TABLE 1—

Special Projects of National Significance Staff Perspectives on Key Strategies for Creating Medical Homes for People Living With HIV Who Are Experiencing Homelessness or Unstable Housing

Strategy	Selected Quote
Use of assessment tools and care planning	The care plan is a good tool to help us guide where the client wants to go next. It is their perception of where they’re at and what they think they need to get them to the next step.—Patient navigator
Meeting patients where they are	We spend a lot of our time meeting clients at the shelter. For me, it’s been a lot at the hospital lately, or at Starbucks or Taco Bell or McDonald’s, where I’ll meet with a client to talk about what we need to do to help them with services.—Case manager
Core services	[The team includes] myself, the housing staff, the medical case manager, maybe a therapist or case manager that’s connected to mental health…. [We’re] making sure that the substance abuse and the mental health is being treated, adhered to; we’re making sure that the medical piece [and] medication is being adhered to; we’re ensuring [the housing piece], such as the savings and learning different life skills and coping skills when you move out…and the importance of how all three of [these kinds of staff] work together to stabilize housing.—Patient navigator
Development and use of networks	We can’t know everything. Aging and Disability Services is…a huge system. I know some parts of it that are relevant to my work with folks, but I also have some people there that I really trust and so if something comes up that I don’t know the answer to, I can call them and say “Here’s the scenario. What should we do?” That stuff is really important.—Case manager
Rapport and trust building	That’s so important, building the relationship with [the patients], that they can trust you, that [you’re] not gonna go out and tell anybody else what’s going on. Or you sit down with them, whether it’s under the bridge, whether it’s to the park, and they feel that you can connect with them…that they feel that they can trust me, that I’m gonna be there for them.—Patient navigator
Use of technology and technological tools	We’re officially locked in our schedule an hour a day for telemedicine visits and the team is booking telemedicine visits…. So far it’s great. We love it, the patients love it…. So it saves the patient transportation time, we can talk about a lot of things over the phone without having to do a physical exam. So that is yet another new option that we didn’t have before.—HIV physician