AFAI’s New York Immigrant AIDS Link (NYIAL) program has signed on to a new government-funded program to better coordinate care for New Yorkers living with HIV or AIDS. The “Care Coordination” program aims to assist individuals whose access to appropriate medical care is impeded by language, lack of adherence to a medication regimen, lack of insurance, an unstable housing situation, or other significant barrier. The goal of the program is to help PLWHA obtain regular primary care; get and stay healthy, which includes keeping a low viral load; take medication as prescribed; get the social services they need, and ultimately take control of their own medical and social needs.
Under the program, services are provided by an office- or clinic-based “Care Coordinator” who oversees the medical and social services, and a “Navigator”, who travels to the participants’ homes or other meeting spots. Another staff member provides Directly Observed Therapy (DOT), which calls for the worker to regularly observe the participant taking his/her ARV medications. The three specialists work with the participants to ensure that they are getting all the benefits for which they are eligible; to help them find financial assistance or housing, if needed; and to make sure they are getting comprehensive medical care that fits their needs. The care coordination piece is handled by Housing Works Inc., a large non-profit focused on AIDS and homelessness. NYIAL is one of a number of local agencies providing navigator services. NYIAL is specifically working with the immigrant community in the New York metro area, and is doing outreach to expand the enrollment of that population in the Care Coordination program.
“We’re very excited about participating in this initiative,” says Gladys Ochoa, a senior case manager at NYIAL and program navigator. “We believe it provides an excellent model for ensuring that people with HIV or AIDS get and maintain the right care.”