LifeLong Medical Care proposes to increase engagement in care to a minimum of 138 individuals within the population of focus, which includes individuals, ages 18 and over, of racial and ethnic minorities with a mental health disorder or co-occurring disorder (MH/COD) living with or at risk for HIV and/or hepatitis. Services will be provided at LifeLong's East Oakland and Ashby Clinics in Alameda County, CA.
The program will hire a licensed/registered mental health clinician as the Project Director to oversee the program and to provide MH/COD services. The program will hire two certified/registered Recovery Support Counselors to provide counseling, coaching, and peer support to participants in the program. The program will hire a Community Health Worker who will assist the Recovery Support Counselors in providing case management services, patient navigation, and recovery support services to individuals at the Clinics. LifeLong will use the Evidence-Based Practices (EBPs) of Harm Reduction, Motivational Interviewing, Seeking Safety, and Contingency Management in its service delivery.
Goals include:
Enhancing MH/COD treatment services including case management and recovery support services; offering HIV/Hepatitis prevention services including screening, case management, and referrals/linkages to care; implementing outreach activities to re-engage patients into care; conducting local performance assessments and documentation according to grant requirements and guidelines.
Objectives include:
• MH/COD screening and assessment, and provision of evidence-based MH/COD services including individual and group counseling to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1)
• Providing access to case management services including benefits counseling, food assistance, housing, and referrals for additional treatment as needed, such as Medication Assisted Treatment to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1)
• Providing access to recovery support services including employment and transportation to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1)
• Providing HIV/Hepatitis screening to a minimum of 50 enrolled individuals annually (prorated to 38 in year 1)
• Providing all enrolled patients who have a preliminary positive HIV and confirmatory HIV test with case management, referrals/linkages to primary care within the LifeLong Clinics
• Offering all enrolled patients who screen negative for HIV and are at risk for becoming infected with HIV access to HIV prevention education, case management, and referral/linkages to onsite PrEP services
• Linking all enrolled patients who test positive for viral hepatitis to healthcare within the two LifeLong Clinics; offering patients who are non-immune to hepatitis A and/or B access to hepatitis vaccines.
• Creating and distributing fliers and posters to LifeLong clinics and the community and facilitating learning groups to re-engage patients who are not actively engaged in treatment
• Participating in cross-site evaluation activities, completing health disparities statement, uploading GPRA data, participating in evaluation activities, and compiling data for semi-annual reports