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Transitional Care Coordination for People Living with HIV/AIDS Services

​​​19 Winthrop Street, Brooklyn, NY 11225
T: (718) 462-8654

Program Summary: CAMBA’s Transitional Care Coordinati​​on for People Living with HIV/AIDS (TCC) program links 72 individuals to housing and primary medical care. Program staff work with clients to develop coordinated service plans that will ensure that the clients are connected to a wide range of services, including:​​​​

  • ​Access to public benefits and other supportive services
  • Accompanying clients to medical and other appointments to ensure that their medical and other needs (such as housing) are being met
  • Housing
  • Medical/mental health services
  • One-on-one health promotion counseling sessions with each client at least six times, which follow modules from DOHMH required curricula
  • Substance abuse treatment services​

​Once clients are connected to housing and medical care, program staff will facilitate the transfer of their cases to a Ryan White Care Coordination program, HealthLink or another case management program.​

Finally, staff will follow-up with clients after their transfers to ensure that the transitions have been smooth and positive.
Eligibility: Persons living with HIV/AIDS who are homeless or unstably housed and with one or more of the following: 1) newly diagnosed with HIV; 2) lost to primary care, defined as: no primary care visit within the past nine months OR difficulty​ keeping appointments OR received sporadic, irregular care OR have never been in care OR frequently changed medical providers OR have difficulties adhering to ARV therapy.
Clients Served Annually: 72
Referrals Accepted: Yes
This program is funded by the NYC Department of Health and Mental Hygiene through a contract with Public Health Solutions.