At a workshop at USCHA 2025 this year, Chicago House proposed an interesting care model: "Aging in Place," first "settling people at home," then "bringing services into the home." This supportive housing model is not about building another building, but about making the living space a hub for integrated medical care, social welfare, and peer support; in other words, having stable housing and daily life first, then combining care services at the place of residence.
Observation focus: Designing the "home" as a service hub
Chicago House's aging in place model regards "home" as the primary site of care. Public space is not simply hardware, but the infrastructure for stability and accessibility; at the same time, bringing HIV Case Management Services into the living environment reduces the effort residents spend navigating the institutional maze. This arrangement allows older people living with HIV to stay in their place of comfort, prioritizing autonomy and dignity, while also connecting to health care services.
Early case opening: First "connect the needs to power"
The front-end case opening process adopts a rhythm of "fast, accurate, and first stabilize." The pre-screen does not pursue lengthy questionnaires, but quickly clarifies safety and urgency: whether there is a place to live recently (or where they live), whether antiretroviral or other comorbidity medications are still on hand, and whether contact with the hospital is stable. Then it moves to formal case opening, completing the framework for basic assessment and Individualized Service Plan (ISP); replenishing antiretroviral and comorbidity medications, assisting with transportation services, providing food boxes or vouchers.
After case opening, the Older Adult Specialist (OAS) convenes an InterDisciplinary Team (IDT) to set priorities; if a room cannot be secured yet, alternative accommodation services can be provided: through Peer Navigation, accompanying service users to medical visits and applying for social welfare, occupational therapy (OT) for home safety and assistive device applications if needed, and telehealth for health care needs. The original intention and goal of the Chicago House program is only one: before resources are fully in place, first retain older people living with HIV to prevent homelessness.
After moving in: Bringing care "into the home"
Case admission is not the end, but the real starting point of the system. The Older Adult Specialist embeds age-specific risk factors (frailty, polypharmacy, cognitive changes, social isolation) into routine daily care; peer navigation can break down the complex processes of various systems and accompany service users to complete them; public spaces in the house can reserve facilities for exercise and rehabilitation, maintaining users' physical strength and balance, while telehealth allows health care to be untethered from hospitals, preventing users from playing a "treasure hunt" in hospitals.
Why is it effective: Three structural reasons
First, prioritize stabilizing safe housing. Safe and affordable housing is the common premise for stable medical care, quality of life, and risk reduction.
Second, peer navigation simplifies complex processes. Systems are often harder to understand than diseases, and with experienced peers, willingness for referral and follow-up naturally increases.
Third, embed the aging perspective into daily life. Through Older Adult Specialists and interdisciplinary teams actively managing common issues for older people living with HIV, such as frailty, accidental falls, polypharmacy, and social isolation; and using telehealth to bring health care from hospitals back to daily living spaces.
Effectiveness review: Avoid only doing processes without seeing results
Chicago House believes that assessing feasibility is equally important, and the housing aspect is evaluated by 90/180/365 days housing stability ; the medical aspect focuses on clinic visits, medication refills, and completion of multiple chronic disease screenings; the functional and safety aspect is professionally assessed based on Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL), fall risk, and occupational therapy; the psychosocial aspect requires assessment of depression, anxiety, and social connectedness; the system aspect of the program focuses on referral completion time, care interruption rate, and staff competency after completing aging training. They believe that regular review and public learning of these indicators can continuously improve and revise this service model.
Comments
I like how the model frames the home itself as the center for care, rather than a separate facility. The idea of reducing the effort for residents to access services, especially for older people living with HIV, makes a lot of sense. It’s a fresh angle on what stability can look like.
I appreciate how the Chicago House model centers the home as the main hub for care instead of relying on more institutional settings. It seems like bringing HIV Case Management Services directly into people's living spaces could really help reduce barriers and make things less overwhelming for older adults.
I found the idea of making the home itself a hub for integrated care really compelling, especially since it sidesteps the need for new buildings. Framing public space as infrastructure for stability makes a lot of sense, and it seems like bringing HIV case management right to residents could really reduce stress for people aging in place.
I really like how the model emphasizes turning the home into a service hub instead of moving people into new facilities. The idea of reducing the effort residents spend navigating the system seems especially important for older folks, and I think it would make care feel less disruptive overall.
I like how the model focuses on 'settling people at home' before layering in services. The idea of turning the living space into a service hub, especially for people aging with HIV, seems much more empowering than moving folks into new facilities.
I really like how Chicago House focuses on turning the home itself into a care hub rather than just a place to live. It seems like this approach could genuinely help people maintain their independence while still getting the support they need, especially for those navigating complex health services.
I find the idea of turning the home into a central hub for both medical and social support really thoughtful. It seems like prioritizing stability in living spaces could make a big difference for older adults with HIV, especially by reducing the stress of navigating complex services.
I really appreciate the idea of using the home as the primary site for care. It seems like a thoughtful way to maintain comfort and autonomy for older adults while still providing necessary support. The focus on reducing the complexity of accessing services at home sounds like a practical step forward.
I appreciate how the Chicago House model treats the home as a hub for integrated support, rather than just focusing on physical space. It seems like combining medical care and peer support where people already feel comfortable could really help reduce barriers, especially for older folks living with HIV. The idea of 'fast, accurate, and first stabilize' for case opening also makes sense in this context.
I find the idea of transforming the home into a hub for care really thoughtful. It seems like focusing on stability and comfort first could make a big difference for older adults managing complex needs like HIV. The emphasis on reducing the burden of navigating systems feels especially important.
I appreciate the way Chicago House focuses on making the home a true service hub rather than just another building. The idea of reducing the need for residents to navigate a complicated system by bringing HIV Case Management Services directly into their living space makes a lot of sense.