Project health - the gandara (GC) project health/projecto salud (PH/PS) program integrates primary and infectious disease care within a hispanic, minority-focused behavioral health clinic (MH/SUD)…

Project health - the gandara (GC) project health/projecto salud (PH/PS) program integrates primary and infectious disease care within a hispanic, minority-focused behavioral health clinic (MH/SUD) with the clear aim to provide HIV/HCV prevention and treatment coordination to individuals with high social and health disparities in springfield, MA. The project is based on the principles of integrating social needs into health care including clear aim, model testing and cede control. The population of focus is primarily hispanic minorities with SUD, SMI, DOD who are at the high risk of contracting, or are living with HIV/aids or hepatitis. Nearly 5000 individuals are served at the clinics annually (73% hispanic or mixed race, 74% non-white, women 45%, men 54%). Approximately 2,500 people meet the target eligibility criteria. The program is embedded within our minority focused, community-based outpatient clinic. Gandara's clear aim is to fully address the cultural, access, and care coordination barriers experienced by many high needs hispanic/other minority individuals with complex medical and BH care needs by expanding our existing multi-disciplinary coordinated care setting that offers individuals an array of services at delivered by an integrated, bilingual team of staff. The PH/PS integrated care team will be led by an experienced nurse case manager, and consist of outreach case managers, peer recovery support specialists, substance use clinicians, and primary infectious disease care (through an established partnership). The program will provide both internal and external community outreach, engagement, and education, comprehensive case management, SUD treatment, and infectious disease treatment and prevention. The utilization of motivational interviewing (MI) and stages of change facilitates successful engagement and a collaborative treatment effort. An outreach/case manager/peer team supports individual goal setting/achievement and linkages to community services- mat, adherence support, other medical and dental, benefits, housing, recovery and relapse prevention, vocational/employment placement, and wellness services. Core goals /measurable objectives include 1) reduce the incidence of HIV/aids and HEP and improve overall health outcomes for individuals with SUD or CO-occurring disorder (COD) via increased engagement with care, use of culturally competent SUD treatment with HIV/HEP primary care, prevention services, screening for individuals with SUD/COD living with or at risk for HIV/aids. 2) deliver comprehensive services, through an infectious disease cooperative care team led by a nurse case manager for individuals with SUD/COD, including infectious disease primary care, psychiatry, RN prescribers, SUD clinicians, outreach/case managers(CM), peer/ recovery coaches and service linkages to increase physical/ recovery stability outcomes. 3) build a system to track coordinated linkages to treatment, recovery services and other wraparound supports, as well as participant access to services, to implement an integrated treatment model that promotes overall health and wellness stability 4) implement the program evaluation plan to determine whether program goals, objectives, and outcomes have been achieved and whether adjustments to programming and workflows are needed. Numbers served 500 individuals across the 5 years, Y1 90, Y2 110, Y3 110, and Y4 100. Individuals receiving annual enhanced risk screening 1500, prevention/education 750 rapid testing: 600.