Abstract: Background: Veterans Health Administration (VHA) has been at the forefront of offering integrated and patient-centered care to address the complex needs of more than 30,000 Veterans with HIV in the United States of America. These Veterans present with diverse cultural identities, personal values, and goals pertinent to their care, and they are often managing multiple comorbid chronic conditions, mental health diagnoses, and psychosocial stressors alongside HIV. The quality of their care has often been affected by stigma, minority stress, and the quality of the patient-provider relationship and associated collaborations over treatment approaches and goals, which has a direct effect on outcomes. Objective: At San Francisco VA Health Care System, the Infectious Disease Care and Resilience (IDCaRe) team was established to improve outcomes for Veterans with acute needs or persistent difficulties in care delivery and efficacy. Method: A five-step model to address complex needs in HIV care was adapted from existing literature and evidence base, combined with a culturally-aligned, interdisciplinary care orientation. This model was implemented with patients determined to be at high-risk for poor health engagement. A representative composite case study demonstrates the process. Results: Three Veterans underwent the intervention with results presented. Lessons learned and future discussions are also discussed. Conclusion: The IDCaRe model has promise as an integrated, patient-centered, behaviorally-grounded intervention for improving HIV-related care outcomes for Veterans with complex needs.