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Transitional HIV Care Coordination Tools

The protocol is intended to be a reference for transitional care coordination providers for the purpose of time-limited case management for persons living with HIV/AIDS (PLWHA).

The resource section offers key documents to assist Ryan White (Part A) funded TCC programs with care coordination and stabilization for HIV-infected individuals.

Transitional Care Coordination Forms:

TCC-CTI Model Presentation Part I, TCC-CTI Model Presentation Part II
This two-part presentation by Center for Urban Community Services (CUCS) gives an in-depth overview of the NYC Health Department’s vision for the Transitional Care Coordination program. TCC is adapted from the Critical Time Intervention Model, developed and tested by researchers at Columbia University and listed in the National Registry of Evidence Based Practices.

Transitional Care Coordination to Homeless and/or Unstably Housed Persons – Health Promotion Guide
  • Health promotion activities consists of curriculum supported skills building discussions toaddress basic and HIV-related health needs, harm reduction strategies, and to target medication adherence and risk reduction.
  • The following health promotion guide consists of conversations that should be discussed with clients as it pertains to their needs and risk factors.
  • Information presented in this curriculum relies heavily on the Prevention and Access to Care Treatment (PACT) Project, a community-based project in inner city Boston committed to improving the health outcomes for marginalized individuals, which is currently in partnership with the NYC DOHMH.

Care Coordination (MCM), Mental Health Services (MSV), and Supportive Counseling and Family Stabilization (SCF) Resource Guides
This comprehensive listing provides contact information for all Ryan White Part A HIV Care Coordination and SCF Programs in New York City

Transitional Care Coordination Provider Meeting Information


Meeting notes and other resources

Program Updates