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
Abstract Format : Coordination of housing and medical case management services can be more effective when regular data monitoring and analytics are used to help inform programmatic decisions. By building real-time data dashboards and using them to monitor agency performance and client outcomes, staff at the AIDS Foundation of Chicago (AFC) were able to pinpoint specific areas where programmatic innovation was needed to make systems-level changes to service provision. In particular, one major Ryan White case management subcontractor was identified as in need of additional support, due to the size of its client population, demographic and socioeconomic characteristics of clients served, and its prominence in serving the South and West sides of Chicago. This year, AFC Housing staff used a new funding opportunity to place a HOPWA-funded Housing Navigator at this clinical site, supervised directly by the site’s Ryan White case management supervisor. While Housing Navigators are typically placed at agencies specializing in Permanent Supportive Housing (PSH) programming, this new model represents a clear and purposeful linkage between Ryan White and HOPWA services. Further, this process highlights the ways in which data teams and programs staff can collaborate to identify improvement areas and develop solutions.
Methods : Housing staff at the AIDS Foundation of Chicago (AFC) used Ryan White case management data to identify new strategies in improving coordination of Ryan White and HOPWA services. One Ryan White subcontractor, a large clinical site, was identified as a partner for new strategy and targeted intervention. Currently, AFC coordinates funding for Ryan White case management services at this site for nearly 700 clients, representing nearly a quarter of all Ryan White Part A clients in Chicago. Less than half of Ryan White case managed clients at this site report being stably housed, and nearly 80% report incomes at or below the Federal Poverty Level. The proportion of clients who identify as Black or African American is significantly higher at this site than the rest of the city’s Ryan White Part A client population, and this site’s clients are nearly twice as likely than the rest of the population to be uninsured and to have unsuppressed viral loads. AFC is implementing a new model of HOPWA-funded Housing Navigation services, in which a Housing Navigator is placed at this site on a full-time basis to operate as a direct resource for Ryan White case-managed clients, walk-in patients, and referred clients. This Housing Navigator will provide a number of services to assist clients in navigating the housing system, including help with linkage to emergency financial assistance, connection to affordable housing units, and referral and placement into HOPWA-funded subsidized housing.
Results : Data monitoring and analysis processes were used to inform decision-making processes and develop innovations in service delivery to improve coordination of medical and housing services. In addition, procedures for data monitoring and analysis have been established around specific performance measures, including programmatic outputs and client outcomes data. These procedures provide the impetus and evidence for further innovation in programming between medical and housing services.
Conclusions : This project serves as one model for how data analytics, in combination with the knowledge and experience of programs staff, can be used not only to provide evidence to support programmatic changes, but can also help shape innovations in programs and resource allocation. Regular data monitoring and collaboration between medical case management, housing, and data teams can contribute to improving our own systems' ability to address structural barriers to care for PLWHA.