Community Support Services

The Benefits Counseling Pilot Project

Navigating public benefits is often challenging for Persons Living with HIV (PWLH) who are looking to maintain employment or return to work and need assistance with understanding how their income may affect their benefits.  The Bureau of Community Support Services (BCSS) has initiated a two-year pilot project with some of its existing Legal and Supportive Services for Individuals and Families (LASSIF) programs in order to address this unique need.

Benefits Counseling programs will help clients make decisions about returning to work and potentially reduce benefit loss and overpayment issues, while working closely with their legal counterparts to refer clients for legal services if needed. They will also conduct promotional and educational sessions for providers and consumers about this new service.

In collaboration with Cornell University’s Yang Tan Institute on Employment and Disability, funded staff will participate in an HIV specific Work Incentive Practitioner Credentialing program to prepare them to provide services. 

Community Service Society of New York is a recognized leader in the field of benefits related training and has been funded to serve as the Training and Technical Assistance Center for this project. Their role will be to continue supporting credentialed benefits counselors with promotion of services, maintaining an extensive resource guide for providers, developing and delivering additional trainings, and offering individual case review as needed.  

Contact:

John J. Hartigan,  LCSW
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
john.hartigan@health.ny.gov

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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
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
deborah.hanna1@health.ny.gov

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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
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
maryland.toney@health.ny.gov

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Engagement and Supportive Services Initiative: Case Management, Health Education Services and Emerging Communities

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.

Emerging Communities – 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:

Mark Perez
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
mark.perez@health.ny.gov

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Engagement and Supportive Services Initiative: Medical Transportation Services

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.

Contact:

John J. Hartigan,  LCSW
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
john.hartigan@health.ny.gov

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Supportive Housing Initiative

Financial Assistance and Housing Retention Services for PLWHA

This program provides financial assistance and housing retention services to support PLWHA in obtaining and maintaining safe and affordable housing, and to prevent eviction and utility shut off.  Services include, but are not limited to:

  • One-time-only emergency financial assistance may be provided to eligible clients living outside of New York City once during a 12-month period for emergency assistance for rent, utility, moving costs, and brokers fees. It is not intended to provide ongoing financial support.
  • Short-term financial assistance provides support to clients living outside of NYC at risk of eviction or foreclosure and enables them to gain and/or maintain stable housing and medical care.  Short-term rental assistance provides financial assistance to pay for a portion of an eligible client’s rent for multiple periods, unlike emergency assistance.  Short-term rental assistance can be provided for up to 24 months.
  • Educational services such as independent living skills (e.g., budgeting, parenting, tenant property management), health education and nutrition education.
  • Coordination of services in conjunction with the assigned care manager (e.g., health home or managed care organization care manager).
  • Case conferencing with other service providers including health home care managers, health care providers, substance use providers and/or mental health providers.

Financial Assistance and Housing Retention Services for HIV Infected Lesbian, Gay, Bisexual and Transgender (LGBT) Young Adults (Age 18-24) in New York City

This program provides limited financial assistance and housing retention services to LGBT young adults between 18 and 25 years old living with HIV in New York City. It assists with developing the skills necessary for remaining in stable housing so that they may engage in and maintain enrollment in medical care and acquire the skills and stability needed to successfully achieve independent living. Services include, but are not limited to:

  • Limited-term rental assistance provides financial assistance to clients who are not HASA eligible to pay for a portion of an eligible client’s rent until the client develops the skills and stability needed to successfully achieve independent living, or until the client reaches the age of 25.
  • Educational services such as independent living skills (e.g., budgeting, parenting, tenant property management), health education and nutrition education.
  • Coordination of services in conjunction with the assigned care manager (e.g., health home or managed care organization care manager).
  • Case conferencing with other service providers including health home care managers, health care providers, substance use providers and/or mental health providers.

Medicaid Redesign Team (MRT) Long-Term Rental Assistance and Housing Retention Services for High-Need Medicaid Beneficiaries Living with HIV/AIDS Outside of New York City

This program provides long-term rental assistance and housing retention services to high-need Medicaid beneficiaries living with HIV/AIDS as well as other morbidities, who are homeless, unstably housed, or at high risk of becoming homeless, and who live outside of New York City. Services include, but are not limited to:

  • Long-term rental assistance provides financial assistance to pay for a portion of an eligible client’s rent until the client develops the skills and stability needed to successfully achieve independent living.
  • Educational services such as independent living skills (e.g., budgeting, parenting, tenant property management), health education, nutrition education, and vocational readiness education.
  • Coordination of services in conjunction with the assigned care manager (e.g., health home or managed care organization care manager).
  • Case conferencing with other service providers including health home care managers, health care providers, substance use providers and/or mental health providers.

Empire State Supportive Housing Initiative (ESSHI)

This program provides the funding needed to operate and provide rental assistance and housing retention services to eligible target populations so that they remain stably housed in permanent supportive housing units. The eligible target populations to be served under this program are families, individuals and/or young adults who are homeless, are identified as having an unmet housing need, and have one or more disabling conditions including, but not limited to:

  • Serious mental illness;
  • Substance use disorder;
  • Persons living with HIV or AIDS;
  • Victims/Survivors of domestic violence;
  • Homeless young adults between 18 and 25 years old;
  • Adults, youth or young adults reentering the community from incarceration or juvenile justice placement, particularly those with disabling conditions; and
  • Individuals who are Medicaid Redesign Team (MRT) high cost Medicaid populations (MRT Eligible).

Services assist eligible families, individuals and young adults to live independently and remain stably housed, and may include but are not limited to:

  • Promoting access to and engagement in primary health services;
  • Promoting access to and engagement in behavioral health services;
  • Housing case management;
  • Counseling and crisis intervention;
  • Legal system advocacy and court assistance;
  • Parenting skills development and support;
  • Life skills training and support; and
  • Transportation assistance for needed services/entitlements.

New York/New York III Supportive Housing Agreement

The New York/New York III (NY/NYIII) Supportive Housing program is a cooperative agreement originally signed on November 3, 2005 by five City and five State agencies to provide 9,000 new units of supportive housing in New York City to chronically homeless populations, including those with HIV/AIDS. The overall goal of this initiative is to reduce homelessness and provide safe and affordable housing and supportive services to clients who meet the eligibility criteria.

The AIDS Institute is responsible for the development of a total of 500 supportive housing units -- 300 congregate and 200 scatter-site. The AIDS Institute and the New York City Human Resources Administration (HRA) HIV/AIDS Services Administration (HASA) have cooperative agreement effective through June 30, 2020 for HRA HASA to directly manage this NYC based supportive housing initiative.

Those eligible for these supportive housing units are chronically homeless single adults (or single adults who are at serious risk of street or sheltered homelessness) who are persons living with HIV/AIDS, and who are clients of HASA receiving cash assistance from the city, and who suffer from a co-occurring serious and persistent mental illness, a substance abuse disorder, or a MICA disorder. 

Contact:

Cindy Ravida
Initiative Director
Bureau of Community Support Services
Division of HIV and Hepatitis Health Care
cindy.ravida@health.ny.gov

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