HRSA HAB has long supported an evaluation pipeline of promising care models to identify those that deserve a wider audience. The Special Projects of National Significance (SPNS) program has been the primary vehicle for supporting, documenting, and disseminating Ryan White Community innovations. The IHIP: Integrating HIV Innovative Practices project has developed a series of robust implementation packages based on SPNS findings.
The list below includes implementation packages and toolkits from SPNS, IHIP, and other innovation projects.
- Using Community Health Workers to Improve Linkage and Retention in Care
Resources to help clinics integrate community health workers (CHW) into an HIV multidisciplinary team model. Includes extensive implementation guide and TA webinars. - Improving Health Outcomes: Moving Patients Along the HIV Care Continuum and Beyond
Resources to help HIV care programs improve health outcomes along with HIV care continuum. Materials include a manual, case studies, pocket guides, and TA webinars and cover a broad range of approaches and audiences. (IHIP) - Engaging Hard-to-Reach Populations
Tools (training manual, curriculum, webinars) for programs on how to create programs to reach clients not in HIV care via outreach, motivational interviewing, patient navigation, case management, and other models. (IHIP) - Social Networks Testing
Social Networks Testing demonstrates that members of high-risk groups are often more effective at identifying and recruiting HIV-positive and at-risk individuals than traditional testing and outreach models. Overview, replication tips, and case study. (IHIP)
- HisHealth: Models of Care for Young, Black, Men who Have Sex with Men
Website features 11 models of care (summary fact sheets and program tools) and multidisciplinary training modules for both providers and community agency leaders and staff (CEUs provided). (CEBACC) - Well Versed
Website for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)
- Correctional Health Linkage Interventions
Implementation resources for an evidence-based intervention to facilitate linkage to community-based HIV care after incarceration. Includes manual, training curriculum, and tools. (IHIP) - Transitional Care Coordination
Evidence-based intervention to facilitate linkage to community-based HIV care after incarceration featuring a training curriculum for agencies and implementation activities and tools. (DEII) - Assess, Test, Link- Achieve Success (ATLAS) Program
Integrates jail-based case managers into the community HIV case management system to engage and subsequently link incarcerated individuals as they transition from jail to community. Overview, replication tips, and case study. (IHIP) - Care Coordination Intervention
Intervention promotes HIV medication access, coverage, and pickup for individuals transitioning from correctional facilities. Overview, replication tips, and case study. (IHIP) - Enhancing Linkages to Care for Women Leaving Jail
Innovative, evidence-informed intervention integrates jail-based case managers to work with jail-based discharge planners and peers to support HIV-positive women as they transition from jail to the community. Overview, replication tips, and case study. (IHIP) - Video Conferencing Intervention: Case Study, Overview, and Replication Tips
This intervention allows community-based case managers to connect via video chat with incarcerated clients prior to release. Overview, replication tips, and case study. (IHIP)
- Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations
Implementation manuals and other tools on models of care (e.g., medical homes, patient navigation, case management) for people living with HIV who have co-occurring conditions (substance abuse, mental health, homelessness). (SPNS ETAC)
- Integrating Hep C Treatment into HIV Care
Methods for integrating HCV and HIV care, outlined in an implementation guide, two case studies, and pocket guide that present steps, best practices, and tools (e.g., staffing, checklists). (IHIP) - Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care
Training curriculum and manual on how to set up a buprenorphine program within an HIV agency with tools and examples of programs (spotlights and handouts). (DEII) - Integration of Buprenorphine into HIV Primary Care Settings: Tools from the Integrating HIV Innovative Practices Program
Training manual and curriculum on setting up buprenorphine services, covering prescribing, selecting and managing patients, patient education, staff training. Includes educational webinars and FAQs. (IHIP)
- Culturally Appropriate Interventions of Outreach, Access and Retention among Latino/a Populations Initiative: An Intervention Monograph
Detailed descriptions of nine Latino SPNS demonstration projects. - Building Effective Interventions for Latino Clients
Webinar featuring two demonstration sites implementing effective linkage and retention strategies for Latino clients with HIV and substance use disorders - Culturally Appropriate Engagement and Service Delivery with Latino/as
Webinar series on ways to improve HIV primary care patient outcomes for Latinos/as who are incarcerated or have a history of incarceration.
