Title: Coordinated HIV Services & Access to Research for Women, Infants, Children & Youth Applicant: Fresno Community Hospital & Medical Center Address: 290 N. Wayte Lane, Fresno CA 93701-2124 Project Director: Robyn Gonzales, Vice President, Operations 559-459-5750; 559-724-4271 (Fax) rgonzales@communitymedical.org; www.communitymedical.org Funds requested for Year 1: $429,636 (years 2-4 anticipated to be the same) MODEL OF CARE: Community Special Services (CSS) has developed an effective model for provision of WICY HIV care that integrates consumer involvement, focused medical case management, and HIV specialist care. Since 1989, CSS has been at the forefront of Central Valley HIV medical and medication management, mental health care, medical and non-medical case management services, and referrals for substance abuse treatment and research activities. Primary care services provided by CSS include diagnosis and treatment of HIV/AIDS, prophylactic and treatment interventions for opportunistic infections and other complications, and referrals to nutritional, dental and specialty care services. CSS also has established relationships upon which to build increased linkage to care for WICY affected by HIV. In partnership with the University of California San Francisco (UCSF) Fresno Medical Education Program, CSS is also the only program in the region that trains physicians and infectious disease fellows specializing in HIV/AIDS. This connection with graduate medical education keeps faculty providers at the forefront of HIV research and care and improves CSS’s ability to coordinate services throughout the Central Valley. NUMBER OF WICY WITH HIV SERVED ANNUALLY: CY 2019, 346; CY 2020, 363; CY 2021, 377. The number of WICY served by CSS increased by nine percent (8.96%) over the three-year period. SERVICE AREA: Community Medical Centers’ Special Services HIV/AIDS program serves Fresno County, a mix of urban and rural areas with a to
tal population of 1,008,654, according to April 2020 US Census QuickFacts. POPULATIONS TO BE SERVED: Part D funding will allow Community Special Services to provide support services to women, infants, children, and youth infected with and affected by HIV/AIDS. Priority populations include pregnant women, women of childbearing age and male partners of pregnant women and men who have sex with men. In 2021, 78.7% of CSS patients are White, 14.9% are African American, 3.3% are Asian, 0.9% are American Indian/Alaskan Native, and 0.5% are Native Hawaiian or Other Pacific Islander. Ethnicity data indicates 33.2% are Hispanic or Latino and 66.8% are not Hispanic or Latino. KEY SERVICES, QUALITY IMPROVEMENT MEASURES: Community’s HIV primary care program is an integral part of an academic tertiary-care hospital. The program offers primary and HIV specialty care services within the CSS clinic setting; specialty care medical services are available through Family HealthCare Network, an FQHC, within the Ambulatory Care building. Ambulatory Care also houses an adolescent clinic and a general pediatric clinic, as well as pediatric subspecialties. Additional services include case management, insurance enrollment, rapid HIV and Hepatitis C screening, and referrals to HIV Pre Exposure Prophylaxis (PrEP) navigators. Specialty services are also available within the larger Fresno Community Hospital environment. CSS’s primary QI focus includes three clinical indicators: 1) Adherence with appointments; 2) Reduction of HIV viral load <200; and 3) Cervical PAP screening. Other goals, such as patient satisfaction and cultural competency, are addressed and contribute to improving appointment and medication adherence, which are critical steps to achieving other care goals.