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August 2011 Slides from: Amy M. Sitapati, M.D At the UCSD Owen Clinic

ANCHORING INTO THE MEDICAL HOME Engagement in Care. August 2011 Slides from: Amy M. Sitapati, M.D At the UCSD Owen Clinic. Engagement in care (one component of care management). The 39 Core Components. C.R. Jaen, et al. Ann Fam Med. 2010;8(Suppl 1):s57-67. STEP 1: Pilot RETENTION.

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August 2011 Slides from: Amy M. Sitapati, M.D At the UCSD Owen Clinic

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  1. ANCHORING INTO THE MEDICAL HOME Engagement in Care August 2011 Slides from: Amy M. Sitapati, M.D At the UCSD Owen Clinic

  2. Engagement in care (one component of care management) The 39 Core Components C.R. Jaen, et al. Ann Fam Med. 2010;8(Suppl 1):s57-67

  3. STEP 1: Pilot RETENTION • A pilot “lost to follow up” project: 2009 • May-June 2009 collaboration with AVRC Bridge Program • Inclusion: one visit in past 12 months, no visits in past 6 mo • Greeting script with decision tree to determine best method to get patient back into care • “I’m so grateful someone thought of me.”

  4. Collaborative Pilot: Owen Clinic and the AVRC Bridge Program targeted 492 patients: Resulted in 33 patients returning to care

  5. Moving Engagement into ACTION! By getting involved in an organized quality improvement project STEP 2:

  6. Creation of Project PUFF: Patients unable to follow-up…FOUND One person can make a difference Objectives: outreach interventions engaging HIV patients back into primary care Aimed to get patients unable to follow up back into care Develop innovative methods to target the 53% unable to reach by telephone alone Determine methods to prevent future loss to follow up

  7. Tool 1: Creation of a NEW Job Previous phone political/non-profit work HIV science and research exposure Volunteer in community Read articles on background Cross-training to navigate barriers: 4 system training & all staff roles (MA/ desk/ phones/ adhere/ enroll/ edu/ case mgt)

  8. Tool 2: Making algorithms/flyers

  9. Flow diagram for re-engagement Reason Why? Moved, etc. Check Lab Tracker: Return on Own? No No Search: - EMR for Hospitalization/Death - Sheriff Inmate Log http://apps.sdsheriff.net/wij/wij.aspx - Social Security Death Indexhttp://ssdi.rootsweb.ancestry.com/ - County Health Call -LM -Message not returned in 2 days Call Again Email Send Same day as 2nd call w/ no contact Mail Letter to known address -Send 2 days after email w/ no contact Call Emergency Contact/Case Manager -3 days after mail w/ no contact Call Emergency Contact/Case manager – Call again after two days Contact Pharmacy Consider other resources: -Support groups -Centers -etc Search Google Search Facebook/Myspace Search ADAP Consider Patient LOST • Send message via website messenger • - Use contact information

  10. Posted outreach: Flyer creation

  11. Tool 3: Track in Access database

  12. PUFF: Access: patient search

  13. Tool 4: Calls, calls, and calls Dedication of a singular VIP phone line with after hours messages Many calls to same phone when appeared to be correct; then called frequently to leave messages Got to know the client from chart/phone

  14. Tool 5: Untapped pharmacy link 61/70 lost patients with e-prescribing Called 20 pharmacies, looking for: Date of last refill Newest phone # Other pt info Message left at pharmacy for pt upon next refill “Please call your doctor’s office at the Owen Clinic to schedule an appointment xxx-xxxx” (PUFF program phone #)

  15. Inclusion Criteria • HIV+ • At least one clinic visit in past 12 months • Excluded subspecialty and consult only visits • Over 6 months since last visit • 478 patients in first 6 mo • (716 patients identified for the year in 2 separate 6 mo cycles)

  16. Tool 6: Inside TIPs/what didn’t work Persistence in calling was key Getting to know the patient A bit of help with mail & pharmacy Limitations with myspace/facebook due to access restraints institutional Confidentiality restricts intervention into community outreach of Homeless programs, etc. for referrals

  17. Impact Summary Sitapati, unpublished data, 1/2011

  18. Patient calls and outreach: No hx prolonged absences or missed visits. Always did 3 to 4 month F/U. He just forgot. Pt has new insurance; recovering from met cancer, contacts Dr. by phone; RW; many cancels & no shows Phone #'s bad in 2 databases; letter returned; medical records detail govt persecution perception; needs to renew RW/ADAP  Phone #'s in PCIS and LT and IDX no good; moved to New Orleans per case manager

  19. Oh, my God, I think you just saved my life….- B DxHIV 1990 & clinic pt since1995 Last appt 3/27/2009 7 phone calls and 1 letter: multiple attempts. Calls taken by a housemate claimed B would get messg and call right back… but never did On the 8th call, B answered. Explained lost insurance, MediCal; upon asking if knew about Ryan White funding, pt B“who is that”. Did not detail health. Return visit given 2 days. B direct admitted from clinic to hospital and now well.

  20. Reasons Patients Gave for Missing Care Sitapati, unpublished data, 1/2011

  21. PUFF is afforbable This is a project requires a ½ time employee at low cost Community Health Program Representative and is an affordable option.

  22. Unanswered Questions:Improving FUTURE engagement Med refills may tie patients to their providers. How utilize without risking interruptions in therapy? How do we changing pt health beliefs and goals for care? What better contact pro-active info gathering is needed?

  23. PUFF “Toolbox” of Retention Resources: • Work flow diagrams for Retention Specialist • Retention Patient Letter • Retention Community Flyer • Patient engagement Hand out • Access Database tool

  24. HEALTHCARE IS UNDERGOING A REVOLUTION • The Patient Centered Medical Home (PCMH) • encompasses this fundamental change. • Construction requires thoughtful allocation of processes/people/and data. • A formalized engagement program is a necessary addition to the HIV medical home and is entirely achievable.

  25. PUFF is Supported by: • Health Resources and Services Administration Funding Opportunity:HRSA 5-H76-10-003 - San Diego HIV Funding Collaborative of San Diego Human Dignity Foundation:Grant No. 09-00009(CAT) The ANCHOR Medical Home is Supported by: - University of California; California HIV/AIDS Research Program:Award No. MH10-UCSD-640 A Special Thanks to: Jan Limneos for PUFF data support Stephanie Moody-Geissler & Sara King; PUFF Retention Specialists Susan Benson for staff/project oversight

  26. Suggested Reading: M Mugavero. Improving Engagement in HIV Care: What can we do? IAS-USA Topics in HIV Medicine Vol 16(5); December 2008: 156-161. KB Ulett, et al. The Therapeutic Implications of Timely Linkage and Early Retention in HIV Care AIDS Patient Care and STDs Vol 23(1); 2009: 41-49. MJ Mugavero, et al. Missed Visits and Mortality among Patients Establishing Initial Outpatient HIV Treatment Clin Infect Dis 48; Ja 15 2009: 248-256. LW Cheever Engaging HIV-Infected Patients in Care: Their Lives Depend on It. Clin Infect Dis 44; June 1, 2007: 1500-1502. TP Giordano, et al. Retention in Care: A Challenge to Survival in HIV Infection Clin Infect Dis 44; June 1, 2007: 1493-1499. DR Rittenhouse, SM Shortell The Patient-Centered Medical Home: Will It Stand the Test of Health Reform JAMA 2009; 301(19): 20038-40 Linkage, Engagement and Retention in HIV care Clin Inf Dis 2011; 52(2)

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