Approaches to practice transformation to improve outcomes along the HIV Care Continuum Panel Session 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Integrating Quality Improvement and Population Health Approaches into Panel-based Care through Practice Transformation: A SPNS Initiative Susan Olender, MD, MS Mila González, MPH Jesse Thomas, BA NewYork-Presbyterian Hospital Comprehensive Health Program 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
STaR SPNS Team Susan Olender Principal Investigator Mila Gonzalez Project Director Audrey Perez Clinical Care Coordinator Marilena Lekas Evaluator James Beltran Data Coordinator Jesse Thomas HIT Consultant, RDE Anusha Dayananda HIT Consultant, RDE 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Outline Practice Transformation Model at the Comprehensive Health Program Needs Assessment and Planning the Practice Transformation Implementation of Treatment Adherence Program through Primary Care Nursing Development of Health Information Technology (HIT) for Population Health Management and Quality Improvement Integrating Quality Improvement into Panel-Based Care 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
1) STaR’s Practice Transformation: A SPNS Initiative 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Comprehensive Health Program Academic medical center in Upper Manhattan, NY Provides outpatient & inpatient care to people living with or at-risk for HIV Over 2,200 outpatients with HIV and 20 bed inpatient unit Growing attention to at-risk population, PrEP, and STI services Approximately 100 staff operating in a variety of settings: inpatient, outpatient, community, and home visits Multidisciplinary clinical care Providers, nurses, social workers, care coordinators, nutritionist, psychiatrists, patient navigators, medical and nursing assistants 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
SPNS Workforce Initiative Project Title: Stimulating Transformation of Technology and Team Structure to Reach People Living with HIV 4-Year SPNS Grant Funded to design, implement, evaluate, and disseminate the intervention Multi-site: 15 demonstration sites across the country “Practice Transformation Models” or PTMs System level staffing changes Heavily based on Patient Centered Medical Home (PCMH) Improves capacity to care for people living with HIV, valuing efficiency and sustainability Optimizes resources in changing landscape Improves linkage, engagement, retention in care, and suppression rates Cross-site Evaluation UCSF’s Evaluation and Technical Assistance Center (ETAC) 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Demonstration Sites New York and Presbyterian Hospital, New York, NY Bright Point, Bronx, NY New York City Department of Health and Mental Hygiene, Rikers Island, NY UPMC Presbyterian Shadyside, Pittsburgh, PA La Clínica del Pueblo, Washington, DC Florida Department of Health, Kissimmee, FL FoundCare Inc., West Palm Beach, FL University of Miami, Coral Gables, FL The MetroHealth System, Cleveland, OH Access Community Health Network, Chicago, IL Hektoen Institute for Medical Research (Core Center), Chicago, IL Coastal Bend Wellness Foundation, Inc., Corpus Christi, TX Special Health Resources for Texas, Inc., Longview, TX Family Health Centers of San Diego, Inc., San Diego, CA Centro de Salud de la Comunidad de San Ysidro, Inc., San Diego, CA 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Stimulating Transformation: Needs Assessment Care coordination Inefficiencies in identifying who to follow-up Separate programs for adherence, care coordination, nursing care, medical care Communication Complex communication patterns Multiple staff members in various settings with variable communication Untapped opportunities for efficiencies through HIT Accessibility Many providers are not on-site full time (fellows, researchers, etc.) 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Stimulating Transformation: Needs Assessment Staff working at the top of their license Opportunities with experienced nursing team: Primary Care Nursing No-shows and walk-ins High no-show rates resulting in lost capacity Need for strengthening patient access to same-day walk-in care 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
STaR Practice Transformation Model: Providing More Care Through Harmonious Redesign (without sacrificing quality) Enhanced Communication Panel-Based Efficient Use Clinical Care Team of Clinical Space (Quality Teams) Integrating Health Information Coordinated Care Technology (HIT) for Population Across Settings Health Management 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Planning the Practice Transformation: PRECEDE PROCEDE Framework 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Inputs Activities Outputs Outcomes Impact (Distal Effects) (Intermediate Effects) CHP Funding & Clinical & Non-Clinical Resources Services Prevention, Care & Support, and Program Psychosocial Treatment Services wellbeing improved Provided Facilities & among HIV-positive Patient Flow Redesign Improvements in Equipment individuals Service Delivery : Impact Access Coverage Expanded Walk-In Workflow Changes & Quality Evidence-Base Capacity & Targeted Quality Improvements Cost-Effectiveness Coordination of Same Implemented HIV prevalence Day Services Pathway decreased in the community Policies, Protocols Population Health & Guidelines Management by Clinical Care Teams Increase Capacity in (Logic (CCT) Team-Based Care Training & Coordination & Technical Population Health Integrated Clinical & HIV incidence Assistance Management Non-Clinical Care decreased in the Model) Coordination via CCTs community Staff- & Team-Level CHP & NYP Changes in: Strategic Plans Knowledge RN & Non-RN Care Attitudes Coordinator Support of Practices Care Transitions HIV morbidity & Health Information Successful Outreach & mortality decreased Technology Engagement of High- among HIV-positive Referrals & Linkages to Risk Populations and individuals Community-Based Linkage to Treatment, Services Monitoring and Care, and Supportive Evaluation (M&E) Services Systems Community-Based Outreach & Increase Proportion of Engagement Patients: Community Retained in Care & Partners Achieved Viral Suppression Consumer Education Patients Self-Efficacy, Satisfaction & Engagement in Program Development Consumer Advocacy CHP Quality Improvement, Monitoring & Evaluation of Program 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Panel-Based Clinical Care Teams & Coordinated Care Across Settings STaR Clinical Care Coordinator at the Comprehensive Health Program CCT A CCT B CCT C CCT D Social Social Social Social Worker(s) Worker Worker Worker(s) STaR Clinical Care Care Enhancements: Registered Registered Registered Registered Nurse Nurse Nurse Nurse Coordinator: Better communication Dedicated to supporting the Social Worker co-lead care team structure Clinical Care Teams Clinicians Clinicians Clinicians Clinicians Provide clinical support to Medication adherence through Primary Care RN Care Coordinators Care Care Care Care Coordinators Coordinators Coordinators Coordinators Patient Navigators Community Health Workers Patient Patient Patient Patient Navigators Navigators Navigators Navigators Adherence Supervisor, Case Managers, Community Health Workers, Peer Educators, Nutritionist, Psychiatrists, Patient Financial Advisors, & Other Staff 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Building the Clinical Care Teams Social Worker Distribution Provider (PCP)-Social Worker (SW) by Team A Provider Team Alignment 300 600 250 500 200 400 150 300 100 200 50 100 0 0 PCP Team A PCP Team B PCP Team C PCP Team D PCP Team E No SW Assigned SW Team E SW Team D Salcedo Rojas Pudil Hidalgo Cruz Cella- Shackelford SW Team C SW Team B SW Team A Cabrera Cabreja Campos 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Coordinating Weekly Care Team Meetings RN Care Coordinators send out daily email reminders Pre-meeting planning between RN Care Coordinators and Social Worker (Team Co-Captains) Theme-based discussion calendar Review of Dashboard indicators 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Patient Discussion Structure 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
2) HIT Development 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
Integration of Health Information Technology (HIT) for Population Health Management Updates to HIT to support team discussions (population health) and create efficiencies Collaboration with RDE Systems Dashboard design Adding additional key clinical indicators 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT
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