Our Initiatives


Performing Provider System

HIV Center of Excellence/Reducing HIV Morbidity (Project 3.e.i and 4.c.i)


What do we hope to accomplish?

  • Transform three HIV practices into true Centers of Excellence (CoE) where all services for People Living with HIV and/or HCV or those at risk for HIV are integrated into one practice. These services include prevention services, increasing primary care, HIV/HCV consultation and treatment, dental care, specialty care, behavioral health care, prenatal care, nutritional services and substance abuse services.
  • Develop a network of collaborators that engages people who are at risk for HIV or who are newly diagnosed or living with HIV and/or HCV who are not engaged in care or lost-to-follow-up.

Who is our target population?

  • People Living with HIV and/or HCV and persons at risk for HIV

How will we do it?

  • Develop a Steering Committee that engages a group of community-based providers and collaborators to design collaborative workflows and advance the goals of DSRIP and the New York State Department of Health initiative to End the AIDS Epidemic.
  • Integrate a team of Community Health Workers and Peers into both collaborators and on-site at CoE to increase outreach, screening, linkage and retention to needed social and clinical services through education, advocacy and motivational interviewing.
  • Identify and link those at risk for HIV or living with HIV and/or HCV and not engaged in care to  preventive services (e.g., PrEP/PEP) or clinical care (e.g., HIV or HCV treatment)  as well as link them to community-based services to address psychosocial needs that may impact on engagement and/or retention in clinical care.
  • Expand the nature and number of clinical services provided at three NYP HIV ambulatory sites to better meet the emerging DSRIP standards for a CoE.
  • Enhance and integrate co-located behavioral health services including both mental health (with the addition of a Psychiatric NP) and substance use services (through co-located Credentialed Alcoholism and Substance Abuse Counselor (CASAC)) into the CoE to meet this under-met need.
  • Provide more alternatives for pharmacy intervention and support to increase access and adherence to HIV prevention or treatment.
  • Enhance care coordination and care management services to connect people at risk for or living with HIV and/or HCV to the CoE to ensure patients are receiving appropriate preventative services, engaging in care and transitioning to appropriate settings when leaving the Emergency Department or hospital.

NY State Requirements for HIV Center of Excellence (Project 3.e.i)

  1. Identify site location for a Center of Excellence (COE) which would provide access to the population infected with HIV (and/or HCV).
  2. Increase peer-led interventions around HIV care navigation, testing, and other services
  3. Co-locate care management services including Health Home care managers for those eligible for Health Homes.
  4. Design all HIV interventions to address at least two co-factors that drive the virus, such as homelessness, substance use, history of incarceration, and mental health
  5. Assure cultural competency training for providers
  6. Empower PLWHA to help themselves and others around issues related to prevention and care
  7. Educate patients to know their right to be offered HIV testing in hospital and primary care settings
  8. Promote delivery of HIV/STD Partner Services to at risk individuals and their partners

NY State Requirements for Reducing HIV Morbidity (Project 4.c.i)

  1. Decrease HIV and STD morbidity and disparities; increase early access to and retention in HIV care
  2. Establish clear linkages with Health Homes, ER and hospital services to develop and implement protocols for diversion of patients from emergency room and inpatient services.
  3. Establish agreements with the Medicaid Managed Care organizations serving the affected population to provide coverage for the service array under this project.
  4. Develop written treatment protocols with consensus from participating providers and facilities.
  5. Include at least one hospital with specialty psychiatric services and crisis-oriented psychiatric services; expansion of access to specialty psychiatric and crisis-oriented services.
  6. Expand access to observation unit within hospital outpatient or at an off campus crisis residence for stabilization monitoring services (up to 48 hours).
  7. Deploy mobile crisis team(s) to provide crisis stabilization services using evidence-based protocols developed by medical staff.
  8. Ensure that all PPS safety net providers are actively connected EHR systems with local health information exchange/RHIO/SHIN-NY and share health information among clinical partners, including direct exchange (secure messaging), alerts and patient record look up by the end of Demonstration Year (DY) 3.
  9. Establish central triage service with agreements among participating psychiatrists, mental health, behavioral health, and substance abuse providers.
  10. Ensure quality committee is established for oversight and surveillance of compliance with protocols and quality of care.
  11. Use EHRs or other technical platforms to track all patients engaged in this project.

Scale and Speed (Domain 3)

Metric: The number of participating patients who received two, sequential anti-retroviral medication scripts and/or attended two office visits within the previous 12 months. Duplicate counts of patients are not allowed. The count is not additive across DSRIP years.

DY1Q2-only: PPS may report patients who received two, sequential anti-retroviral medication scripts and/or attended two office visits within the last 6 Reporting Quarters (DY0 +DY1Q1 + DY1Q2) through September 30, 2015.

For DY1Q3 & future quarters: The PPS will report patients who received two, sequential anti-retroviral medication scripts and/or attended two office visits within the last 4 Reporting Quarters (beginning in the Quarter during which the member is engaged).

Commitment: At the completion of DY4 Q4, 5,040 patients will have filled at least two sequential antiretroviral prescriptions within the previous Demonstration Year (DY).