3 Steps for Developing Integrated Care Coordination for Homeless Individuals with HIV/AIDS


Homelessness and HIV are two critical issues that frequently go hand in hand. According to the National Alliance to End Homelessness, nearly half of the individuals in America who are living with HIV/AIDS are at risk of becoming homeless at some point in their lives. Adults and adolescents living with HIV/AIDS make up about 0.33% of the general population of the United States, and yet they make up nearly 2% of the homeless population in America. Possible explanations for the prevalence of individuals with HIV/AIDS in the homeless community include the high cost of medical care for their condition and the difficulty in maintaining steady employment when living with chronic health problems.

Many factors, or social determinants, contribute to the situation of those experiencing homelessness. These determinants include a diverse set of conditions that may include availability of affordable transportation, literacy or other language fluency concerns, lack of family or social support network, lack of financial resources, untreated mental health concerns or, as in the case of those living with HIV/AIDS, other chronic health issues. It is critical to understand each of the factors and how they affect the individual’s situation in order to provide whole person support and care.

For example, when dealing with individuals who are living with HIV/AIDS and experiencing homelessness, it is critical to understand the importance of finding dependable housing as a top care priority. Because HIV/AIDS weakens the immune system, people who live with it are far more susceptible to serious infections that can be contracted from sleeping in unsanitary conditions or in communal shelters with large populations. In addition to the risk of illness, refrigeration is often required to properly store many of the medications used to treat HIV/AIDS.

Because of the health and housing complexities associated with living with HIV/AIDS, creating an individualized integrated care plan for these high-risk individuals is of particular importance. To aid in this effort, we would like to recommend three steps for creating an integrated care plan for homeless individuals who are living with HIV/AIDS.

Step 1: Identify specific Needs

The first step in creating an integrated plan to identify the specific needs of the individual and then identify the gaps in the services that are currently available. Individuals who are experiencing homelessness, whether acute or chronic, have a variety of needs that may include things such as housing, food, medical care, vocational training, clothing, transportation or legal assistance. Many local communities have resources available to help with each of these individual needs, but these resources are often provided by separate organizations and are not well coordinated. By creating an integrated plan that takes into account all available resources, it can help prevent homeless individuals from missing critical pieces of their care due to lack of cooperation or communication between care providers.

Step 2: Engage Community Providers

A second step to creating an integrated care plan is to engage health and human service providers in the community when designing the plan. Every community has a variety of health and human services providers that vary from faith-based non-profits, to private charities, to government programs. The range of service providers allows for a wide variety of needs to be met, but it also creates complex system to navigate for the individuals experiencing homelessness. By engaging with the human services providers when creating an integrated care plan, the individuals being helped can be made aware of all of the services available and can receive accurate information that is needed to select the services which best fit their needs.

Step 3: Utilize Technology

A third step in creating an integrated care plan is utilizing technology. Traditionally, HMIS software and Health IT systems have been siloed from one another. This has been done both because of limits in technology and because of complex privacy laws. However, care coordination platforms can now seamlessly integrate HMIS and health data in a way that protects privacy while improving both the quality and efficiency of the client care. Many homeless individuals receive care from a variety of resources and by tracking their cases in one location, their needs can be met more completely. Integrated data can also benefit the resource providers by lowering the manpower costs required for coordination and communication as well as giving providers a more comprehensive view of how programs are doing in meeting their goals.

There are many and varied factors that affect individuals who are homeless. For those individuals who also live with HIV/AIDS, their situation has an additional layer of complexity. That complexity makes creating an integrated care plan that much more essential to provide effective and efficient care for those individuals. By identifying and addressing person-specific needs, involving health and human service providers in the initial planning, and utilizing integrated technology to smooth communication, the best possible results can be achieved for individuals facing the dual challenge of homelessness and HIV/AIDS.

Blog Resources

https://www.hiv.gov/blog/hrsa-and- hud-launch- data-integration- pilot-to-improve-hiv- care-and- housing-coordination




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