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Ryan White Part A Care Coordination Program for City Request for Proposals (RFP) Solicitation #: 2017.11.HIV.03.01

Issued by Public Health Solutions on behalf of the Department of Health and Mental Hygiene Issue Date: November 8, 2017

Care Coordination Program

Contract Awards AIDS Center of County, Inc. APICHA Community Health Center Argus Community, Inc. Beth Israel Medical Center Bronx Parent Housing Network Bronx-Lebanon Center Plaza Medical Center, Inc. Community Health Action of Community Health Project, Inc. (Callen-Lorde) Diaspora Community Services Gay Men’s Health Crisis, Inc. HHC HHC HHC Kings County Hospital Center Housing Works Health Services III (dba Housing Works Community Healthcare) Joseph P. Addabo Family Health Center, Inc. La Casa de Salud, Inc. Morris Heights Health Center Mount Sinai Hospital (dba Mount Sinai Hospital Institute for Advanced Medicine) Research Foundation of State University of New York (dba SUNY Downstate Medical Center) (DMC) Services for the Underserved, Inc. St. Luke's - Roosevelt Hospital (dba Mount Sinai St. Luke’s, Mount Sinai West) (MSSLW)

Sunset Park Health Council, Inc. (dba Family Health Centers at NYU Langone) The Institute for Family Health Wyckoff Heights Medical Center

Background: While advances in medical care for people living with HIV (PLWH) have been significant, disparities exist in access to healthcare and optimal health outcomes. Factors associated with poorer health outcomes include being from a racial or ethnic minority, being transgender or gender non-conforming, having a history of, or current, injection drug use, having a mental illness, and being from a lower socioeconomic status.

HIV has evolved into a chronic illness for a large number of PLWH, requiring a broad range of services and necessitating the development of self-management skills. The complex requirements of anti-retroviral treatment (ART) and the life-long nature of HIV care are challenges best met in the context of stable life situations and strong support systems, including stable and good-quality housing, access to sufficient food and adequate social support. The Care Coordination Program seeks to address HIV healthcare disparities by facilitating access to care and other services. The driving principle of the Care Coordination Program is to take a client-centered, holistic and comprehensive approach to meeting the needs of PLWH through team-based care management. The program uses patient navigation to identify, advocate for, and coordinate resources for PLWH, thereby coordinating the complex healthcare and social service systems necessary to ensure improved outcomes. Purpose: The Care Coordination Program aims to provide medical case management and treatment adherence services to clients who meet the eligibility criteria for the program in order to engage and retain PLWH in care and treatment, thereby improving health outcomes. The goals of the program are to:  Increase retention in HIV care and treatment.  Increase the proportion of clients who have an optimal level of ART adherence.  Increase the proportion of clients with an undetectable viral load and improve immunological health.  Reduce mortality.  To reduce (and then maintain below significance) socio-demographic differences in: prompt linkage to HIV/AIDS care following HIV diagnosis, retention in primary medical care, and undetectable viral load and HIV-related mortality.

The objectives of the program are to:  Provide coordinated access to medical appropriate levels of health and support services and continuity of care.  Provide referrals and linkages to medical or supportive services that improve clients’ physical and behavioral health.  Provide comprehensive treatment adherence services, promoting access to, and the consistent utilization of, ART.

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