Integration of Care – Minutes – 3/16/22



Veronica Fortunato & Donald Powell, IOC Co-Chairs

Wednesday, March 16th, 2022, 10a-12p

Zoom Meeting



Veronica Fortunato (co-chair)Bill GrossBilly FieldsBrenda Starks-Ross
Cassandre MooreChristopher JosephDeborah GreeneDorothy Farley
Francine CournosJames WalkupJanet GoldbergJoel Zive
John SchoeppKaren McKinnonMichael EalyMitchell Caponi
Paul CarrPress CanadyRose ChestnutTim Frasca

Guests: Andrea Yaffe, Brian Colon, Mirnelly Fernando, Mrytho Gardiner


Frances SilvaJohanna AcostaCullen HunterKimbirly Mack
Noelisa MonteroScott Spiegler (Acting Recipient)Nadine AlexanderJacinthe Thomas
Johnell LawrenceRenee James  

Agenda Item #1: Welcome/Introductions w. Pronouns/Moment of Silence/Review of Minutes

In honor of deepening our understanding of trauma informed care with invited guest presenters from Exodus, the icebreaker was simply – how are you feeling today? Many people shared deeply, highlighting our understanding that we frequently do not know what people are bringing into the room. John Schoepp led the moment of silence. The minutes were approved with no corrections. 

Link to video of the meeting:

Agenda Item #2: Trauma Informed Care and Healing Centered Care 

Exodus staff Brian Colon, Director of Training & TA and Mythro Gardiner, LCSW-R Clinical Director with support from Andrea Yaffe presented on trauma informed and healing centered care.

Agenda Item #3: Ryan White Part A Mental Health and Harm Reduction Services in New York City

Perminder Khosa, MPH presented on the analysis of the match between the NYC HIV Registry and the Bureau of Mental Health’s two databases: SPOA, Single Point of Access and AOT, Assisted Outpatient Treatment. Key points of the presentation follow:

  • Compared to PWH in NYC overall, HIV diagnosis among PWH-SMI was more likely to occur at a hospital.
  • Stage of HIV infection at diagnosis among PWH-SMI was relatively steady from 2014-2018.  
  • Compared to PLWH overall, PLWH-SMI had poorer outcomes along the care continuum
  • Compared with PLWH-SMI of other race/ethnicity groups, Hispanic/Latino PLWH-SMI had highest HIV care rates. 
  • Similar to trends among PLWH overall, compared with PLWH-SMI of other race/ethnicity groups, Black PLWH-SMI in HIV care had the lowest viral suppression. 
  • Among PWH-SMI, 37% with an HIV-related cause of death were virally suppressed within 6 months prior to death and 56% with a non-HIV-related cause of death were suppressed within 6 months prior to death.
  • Compared with PWH overall, death rates among PWH-SMI were consistently higher between 2014 and 2018. 

Karen McKinnon noted that research lit shows HIV rates of 4-23% for people with SMI in US

Agenda Item #4: Fact Sheets on Harm Reduction (HRM), Supportive Counseling (SC) 

& Mental Health (MH)

Noelisa Montero presented on the analysis conducted among RWPA clients and matched to the NYC HIV Registry. Key points from the presentation follow: 

  • 59% (n=4,335) of 7,317 NYC RWPA clients in GY2018 had one or more lifetime MH diagnoses
    • Among these clients, the most frequently reported types of MH diagnoses were:
      • Depression: (49.6%; n=3,629)
      • Anxiety disorder: (28.7%; n=2,097) 
      • Bipolar disorder: (17.5%; n=1,283)

NYC RWPA clients with one or more lifetime MH diagnoses (N= 4,335)

  • Engaged in care: 98.8% (n=4,282) 
  • Retained in care: 90.3% (n=3,913)
  • Virally suppressed: 75.9% (n=3,292)

NYC RWPA clients without a lifetime MH diagnosis (N=2,933) 

  • Engaged in care: 98.3% (n=2,884)
  • Retained in care: 86.6% (n=2,540)
  • Virally suppressed: 81.5% (n=2,390)
  • Treatment strategies in NYC RWPA MH programs should focus on addressing depression, anxiety disorder, and bipolar disorder as these were the most frequently reported MH diagnoses
  • There is a need to improve viral suppression among PLWH with a MH diagnosis. Viral suppression seemed particularly low among people with a diagnosis of psychosis and bipolar disorder

Limitations on the analysis: 

MH diagnosis question: 

The information source for the MH diagnosis questions is not recorded in eSHARE and could include: 

  • Client self-report 
  • Observation/impression (mental health provider/any provider)
  • Measures assessing the presence of a MH diagnosis
  • Diagnostic information from a client’s electronic medical record

Service categories for which assessment forms do not include MH diagnosis questions: 

  • Case management (non-medical), Food bank/home-delivered meals, Legal services, Psychosocial support services, Medical transportation
  • Clients who were only served in those RWPA service categories were not included in our sample

Council follow up: For engagement in care for people with MH diagnosis – what does the service utilization look like?

RWPA requires providers to ensure clients are engaged in care.