► See Transitional Care Coordination (TCC)

Detailed Fact Sheet (PDF)

Current Care Coordination Protocol and Tools
- The protocol is intended to be a reference for medical case management or care coordination providers for the purpose of care coordination for persons living with HIV/AIDS (PLWHA).  It is also a requirement for Ryan White (Part A) funded Care Coordination Programs per the terms of the contract (solicited through the Care Coordination Request for Proposal).

HIV Care Coordination Program in NYC: An Evidence-Based Intervention (PDF)
- This presentation by Fabienne Laraque, MD, MPH gives a brief overview of the NYC Health Department’s vision for care coordination in NYC and takes a deeper look at its implementation.

Prevention and Access to Care and Treatment (PACT)

• The Care Coordination program adopts principles from the Prevention and Access to Care and Treatment (PACT) Project.  PACT is modeled on a Haitian DOT-HAART program launched in 1998 using accompagnateurs to educate and provide psychosocial support to HIV-infected patients via home visits.  In 2002, PACT Project started in inner-city Boston and adopted community health promoters & introduced Directly Observed Therapy (DOT) Specialists to increase antiretroviral adherence and promote self-sufficiency.



• Basic Principles of PACT include:
  • Curriculum-based skills building.
  • Intensive home-based weekly health promotion.
  • Home-based DOT.
  • Accompaniment to medical visits by a Health Promoter to serve as a patient navigator, coach, and advocate.

Care Coordination Guides and Other Print Materials:

Living Positively with HIV (PDF) 
Other languages: [En Español]

Poster (PDF)
Other languages: [En Español]

Provider Pocket Guide (PDF)

Patient Brochure (PDF)
Other languages: [En Español]

Patient Workbook (PDF)
Other languages: [En Español]

Fact Sheet (PDF)

Client Journal Wallet Card (PDF)
Other languages: [En Español]

Early HIV Treatment Brochure (PDF)
Other languages: [En Español] 

Presentations

• December 16, 2011 eSHARE (PDF)
  • Welcome to eShare (PDF)
  • Working with Clients (PDF)
  • General Assessments (PDF)
  • Individual Services Delivered (PDF)
  • Reports (PDF)
  • Referrals (PDF)
  • Contract Management (PDF)
• November 9, 2011 (PDF)
• September 27, 2011 (PDF)
• May 24, 2011 (PDF)
• May 4, 2011 (PDF)

Agendas

• November 9, 2011 (PDF)
• September 27, 2011 (PDF)
• May 12, 2010 (PDF)

Meeting Notes

• eSHARE Update - November 9, 2011 (PDF)
• Procedure for Provider Communications - November 9, 2011 (PDF)
• Breakout Discussion Guide-May 12, 2010 (PDF)

Care Coordination Newsletter (PDF)

Official Correspondence  

Referral Resource Guide (PDF)

Care Coordination Provider Meeting Information

• Presentations
  • CC Provider Meeting Presentation - May 9, 2012 (PDF)

• Agendas
  • Agenda - May 9, 2012 (PDF)

Substance Abuse and Harm Reduction Presentations

• HIV and AOD Forum - February 3, 2011 (PDF)

• Planning Council approved Substance Abuse and Harm Reduction Services Guidance - July 29, 2010 (PDF)

Research Abstracts

• Development of a Comprehensive HIV Care Coordination Program
  in NYC (PDF)



• The Development and Implementation of a User-Friendly Priority Setting Tool for HIV Care and Treatment Services in New York City
  • This was the Target Center's “Tool of the Month” in August 2010. For more information, search the Target Center's Technical Assistance library