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eau, SPNS Program and Department of Housing and ban Development, HOPWA Program CV4 — .^-J « T3S Lessons Learned: Innovations in the Delivery of HIV/AIDS Services March 9, 2001 DearColleague: The Special Projects ofNational Significance Program (SPNS) in the HIV/AIDS Bureau (HAB) ofthe Health Resources and ServicesAdministration (HRSA) has a unique role in the field ofHIV/AIDS service delivery the supportofinnovation. Through five- and three-yearfunding initiatives targeting themes as diverseas service integration, palliativecare, and borderpopulations, the SPNS Program is able to provide experienced andcommitted HIV/AIDS providers the freedom to create andtestnew models ofcare designed to meet emerging issues and the needs ofunderserved populations. SPNS grantees identify the challenges, develop models to meet these challenges, implement and refine these models overanumberofyears and evaluate their impact. This work is complicated, difficult and absolutely essential. The obligation ofthose who travel the road ofinnovation is simple: tell us what you have learned and help us replicate the successes and avoid the failures. This document is one ofthe ways in which agroup ofSPNS grantees is meeting its obligation to the HIV/AIDS service providercommunity. The projects represented in this collection provide a wonderful insight into the richness ofthe innovation supported by SPNS and the depth oflearning that has taken place overthe fouryears these projects have been inexistence. In these pages we have the opportunity to read about providing HIV/AIDS care to homeless youth,Asian and Pacific Islanderpopulations, migrant workers, ex-offenders. NativeAmerican populations and multiply diagnosed individuals. These reports address issues as diverse as service integration across large geographic regions and the provision ofhigh quality mental health care to indigent populations. We also hear in these reports from providers working across the nation, in the rural south and in urbancenters on both coasts and in the mid-west. The lessons taught here come from real-world experiences andrepresent the kinds ofproblem solving that has enriched the service delivery field time and time again. Also characteristic ofthe field are the collaborations thatrun through every stage ofthese models even to the creation ofthese documents. The projects represented here are part ofan initiative in which the SPNS Program partnered with the Housing Opportunities forPersons withAIDS Program in the US DepartmentofHousing and Urban Development (HUD). Each ofthese projects has also workedclosely with members ofthe Evaluation andTechnical Assistance Center(ETAC) atColumbia University's Mailman School ofPublic Health on the evaluation of these interventions. In fact, the authors ofthese pieces are drawn from ETAC and each ofthe SPNS and HOPWA funded projects profiled here. The SPNS Program exists toensure bettercare forpeople living with HIV/AIDS. At a fundamental level this is about getting care to those who do not have it. The lessons shared here are about accomplishing this goal. I am sure you will find them as inspiring as I have. Sincerely, BarbaraAranda-Naranjo, Ph.D., FAAN Branch Chief, Demonstration ProjectDevelopmentand Evaluation/SPNS HRSAvH^.RC-KnOV^ 1-800-444-6472 Table of Contents Introduction Providing Housing Services Developing Permanent Housing 1 Canaan House Project, Catholic CommunityServices Housing and Services for Multiply Diagnosed Women and Their Children 11 Positive Match Program, BernalHeightsNeighborhoodCenter Housing for Multiply Diagnosed Men and Women with Aids 21 The Bridge Project, Lutheran SocialServices, San Francisco Linking Multiply Diagnosed Homeless Persons to Care 29 The DiamondProject, Health Careforthe Homeless, Inc Long Term Housing and Supportive Services to Individuals and Their Families 39 Hope Harbor/HarvestHills, SalvationArmy Sheltering and Engaging Multiply Diagnosed HIV-positive Homeless 47 Operation Link, Catholic Community Serx'ices Transitional Housing and Supportive Services 59 The BridgeportMultiple Diagnosis Program, City ofBridgeport Providing Culturally Responsive Care Culturally Competent Mental Health Care 67 MontefioreMedical Center: Culturally CompetentSerx'ices Engaging and Retaining HIV-positive Ex-offenders in Primary Medical Care 79 The Fortune Society, ETHICS3 CoordinatedHealth Care Program HIV/AIDS Care for Native Americans 87 Native Care: HIV/AIDSIntegratedServicesNetwork, NorthAmericanAIDSPrevention Center Linking HIV-positive Inmates to Services after Release 95 ProjectBridge: Prison andDetoxProgram, The Miriam Hospital Reaching Border Migrant and Seasonal Farmworkers 105 La Frontera, University ofTexasHealth Science CenteratSanAntonio Training Providers to Improve Service Delivery toAsians and Pacific Islanders 117 The Bridges Project, Asian andPacificIslanderCoalition on HIV/AIDS, Inc. Networking Services A Continuum of Care forthe Houston Homeless 127 Houston MDIProject, Houston RegionalHIV/AIDSResource Group Creating a Service Continuum 133 TheArkansas HIVCare andSupportNetwork, Jefferson Comprehensive Care Systems, Inc. Cross-system Training BuildsAgency Capacity 141 The Tri-County Collaboration Project, UniversityofWashington Facilitating Workforce Entry 149 HarborProject, UniversityofCalifornia, LosAngeles An Integrated Service Delivery System for Rural People Living with HIV/AIDS 157 North Carolina SPNSIntegration Project, Duke University Integrating Services for Poor Women of Color 163 The WholeLife Project, University ofMiamiDepartmentofPsychiatry Using Collaborative Case Management to Create Integrated Services 173 Collaborative CareManagementProgram, EastBoston NeighborhoodHealth Center A Wide-area Computer Network for Comprehensive HIV Service Delivery 183 HIVCybermall, Northeast ValleyHealth Corporation Working with Youth Identifying HIV-positive Youth and Transitioning Them into the Health Care System 193 ChicagoHIVRiskReduction Partnershipfor Youth, Cook CountyHospital Outreach Services to Medically Underserved Adolescents 203 Teen Outreach Project UniversityofMiami(TOP-UM), UniversityofMiami Providing Age-appropriate HIV Service toAdolescents 207 Division ofAdolescentand YoungAdultMedicine (DAYAM)AdolescentHIVProject, DepartmentofPediatrics, NewJerseyMedicalSchool Providing HIV Prevention and Services to Homeless Youth 217 SafeSpace, CenterforChildren andFamilies 193 "I 1 1 J The First Steps to Replicating New