How Harlem United Integrates Services in the Big Apple

The last in a three-part series about the need for AIDS service organizations that serve Black communities to adapt to the changing landscape.

Harlem United was founded in 1988 as the HIV epidemic was exploding in the New York City neighborhood that many have long regarded as the capital of Black America. From its roots as a small paraprofessional organization, Harlem United has grown into a $40 million, 400-employee agency and has one of the most expansive, integrated service portfolios of any AIDS organization in the country. The Harlem neighborhood is one of the most heavily affected by AIDS in the entire developed world. Today nearly 3 percent of Harlem residents are living with diagnosed HIV infection, and the age-adjusted death rate for people living with HIV is nearly 50 percent higher in Harlem than for the Manhattan borough as a whole, according to the New York City Department of Health and Mental Hygiene.

As the epidemic has expanded and the AIDS landscape has evolved, Harlem United has distinguished itself by remaining ahead of the curve. It was among the first AIDS service organizations to venture into the delivery of adult day health-care services, and the agency took early steps to diversify its funding by creating Medicaid-reimbursable services.

"Our philosophy as an organization has always been about how we continue to provide more services to our clients," says Harlem United CEO Steven C. Bussey. "We want to have a holistic approach that ensures better outcomes, reducing the average length of stay in hospitals and the number of emergency room visits as well as increasing viral-load suppression and CD4 counts. We continue to add on to our model as we understand better what our clients need."

Staying Ahead of the Curve

Throughout its history, Harlem United has emphasized integrating its programs and achieving synergy between them. "We allow our services to feed off each other and support each other," Bussey says. "It's hard to ensure outcomes if you don't have an ability to impact all areas affecting the client."

Following the emergence of highly active antiretroviral therapy, Harlem United adapted its service offerings to capitalize on the treatment revolution. Harlem United's adult day health-care program was the first in New York State to offer directly observed therapy, comprehensive oral care and a full continuum of mental-health services. Harlem United helped found New York's only community-controlled special needs plan for PLWHA. Recognizing the toll of late diagnosis on the health prospects of PLWHA, Harlem United also led statewide advocacy to obtain state approval for regulations to streamline the HIV-testing process.

Recognizing the critical role of stable housing in effective management of HIV, Harlem United moved early into the field of supportive housing. In 2012 the agency operated 586 units of supportive housing reserved for clients at risk of becoming homeless, offering primary care and other wraparound services specifically tailored to the needs of unstably housed individuals living with HIV. In 2007 Harlem United was awarded a federally qualified health center grant to provide health services to the homeless.

"We saw early on what impact providing housing to clients would mean," Bussey says. "How can you address health issues when your clients don't have a roof over their heads or can't get proper food and nutrition?"

Strategic alliances have helped Harlem United respond to the multifaceted and widely varying needs of the community it serves. In 2007 the organization formed a strategic alliance with FROST'D to expand health-care access to chronic substance users, HIV-positive formerly homeless individuals and young men who have sex with men. At the time this report went to press, Harlem United was actively exploring a potential merger with the organizations Housing Works and HELP/PSI, which, if completed, would establish a mammoth, integrated service system for the underserved that stretches from one end of New York City to the other.

Becoming Less Dependent on Philanthropy

Harlem United's integrated, client-centered, community-grounded approach has achieved results. Six months after entering the agency's supportive-housing program, clients had 8 percent fewer emergency room visits and 17 percent fewer episodes of hospitalization, generating $900,000 savings in acute care costs. By helping medically frail clients avoid costly nursing home care, Harlem United's adult day health-care centers save New York's Medicaid program an estimated $5 million a year. Clients enrolled in the agency's health center for the homeless have one-third the number of emergency room visits of similarly situated individuals who are not enrolled. Using geographic mapping to identify "hot spots," the agency's HIV-testing initiative has proved effective in reaching a larger percentage of HIV-positive individuals, saving New York's taxpayers an estimated $618,900 in 2009.

Harlem United's service continuum not only improves health outcomes for its clients but has also proved attractive to key funders because it saves taxpayers money. "For better or worse, governments focus on reducing costs to the system, particularly as it pertains to the Medicaid and Medicare populations," Bussey explains. Significantly, the attractiveness of the agency's service model to government funders has made Harlem United less dependent on philanthropic funding than many other service organizations.

As the health-care system has evolved, Harlem United has adapted its program models and organizational approaches to minimize risk and optimize results. When New York State launched a comprehensive redesign of its Medicaid program to improve health-care outcomes and enhance efficiency, the organization capitalized on the opportunity to highlight its model. As a result it has been designated a Level 1 medical home, a status that will become increasingly important for both patients and providers as the Affordable Care Act is implemented.

As it has evolved, Harlem United has maintained a commitment to quality. "The programs and services you provide have to be driven by data supervision, clinical supervision and quality," Bussey notes. "And we couple that with fiscal responsibility and effective management, all integrated and tied together to help ensure that programs are running efficiently."

In many ways, Bussey believes we've seen only the tip of the iceberg when it comes to environmental shifts in the AIDS response. "Government's focus on reducing costs to the system creates a need for efficiencies," he says. "As a result, there is going to be less room for small organizations that make small or incremental changes to the cost structure. This will require organizations to have a bigger footprint in order to have a larger influence on the population they serve.

"This creates a huge risk in urban communities where you currently have a lot of small organizations performing very important tasks," he continues. "These organizations are feeling threatened by cuts in prevention funding, a lack of support for their administration costs and the focus of Obamacare on fully accountable care organizations. There is a real risk that smaller organizations won't have the resources to survive in this environment. The question on the table is whether we can convert a system that has been smaller, grassroots-based into the one desired by governments, with more consolidated tools and resources to address community needs."

Although the risks for small AIDS organizations are real, Bussey suggests that avenues exist to remain relevant--both for clients and for government funders. "With increasing pressures at the state, local and federal levels to reduce costs to the system, we are going to see increasing challenges to the care model that has long been used in the AIDS field," he says. "We need to ask ourselves what is going to be the most efficient way for us to continue to provide the services our clients need. This is going to force people to explore strategic alliances, joint ventures and consolidation. It's going to be harder and harder for agencies to survive when they are providing only one service."

Excerpted from the Black AIDS Institute's State of AIDS Report, "Light at the End of the Tunnel: Ending AIDS In Black America."