Family Health Centers of San Diego, Inc., San Diego, CA

Practice Transformative Model to Build San Diego’s Primary Care Capacity to Provide HIV Treatment and Comprehensive Care Services

Family Health Centers of San Diego (FHCSD) is one of the largest federally qualified health centers (FQHC) in the U.S and provides comprehensive HIV care and prevention services in San Diego County at its 12 primary care sites. To address the growing shortage of HIV care providers and an increasing patient caseload, FHCSD’s Practice Transformative Model will train a minimum of three primary care providers each year to provide HIV care. Training will include a rotation at the HIV clinic, the Ciaccio Memorial Clinic; in-clinic shadowing with an HIV specialist physician; specialist consultation; and workshop trainings.

Their PTM also includes training primary care-based staff, including health educators, mental health staff, clinical support staff (medical assistants, case managers, patient service representatives) in HIV-related topics specific to their job functions, including treatment adherence counseling and Ryan White program enrollment. These staff also will receive training in Trauma-Informed Care practices. In addition to workforce training, an interdisciplinary care team will provide coordinated, wrap-around services (case management, care coordination, substance abuse counseling, and treatment adherence counseling) to HIV patients seen in the primary care setting. A Patient Navigator will ensure ongoing coordination between the interdisciplinary care team, primary care providers, and the primary care team; and will standardize patient follow-up processes to improve patient follow-up and retention in care. By implementing these system-level changes, FHCSD aims to improve patient access to HIV primary care, retention in care, ART adherence and viral suppression.