Connected Care Initiative: Evidence-based integration of mental health/co-occurring disorders services and primary care services for people living with, or at risk of, HIV - Connected Care Initiative (CCI) integrates mental health (MH) and co-occurring disorder (COD) treatment with HIV/viral hepatitis (VH) medical care and prevention services, at Positive Impact Health Centers, an AIDS Service Organization with a 30-year history in the Atlanta, GA area. During the four-year project, 376 people living with, and at risk of, HIV, will enroll in evidence-based services, including trauma treatment, psychiatry, case management, and peer support. The majority of consumers will be African Americans who identify as gay men or cis/trans women.
The overarching goals of this initiative are to: 1) reduce the incidence of HIV 2) improve health and mental health outcomes for people with MH/COD. These could not be more critical than in Atlanta, where, according to the CDC, HIV is 16 times more prevalent than the US prevalence.
Service integration is first key to reaching these goals. CCI implements the evidence-based practice (EBP) of Patient Centered Medical Home (PCMH), a formal care delivery model that provides care to patients when and where they need it, in a manner they can understand. MH/COD providers, primary care providers, and case managers are assigned to Care Teams that meet in daily huddles, and weekly for case consultation, ensuring that care is fully coordinated to meet patient needs. The model also requires non-traditional hours, walk-in services, and 24-hour emergency phone access to providers.
The second key is the provision of accessible, evidence-based, culturally appropriate MH/COD treatment. Because people living with HIV experience post-traumatic stress disorder (PTSD) at up to eight times the general population rate, and untreated MH/COD can lead to risk behavior and non-adherence to care, CCI utilizes two EBPs to treat trauma: Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR). CCI also provides peer support utilizing the Wellness Recovery Action Plan (WRAP). CCI consumers can access the agency's wrap-around services that include psychiatry, medication co-pay assistance, case management, HIV/VH testing, VH vaccination/treatment, a licensed Intensive Outpatient Substance Abuse Treatment program, and Medication Assisted Treatment for opioid use.
The third key is to reach those most at need of services, including the 29% of people living with HIV in Atlanta who are not in HIV care. CCI does this through a successful prevention strategy: geo-fenced social media advertisements that are pushed when people are in specific locations (sex clubs, gay bars, and ballroom scene events). Implementation of these strategies results in more individuals recovering from MH/COD issues, reducing HIV risk behavior and, reducing lapses in care.
