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Hyacinth Care and Treatment Programs

Hyacinth addresses the economic and social circumstances that may impact our clients’ health status or the quality of their lives through our Care and Treatment Program. The goal of the program is to help our clients prioritize health, adhere to their medical prescription so that they may achieve viral load suppression and live a healthy life.

Our Supportive Services include

• Non-Medical Case Management (Paterson, Jersey City, Newark, Trenton)
• Emergency Financial Assistance (Jersey City, West New York, Newark, Plainfield, New Brunswick, Trenton)
• Community Health Worker Program (Hudson, Passaic, Essex, Union, Middlesex and Mercer Counties)
• Legal Client Advocacy (Jersey City, Newark)
• Psychosocial Services (All Offices)
• Medical Transportation is available to clients of the program (All offices)
• Status Neutral Case Management (Plainfield and Trenton)
• Housing Placement Assistance (West New York, Paterson, Newark, Plainfield, New Brunswick and Trenton)
• Our HOPWA program serves people in Atlantic, Cape May, Cumberland, Mercer, Warren and Salem Counties while our HOP-2 program is statewide.

We also offer Direct Services that include

• Mental Health Groups (Wellness groups) (All Offices)
• Individual & Group Substance Abuse Counseling (Paterson, Newark)
• Individual Mental Health (All Offices)
• Medical Case Management (Paterson, Newark)
• Our Newark office hosts the Hyacinth Health & Wellness Center where HIV medical services as well as PrEP treatment are offered.

NON-MEDICAL CASE MANAGEMENT Our Case Managers provide assistance with clients’ daily living activities and intervention. They manage the client’s cases, ensuring that clients can navigate the different systems of care and of support services.  Services include advice and assistance in obtaining medical, social, community, legal, financial, and other needed services. An Emergency Financial Assistance fund helps clients pay for rental and utility arrears.

MEDICAL CASE MANAGEMENT (MCM) Medical Case Managers provide a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Treatment adherence counseling ensures readiness for and adherence to complex HIV/AIDS regimens. The program offers client-centered services that link clients with healthcare, psychosocial, and other services.

CLIENT LEGAL ADVOCACY Our Client Legal Advocates aim to guarantee a client’s access to benefit programs that provide needed financial assistance and medical insurance coverage so that people living with HIV maintain optimal health care without interruption and maximize the benefits of HIV treatment. They assist consumers to navigate complicated filing systems of entitlement programs that provide health insurance and treatment access, and assistance with appeals of ineligibility for Social Security, private disability programs and other state benefits program. They assist with Legal Documents, wills, guardianship; advance health care directives, power of attorneys, medical insurance/coverage; as well as discrimination issues. 

COMMUNITY HEALTH WORK Our CHWs link previously diagnosed and out of care PWH to HIV care and other needed services; they support continuous participation in care through individualized escorts to the doctor’s office, and they follow up to help clients who are newly in care to “navigate” the support services. The CHWs collaborate with local clinics to ensure the client’s participation in care and to discuss eligible health insurance. They provide education, motivational counseling, and escort to appointments, so that clients can participate more fully in their health care.

HOUSING PLACEMENT ASSISTANCE Housing Specialists assist clients who are homeless, in process of eviction, or living in transitional housing, shelters and inadequate housing conditions. Housing Specialists locate and offer access to permanent housing, and provide supportive services to assist with housing stability, access to medical care, and independent living. Emergency Financial Assistance funding allows the program to provide help to clients in need with utility assistance, and rental assistance. They conduct apartment-viewing activities and negotiate leases with property owners. They educate the client and ensure that they are ready for their next level of housing.

PSYCHOSOCIAL SUPPORT Regional Services Managers (RSM) work individually with clients to address concerns in a safe space and develop a personalized plan of action that may include referral to clinical mental health services. The RSM communicate with the team to keep them aware of the psychosocial services the client is receiving and any referrals that were made. The RSM also facilitate monthly health literacy skills building groups that address barriers to care.

MENTAL HEALTH AND SUBSTANCE ABUSE COUNSELING Our licensed clinicians facilitate mental health counseling and or substance abuse therapy groups as well as individual sessions for our clients according to the principles of The Wellness Community at Hyacinth. The Patient Active model empowers participants to become actively involved in their care and to identify and address loss of control, loss of hope and unwanted aloneness, which are the primary sources of stress for individuals confronting life threatening, chronic diseases.

WELLNESS NAVIGATION (WN) The Wellness Navigators assist clients in their journey with HIV/AIDS by providing an atmosphere of community among the members of the TWCH program. The WN call the members weekly to invite them personally to the upcoming mental health group; they build relationships with community providers and reconnect clients who lost touch with the program.  They plan a lunch and ready the atmosphere, to host the weekly mental health groups, which they attend with the clients to bridge the provider/customer customer/provider balance and to serve as a role model.  The WN also plan and facilitate weekly, fun, social activities that encourage social skills and fraternity.

HYACINTH CAR SERVICE Regional Services Managers at each Hyacinth office can arrange Uber service for qualifying Hyacinth clients who need transportation to medical appointments or supportive services.

The clinic is supported by a multidisciplinary team that includes a full-time nurse practitioner, clinic nurse, medical assistant, medical case manager, PrEP counselor, medical receptionist, and 340B coordinator, with additional support from a part-time psychiatric nurse practitioner. Together, this dedicated team works collaboratively to provide:

• Hepatitis C Treatment
• HIV specialty care
• HIV testing
• Medical case management
• Mental Health Evaluation and Treatment
• nPEP (Non-Occupational Post-Exposure Prophylaxis) Education and Prescribing
• PrEP (Pre-Exposure Prophylaxis) education and prescribing
• Sexual Health Education
• STI Testing and Treatment

To learn more about the clinic, call 862-240-1461.

TWCH offers client-centered, theme-based, and goal-oriented wellness groups where participants explore strategies for emotional wellness, self-care, and maintaining healthy lives. Facilitated by licensed therapists, these groups address the emotional impact of HIV while promoting treatment adherence and continued engagement in care.

A cornerstone of TWCH is the Wellness Navigator model, a unique peer-support approach rooted in lived experience. Wellness Navigators (WN) know the value of the Wellness Community and serve as sources of encouragement and guidance for others. Our WN’s combine their ongoing training and professional development to support participants who are continuing their own growth. This experience helps create a space where participants feel understood, welcomed, and supported.

Through wellness activities, shared meals, and community gatherings, participants have additional opportunities to strengthen relationships and experience the sense of belonging that comes from being part of a supportive community.

TWCH services include:

• Social and emotional support groups
• Weekly mental health group counseling
• Co-ed Wellness Group
• Women’s Wellness Group
• Men’s Wellness Group
• Individual mental health counseling
• Individual and group substance use counseling
• Wellness activities that promote connection, community, and self-care
• Support from Wellness Navigators with lived experience

The Wellness Community at Hyacinth is available throughout the communities we serve:

• Jersey City – Hudson County
• Paterson – Passaic County
• Newark – Essex County
• Plainfield – Union County
• New Brunswick – Middlesex County
• Trenton – Mercer County

If you are living with HIV and interested in participating in The Wellness Community at Hyacinth, please contact your closest regional office.