NC-REACH: A Rural Patient-Centered Medical Home for People Living with HIV Who Experience Unstable Housing

The patient-centered medical home (PCMH) has gained international recognition as a viable method for treating patients with chronic diseases, leading to improved health outcomes, decreased health care spending, and better quality of care.¹ The PCMH has become an integral part of the Health Resources and Services Administration’s Ryan White HIV/AIDS Program and was acknowledged as a vital component of the National HIV/AIDS Strategy.² In rural areas, where the HIV/AIDS epidemic is burgeoning, this model offers people living with HIV (PLWH)—who are often uninsured or underinsured and unstably housed—comprehensive primary care and support services.³ Nearly two thirds of substandard housing in the United States exists in rural areas, affecting 73% of PLWH in rural counties in North Carolina.⁴

A multitude of factors contribute to the necessity of targeted HIV care in rural populations, including lacking health insurance, absence of providers and specialists, socioeconomic status, cultural and linguistic barriers, substance use, psychiatric disorders, and incarceration. Aggregately, these difficulties contribute to decreased access to antiretroviral treatment and subsequent achievement of viral suppression. Unmet housing needs, stigma, and lack of transportation and education exacerbate barriers to timely entry and retention into quality HIV care.^4–6 Therefore, there is a critical need for programs addressing factors that increase the risk of disease progression among homeless or unstably housed PLWH.

From 2012 to 2017, the Health Resources and Services Administration’s HIV/AIDS Bureau Special Projects of National Significance project—called Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations Initiative—funded nine sites, including one rural site: CommWell Health. This was done to develop and evaluate innovative, effective systems that address barriers in HIV care and achieve the continuum of care. The CommWell Health site developed the North Carolina–Rurally Engaging and Assisting Clients Who Are HIV-Positive and Homeless (NC-REACH) demonstration project to provide the PCMH model of care for homeless or unstably housed PLWH in rural North Carolina, using a network navigator and a continuum of care coordinator (CCC) to address care management plans and connect participants to local support services.

THE PROJECT IN ACTION

From September 2013 to February 2016, NC-REACH recruited 80 clients in Dunn, North Carolina, through an out-of-care list of patients, internal referrals, and referrals from housing and other social service agencies in the six counties surrounding CommWell Health. All patients were aged 18 years or older, were confirmed HIV positive, were currently unstably housed as defined by the US Department of Housing and Urban Development (e.g., living in shelters, “couch-surfing,” moving every 60 days, dwelling in substandard living conditions), and had a previous or current diagnosis of substance use disorders or mental illness. Median age was 41.3 years (range = 21.4–72.6). Most participants self-identified as non-Hispanic Black, male, and heterosexual. Two thirds were unemployed, less than 4% were migrant laborers, and nearly half (47.5%) did not self-identify as homeless.

At 12-month follow-up, 66 participants (82.5%) were retained in care (Table 1). The proportion of participants who were virally suppressed increased from 61.3% to 74.7% by the end of 12 months (P < .01). Unmet housing needs decreased by 20% over 12 months (P = .007). The proportion of participants with stable housing increased from 3.9% to 16.9% by the end of 12 months (P = .04). Transportation and employment needs decreased by 9.1% (P = .35) and 14.1% (P = .06), respectively. Self-perception of homelessness was not associated with housing status at 12 months (odds ratio [OR] = 0.3; 95% confidence interval [CI] = 0.1, 1.3) or retention in care (OR = 1.8; 95% CI = 0.5, 5.9). At 12 months, those who perceived themselves as homeless or unstably housed were 70% less likely to have achieved viral suppression at their most recent visit than were those who did not perceive themselves as homeless (OR = 0.29; 95% CI = 0.09, 0.91).

TABLE 1—

Health and Care Access Outcomes Over 12 Months: NC-REACH, North Carolina, 2013–2017

