Integration of Care – Minutes – 4/20/22



Veronica Fortunato & Donald Powell, IOC Co-Chairs

Wednesday, April 20th, 2022, 10a-12p

Zoom Meeting


Veronica Fortunato (co-chair)Rose ChestnutBilly FieldsBrenda Starks-Ross 
Donald Powell (co-chair)Cassandra MooreLeo RuizGraham Harriman 
Cassandre MooreFrancine CournosDeborah GreeneDorothy Farley 
Janet GoldburgKaren McKinnonMichael EalyJoel Zive 
Emma KaywinGregg BrucknoRose ChestnutMitchell Caponi 
John SchoeppCharmaine GrahamTim Frasca

Guests: Marcelo Maia, Tempest Perkins, Monica Pathak, Annette Roque, Max Sepulveda, Chet Balron, Alison Mailing, Monica Thompson, Maiko Yomogida, Raffi Babakhanian, Lucie Toussaint, Laura Anhalt, Lenny Collado, Tom Smith, Grace Mackson, Jennifer Cruz, John Paul Reyes


Johanna AcostaFrances SilvaBryan MeiselKimbirly Mack
Renee James Giovanna NovoaGuadalupe Dominguez Plummer Cullen Hunter
Noelisa MonteroClaire Simon  

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

Introductions and moment of silence conducted.

Agenda Item #2: CHAIN Presentation 

CHAIN: Community Health Advisory And Information Network – Assesses the system of HIV care – both health and social services – from the perspective of PWH

Questions The Chain Project Addresses:

• What services do PWH need?

• Where do they go for care?

• What are their unmet needs/service gaps?

• What populations are underserved?

• What are barriers and access issues?

• What works well, what doesn’t?

Mental health measures

Mental health functioning: measured using mos sf-12 mental component summary score

• mcs>42: adequate functioning

• low <=42 (poor)

• very low <=37 (poor)

Overall mental and emotional health service needs

• reporting needing help or assistance in emotional or psychological difficulties or Mcs<=42

Professional mental and emotional health services

• received psychological or emotional counseling or therapy from a licensed mental health care professional (psychologist, psychiatrist or clinical social worker in the past 6 months

PWH with MH or AOD needs are less likely to be in consistent care, to adhere to art, and to achieve viral suppression

MH and AOD service impact unclear in terms of HIV outcomes


Consistent care is not missing 2 or more appointments over a 6-month time period. Don’t see an impact on health outcomes for people in need of AOD services – likely reflects a high and complex need of care among population accessing services. 

How is language interpretation access considered in the survey? Language is frequently cited as why people are not able to access services, but because CHAIN does not survey in more than 3 languages, this need is probably underestimated in the study.

The CHAIN data represents a correlation, not a distribution. Statistical differences are not included but will be in the report.

There are not enough people who drop out and re-engage in care to provide accurate data as a group. Not possible to get into details of what appointments look like to understand of there are micro-trends in consistency of care among people in need of services.

What and where are the facilities the services delivered in? Maiko will follow up.

Especially people involved in the carceral system.

Agenda Item #2: RWPA Provider Panel

Bryan Meisel introduced the behavioral health providers.

Agencies & providers in the room represented Tempest of Housing Works/Bailey House, MH services, Harlem, East NY, LES and downtown Brooklyn. Housing Works Harm Reduction with Max Sepulveda – offer low threshold services, LES and Penn Station and Port Authority, target multiple priority populations, operate drop in sites, deliver services to about 1500 people per year. Annette of La Nueva Esperanza, WIlliamsburgh, Greenpoint and Bushwick, Supportive Counseling. Chet of GMHC, MH and HR, in Manhattan, majority of clients are LGBTQIA and Black and Brown. Laura of ACQC MH, HR, SCI, large Spanish speaking population, Queens, staffing is difficult, including peers. Lucy of VIP Community Services, mostly in Bronx, did a lot of work in nursing homes, MH, conducting mobile services. Tom and Lenny from the Alliance for Positive Change, Bronx, Manhattan, syringe services (HR), staffing has been an issue, covid has posed a lot of difficulty. SCI, help stabilize people, navigate and refer. Monica from IFH, MH and Care Coordination, Manhattan and Bronx, work with people connected to primary care services, also understaffed.

Are syringes available for hormone therapy?

