Toolkit Highlights Ways to Improve HIV Outcomes through Data Sharing and Housing and Care Coordination

Content From: Amy Palilonis, M.S.W., Senior Program Specialist, Office of HIV/AIDS Housing, U.S. Department of Housing and Urban Development, and Chau Nguyen, MPH, Project Officer, Special Projects of National Significance Program, HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human ServicesPublished: April 22, 20203 min read


Amy Palilonis and Chau Nguyen
Amy Palilonis (HUD) and Chau Nguyen (HRSA)

A new toolkit offers lessons and insights on how more effective data sharing and coordination of housing and care services can improve outcomes for people with HIV. A collaborative effort developed by the RAND Corporation, and a product of the Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) Special Projects of National Significance (SPNS) and the U.S. Department of Housing and Urban Development’s (HUD) Office of HIV Housing (OHH), this resource should be a useful tool to multiple jurisdictions seeking to innovate in their response to HIV under the Ending the HIV Epidemic initiative.

This toolkit is among products derived from the SPNS initiative Addressing HIV Care and Housing Coordination Through Data Integration to Improve Health Outcomes Along the HIV Care Continuum (2015-2019). Funded by the Minority HIV/AIDS Fund, this project demonstrated how the integration of local Housing Opportunities for Persons with AIDS (HOPWA) and Ryan White HIV/AIDS Program (RWHAP) electronic data systems and coordination of housing and HIV care services affected health outcomes for unstably housed individuals with HIV. Housing is one of the most significant social determinants of HIV-related medical outcomes. In particular, poor housing is linked to lower levels of access to medical care and diminished antiretroviral use and adherence.

The RAND Corporation led a multisite evaluation and provided technical assistance to four performance sites, jointly reaching more than 3,000 RWHAP/HOPWA clients. The sites were:

  • City of Hartford Health and Human Services Department (Hartford, CT);
  • Kansas City Health Department (Kansas City, MO);
  • Palm Beach County Department of Community Services (West Palm Beach, FL);
  • Cascade AIDS Project (Portland, OR)
SMAIF HUD-HAB data grantees kickoff meeting_group photo
MHAF HUD-HAB data grantees kickoff meeting

Based on the experiences of these sites, the toolkit highlights critical decision points, options, and activities to help other organizations interested in replicating a similar project and undertaking their own data sharing and care coordination projects. Findings include:

  • Improved collaboration. Data integration seems to improve communication and coordination between service providers.
  • Better transparency. Integrated data systems add value: housing case managers are able to access and view client HIV care data and HIV case managers are able to view more detailed client housing status information.  This enables them to better understand each client’s situation more broadly.
  • Increased opportunities to spot problems. ‘Flags’ in the data system can alert case managers to real-time opportunities to offer support when a client leaves care or becomes unstably housed.
  • Improved efficiencies. Bridging the gap between the HIV and housing sectors can result in efficiencies for providers and clients (e.g., streamlining processes, reducing duplication, and improving the ability to coordinate client services).
  • Reduced structural barriers. Sharing data across sectors can help reduce unmet needs, gaps in care, and barriers to engaging and staying in health care for people with HIV who are unstably housed or experiencing homelessness.

These and other lessons learned demonstrate that the collaboration between HUD and HRSA’s programs, together with strong local partnerships between HIV and housing service organizations, play important roles in helping end the HIV epidemic. This toolkit will assist organizational leaders who wish to tap into the power of data sharing and care coordination. As it does, they will better be able to help people with HIV improve their health.

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