Description: Complete initial assessment of eligibility; reassessment and preparation of AIDS Medicaid Waiver home care service plans for eligible members.
Targeted members: Members that are deemed eligible for the AIDS Waiver following the initial health risk assessment.
Benefits: Maintain continuity of care; minimize duplication of case managers; established and experienced workforce.
BEHAVIORAL HEALTH SERVICES
Description: Intensive, home-based mental health and substance use assessment and treatment to promote improved emotional health and decreased and/or safer substance use.
Targeted members: Members not currently engaged in behavioral health services and/or in-need of home-based treatment, identifying with problematic substance use and/or mental health concerns.
Benefits: Improved emotional health, management of mental illness and/or substance use. Decreased health and social consequences stemming from problematic substance use or mental illness. Reduced barriers to medical treatment engagement, such as transportation and health limitations. Increased convenience of appointment attendance due to in-home service provision.
HIV-CONNECT CARE COORDINATION
Description: Intensive case management services to keep members healthy and able to avoid hospitalizations and over-utilization of the emergency room.
Targeted members: All members who are HIV-positive. Individuals may be newly diagnosed with HIV or not accessing care as needed.
Benefits: Our cost-effective approach has proven to be successful in engaging and retaining members in care. It ensures that members are connected to HIV primary care, adhere to their medical treatment regimens, and have care that is coordinated with a wide variety of related community services (from nutrition, education and food pantry services to housing and transportation).
HOUSING STABILIZATION
Description: Access to affordable housing, intensive case management and rental subsidies.
Targeted members: Eligible members for homeless individuals suffering from a wide range of chronic medical illnesses including HIV.
Benefits: Chronically ill, homeless people treated with stable, supportive housing achieve better health outcomes at a lower cost than those who are not stably housed.
LINKAGE TO MEDICAL CARE
Description: Connects newly diagnosed HIV and/or hepatitis C (HCV) members to in-network medical care providers; provides support for first few medical appointments and education regarding HIV and/or HCV diagnosis. Targeted members: Members who have recently tested positive for HIV and/or HCV.
Benefits: Connection and support to HIV and/or HCV medical care and support services that is culturally competent and appropriate. It is especially important to quickly connect these members to medical care to improve their health outcomes and reduce the number of new HIV infections in the community.
Description: Our Mobile Engagement Team is designed to find and engage health insurance members to inform them about health plan benefits and provide a brief health assessment.
Targeted members: “Unable-to-locate” health insurance plan members.
Benefits: By rapidly connecting and re-engaging those who are not yet connected with their primary care provider and coordinate their care with their health plan., members will be able to begin access services and appropriate treatment on a timely basis.
PREVENTION TESTING — HIV AND CHRONIC DISEASES
Description: HIV, hepatitis C (HCV) and sexually transmitted infections (STI) testing, which promotes earlier access to treatment and retention in care.
Targeted members: Members who live in high-prevalence communities and/or are uniquely vulnerable to HIV and HCV.
Benefits: Access to HIV, HCV and STI testing with linkage to appropriate, culturally-competent medical care and support services for people with these chronic conditions. It is especially important to screen for these diseases to decrease transmission and morbidity.
TRAINING AND PROFESSIONAL EDUCATION: HIV AND CHRONIC DISEASE
Description: Staff training to meet the annual training requirements on HIV and AIDS and evidence-based practices for working with vulnerable populations.
Targeted members: Clinical staff within the Chicago community, partnering agencies and insurance plans.
Benefits: To facilitate clinical staff in meeting their required annual hours of professional development training.