Housing Works and Positive Health Project provide syringes for HRT

Alliance- LESHRC provides syringes for HRT

How do you support peers in your employ?

Housing Works has always hired peers through multiple in-house programs. Peers conduct outreach and deliver multiple services. Peers facilitate communication between staff and clients, these relationships require rapport – peers help with that. Hire stipended peers for a period of 2 years, helps to balance benefits with extra funds. Provides on-site training and education – hope is they can move into a salaried position at end of 2 years. Move them through the AI certification. Require that peers have a support system outside of the workplace. Try to partner peers with a colleague who has transitioned into the full time role as supervisors, and to help with the move away from benefits.

ACQC – hire peers – huge part of the work. Many have become full time staff.

GMHC – run a peer program, find the benefits to be highly impactful.

Housing Works ensures clients know about the Overdose Prevention Centers (OPCs) 

Challenges of leveraging and integrating RW and Medicaid?

Housing Works has a RW and a health home. Most clients come to RW because they can’t comply with HH requirements. Client has to wait for an HH assignment and wait for the case manager. In RW, happens much faster. The wait is a big barrier for HH. The service structure is different, HH doesn’t provide accompaniment. HH is virtual, RW has been open for the entire pandemic. Funds should be focused on identifying more language appropriate providers. Specially mental health providers.

VIP – RW allows providers to be creative in delivering interventions. Go to patients, create relationships with other CBOs to go to them to provide MH interventions. No conflict with Medicaid bc Medicaid does not provide this service. Can do treatment while a patient is on line at a pantry. No regulations in same way as other funding. 

NYPH – RW not confined by same funding regulations associated with licensure i.e. article 31. Able to support a higher level of care than other funders. When patients are in hospitals, can pay providers to go and see them, even though Medicaid is funding the hospital visit.

Housing Works – have a hierarchy of case managers based on need – try to do a lot of cooperation to ensure everyone knows what is happening with clients. HH+ is supposed to be more intensive, but RW has more touchpoints, and can re-engage them into services more intensively.

What work are you doing to dismantle racism and stigma and address vicarious trauma?

NYPH – have a lot of work to do, many initiatives happening, real overwhelming disparity in hiring retaining Black and Brown providers. Doing a lot of hiring. Need more bilingual providers

IFH- our department is very small, one Black and one White person. Almost all the clients are Black and Brown. Can be difficult for a young white woman relating to the community. Try to support her in supervision. Important to be culturally respectful.

Housing Works – has been sponsoring the SEE program, an anti-oppression program, 6 week training to learn about power dynamics, oppression, etc. Idea is to support staff voicing concerns about this. Wellness Wednesdays that develop skills like managing vicarious trauma. Help staff to process things that happen in the workplace.

Are entities focused on structural determinants?

Living wage paid to staff?

Housing Works – agency is trying to address this issue and others to retain staff. In the middle of a union drive, offer $15 an hour, raising it to $17

La Nueva – pay staff an enhanced wage to help retain staff. Funding is not enough to satisfy everyone. Pay a $15 wage. But there is a lot of trauma among staff and clients. 

Housing Works – important to recognize the balance between access to benefits and covering costs with a salary

What are BH needs that are not currently funded?

VIP – high need for technology access among clients. Very hard to manage applying for grants to improve access to this technology. Food, housing always an issue. Clients need data on their phones

ACQC – strong need for language services for people who are mono-lingual. Particularly Spanish.

Case manager to client ratio?

La Nueva – 20:1 but currently the high and complex needs is difficult 

ACQC – Case management is robust in RW. Cannot manage more than 15-20 clients.

What are benefits of offering all 3 BH services (ACQC)?

Lots of in house referrals. 

How do programs without all 3 BH services manage continuity of care?

Housing Works – through referrals. Must establish linkage agreements. It’s a mixed bag.

In HR clients lose phones often – important to gather info on where they hang out and develop relationships 

IFH – connecting clients to psych services – very stringent requirements, creates a level of distance that does not help care continuity. Looking into our own system to eliminate barriers. 

NYPH – thinking a lot about how to reinstate home based visits – haven’t been doing this due to covid. It’s a big focus.

Agenda Item #4: Public Comment 

The NY HIV Health & Human Services Council is recruiting new members. Applications can be found at