clients, provide social service support, linkages to care, referrals, and transportation.

Contact Information: 
Ruthanne Marcus, Program Manager
270 Congress Ave
New Haven, CT 06510
(O) 203-764-9958 (C) 203-444-2621


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