12/13/2013 François-Xavier Bagnoud Center Today’s Webinar will be starting soon For the audio portion of this meeting: Dial 1-888-394-8197 Enter participant code 733225 HIV-MHRC Supporting Engagement and Retention in Care Using the PCMH Model: Best Practices from the California HIV/AIDS PCMH Demonstration Project François-Xavier Bagnoud Center Guidelines for Our Online Meeting Room • PLEASE TURN OFF YOUR COMPUTER SPEAKERS • Kindly mute your phone line – Dial in: 1-888-394-8197 – Enter participant code: 733225# • Questions & Interactive activities – Enter questions into the chat room – Polls • Evaluation 3 HIV-MHRC 1
12/13/2013 François-Xavier Bagnoud Center Today’s Presenters: Steve Bromer, MD Medical Director of Practice Facilitation HIV Medical Homes Resource Center Amy Sitapati, MD Interim Medical Director, Owen Clinic Associate Clinical Professor of Medicine UC San Diego Health System Kathleen Clanon, MD Associate Chief Medical Officer Alameda Health System 4 HIV-MHRC Learning goals Participants will: Recognize how key concepts of the PCMH model support sustainable improvement in the HIV Treatment and Care Cascade. Employ effective strategies for population and panel management to retain patients after empanelment. Recognize specific challenges/solutions in engagement and retention from the UCSD and HIV ACCESS (CHC) perspective. Discuss the role of team- based care in supporting clients’ access to wraparound services. Identify engagement and patient retention deliverables specific to PCMH recognition. Today’s Agenda 1. PCMH Commercial 2. Case Discussions 3. Your Questions, Answered! 2
12/13/2013 GARDNER CASCADE GOT YOU DOWN?!?! 100% 100% 90% 80% 82% 70% 66% 60% 50% 40% 37% 30% 33% 25% 20% 10% 0% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed 100% 100% 90% 80% 82% 70% 66% 60% 50% 40% 37% 30% 33% 25% 20% 10% 0% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Retention Imperative • Health of patients 100% • HRSA/Ryan White requirements 82% • Future funding • Prevention of HIV 66% transmission 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed 3
12/13/2013 PCMH IS HERE TO HELP!!! 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed THE PCMH MODEL CAN HELP YOU IMPROVE PATIENT RETENTION THE BUILDING BLOCKS OF THE PATIENT-CENTERED MEDICAL HOME ARE DESIGNED TO KEEP PATIENTS ENGAGED IN CARE 4
12/13/2013 The Building Blocks can help us address the cascade! 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Retention Improved access (8) → Patients can be seen by care team when they need to be Empanelment (3)/team-based care (4)/population management (6) → Team takes responsibility for identifying out-of-care patients and facilitating outreach Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (7) → Fostering long-term relationships between patient and provider/team to build a sense of connection to care Data-driven improvement (2) → Using data to understand characteristics of out-of-care patients to identify opportunities for intervention 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Prescription of ART Empanelment (3) /team-based care (4) /population management (6) → Team is accountable for identifying patients not on ART Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (7) → Building trust between patient and provider/team and shared decision-making about treatment 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed 5
12/13/2013 Viral Load Suppression Improved access (8) → Patients can be seen by care team when they need and have phone and/or electronic access to provider/team to avoid treatment interruptions Empanelment (3) /team-based care (4) /population management (6) → Team takes responsibility for identifying opportunities for outreach/intervention with patients at risk for poor outcomes Care coordination (9) → Addressing patients’ other needs so they can focus on their health Patient-team partnership (5) /Continuity of care (9) → Fostering long-term relationships between patient and provider/team and shared-decision-making Data-driven improvement (2) → Using data to understand characteristics of non- virally-suppressed patients to identify opportunities for intervention 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Diagnosis and Linkage Access to care (8) → New patients can be seen upon diagnosis; out-of-care patients can access appointments when they are ready to come back to care Engaged Leadership (1) / Empanelment (3)/team-based care (4)/population management (6) → Larger organization (hospital/health center) effectively manages patient population to promote HIV testing and linkage to care 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed THANKS FOR SAVING THE DAY, PCMH!!! 6
12/13/2013 Another Benefit: Avoiding Quality Whack-a-Mole a ddress multiple quality indicators at once… Poll Question Which of the following describes your clinic’s current retention efforts? Working very well, retention is >95% Could be better, retention is 80-95% Need help, retention is < 80% We have a retention program, but I’m not sure how well it’s working We don’t have a retention program Don’t bother me, I’m eating my lunch UC San Diego Health System: Our HIV/AIDS medical home: The Owen Clinic Providing care for 3,100 HIV/AIDS lives 7
12/13/2013 What is fundamentally different about the PCMH model of care delivery? hspca.convio.net Retention Do you know your data? And have you addressed access, teams, population management, care coordination to improve the care delivery? What do you do proactively to prevent patients from falling out of care? 100% 82% 66% 37% 33% 25% HIV Infected Diagnosed Linked to Care Retained in Care Prescribed ART Virally Suppressed Do you know your RETENTION PERFORMANCE data? Medical Visits Milestone: Improve medical visit performance by 10% over baseline for the period 1/1/2013-12/31/2013 Metric: Number of HIV-infected clients who had a medical visit with a provider with prescribing privileges, i.e. MD, PA, NP, in an HIV care setting two or more times at least 3 months apart during the measurement year / Number of HIV-infected clients who had a medical visit with a provider with prescribing privileges at least once in the measurement year Scheduled Visits Predicted (actual + Gap between Actual between now and Year Scheduled Visits (Plus scheduled and 20% Predicted visits Reported Baseline 01/01/2013-10/31/2013 end 20% no show rate) no show) Target and Target Numerator 2217 1911 262 210 2121 2286 165 Denominator 2823 2628 18 2646 2646 Percentage 78.53% 72.72% 80.14% 86.39% Targeted Goal (visit gap with 20% no show) 198 Dynamic Reports run every 1-2 weeks Adjust strategy MONTHLY Do you only run reports on patients who have fallen Out of care , or do you run reports for patients at risk? Publish: Clinic wide with baseline and goal Team based report card Provider based report card 8
12/13/2013 Are there opportunities for you to IMPROVE ACCESS? Have you adopted an OPEN ACCESS model of care delivery? Do you have EVENING and WEEKEND access for routine care delivery? washingtonpost.com gradschool.usciences.edu How do you use the REGISTRY and TEAM BASED care delivery to proactively prevent poor RETENTION? WHO & HOW: 1. Retention Weekly Meeting: Retention Specialist, RN Panel Manager, Director, Nurse Manager, Case Manager 2. Inpatient Care Transitions Weekly Meeting: Transition of Care Nurse, Inpatient HIV Attending; Case Management; Inpatient and Ambulatory Pharmacists THE TOOLS: 1. Tracking database 2. Operational “live” database in the EHR 3. Marry panel management activity and case management Are you offering patient centered promotion of literacy and HEALTH INFORMATION and ACCESS? Patient computer lab, English and Spanish Patient Portal Chart Access, English and Spanish Patient Centered Web Page 27 9
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