Outcome	Baseline Visit, No. (%)	6-Mo Visit,a No. (%)	12-Mo Visit,a No. (%)	Pb
Retention in carea	. . .	. . .	66 (82.5)
Most recent viral suppressionc				.01
Suppressed (< 200 copies/mL)	49 (61.3)	57 (82.6)	56 (74.7)
Not suppressed (≥ 200 copies/mL)	31 (38.7)	12 (17.4)	19 (25.3)
Has housing needs				.01
Yes	64 (80.0)	39 (57.4)	40 (61.5)
No	16 (20.0)	29 (42.6)	25 (38.5)
Housing status in 12 moc				.04
Homeless	23 (28.8)	10 (14.7)	13 (20.0)
Controlled environment	11 (13.7)	5 (7.4)	4 (6.2)
Unstably housed	46 (57.5)	43 (63.2)	37 (56.9)
Stably housed	0 (0.0)	10 (14.7)	11 (16.9)
Has transportation needs				.35
Yes	66 (82.5)	54 (81.8)	47 (73.4)
No	14 (17.5)	12 (18.2)	17 (26.6)
Has employment needs				.06
Yes	35 (43.8)	18 (26.5)	19 (29.7)
No	45 (56.2)	50 (73.5)	45 (70.3)

Note. NC-REACH = North Carolina–Rurally Engaging and Assisting Clients Who Are HIV-Positive and Homeless. Participant size was n = 80.

^aDefined as two consecutive visits at least 90 days apart in 12 months.

^bP value for trend.

^cSample size is less than the total sample because of missing data or loss to follow-up.

STRATEGIES AND LESSONS LEARNED

CommWell Health’s NC-REACH tailored the PCMH model to increase collaboration among community stakeholders in serving a “hidden” population in rural areas: PLWH who experience homelessness or unstable housing. After 12 months of the program, most participants were successfully retained in HIV care, accompanied by improvements in viral suppression and addressed housing, transportation, and employment needs.

Implementation of the NC-REACH in a rural setting required multipronged approaches to patient care to reach patient self-sufficiency and stability and overcome barriers such as shortage of mental health professionals and stigma in seeking care. Most CommWell Health clients lacked basic needs, including stable housing, employment, transportation, and social support. Supplementing clinical staff in the PCMH model, the network navigator and CCC were pivotal in guiding PLWH who experience homelessness or unstable housing to care and to local social service organizations. The CCC ensured HIV treatment adherence and care plans, and the network navigators recruited patients from clinics and the community to participate in NC-REACH. Network navigators also transported and physically accompanied clients for medical or behavioral health appointments at CommWell Health; they also advocated for PLWH who experience homelessness or unstable housing with private landlords and with housing and social service providers to facilitate stable housing and work opportunities.

NC-REACH also enhanced participant access to behavior health care as necessary. The CCC, network navigator, HIV medical staff, and behavioral health counselors had team huddles weekly to refer and connect participants who needed substance use or mental health treatment.

Staff also attended regular cultural competency trainings and lived in the community served by NC-REACH, an advantage to tailored care delivery. As a result, staff members had a deeper understanding of context and challenges faced by the patients, including the importance of religion, the influence of family on behavior and decision-making, and the effects of stigma and perceptions owing to simply being affiliated with CommWell Health (e.g., being seen entering a CommWell Health vehicle).

Although all participants were homeless or unstably housed at baseline, nearly half did not consider themselves homeless (called “hidden homelessness”). For most NC-REACH participants, being homeless or unstably housed meant living in a shelter or a car. Most participants did not recognize having a different place to stay each night as unstable or homeless. Perceptions around homelessness are critical factors in identifying vulnerable populations who are at risk in the HIV epidemic, particularly in the rural context. Education was necessary for patients, staff, and community partners to understand the influence of hidden homelessness and unify the approach to improving the well-being of the local community.

In addition to the intensive individual work by the CCC and the network navigator, NC-REACH created the Community Housing Coalition to work across housing, social service, and health care systems to address client needs. The coalition met quarterly and consisted of 40 members from organizations and individuals, including the United Way, Veterans Affairs, faith-based organizations, private landlords, and the Salvation Army. These meetings served as a forum to share housing opportunities, health information, new services, and funding opportunities across the local counties.

By creating a community inside and outside the clinic, NC-REACH established a system of social support to establish patient rapport and trust, which in turn helped identify patient needs, create a platform for patient advocacy with housing and other social need providers, and improve health outcomes among rural populations.

PUBLIC HEALTH IMPLICATIONS

Findings from NC-REACH have major implications for improving clinical outcomes and reducing the burden of HIV in rural populations. Navigation and care coordination, essential components in the PCMH model, can facilitate collaboration between patients, health care providers, and support services in the community to establish integrative care while addressing the needs of PLWH regarding housing, employment, and transportation and barriers prevalent in rural settings. Integration of these services into care for this hidden stigmatized population advances the delivery of HIV care services and decreases HIV transmission with viral suppression, ultimately improving the continuum of care for PLWH who experience homelessness or unstable housing.