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Internal (Harris Health System) Patients
Track 1 – Scheduled Current or out of care homeless TSHC patients Hospital Inpatients Less urgent patients from HHS HIV testing programs Track 2 – Rapid Response New or previous diagnoses from HHS testing programs HIV+ encountered elsewhere in HHS & in poor health and/or unstably housed Yes Have upcoming appointment? No HHS Staff notify CMT CMT meet patient at patient location before patient leaves DM generates list weekly DM generates list monthly CMT present intervention Interested Not interested CMT review list to identify patients to approach CMT review list to identify patients to approach CMT continues with linkage process and is still eligible to receive services CMT flag selected patients in EMR to be notified when the patient arrives CMT try to locate patient and schedule a TSHC appointment CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services CMT schedule TSHC screening appointment When patient is at TSHC, CMT present intervention and perform brief assessment CMT plan and goals developed CMT continue to provide services until patient goals are met and HIV is managed CMT work on transitioning patient to shelter clinic if patient so chooses Interested Not interested No Yes Goals met Graduate from intervention to 90-day transition period CMT continue with re-linkage process No Goals remain met Yes Standard Care This publication is part of a series of manuals that describe models of care that are included in the HRSA SPNS Initiative Building a Medical Home for HIV Homeless Populations. Learn more at
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External (non- Harris Health System) Patients
Track 1 – Scheduled Less urgent HIV+ homeless patients referred by external agencies serving homeless and/or HIV populations Track 2 – Rapid Response Urgent patients from external agencies serving homeless and/or HIV populations (poor health and/or unstably housed) Referring agency informs CMT Referring agency informs CMT CMT schedule TSHC screening appointment CMT meet patient at patient location before patient leaves When patient is at TSHC CMT present intervention and perform brief assessment CMT presents Intervention and performs brief assessment Interested Not interested Not Interested Interested CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services CMT schedule TSHC screening appointment CMT continues with linkage process and is still eligible for services CMT continue with re-linkage process CMT plan and goals developed CMT continue to provide services until patient goals are met and HIV is managed CMT work on transitioning patient to shelter clinic if patient so chooses No Yes Goals met Graduate from intervention to 90-day transition period CMT: Case Management Team DM: Data Manager MH: Mental Health SA: Substance Abuse TSHC: Thomas Street Health Center No Goals remain met Yes Standard Care
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