- Creating Innovative Oral Health Care Programs
Training manual (with lessons learned), a curriculum (with instructions and oral health replication models), a pocket guide for providers, and webinars on dental case management and clinical aspect of oral care. (IHIP) - Integration of Oral Health and Primary Care Technical Assistance Toolkit
Outlines steps to oral care integration and provides practical, evidence-based advice on how to implement and sustain them in your program. (HRSA HAB)
- Building Blocks to Peer Success: Training HIV-Positive Peers to Engage PLWHIV in Care
Multi-part manual to train HIV-positive peers as clinic staff to engage people living with HIV in care. Companion toolkit on establishing a clinic peer program (Peer Center, HRSA HAB) - Peer Linkage and Re-engagement of HIV-Positive Women of Color
Resources to prepare women of color living with HIV to provide peer support to link/re-engage clients in HIV primary care. Includes training curriculum for peers and a manual for staff on how to implement a peer program, with extensive tips and tools in both. (DEII)
- Kaleidoscope of Care: Responding to the Challenges of HIV and Substance Use
Cross-disciplinary training curriculum on the relationship between HIV infection and substance use. Modules include health promotion/adherence, harm reduction, interdisciplinary care, and care engagement strategies. In English and Spanish. (SPNS ETAC) - Integrating Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care
Training curriculum and manual on how to set up a buprenorphine program within an HIV agency with tools and examples of programs (spotlights and handouts). (DEII) - Integration of Buprenorphine into HIV Primary Care Settings: Tools from the Integrating HIV Innovative Practices Program
Training manual and curriculum on setting up buprenorphine services, covering prescribing, selecting and managing patients, patient education, staff training. Includes educational webinars and FAQs. (IHIP)
- Active Referral Intervention
This intervention uses Disease Intervention Specialists (DIS) to more actively and immediately link clients to HIV care services. Overview, replication tips, and case study. (IHIP) - Louisiana Public Health Information Exchange
This intervention facilitates bidirectional information exchange between hospital system records and public health surveillance data to identify and link out-of-care HIV-positive clients back to care and treatment. Overview, replication tips, and case study. (IHIP) - My Health Profile Continuity of Care Record Intervention
My Health Profile is a patient portal leveraged across a regional health network containing critical health information to improve continuity of care. Overview, replication tips, and case study. (IHIP) - SPNS Systems Linkages Project
Manuals and tools from five demonstration sites on how to replicate linkages across public health systems via innovative strategies (e.g., referral systems, care engagement techniques, patient navigation, electronic medical records). (SPNS ETAC)
- SPNS Transgender Women of Color Initiative Intervention Manual
Intervention ideas for engaging transgender women of color living with HIV into HIV care, with intervention descriptions and lessons learned from each of nine sites. (SPNS ETAC)
- Peer Linkage and Re-engagement of HIV-Positive Women of Color
Resources to prepare women of color living with HIV to provide peer support to link/re-engage clients in HIV primary care. Includes training curriculum for peers and a manual for staff on how to implement a peer program, with extensive tips and tools in both. (DEII) - Enhanced Patient Navigation for HIV-Positive Women of Color
Tools for use of patient navigators to support women of color living with HIV to optimize their engagement in care via support and patient empowerment. Includes training curriculum for navigators and manual for program staff on implementing a program. (DEII) - Women of Color: Enhancing Access
Guide for ways to expand/improve services for women of color living with HIV, with planning and implementation steps based on best practices from demonstration sites, from steps on getting started to lessons learned. (IHIP)
- Expanding Care for People Living with HIV Toolkit
Actions that health agencies can take to either add or increase HIV care to their service offerings. Four steps are outlined, and each presents an implementation tool to guide that step. Also presents lessons learned. (SPNS ETAC) - Optimizing the Care Team
Insights on operating Care Teams: multidisciplinary collection of providers who work together to meet multiple patient needs to improve care delivery and outcomes. Best practices cover: preparation, staffing, buy-in, formalization, and adaptability. (SPNS ETAC) - Patient Engagement and Care Coordination in HIV Health (PEACCH) Tool
Steps for setting up an HIV care coordination program (e.g., getting buy-in, staffing, health information systems). (SPNS ETAC)
- SPNS Social Media Initiative Demonstration Site Monographs
Intervention monographs from ten demonstration sites on technology-based projects to improve engagement, retention, and outcomes in youth. - Building Futures: Supporting Youth Living with HIV
Activities agencies can undertake to enhance delivery of HIV care to youth living with HIV, presented under the themes: clinical service models, infrastructure development, information program development, and wraparound services. (HRSA HAB) - HisHealth: Models of Care for Young, Black, Men who Have Sex with Men
Website features 11 models of care (summary fact sheets and program tools) and online multidisciplinary training modules for both providers and community agency staff and leaders. (CEUs provided). (CEBACC) - Well Versed
Website for Black MSM living with HIV focused on finding and getting the most out of HIV care. (CEBACC)
Guide to Sources
- CEBACC: Center for Engaging Black MSM Across the Care Continuum. TA project ending in 2018.
- DEII: Dissemination of Evidence-Informed Interventions. SPNS project evaluating implementation packages for four interventions.
- HRSA HAB: Health Resources and Services Administration HIV/AIDS Bureau.
- IHIP: Integrating HIV Innovative Practices - develops and disseminates replication tools derived from the SPNS program after projects have completed.
- SPNS: Special Projects of National Significance. Program under RWHAP Part F responsible for HIV care model identification, evaluation, and dissemination.
- SPNS ETAC: Each SPNS project has an Evaluation and TA Center (ETAC) with responsibility for compiling dissemination tools (manuals, training resources) developed under the initiative.
Innovation Pipeline
Active Innovation Projects
Watch for resources from these ongoing RWHAP projects.
- Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Coinfected People of Color. 2016-2019.
- Improving HIV Health Outcomes through the Coordination of Supportive Employment and Housing Services. 2017-2020.
- Curing Hepatitis C among People of Color Living with HIV. 2017-2020.
- Dissemination of Evidence-Informed Interventions. 2015-2020.
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Evidence-Informed Approaches to Improving Health Outcomes for People Living with HIV. 2018-2020.
- E2i: Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV. 2017-2021.
- Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black MSM. 2018-2021.
- Improving STI Screening and Treatment among People Living with or at Risk for HIV. 2018-2021.
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Capacity Building in the RWHAP to Support Innovative Program Model Replication. 2019–2022.
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Strengthening Systems of Care for People with HIV and Opioid Use Disorder. 2019–2022.
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Enhancing Linkage of STI and HIV Surveillance Data in the RWHAP. 2019-2022.
Comprehensive inventory of SPNS-derived resources on the TargetHIV website.
Ryan White Conference on HIV Care and Treatment
Access dozens of slide presentations from your RWHAP peers.