Community Support Services

Behavioral Health Education Services Initiative

The Bureau of Community Support Services oversees the Ryan White Part B HIV/AIDS Behavioral Health Education (BHE) Initiative, which supports community based HIV/AIDS behavioral health education and engagement service programs and a HIV/AIDS behavioral health education training and technical assistance center.

The purpose of the community based HIV/AIDS behavioral health education and engagement service programs is to educate clients about the benefits of engaging in mental health and substance abuse treatment, and help address stigma or related anxiety that impact a client’s willingness to engage in, adhere to, and be retained in HIV medical and behavioral health care and treatment. BHE programs provide behavioral health screenings, referrals, and psychoeducational interventions to PLWH/A. These are short term mechanisms for identifying clients and promoting treatment readiness for linkage to and engagement in behavioral health treatment. Behavioral Health Educators and Peer Navigators work together to screen clients for behavioral health needs, conduct individual behavioral health education sessions to destigmatize behavioral health issues, encourage engagement into appropriate treatment, and facilitate expedited referrals to licensed behavioral health professionals.

The purpose of the HIV/AIDS behavioral health education training and technical assistance center is to provide HIV/AIDS focused behavioral health education training and technical assistance services to the funded BHE programs in order to advance the capacity of the behavioral health education and engagement service programs funded through this initiative. Services are intended to increase the number of staff who are educated and motivated to perform behavioral health education, screening, engagement, and linkage services to PLWH/A with behavioral health needs.  

Contact:

John J. Hartigan,  LCSW
Director, Behavioral Health Education Initiative
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(518) 486-1323
john.hartigan@health.ny.gov

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Legal Services for Individuals and Families Living with HIV/AIDS and Family Stabilization Support Services Initiative

The Bureau of Community Support Services oversees the Legal Services for Individuals and Families Living with HIV/AIDS & Family Stabilization Support Services (LASSIF) Initiative throughout New York State.  

The purpose of the LASSIF Initiative is to ensure the provision of comprehensive legal services for HIV positive individuals and HIV affected families with dependent children, and family stabilization support services for HIV affected families with dependent children. Legal assistance is to be provided for a wide variety of legal matters including consumer/finance, education, employment, health, housing, income maintenance, individual rights, care and custody plans and other issues such as wills, health care proxies and advance directives. Family stabilization support services are designed to help HIV affected families cope with the emotional and physical needs of living with HIV/AIDS with a focus on working with families to make decisions for future care and custody planning.

The LASSIF Initiative supports fully integrated models of legal services for HIV positive individuals and families affected by HIV/AIDS with focused stabilization support services for families. The legal services programs are designed to provide comprehensive individual and family legal services including legal counsel, advice and/or representation in such matters as discrimination, domestic violence, public benefit programs, housing, health care access, consumer finance, education, and the many other diverse legal issues that arise for persons living with HIV/AIDS.

Legal assistance or representation is often needed to enable people with HIV/AIDS to overcome barriers to care or services, maintain benefits or services, or assert legal rights. Funded programs provide:

  • comprehensive legal needs assessments of all clients at intake and regular reassessment to identify new legal needs and problems and provide referrals for other identified needs including health care, case management and other services needed by clients;
  • comprehensive legal services, including legal counsel and advice in such matters as discrimination, domestic violence, entitlements, housing, health care, consumer finance, education, individual rights, etc.;
  • family legal services focusing on future care and custody, guardianship, standby guardianship, adoption and foster care for dependent children;
  • preparation of wills, health care proxies and living wills;
  • legal services for transgender persons requiring assistance, such as assistance with documentation issues related to access to care;
  • client education about legal issues and available services as part of the resolution of a legal problem; and
  • provision of outreach, technical assistance and education to community-based health and human service providers about legal issues and services available for PLWHA and families affected by HIV in order to ensure timely and appropriate referrals.

Family stabilization support services assist HIV affected families cope with the emotional needs of living with HIV/AIDS. Services are family-centered and work in conjunction with the program’s legal staff to help HIV positive parents, their dependent children and identified caregivers make care and custody decisions, address transition issues faced by new caregivers and children, and stabilize the newly formed family constellation. Family is defined as the chosen support system of a client. These services are focused, conveniently located for the family such as home based service delivery, and are short-term in duration. Services may be provided individually or in a group setting for all members of the HIV affected family. Families needing longer term mental health or supportive services are referred to other programs in the community.

