For Institutions: Our Model

The Comprehensive Care for Older Adults With HIV uses a team approach to meet the myriad needs of older adults with HIV and their caregivers. As a demonstration program, we provide materials to enable institutions to establish their own versions of this model.

The key to the process is an in-office visit that includes patient assessments and interventions conducted by members of the team. The team includes a geriatrician, a pharmacist, a nurse, a social worker, and a community health care worker (CHW). All team members follow the standard of care in geriatric practices. 

CHWs are the backbone of the program, serving as patient navigators, advocates, and educators. They guide the patient’s clinic visits with the team members. The material and tools we provide are designed to strengthen the CHW’s integration into the team. 

Staff Time Commitment

Our team has allocated one day a week to this demonstration project. Other programs may be able to dedicate more—or less—time to a program for older HIV patients depending on available staffing. For a one-day-a-week effort, we use the following staffing levels. You can assess and modify this based on your resources and need:

  • CHW: Full-time equivalent (FTE) – 0.5, including time outside of clinic visit
  • Geriatrician: FTE – 0.2
  • Registered Nurse: FTE – 0.2
  • Social Worker: FTE – 0.1 to 0.2 tailored to pre-existing available case management 
  • Pharmacist: FTE – 0.2

Workforce Development 

The CHW is the linchpin of this model. To help ensure that the CHW receives appropriate support, we offer the following guidance: 

Assessments and Screenings

The program uses a variety of validated screening tools and assessments to identify potential risks and determine areas where patients might need additional care or support to prevent illness and manage their health. We use the appropriate tools based on the reason for the referral. While these tools are non-diagnostic, they can help identify risks of certain conditions, health outcome changes, and quality of life issues. As a fully integrated team member, the CHW does many of these screenings.

Clinical Screening Tools

The clinical screening tools we use are organized by the 6Ms framework, and include:

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