1. Health System Navigation The Intervention Judith Bradford, Principal Investigator Allison Jones, Project Manager Yvonne Colon, Health System Navigator

2. Identify Clients Potential participant identified by staff at partner agency. OR Potential participant may also be approached by HSN (if at the Boston Living Center). MAC LARC Span FCHC BLC

3. Introductions Potential participant is introduced to an HSN and prescreened for eligibility (this may happen on the phone or in person) IF ELIGIBLE: HSN schedules an appointment to meet with the participant face-to-face and conduct the intake interview (multi-site tool). HSN makes appointment to follow-up with client within 2 weeks (preferably one week).

4. Review the 411 After the intake, HSN reviews client file (including the multi-site tool) and makes notes on areas where client reports greatest barriers and needs. HSN reviews readiness assessment document and flags applicable sections to inquire further.

5. Are We on the Same Page? HSN and client use readiness assessment questions as a starting point for further discussion. –HSN gets a history of client’s medical care- seeking patterns and case management seeking patterns. –HSN and client set healthcare goals –HSN and client set case management goals –HSN obtains permission from client to speak with Health Care and Case Management providers.

6. So, What Do You Think? HSN guides client in identifying her/his barriers and needs using: –Brief Motivational Interviewing –Stages of Change –Strengths Based Case Management –Harm Reduction HSN and client fill out wellness plan, identifying areas the client wishes to focus on between first and second meeting.

7. Next Time We Meet Client schedules second face-to-face appointment before leaving first intervention meeting. –Second (and subsequent) meeting may include the HSN accompanying the client to appointments. –Client may call HSN between meetings if s/he encounters difficulties completing agreed upon tasks. HSN may call client between meetings to provide additional support and coaching. –HSN will contact Case Manager or Health Care Providers as necessary.

8. Reducing Intensity of Intervention HSN and client meet 2x/ month and maintain regular phone contact until client demonstrates that s/he is understanding and making positive progress towards overcoming her/his barriers and meeting her/his goals.

9. Transitioning to Maintenance –At this point, HSN maintains phone contact with client but may only meet face-to-face 1x/month. –HSN will contact Case Management and Health Care Providers on behalf of the client only when necessary. –HSN will provide ample coaching and support as client advocates for her/his self with providers.

10. Follow-Up Once client is consistently receiving case management and health care services, HSN moves into the background. –HSN will call monthly or more as needed. –HSN and client will meet every three months to revisit wellness plan –Client will meet with research staff (not client’s HSN for the multi-site assessment) every six months for 18 months.