Many individuals with HIV/AIDS deal with multiple issues, including poor medical health, behavioral health, and homelessness. Unfortunately, they don’t always know where to go for assistance. The mission of AIDS Help of Monroe County (AIDS Help) is to lead the fight against HIV/AIDS in the Florida Keys and improve the lives of individuals affected by the epidemic. Since 1986, AIDS Help has worked to coordinate compassionate medical care and social services for people with HIV/AIDS, including:

  • Healthcare case managementAIDS Help of Monroe County
  • Food programs
  • Counseling
  • Housing
  • Advocacy
  • Health education
  • Provider referrals

Managing a diverse group of patients whose needs span across different programs is no easy task. By 2014, the success of AIDS Help and the expansion of their services lead to the need for a software solution that could help streamline patient care coordination, reduce costs, and grow with their organization. They created a project team that was tasked with conducting an organizational analysis to identify gaps and weaknesses in serving the HIV/AIDS population in Monroe County, and creating a recommendation for a cloud software solution. After researching multiple solutions, the project team recommended ClientTrack Case Management Platform for its specialized and flexible case management, native mobile functionality, housing manager, reporting, and billing module.

CARE COORDINATION

AIDS Help works to address the social determinants of health that affect individuals with HIV/AIDS and coordinate their care with other community providers. New patients come to AIDS Help from multiple sources, including the Monroe County Health Department, local clinics, as well through their year-round HIV testing outreach services. In order to improve health outcomes for the new patients and identify possible barriers to care, staff at AIDS Help conduct a comprehensive assessment within 72 hours for individuals with newly-identified HIV. The case worker enters patient information in the ClientTrack intake to quickly determine eligibility and then creates a unique care plan that includes housing, medical health, behavioral health, employment, and medication. The staff at AIDS Help work to ensure collaboration among all providers who coordinate care to address all their patients’ needs. Costs go down while the patient’s overall health and wellbeing goes up.

HOUSING FIRST

Housing is one the key service areas AIDS Help coordinates for their patients. AIDS Help has taken a leadership role in improving the availability of safe and affordable housing for low-income individuals with HIV/AIDS. At the center
of their housing efforts is a Housing First program that provides housing to high-risk individuals with HIV/AIDS who are experiencing homelessness. When AIDS Help receives a patient referral, the staff uses ClientTrack to quickly assess eligibility for housing programs and then create a comprehensive care plan. In addition, AIDS Help uses ClientTrack Housing Manager to manage all unit housing data in one central database, including unit size, amenities, location, requirements, availability, deposits and payments.

MOBILE CASE MANAGEMENT

An essential part of the vision of AIDS Help Monroe County is taking the services they provide and taking them to individual’s homes. Esneider Gomez, Director of Quality Control for AIDS Help, said “We were doing home visits before we moved to ClientTrack, but everything on the intake form was filled out manually and then we did data entry later. Now we can quickly enter all of the patient information in ClientTrack Mobile and then use Query Builder to pull reports.”

ClientTrack Case Management runs natively as a fully functioning software in all mobile browsers. As part of the new Home Visits program, a team of nurses goes into individual’s homes and uses ClientTrack Mobile to access their overall care and refer them to local providers. In addition, ClientTrack also helps the nurses identify high risk clients and prioritize their care.

AIDS Help Monroe County is a growing organization with plans for expanding the care network in their community. Eccovia Solutions™ is proud to partner with them to help improve care and outcomes for individuals with HIV/AIDS in Monroe County, Florida.

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