Track 1 Scheduled Current or out of care homeless TSHC patients Hospital Inpatients Less urgent patients from HHS HIV testing programs Track 2 Rapid Response New or previous diagnoses from HHS testing programs ID: 911096
Download Presentation The PPT/PDF document "Internal (Harris Health System) Patients" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Internal (Harris Health System) Patients
Track 1 – ScheduledCurrent or out of care homeless TSHC patientsHospital InpatientsLess urgent patients from HHS HIV testing programs
Track 2 – Rapid ResponseNew or previous diagnoses from HHS testing programsHIV+ encountered elsewhere in HHS & in poor health and/or unstably housed
CMT continues with linkage process and is still eligible to receive services
HHS Staff notify CMT
CMT meet patient at patient location before patient leaves
CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services
CMT schedule TSHC screening appointment
Not interested
Interested
CMT plan and goals developed
CMT continue to provide services until patient goals are met and HIV is managed
CMT work on transitioning patient to shelter clinic if patient so chooses
DM generates list weekly
DM generates list monthly
Have upcoming appointment?
No
Yes
CMT review list to identify patients to approach
CMT review list to identify patients to approach
CMT continue with re-linkage process
CMT try to locate patient and schedule a TSHC appointment
When patient is at TSHC, CMT present intervention and perform brief assessment
Not interested
Interested
CMT present intervention
CMT
f
lag selected patients in EMR to be notified when the patient arrives
Graduate from intervention to 90-day transition period
Goals remain met
Goals met
Standard Care
Yes
Yes
No
No
This publication is part of a series of manuals that describe models of care that are included in the HRSA SPNS Initiative
Building a Medical Home for HIV Homeless Populations
. Learn more at
http://cahpp.org/project/medheart/models-of-care
Slide2Referring agency informs CMT
CMT meet patient at patient location before patient leavesReferring agency informs CMT
CMT schedule TSHC screening appointment
CMT continue with re-linkage process
Interested
Not Interested
External (non- Harris Health System) Patients
Track 1 – Scheduled
Less urgent
HIV+ homeless patients referred by
external agencies serving homeless and/or HIV populations
Track 2 – Rapid Response
Urgent patients from external agencies serving homeless and/or HIV populations (poor health
and/or unstably housed)
When patient is at TSHC CMT present intervention and perform brief assessment
CMT continues with linkage process and is still eligible for services
Not interested
Interested
CMT presents Intervention and performs brief assessment
CMT: Case Management Team
DM: Data Manager
MH: Mental Health
SA: Substance Abuse
TSHC: Thomas Street Health Center
CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services
CMT schedule TSHC screening appointment
CMT plan and goals developed
CMT continue to provide services until patient goals are met and HIV is managed
CMT work on transitioning patient to shelter clinic if patient so chooses
Graduate from intervention to 90-day transition period
Goals met
Standard Care
Yes
Yes
No
No
Goals remain met