Table Of Contenteau, SPNS Program and Department of Housing and
ban Development, HOPWA Program
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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
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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.
