Clients are referred from the Monroe County Health Department and from the local Guidance Care Clinic, as well as from year-round HIV testing conducted by our Prevention Specialists throughout Monroe County, the Monroe County Homeless Services Continuum of Care and self-referral.
Our constant goal is to achieve an undetectable zero viral load. This term, viral load, refers to the amount of HIV in a blood sampling. When viral load is high, that means HIV in the body and the immune system is not fighting HIV.) Having an “undetectable” viral load doesn’t mean that the virus is completely gone, but studies show that this can dramatically shift a client into the low risk category of sexually transmitting HIV to someone else. This, obviously, is of benefit to everyone, by reducing infection in Monroe County. All of this relies on a working rapport and dialogue with their Medical Case Manager…medical adherence, from appointments to prescriptions to an overall emphasis on wellness…remaining housed…socialization and taking responsibility…this means avoiding the pitfalls of substance abuse…safeguarding against depression and other mental health challenges.
The initial, comprehensive intake, within 72 hours, determines eligibility, including a third-party documentation of financial information, third party verification of HIV status and Mental Health and Substance Abuse or Dual Diagnosis through a High Risk Assessment performed by our staff psychologist. There is also third- party verification of homelessness, as well as third-party verification of disability.
To close the loophole to increase healthier outcomes and to identify barriers to care, newly-identified positive individuals are brought swiftly into the medical/social support system:
Medical Case Management: Referrals for medical, home health, pharmaceutical and clinic; managed healthcare assistance; securing support from Medicare, Medicaid, and Social Security Administration and payment assistance for health insurance premiums, co-pays and deductibles; referrals to agencies providing services
Linkage to Care: Referrals/prescriptions to dental and other specialty care; appointment reminders and follow-up; medical transportation; neuropathy and holistic programs; and high-risk prevention.
Intensive RN Case Management: Determines the level/intensity of care so that all clients are in appropriate levels of care to allocate resource appropriately:
• Level 1 – Client has a 0 Viral Load and engaged in his/her healthcare.
• Level 2 – Client may or may not have a 0 viral load, but barriers exist such as housing, health care, mental health or substance abuse issues. The goal: get this group to a level 1.
• Level 3 – Client has either a high viral load, or other comorbidities such as cancer, liver disease, and kidney failure.
Health Care Clinic Case Management: Two days weekly at Health Care Clinic; case/clinical/physician notes; gather comprehensive data for all patients in order to determine level of care and follow-up care
Substance Abuse and Mental Health: Build relationships with other providers; establish relationships with mainland providers such as Rehab Facilities
Reassessment: Minimum six (6) month update with every client
Compliance Management: Internal Auditing of all files to achieve excellence, eligibility and consistency of all client/tenant files
Nutrition: Vouchers and supplements for alternative medical care