Improving Patient Retention April 6, 2010 CTHIVQUAL Workgroup

1. Improving Patient RetentionApril 6, 2010 � CTHIVQUAL Workgroup Facilitator: Nanette Brey Magnani, Ed.D., NQC, HIVQUAL Quality Consultant

2. Learning Objectives Through discussion with your peers, Define a retention performance measure for your HIV program. Connect QI interventions to reasons why patients are not retained in care. Determine next steps for improving patient retention.

3. Agenda Welcome Defining retention Testing and measuring interventions Sustaining retention

5. Why is Retention Important? Patient Care and Public Health Retention has now been proven to correlate with improved biological outcomes that improve quality of life for patients and reduce the likelihood of further transmission of HIV to others Agins. Reflections on Retention: Connecting to Care.�

6. Why is Retention Important? Healthcare Cost If patients are retained in care, they are more likely to receive preventive care, use emergency services less and keep overall healthcare utilization and costs lower, placing less demand on human and material resources. Agins. Reflections on Retention: Connecting to Care.�

7. Where do you start? Step 1: Define a retention performance measure Numerator: Requires a precise definition of expected number of visits during a specified time interval Denominator: The number of eligible patients (population) requires a determination of visit type and determination of active caseload of the clinic

8. Check-in If you are working on a patient retention QI Project, what is your measure?

9. Questions in Defining a Measure Do different populations require different measures? Can we use no show rates? How do we define �lost to follow-up?� How frequently do we measure retention?

10. Retention & No Show Measures: Clarion University Retention measure: (changed over course of project to conform to HRSA definition) Total # of patients with 2 or more visits at least 3 months apart (last 12 mo.) Total # of patients enrolled in clinic at beginning of measurement period Exclusions = Patients who transferred care to another HIV clinic (verified) Patients who died No show measure: Total number of patients who did not attend their scheduled visit Total number of scheduled appointments Exclusion = Patient canceled appointment in time to fill appointment slot This is to replace the blank slide in your slide show � slide # 30 This is to replace the blank slide in your slide show � slide # 30

11. Retention Measure - Horizons Missing any appointment places youth on list and actively pursued for a year Monthly data collection number of kept appointments including walk-ins ______________________________ number of scheduled appointments including walk-ins

12. HIVQUAL and NYS Retention Measureand Scranton Temple Residency Program Number of unique clients with at least 2 or more visits during the past 12 months, one in each 6-month period Number of unique clients with at least 1 visit during the past 12 months

13. HIVQUAL Regional Groups� Retention Measure (CA,AZ,NV) Inclusive of: UCSD Owen Clinic � San Diego USC-MCA � Los Angeles Sonoma Co � Santa Rosa Venice Family Clinic � Venice, CA Community Medical Centers � Stockton, CA Pace Clinic � Santa Clara LA Gay & Lesbian Center Maricopa Health Systems - AZ Plumas Co., Northern CA Santa Cruz Co., CA

14. Retention Measure Numerator: Patients with a visit in 1st and 2nd half of year/ Denominator: Patients with a visit in 1st half of year Exclusion: patients who enter care in 2nd half of year Example: Numerator: 135 (number of pts from 1/1/07 � 6/30/07 and 7/1/07 � 12/31/07/ Denominator: 175 (number of pts with at least one visit from 1/1/07 � 6/30/07 Retention rate: 77%

15. Standard Measure: Tri-State HIVQUAL Regional Group (Ohio, W.PA, W.VA) -modified to reflect HAB measure- All patients will be seen by a medical provider every 4 months (trimester) Numerator: Number of unique patients seen 1x in last 4 months Denominator: Number of unique patients in care Adjusted for patients who have expired, currently incarcerated, relocated or changed provider

16. Next Step Step 2: Establish your baseline

17. Check If you have begun work on patient retention, what is your baseline data?

18. Baseline Data � Scranton Temple Residency Program Engaged in QI Project to increase annual cervical cancer screening rates. The team increased rates from 16% to 70%. To further improve, the team realized there was a retention in care problem. 46 of 128 or 36% of female patients did not meet the HIVQUAL definition of one medical visit in the first six months of the year and one in the second six months; thus, 64% retention rate.

19. Baseline Data for Men - STRP September 1, 2008 through August 30, 2009 183 active male patients 111 / 183 met HIVQUAL criteria of medical visit in the first six months and once in the second six months 111 / 183 = 60% Retention rate Combined rate for female and male patients - 62%

20. Clarion Univ: Aggregate Data for Analysis and Management

21. Baseline � HIVQUAL Regional Groups (CA,AZ,NV)*available as xml files for CAREWare users

22. Next Step Step 3: Investigate the Process and Causal Analysis

23. Causal Analysis and Interventions Act locally: Retention activities and improvements are unique to the context of each organization and its patient population and its community.

24. Check-in If you have done your causal analysis, why are your patients not coming?

25. Reasons identified for patients not being seen every trimester � Tri-State HIVQUAL Regional Group (9 Part C/D grantees) 2005-06 Active Mental Illness Active Substance abuse Transportation Unstable Housing Too sick to keep appt If well, may not perceive appointments as necessary Lack of family and other social supports Inflexible working schedules Inflexible clinic appointment schedules Incarceration Lack of �connection� to medical provider Fear of disappointing medical provider if not adherent to tx

26. Next Step Step 4: Select, Test, and Measure Interventions

27. Check-in Have you started testing your intervention? If so, what Is your QI intervention? Are your results if QI Project is completed?

28. Interventions and Outcomes: Clarion This is updated information to replace slide # 43 in your slide show This is updated information to replace slide # 43 in your slide show

29. Improvement in No Show 2006 � 2008Clarion Univ. This is updated information to replace slide # 44 in your slide show This is updated information to replace slide # 44 in your slide show

30. Next Steps Step 4/5: Next PDSA (Plan, Do, Study, Act) Cycle and Step 6: Sustaining Gains

31. Check-in: If you completed your QI Project, please share: issues you have in sustaining your gains and how you are sustaining the gains you made.

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33. Summary Retention in care is associated with improved health outcomes Practical strategies can improve retention rates involving healthcare providers and community based organizations. Addressing patient needs and barriers to care improves retention. Measurement is the key to investigating the problem and identifying effective solutions Limited data about �at-risk� patients � �drill down� to learn more about those not retained

34. Moving Forward: Next StepsMeeting: April 20, 2010 � CHC, Meriden Discussion and agreement on retention measure Data collection for baseline Causal analysis QI Project Plan Implementation Measure Act

35. Retention of New Patients in Care Download story board from www.nationalqualitycenter.org Ana Lapp, RN, QI Coordinator Esperanza Health Center 3156 Kensington Ave. Philadelphia, PA 19134-2400 Member of: Phila. Regional HIVQUAL Group 215-831-1100 x227; aml@esperanzahealth.com