Evidence Strategies and Practical tools for inclusion of social and structural interventions such as housing, employment, and food security in plans to end the epidemic
Policy, Program, Intervention or other types of research evaluation
Issues : Unstable housing and other social determinants of health are major drivers of suboptimal HIV care outcomes at the individual and population-levels in New York City (NYC) and nationally. In New York State (NYS), Medicaid redesign, the Delivery System Reform Incentive Payment (DSRIP) program, Health Homes, and the Ending the Epidemic (EtE) Blueprint provide a wealth of newly available resources to serve homeless and other low-income people with chronic conditions, especially people with HIV (PWH). This includes the 2016 expansion of NYC HIV/AIDS Services Administration (HASA) housing, food and nutrition supports to all public-assistance-eligible people with HIV infection. However, there is currently little ability for integration between HASA and the evolving integrated health care system.
Persons enrolled in HASA include some of the highest utilizers of health care services, often with the poorest health outcomes. A recent NYC Department of Health and Mental Hygiene (DOHMH) analysis of HASA clients in care reveals 80% viral suppression among those stably housed (<200 copies/ml), compared to only 60% for those in emergency housing. It is imperative to deliver HASA services that are more efficient and better aligned with health care integration, thereby achieving better HIV, behavioral, and other health outcomes.
Description : Regional Health Information Organizations (RHIOs) provide a platform for service coordination through patient consented health data exchange. Recent NYS policy changes make it possible for social service programs such as HASA to participate in a RHIO, creating new opportunities to address social determinants of health as part of integrated care. HASA is working with Healthix, the largest NYS RHIO, to establish client-consented connectivity with health and community-based providers.
Working groups composed of representatives of HASA, DOHMH, Healthix, community-based organizations, health care provider systems, and the City Council have met regularly since March 2017 to design demonstration projects that will pilot use of Healthix connectivity and triaged case management to improve the experience of clients who move through the HASA systems while increasing efficiencies. The proposed three-year projects will be enabled by the consented integration of data from various systems—including HASA, the integrated health care system, and providers of Health Home and other care coordination services—for the purposes of patient identification, linkage and retention in care, and support to maximize durable viral suppression, housing stability and client independence.
HASA and participating housing providers will pilot three integration models for clients with varying levels of need: those with intensive programmatic support (living in permanent supported housing); unstable clients with intensive programmatic support (living in transitional supported housing); and unstable clients with limited or no programmatic support (living in commercial single room occupancy (SRO) hotels).
Each model includes core elements: Mandatory monitoring and reporting of client viral load at regular intervals; promotion of Health Home enrollment for all clients; offer of consent to the Healthix RHIO for all clients; mandatory case conferences at regular intervals with the client, HASA caseworker, supported housing program case manager, Health Home care coordinator, and any other providers; and training to supported housing program case managers on monitoring viral load and supporting clients to achieve and maintain viral load suppression (e.g., motivational interviewing).
Lessons learned : The pilot will launch in 2018 and be evaluated by researchers at the CUNY School of Public Health. Outcomes of interest include durable viral load suppression; housing stability (including movement to independent living when appropriate); Health Home engagement; and HASA programmatic functioning (efficient and timely approval and delivery of housing assistance and other public benefits).
Recommendations : Outcomes will inform demonstration project scale-up throughout the HASA system, strategies for RHIO utilization by social service agencies, and strategies for integrated care coordination among health, social service and care management providers.