Funded programs provide:

  • family needs assessment, service plan development and coordination of services for both family and individual interventions to assist the family in meeting goals related to care and custody;
  • permanency planning services that include working with HIV-positive parents to identify appropriate caregivers for their dependent children;
  • assistance with disclosure of HIV status that is age and developmentally appropriate;
  • transitional services to stabilize newly blended families following parents’ incapacitation or death;
  • grief and bereavement support;
  • referrals to providers of other services needed by the family including case management, domestic violence, partner notification, mental health, transportation and educational services; and
  • outreach, technical assistance and education to HIV-affected families and to case management and community-based health and human service providers about the legal and family stabilization needs impacting HIV-affected families with dependent children.

Contact:

Deborah Hanna
Director, LASSIF Initiative
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(212) 417-4487
deborah.hanna1@health.ny.gov

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Nutrition Health Education and Food and Meal Services Initiative

The Bureau of Community Support Services oversees the HIV/AIDS Nutrition Health Education and Food and Meal Services (NHE) Initiative which funds community based programs throughout New York State that support nutrition interventions that improve, maintain and/or delay the decline of PLWH/A’s health status. The NHE Initiative has two components that assist PLWH/As to support their nutritional goals: 1) nutrition health education, and 2) food and meal services. 

Nutrition Health Education

Nutrition health education empowers clients to learn, practice and apply self-management skills needed to achieve optimal health outcomes; and provides the interventions and skill building necessary for reducing food insecurity and ensuring the development of core competencies that support safe healthy food choices. Self-management skills development includes teaching independent health care behaviors and decision making, while encouraging clients to be responsible for their health care and lifestyle choices. Nutrition health education assists clients with identifying nutritional goals and developing a plan that supports those goals; and provides clients with health and nutrition information that help them make healthy food and lifestyle choices. 

Nutrition workshops are facilitated by a culturally-competent Community Nutrition Educator (CNE) either in group settings or individually, and include HIV/AIDS nutrition related topics and instruction on how to prepare and make appropriate food choices.  The CNE assists clients in identifying community resources that promote self-sufficiency through referrals to other community providers.  

Nutrition health education curriculum topics include:

  • Purchasing, preparing, and cooking healthy foods;
  • food safety and budget strategies/tips when shopping and cooking;
  • shopping and cooking workshops incorporating food pantry items or food gift cards/vouchers;
  • improving food intake and the role of fitness/exercise in maintaining health;
  • symptom management strategies (i.e. loss of appetite, nausea, vomiting); and
  • personal strategies to promote healthy nutrition behavior change.

Community Coordination Activities

Community coordination activities ensure that PLWH/A are referred to additional resources that address their needs (i.e., case management, primary care, and other food and financial sources), promote general health and wellness, and facilitate adherence to and retention in medical care and treatment. It involves a multidisciplinary care coordination process that encompasses collaborative service provision across all disciplines within the program, facility and community involved in the client’s care to achieve optimal outcomes.  Community coordination also involves leveraging other community resources that are critical for: 1) enhancing the provision of service delivery, 2) maximizing client access to nutritional services, 3) assisting clients to overcome personal or cultural barriers that prevent them from making good nutritional choices, and 4) addressing issues that may compromise their health status.

The Nutrition Program Assistant (NPA), in conjunction with the Community Nutrition Educator (CNE), is responsible for performing the community coordination activities. These include identifying and making referrals to appropriate community resources that address the needs of and help remove barriers for the client.

Food and Meal Services

Food and Meal Services assist to stabilize the client while they develop the necessary skills to make appropriate food choices that will improve and/or maintain their health status. Nutrient dense, well balanced and safe meals, and food tailored to the specific dietary needs of PLWH/A assist in maximizing the benefits of medical interventions and care. NHE and Food and Meal programs must establish an ongoing mechanism for communicating and coordinating with a Registered Dietitian to obtain dietary recommendations and assessments. This is an important aspect of overall nutritional care and ensures that clients receive the appropriate type and level of food and meals that meet their needs.

There are four food and meal services:

  • Home-Delivered Meals (hot and/or frozen) help to maintain or improve the health and well- being of home restricted individuals with HIV/AIDS by providing high calorie, high protein, therapeutically tailored meals and snacks.  For PLWH/A that lack the ability to shop for and prepare food,
  • Congregate Meals are served in community locations fostering access to health care, prevention, and supportive services, while meeting the nutritional needs of PLWH/A.  Many individuals using the congregate meal programs are indigent, homeless, or in marginal housing which lack kitchen facilities and food preparation equipment. 
  • Food Pantry Bags and Food Vouchers allow PLWH/A with limited financial resources access to nutritious food. In conjunction with nutrition services, PLWH/A are able to increase their levels of independence by preparing meals and making their own food choices. 

