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12/13/2013François-Xavier Bagnoud CenterToday’s Webinarwill be starting soonFor the audio portion of this meeting:Dial 1-888-394-8197Enter participant code 733225HIV-MHRCSupporting Engagement and Retentionin Care Using the PCMH Model: BestPractices from the California HIV/AIDSPCMH Demonstration ProjectFrançois-Xavier Bagnoud CenterGuidelines 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 Evaluation3HIV-MHRC1

12/13/2013François-Xavier Bagnoud CenterToday’s Presenters:Steve Bromer, MDMedical Director of Practice FacilitationHIV Medical Homes Resource CenterAmy Sitapati, MDInterim Medical Director, Owen ClinicAssociate Clinical Professor of MedicineUC San Diego Health SystemKathleen Clanon, MDAssociate Chief Medical OfficerAlameda Health System4HIV-MHRCLearning goalsParticipants will: Recognize how key concepts of the PCMH model supportsustainable improvement in the HIV Treatment and CareCascade. Employ effective strategies for population and panelmanagement to retain patients after empanelment. Recognize specific challenges/solutions in engagement andretention 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 deliverablesspecific to PCMH recognition.Today’s Agenda1. PCMH Commercial2. Case Discussions3. Your Questions, Answered!2

12/13/2013GARDNER CASCADEGOT YOU 5%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally %25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedRetention Imperative Health of patients HRSA/Ryan Whiterequirements Future funding Prevention of 30%33%25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally Suppressed3

12/13/2013PCMH ISHERE 25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedTHE PCMH MODELCAN HELP YOUIMPROVE PATIENTRETENTIONTHE BUILDING BLOCKS OF THEPATIENT-CENTERED MEDICALHOME ARE DESIGNED TO KEEPPATIENTS ENGAGED IN CARE4

12/13/2013The Building Blocks can help usaddress the 5%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in Care Prescribed ART Virally SuppressedRetentionImproved access (8) Patients can be seen by care team when they need to beEmpanelment (3)/team-based care (4)/population management (6) Teamtakes responsibility for identifying out-of-care patients and facilitating outreachCare coordination (9) Addressing patients’ other needs so they can focus ontheir healthPatient-team partnership (5) /Continuity of care (7) Fostering long-termrelationships between patient and provider/team to build a sense of connectionto careData-driven improvement (2) Using data to understand characteristics ofout-of-care patients to identify opportunities for 33%25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedPrescription of ARTEmpanelment (3) /team-based care (4) /population management (6) Teamis accountable for identifying patients not on ARTCare coordination (9) Addressing patients’ other needs so they can focus ontheir healthPatient-team partnership (5) /Continuity of care (7) Building trust betweenpatient and provider/team and shared decision-making about 25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally Suppressed5

12/13/2013Viral Load Suppression100%100%90%80%Improved access (8) Patients can be seen by care team when they need andhave phone and/or electronic access to provider/team to avoid treatmentinterruptionsEmpanelment (3) /team-based care (4) /population management (6) Teamtakes responsibility for identifying opportunities for outreach/intervention withpatients at risk for poor outcomesCare coordination (9) Addressing patients’ other needs so they can focus ontheir healthPatient-team partnership (5) /Continuity of care (9) Fostering long-termrelationships between patient and provider/team and shared-decision-makingData-driven improvement (2) Using data to understand characteristics of nonvirally-suppressed patients to identify opportunities for HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedDiagnosis and LinkageAccess to care (8) New patients can be seen upon diagnosis; out-of-care patientscan access appointments when they are ready to come back to careEngaged Leadership (1) / Empanelment (3)/team-based care (4)/populationmanagement (6) Larger organization (hospital/health center) effectivelymanages patient population to promote HIV testing and linkage to %10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedTHANKS FORSAVING THEDAY, PCMH!!!6

12/13/2013Another Benefit: Avoiding Quality Whack-a-Moleaddress multiple quality indicators at once Poll QuestionWhich of the following describes your clinic’s currentretention 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 howwell it’s working We don’t have a retention program Don’t bother me, I’m eating my lunchUC San Diego Health System:Our HIV/AIDS medical home: The Owen ClinicProviding care for 3,100 HIV/AIDS lives7

12/13/2013What is fundamentally different about thePCMH model of care delivery?hspca.convio.netRetentionDo you know your data? And have you addressedaccess, teams, population management, carecoordination to improve the care delivery?What do you do proactively to prevent patients fromfalling out of 0%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedDo you know your RETENTIONPERFORMANCE data?Medical VisitsMilestone: Improve medical visit performance by 10% over baseline for the period 1/1/2013-12/31/2013Metric: 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 monthsapart 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 yearNumeratorDenominatorPercentageScheduled VisitsActualbetween now and Year Scheduled Visits (PlusReported Baseline 01/01/2013-10/31/2013end20% no show rate)22171911262210282326281878.53%72.72%Predicted (actual scheduled and 20%no show)Target212122862646264680.14%86.39%Targeted Goal (visit gap with 20% no show)Gap betweenPredicted visitsand Target165198DynamicReports run every 1-2 weeksAdjust strategy MONTHLYDo you only run reports on patients who have fallenOut of care , or do you run reports for patients at risk?Publish:Clinic wide with baseline and goalTeam based report cardProvider based report card8

