Community Support Services

Behavioral Health Education Services Initiative

The Ryan White Part B HIV/AIDS Behavioral Health Education (BHE) Initiative supports community-based HIV/AIDS behavioral health education and engagement service programs and an 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 to the funded BHE programs 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

Back to top of page

Legal and Supportive Services for Individuals and Families Living with HIV/AIDS (LASSIF)

The purpose of the LASSIF Initiative is to ensure the provision of: (1) comprehensive legal services for HIV-positive individuals and HIV-affected families with dependent children; and (2) family stabilization support services for HIV-affected families with dependent children. Legal assistance is to be provided for a wide variety of legal matters.  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. 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 in coping 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 children and new caregivers, and stabilize the newly formed family. 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) 417-4758
deborah.hanna1@health.ny.gov

Back to top of page

Nutrition Health Education and Food and Meal Services Initiative

The HIV/AIDS Nutrition Health Education and Food and Meal Services (NHE) Initiative funds community-based programs throughout New York State for nutrition interventions that improve and maintain the health of persons living with HIV/AIDS (PLWHA).  The NHE Initiative has two components that assist PLWHA 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. Nutrition health education assists clients in 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 make appropriate food choices and prepare food.  The CNE assists clients in identifying community resources that promote self-sufficiency through referrals to other community providers.  

Community Coordination Activities

Community coordination activities ensure that PLWHA 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 CNE, is responsible for performing community coordination activities, including identifying and making referrals to appropriate community resources that address the needs of and 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 meals tailored to the specific dietary needs of PLWHA 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.

There are two food and meal services:

  • Pantry/Grocery Bags provide a supplemental supply of food to PLWHA in need while also promoting self-sufficiency through referrals to other community resources. Food pantry bags can include non-perishable foods, fresh fruits and vegetables, and meats and poultry to supplement and/or create healthy meals.
  • Food Gift Cards/Vouchers provide a supplemental supply of food to PLWHA in need while also promoting self-sufficiency through referrals to other community resources. Voucher programs must develop a system that ensures only authorized clients redeem vouchers and purchase only allowable foods.

Contact:

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

Back to top of page

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

The Ryan White HIV/AIDS Engagement and Supportive Services (ESS) Initiative reinforces the priorities of increasing linkage to and retention in HIV medical care and treatment 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 and 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 serves as a bridge to help consumers learn to navigate the health care and support services systems and gain the knowledge and skills necessary to effectively self-manage.   Case management efforts are solution focused with frequent consumer and provider contacts, regular monitoring and medical updates, quarterly reassessments and case conferences. 

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.

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.

Community-based HIV/AIDS case management and 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 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 assist in contacting and engaging consumers, accompany consumers on appointments, provide encouragement and coaching, 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
Engagement and Supportive Services Initiative
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
(212) 417-4480
mark.perez@health.ny.gov

Back to top of page

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

The Ryan White HIV/AIDS Engagement & Supportive Services (ESS) Initiative reinforces the priorities of increasing linkage to and retention in HIV medical care and treatment 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.

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 Positive Gay Men and MSM

The ESS Initiative provides funding for Emerging Communities (EC) Programs, which provide services for HIV-positive gay men and MSM. Emerging Communities are specific regions in New York State that have had comparatively high rates of HIV 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 positive 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 of HIV-positive gay men and MSM.  Program services must focus on accessing comprehensive health care with the specific goal of viral suppression. EC programs must contain the following elements:

  • 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 support services.

EC programs 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 assist with contacting and engaging consumers, accompany consumers on appointments, provide encouragement and coaching, 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

Back to top of page