Ryan White Title III HIV Capacity Development and Planning Grants - The Los Angeles LGBT Center (Center) is seeking funding through the FY 2025 RWHAP Part C Capacity Development Program under the HIV Care Innovation category, with a focus on Inclusive Care for Underrepresented Communities with Disproportionately High Rates of HIV. The Center proposes to establish a Transition in Care RN position to enhance early engagement and retention for low-income and underserved people living with HIV (PLWH). This initiative will improve linkage to care by ensuring newly diagnosed and returning HIV+ patients receive comprehensive assessments, social risk screenings, and service referrals before their first medical appointment. By integrating social determinants of health (SDOH) data into electronic health records (EHR), the project will improve care coordination and strengthen patient-centered, inclusive HIV services. Despite The Center’s comprehensive HIV care model, barriers remain in ensuring early and continuous engagement, particularly for Black, Latinx, transgender, and youth populations, who experience disparities in retention and viral suppression. Many patients delay seeking care until their first medical appointment, missing crucial opportunities for early intervention. Additionally, high rates of housing instability, behavioral health needs, and medical mistrust contribute to inconsistent care engagement. The proposed Transition in Care RN will directly address these challenges by facilitating immediate linkage to medical, behavioral health, and support services. The project will strengthen The Center’s organizational infrastructure by integrating structured SDOH screenings, enhancing EHR workflows, and improving multidisciplinary coordination between medical providers, case managers, and social service partners. These enhancements will contribute to a 20% reduction in the time from HIV diagnosis or re-engagement to the first medical visit, a 15% increase in six-month retention, and improved viral suppression rates. The Center requests $150,000 for a one-year period to implement this initiative, ensuring that PLWH in Los Angeles receive timely, high-quality HIV primary care that is responsive to their social and health needs.
