mHEALTH Project Accepting Referrals

mHEALTH Project Description

mHEALTH (Medical Home Engagement and Aligning Lifestyles and Transition from Homelessness) is a program to engage and retain HIV positive, homeless individuals with mental health or substance abuse disorders into medical homes that provide HIV primary care, behavioral health, housing, and care coordination services.  Yale Clinical and Community Research Program at the Yale School of Medicine is collaborating with the Connecticut Department of Correction and Liberty Community Services to improve the quality of life for those living with HIV/AIDS (PLWHA) through integrated primary and behavioral healthcare, care coordination and assistance with housing and supportive services.  The people we wish to help through this program are homeless PLWHA who are primarily transitioning from the criminal justice system (CJS) and those that are not retained in HIV care in New Haven, CT.

The mHEALTH program  will include, but is not limited to:  1) creating and maintaining a patient-centered medical home (PCMH) through an expanded, new Collaborative Network of Services for PLWHA by expanding the existing New Haven Ryan White Consortium to promote access to and retention in primary HIV care for homeless PLWHA; 2) creating a referral form for interagency and Early Alert Service by deploying the city-wide RW Consortium electronic database to identify individuals who are no longer engaged in care; 3) provision of onsite addiction treatment and mental health services provided through a mobile outreach on the Community Health Care Van (CHCV) to ensure early intervention services (EIS); 4) use a Network Navigator (NN) to provide intensive case management (ICM) that includes elements of the Assertive Community Treatment (ACT) and ACCESS programs to ensure that homeless PLWHA are fully engaged in a PCMH structure that will overcome individual, clinician and system level barriers to housing; and 5) provide directly administered antiretroviral therapy (DAART) for homeless PLWHA who are struggling with adherence to ART.

People may self-refer.  Case Managers may make referrals.  Please use this link:

Click Here to Make Referral