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.
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.