Program Purpose & Outcomes
What is the overall purpose of the CYA program?
What age range does the CYA program serve?
13-29 years old
What are the core components of the CYA program model?
HIV primary care, behavioral health, sexual health services, supportive services, multidisciplinary team approach
What is one required staff role for all CYA programs?
Medical Case Manager (1.0 FTE)
How often must the Social Determinants of Health (SDOH) assessment be completed?
At enrollment and at least every 6 months thereafter
Increased viral load suppression, improve retention in care, increased access to HIV/behavioral health services, reduced HIV transmission
Beyond age, what characteristics define the CYA priority population?
Young adults living with HIV, BIPOC, LGBTQIA+ and gender non-conforming individuals, individuals who are newly diagnosed, out of care, or not virally suppressed
What is the role of the multidisciplinary team within the CYA model?
To coordinate care across disciplines, improve engagement, support retention, and address both clinical and non-clinical needs
Clinician involvement in program development, service delivery, and evaluation - up to 20% FTE
What is required after an SDOH need is identified?
A referral must be made, referral outcomes must be tracked to completion
How should leadership ensure that these program goals and outcomes are reflected in day-to-day operations?
Staff training and onboarding, ongoing supervision and reinforcement, use of data to monitor outcomes, integration into workflows and team meetings.
How should programming and service delivery be adapted to effectively meet the needs of this population?
Culturally responsive care, trauma-informed approaches, flexible scheduling/access, peer engagement, addressing SDOH barriers
Prevents fragmented care, improves outcomes, ensures comprehensive service delivery, supports retention and viral suppression
What is the risk if staff are delivering services but are not knowledgeable about the CYA program model?
Inconsistent or misaligned service delivery, inability to meet program expectations, gaps in patient care, potential monitoring findings, leadership oversight gap
What are the implications if referrals are made, but outcomes are not tracked or documented?
Incomplete service delivery, inability to demonstrate impact, inaccurate or missing data, non-compliance with program requirements, potential monitoring findings