Written by Donna Colonna, CEO Services for the UnderServed

Innovation is synonymous with a new way of doing something, an idea successfully applied and adapted as a best practice. Over recent years SUS has earned a reputation for innovation in program and service delivery, as well as in the creation of an outstanding organizational culture.

The SUS Care Coordination Project is the latest example of SUS program development to be championed as a transformative best practice. The New York City Department of Health and Mental Hygiene (NYC DOHMH) awarded a multi-year grant through Public Health Solutions in recognition of SUS’ capacity and capability to create an innovative model of service based upon emerging research in HIV/AIDS care treatment.

New York City continues to be the epicenter of the U.S. epidemic. More than 100,000 New Yorkers are infected with the HIV/AIDS virus. While advances in medical care for people living with HIV/AIDS (PLWHA) have been significant, disparities exist in health care access and health outcomes for PLWHAs.

The people served by SUS are especially challenged by histories of mental illness, substance abuse, inadequate housing, and poverty, which make their adherence to a medical care plan and antiretroviral medications all the harder. The challenges are even more difficult for approximately 150 SUS consumers who live in 10 commercial SROs in Manhattan and the Bronx. They must cope with substandard living environments as well as an informal economy of drug dealing, prostitution and loan-sharking. It is these people who are the targeted beneficiaries of the Care Coordination Project.

The program innovation lies in a model for the organization and deployment of a rapid response team that works with neighborhood medical centers to ensure primary medical care and sustainable treatment adherence. The team includes a care coordinator, a physician’s assistant or nurse practitioner, ‘navigators’ who will coordinate medical and social services, and ‘escorts’ travelling with PLWHAs to necessary interventions including examinations and primary care visits.

The project’s results will be demonstrated in PLWHAs who maintain a stable health status. Linked in a timely coordinated manner to medical and social services will ensure that individuals achieve medical stability and suppressed viral load. The provision of support and coaching in treatment adherence will further increase the number of PLWHAs who become self-sufficient, able to manage their medical and social needs autonomously. “Because we are targeting such a needy, transient population it is our hope,” says Nancy Southwell, Director, SUS PLWHA Services, “is that amidst all the chaos and uncertainty in their lives we can at least support them in receiving consistent, comprehensive medical care.”

Allen Feldman, the Care Coordination Project Director, has led the SUS SRO Intervention project since 2006. He has extensive experience in designing and implementing interventions in socio-economic and cultural peripheries with service resistant target populations. “This expansion of our existing program,” says Mr. Feldman, “is innovative and cutting edge and will address the needs of people in the most marginalized situations in New York City.” With an innovative model and financial support in place, Allen and his team will undoubtedly make an even greater difference in the lives of this underserved population.