Project Title: FY 2022-26 Ryan White HIV/AIDS Program Part D Coordinated HIV Services and Access to Research for Women, Infants, Children, and Youth (WICY) Existing Geographic Service Areas Applicant Name: Cares Community Health dba One Community Health, formerly the Center for A.I.D.S. Research, Education and Services - Sacramento – H12HA24776 Address: 1500 21st Street, Sacramento, CA 95811 Contact: Michelle Monroe, CEO Phone: (916) 914-6240 Fax: (916) 914-6266 Email Address: mmonroe@onecommunityhealth.com Website: www.onecommunityhealth.com Grant Program Funds Requested: $442,265 Model of Care: Cares Community Health dba One Community Health (One Community Health’s) model of care is that of a state of the art, multi-disciplinary, regional HIV service agency providing integrated medical, dental, psychiatric, social, educational, and preventative services to people living with HIV/AIDS (PLWH/A). One Community Health is a NCQA Level 3 Recognized Patient Centered Medical Home (PCMH) and a Federally Qualified Health Center (FQHC). The Number of WICY with HIV served from 2019-21: From 2019-2021, One Community Health served 539, 537, and 668 WICY patients. Despite the ongoing effects of the pandemic, One Community Health has seen the target WICY population increase by 24 per cent in the last three years. On the number of women of color, transgender patients, number of elderly patients, pregnant, and youth. Proposed Service Area Boundaries: For 32 years, One Community Health has been the Sacramento Transitional Grant Areas (TGA’s) sole HIV/AIDS specialty medical care and continuum of care service provider that targets and serves primarily uninsured and underinsured patients. The TGA is a large four-county area of 4,287 square miles, with a geography that presents unique challenges to the efficient delivery of health care to PLWH/A. One Community Health’s service area reaches beyond the TGA and includes all inland California from Sacramento north
to the Oregon border and east to the Nevada border. Most of One Community Health’s specialized services for HIV/AIDS are centrally located in and around the city of Sacramento. WICY Priority Populations to be Served: Funding for this grant opportunity will work towards achieving the objectives outlined in the National HIV/AIDS Strategy (2022-2025) by prioritizing black women and transgender women, particularly older adults in these priority populations. One Community Health’s PLWH/A patient population over the age of 50 is rapidly increasing. This particular patient population experiences accelerated CD4 loss, decreased immune recover, and are at an increased risk of serious non-AIDS related illnesses and comorbidities. Key Services and Quality Measures: One Community Health will continue to provide access to core medical services and care, linkage to care, and will work to achieve retention in care and viral load suppression goals. Ryan White Part D specifically funds medical services, dental services, mental health services, substance abuse services, psychiatry, clinical pharmacy, family practice physicians, and a community partner, Sierra Foothills AIDS Foundation. Clinical Quality Management efforts are supported as well. Quality improvement measures include but are not limited to: 1. Number of WICY persons with an HIV Diagnosis with a viral load <200 copies/mL at the last measurement. 2. Number of Women (>24 yrs) with HIV who had at least one HIV medical care visit in each 6-month period of a 24-month measurement period with at least 60 days between the visits. 3. Number of Youth (13-24 yrs) with HIV who had at least one HIV medical care visit in each 6-month period of a 24-month measurement period with at least 60 days between the visits. 4. PCP for HIV+ WICY Patients with CD4 count < 200