NC-REACH: NC-Rurally Engaging and Assisting Clients who are HIV positive and Homeless
Summary
- Need Provision of medical care access and follow-up for rural North Carolina HIV patients with mental health, substance abuse, and unstable housing/homelessness challenges.
- Intervention: Medical home staff model expanded to a care coordination program with a core Network Navigator and Continuum of Care Coordinator assisting with medical, behavioral health, and basic life needs.
- Results: To date, the program has advanced three aspects of medical home patient care for this target population: provided further understanding of the spectrum of homelessness, including “hidden” homelessness; implemented outreach with the creation of new community partnerships and a community housing coalition, and integrated medical care and behavioral health care for HIV.
