Work with patients to reduce barriers to full engagement in HIV care and treatment, including via collaboration with legal and housing advocates; assist patients in attending important appointments including medical, benefits, mental health, etc., by arranging transportation and addressing other barriers; accompany patients as needed to important housing, legal and social service appointments; as well as to medical and behavioral health appointments when indicated; track patients who miss appointments and reschedule as necessary, document care appropriately in medical record. Identify, in collaboration with rest of the multidisciplinary team, which patients will benefit from outreach visits at shelters, outside agencies, jail, or their place of residence; participate in HIV care team to exchange information, develop an integrated care plan, etc., in partner notification program, and in multidisciplinary HIV care team meetings to collaborate on integrated care plans and coordinate care.