Models of Care Introduction by Robert Sember Overthe past four years, each ofthe twenty-five projects represented in this monograph have designed, implemented, refined and evaluated an innovative model ofHIVcare. The development ofthese models has involved taking well-established service delivery techniques, such as street outreach and multi-disciplinary care, andredesigning them foruse in settings and with populations that are among the most marginal and isolated in theAIDS epidemic. The providersrepresentedherwork indiverse settings acrossthecountry including along the US-Mexico border, in sparsely populatedareas oftherural south, the extensive suburbsofthe San Fernando andAntelope Valleys north ofLosAngeles, andprisons inthe states ofRhode Island, Washington andNew York.The individuals servedinthecourseofdevelopingthese models are drawn from the ranks ofhomeless youth, the largely invisible rural poor(which include manyAmerican Indians andmigrantfarm workers), women andchildren living in poverty in the innercities, and theadult homeless living withdrug addiction, andmental illness. The Collaboration In addition tocreating these new models ofcare in theirown agencies and settings, key stafffrom these projects have worked togethertobuild the principles ofcare they wish to offerto others in the HIV/AIDS service delivery field who work with similarpopulations. Collaborations on this scale are rare. This one is the resultofacollaboration between two federal programs: the Special Projects ofNational Significance Program (SPNS) in the Health Services and ResourcesAdministration (HRSA), and the Housing Opportunities for Persons withAIDS Program (HOPWA) in the Department ofHousing and Urban Development (HUD). Thecombination offederal resources across agenciesbrought togetheradiverse group ofproviders undera numberofinitiatives. These initiatives focused on youth, integrated services and multiply diagnosedclients. While distinct, they proved complementary, meeting around the common problematic ofhow best to serve HIV-positive individuals with many needs, especially when those needs are in competition with each other, such as when individuals are struggling to survive both poverty and meet the conditions ofHIV therapies. Introduction, Learning Lessons This collection ofpieces documents how these very differentprojects have taken up the issue ofmultiple, competingclient needs and have attempted to fashion workable responses in the form ofservice delivery systems. The pieces are communications with others in the field. They are built on the shared acknowledgement that this work is complicated and effortful. Evident in all ofthem is the fact that this work is notneat; itdoes not progress along simple, clean lines from beginning to end. Like the lives ofthe individuals served, the lives ofthese programs, as well as the process ofkeeping them going from day today, include frustrations, disappointments, unexpecteddisasters (such as the tornado that leveled aclinic used by one ofthe projects), andgreat will power. From Concept to Implementation Each ofthe pieces collected here is made up ofthree components, presented in the following sequence: a description ofthe project, a setofkey lessons developed as aresult ofits implementation, and achronology or timeline ofkey events experienced overthe life ofthe project. Reading the pieces from beginning toend takes us deeper intothe processes that lie behind the architecture of the model's final form. The description oftheprogram outlines whatthe model has become as aresult ofthe work offouryears. The lessons learned section, while also the result offouryears ofwork, provide us with a rationale forthe lessons by describing the successes and failures that were part ofthe process oflearning.And the timeline provides aglimpse into the step-by-stepprocess ofbringingkey program components to fruition. Some ofthe timelines are very effective in documenting the effort, the length oftime and the convoluted process required to putcertain elements in place. By showing how to move from the conceptforan intervention to the intervention itself, these descriptions provide ablueprint forwhat mustbe done ifthe model is tobe replicated. Hopefully, they alsodiminish the inhibiting effects ofreading about programs that appear seamless and smooth functioning when we know full well that ifwe attempted to do the same it will entail greatdifficulty. Two-dimensional representations of program designs can be particularly intimidating as they lack the depth necessary to show whatlies behind the neatly arrange facade. The authors ofthesepieces are intimately acquainted with the mess behindthe model and are generous enough to show us theirprocess oflearning sothat we can betterappreciate the strengths of the interventions and be inspired enough to try them ourselves. Common Lessons While the pieces may be appreciated as individual project narratives, documenting the efforts ofparticular service teams working in specific settings, the common format also makes itpossible to read them together. Reading across the processes described in the variousmodels is very instructive. We are able to see thedifferences between local settings with greaterclarity when we can contrast them with the process followed somewhere else. We are also able to see the common lessons that accumulate when the multiple processes are brought together. Most interesting, however, is holdingboth the common lesson and its particularillustration in place at the same time. Forexample, almost all ofthe models described here required developing linkages with multiple service agencies. The objectives are similaracross the projects, as are some ofthe service settings. The process, however, can be quite different. The common lessons that emerge from reading across the Lessons Learned pieces may be clustered into four broad areas: /. Implementation A great deal ofwork is done before seeing the firstclient. Many elements go into making a service delivery model and bringing those elements togetherrequires skill. This process begins with the writing ofthe proposal when, forexample, letters ofsupport are obtained from potential collaborators. It continues afterthe notice ofaward when certain revisions may be requested by the funder. Planning is required before putting program elements in place and initiating the first intake. And even then, it is likely that significant adjustments will need to be made before the service process is able to function at capacity.