Contact:

Maryland M. Toney, MS
Director, Nutrition Initiative
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(212) 417-4481
maryland.toney@health.ny.gov

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Engagement and Supportive Services Initiative: Case Management and Health Education Services

The Bureau of Community Support Services oversees the Ryan White HIV/AIDS Engagement & Supportive Services (ESS) Initiative. The services funded under the ESS Initiative support the AIDS Institute's commitment to ending the AIDS epidemic by 2020 by reinforcing the priorities of increasing linkage and access to, and engagement and retention in HIV medical care and treatment as a mechanism to assist in achieving viral suppression among PLWHA. Services focus on engaging and re-engaging the PLWHA who has either fallen out of or is sporadically involved with HIV care and treatment. In addition, funded services strengthen the comprehensive continuum of HIV prevention, health care, and supportive services in New York State. 

Case Management

The ESS Initiative provides funding throughout New York State for Community Based HIV/AIDS Case Management & Health Education Services that focus on PLWHA who have either fallen out of, or are sporadically engaged in HIV care and treatment. This is a dynamic, highly proactive model of case management utilizing a multistep process that incorporates a diverse array of activities and interventions that are designed to encourage, support and enhance access to and engagement in care for PLWHA. The model will serve as a bridge to help consumers learn to navigate the health care and support system and gain the knowledge and skills necessary to effectively self-manage and will help support consumer entry into the full continuum of care that is available. Case management efforts are solution focused with frequent consumer and provider contacts, regular monitoring and medical updates, quarterly reassessments and case conferences, and improve health outcomes leading to viral suppression.

Case management providers must establish and document active bi-directional linkages with providers of services including but not limited to: primary medical care services, medical case management, behavioral health (both mental health and substance abuse treatment) services, housing and entitlement services, nutrition services, transportation services, legal services, and peer services.

For Medicaid eligible consumers, Ryan White grant funded Case Management and Health Education programs must maximize existing resources and support consumer entry and retention into Medicaid Health Home programs. Reasons for providing grant-funded services to a Medicaid eligible consumer must be clearly documented in the consumer chart, and all efforts must be geared toward transitioning the Medicaid consumer into the most appropriate program.

Health Education

Health education services support the development of skills and access to systems that will culminate in self-management. The health education interventions provide a didactic forum for learning and opportunities to practice learned skills and process difficulties experienced in achieving treatment adherence. Clients enrolled in the Community Based HIV/AIDS Case Management and Health Education Program must be assessed for and offered health education services as appropriate. Health education services must also be made available to any PLWHA in the region, regardless of where or whether they receive case management services.

The Health Educator must perform a screening and develop a Health Education Service Plan for each consumer to document the consumer’s reasons for participating in the specific service, and what the consumer hopes to accomplish. The Health Educator may conduct individual or group health education sessions. Individual sessions should occur face-to-face but may take place over the phone if there are HIV confidentiality, transportation, or security concerns. Group level interventions involve curricula-based activities designed to improve medical outcomes by reinforcing a consumer’s ability to build necessary support systems, dismantle barriers to accessing and adhering to care, and support the achievement of self-management skills.

Peer Services

Community Based HIV/AIDS Case Management & Health Education programs are expected to incorporate the use of peers to provide specific services that enhance consumer support. Peer Navigators assist with case management efforts to engage consumers who are resistant to or sporadically engaged in HIV health care, (e.g., conduct outreach and engagement efforts) and assist with health education services by sharing insight and personal experience as a consumer of similar services.

Peers are a valuable community resource lending credibility and cultural competence to a program; and can be particularly helpful with individuals who are sporadically engaged in or resistant to care. As frequent contact is an important element of this initiative, peers can assist with contacting and engaging consumers, accompany consumers on appointments, provide encouragement as well as coaching elements, and assist with monitoring of progress. Peers provide a culturally competent approach to self-management that incorporates the sharing of similar experiences and strategies for success from an individual who has navigated similar systems.

Contact:

Mark Perez, Director, ESS Initiative: Case
and Health Education Services
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(212) 417-4480
mark.perez@health.ny.gov

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Engagement and Supportive Services Initiative: Medical Transportation Services and Emerging Communities Programs

The Bureau of Community Support Services oversees the Ryan White HIV/AIDS Engagement and Supportive Services (ESS) Initiative. The services funded under the ESS Initiative support the AIDS Institute's commitment to ending the AIDS epidemic by 2020 by reinforcing the priorities of increasing linkage and access to, and engagement and retention in HIV medical care and treatment as a mechanism to assist in achieving viral suppression among PLWHA. Services focus on engaging and re-engaging the PLWHA who has either fallen out of or is sporadically involved with HIV care and treatment. In addition, funded services strengthen the comprehensive continuum of HIV prevention, health care, and supportive services in New York State. 