12/13/2013Are there opportunities for you toIMPROVE ACCESS?Have you adopted an OPENACCESS model of caredelivery?Do you have EVENING andWEEKEND access for routinecare uHow do you use the REGISTRY and TEAM BASED caredelivery to proactively prevent poor RETENTION?WHO & HOW:1. Retention Weekly Meeting:Retention Specialist, RN Panel Manager,Director, Nurse Manager, Case Manager2. Inpatient Care Transitions WeeklyMeeting: Transition of Care Nurse,Inpatient HIV Attending; CaseManagement; Inpatient and AmbulatoryPharmacistsTHE TOOLS:1. Tracking database2. Operational “live” database in the EHR3. Marry panel management activity andcase managementAre you offering patient centered promotion of literacy andHEALTH INFORMATION and ACCESS?Patient computer lab, English and Spanish Patient Portal ChartAccess, English and Spanish Patient Centered Web Page279

12/13/2013How can we be leveraging HIV POPULATIONMANAGEMENT to improve other qualityoutcomes?Weekly, a team meets with itsMulti-disciplinary componentsSort HIGH VIRAL LOAD, andAim to improve the TEAM VIRALLOADLive operational database with real-timeactionGoal: to improve TEAM HIV VIRAL %10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedPoll QuestionWhat approaches does your clinic use to improve patient engagementand retention? (Select all that apply)1. Continuous quality improvement team with performance goal2. Patient risk acuity3. Provider loading (availability to accept new patients)4. Evening and weekend hours5. Open access (same/next day scheduling)6. Patient web portal to health record7. Bilingual/multilingual patient resources8. Patient registry reports including retention9.Retention specialist Providing care since 1974 3 Federally Qualified HealthCenters, Wellness Centerand Day Labor outreach Primary Care, SpecialtyServices, Dental, Behavioraland Mental Health, HIV,Teen, Wellness, Outreachand Navigation Services10

12/13/2013Who do we serve? 13,000 adults and children3,300 under age 192,300 over age 6049% Medi-Cal, Medicare,CMSP, Healthy Families85% at/below 200% ofpoverty level40% at/below poverty level36% uninsured54,685 visits (2012)350 patients living with HIVThe Building Blocks can help usaddress the 5%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedEngaged Leadership At its core, all of health care is relational Continuous, trusting, non-judgmental,“first-name” relationship over time “Every interaction creates opportunitiesfor empowering patients and staff to buildhealthy lives and communities.”11

12/13/2013Does retention look like this?Or this?Control: Who really makes the decisions100Patient/Family“Control”The “System”0LowAcuityHigh1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influenceon the choices made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)SouthcentralFoundation12

12/13/2013Building Blocks ofHigh-PerformingPrimary Care:Share-the-CareTM ModelEMR and Data for ImprovementEnhancing the Relationship13

12/13/2013The Building Blocks can help usaddress the 5%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally SuppressedThe Building Blocks can help usaddress the 5%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in Care Prescribed ART Virally Suppressed14

12/13/2013Anti-Stigma Campaign15

12/13/2013WCHC retention and engagement %37%30%33%25%20%10%0%HIV InfectedDiagnosedLinked to CareRetained in CarePrescribed ART Virally Suppressed16

12/13/2013NCQA and Retention in Care PCMH Standard 2, Element D Patients not recently seen by practice, patients onspecific medications PCMH Standard 3, Element B Establish criteria and systematic process to identifyhigh-risk patients PCMH Standard 6, Element A, C, D and E (A) Chronic care measure, (C) CQI goals, (D) showimprovement and (E) Report performanceDEBATE: Is it best to have a retention specialistor to have it part of everyone’s job?Should an HIV Primary Care Medical Homehave a RETENTION SPECIALIST?Out of careAdvantages: Knowledge of complex health Navigation Clear tracking in database Follows complex algorithm Coordinates patientstransitioning Out, incarceration, panelmanager Clear focused roles andresponsibilities17

12/13/2013Should an HIV Primary Care Medical Homehave a RETENTION SPECIALIST?Disadvantages: The “you’re it” phenomenon Diversity of patients rewardsdiversity of care givers working onproblems – not just one Staff turnover Retention is too big a job for oneperson No more silos!Poll: What is your opinion?Is it better to have aidentified retentionspecialist or integrateretention intoeveryone’s jobs? Retention specialist Integrate retentioninto everyone’s jobsThoughts?Questions?5418