Medical Transportation Services

The ESS Initiative provides funding throughout New York State for Community Based HIV/AIDS Medical Transportation services. Medical transportation services include conveyances provided directly or through a voucher to an eligible consumer to access HIV related health care. Transportation to Ryan White fundable support services, intended to improve medical outcomes, may also be provided. Medical transportation services must be made available to all PLWHA in the region.

Eligibility for medical transportation must be assessed every six months. Consumers determined to be Medicaid eligible must be referred to a Medicaid transportation provider. Reasons for utilizing this grant funded medical transportation program to transport Medicaid-eligible consumers must be justified and documented in the consumer record. Program policies and procedures related to consumer eligibility, confidentiality, documentation, quality assurance, service prioritization and waiting list management, and tracking systems are critical to the successful implementation of a medical transportation program.

It is expected that programs offering more than one type of conveyance service will utilize the most cost-efficient means of conveyance, based on individual need and circumstance. Medical Transportation Services to be provided include one or more of the following: 1) directly provided agency or subcontracted transport (by car or van), 2) provision of bus tickets or subway fare cards, 3) by taxi or ambulette, and 4) gas cards may be used if determined to be the most cost-efficient means of transportation.

All directly provided or subcontracted transportation services under this component must maintain consumer confidentiality and enable consumers to be transported safely with reasonable waiting and travel times. Medical transportation providers must ensure reasonable scheduling flexibility, including service hours which coincide with consumer appointments, enabling them to arrive in time to keep appointments. Medical transportation services may not be used for personal errands, including shopping, banking, social or recreational events, travel to restaurants or family gatherings.

Emerging Communities Programs – Services for HIV+ Gay Men and MSM

The ESS Initiative provides funding for Emerging Communities (EC) Programs – Services for HIV+ Gay Men and MSM. Emerging Communities are specific regions in New York State that have had comparatively high rates of AIDS diagnoses: Finger Lakes, Northeastern, and Western New York Regions. These regions encompass urban, suburban and rural areas and present specific challenges when addressing the needs of HIV infected individuals.

Funding supports innovative programs that are designed to assist HIV+ gay men and MSM who are not currently engaged or sporadically engaged in treatment and care; and engage/reengage them in HIV health care and treatment by addressing the specific needs that HIV+ gay men and MSM present with when seeking services. Program services must focus on accessing comprehensive health care with the specific goal of viral suppression. It has been clinically proven that HIV infected individuals with undetectable viral loads are far less likely to transmit HIV to their partners; therefore, EC programs are designed to ensure linkage and retention in care and must contain the following elements:

  • services remain within the purview of Ryan White fundable services and must meet Ryan White requirements regarding consumer eligibility and using grant funds as payer of last resort.
  • services are tailored to address the overall health care needs of HIV-infected gay men and MSM, incorporating a network of providers to address medical care, mental health, substance use treatment, and other services in the region that support improved health outcomes.
  • established and documented active, bi-directional agreements with providers listed in their network.
  • documented client intake, assessment, service plans, periodic reassessments, crisis intervention and case closure.
  • maintain staff who are culturally competent, validate consumer identities (i.e. bisexual, closeted, straight), and are aware of the impact that HIV stigma and homophobia has had on this population.
  • services can include case management, health education, treatment education, risk reduction education for sero-discordant couples, social media interventions with consumers and other Ryan White fundable support services.

Peer Services  

Emerging Communities Programs – Services for HIV+ Gay Men and MSM are encouraged to incorporate the use of peers to provide specific services that enhance consumer support. Peers are a valuable community resource lending credibility and cultural competence to a program; and can be particularly helpful with individuals who are sporadically engaged in or resistant to care. As frequent contact is an important element of this initiative, peers can assist with contacting and engaging consumers, accompany consumers on appointments, provide encouragement as well as coaching elements, and assist with monitoring of progress. Peers provide a culturally competent approach to self-management that incorporates the sharing of similar experiences and strategies for success from an individual who has navigated similar systems.

Contact:

Susan J. Kosinski, Director, ESS Initiative: Medical
Transportation Services and Emerging Communities Programs
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(518) 486-1323
susan.kosinski@health.ny.gov

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