in + care Campaign Webinar September 25, 2012

1. in+care CampaignWebinar September 25, 2012

2. Ground Rules for Webinar Participation Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) Slides and other resources are available on our website at incareCampaign.org All webinars are being recorded

3. Agenda • Welcome & Introductions, 5min • Retaining Patients in Care at Truman Medical Center, 10min • Focusing on Patients at Risk of Falling Out of Care: the Whitman Walker Health Story, 25min • Data Review and Discussion of Retention Strategies Collected Through the Campaign, 10min • Q & A Session, 5min • Updates & Reminders, 5min

4. Retaining Patients in Care at Truman Medical Center Rose Farnan, RN, BSN, ACRN Infectious Diseases Program Manager

5. About our Hospital and Clinic • Only safety-net hospital for Kansas City, MO • Located in the urban core • Teaching hospital for University of Missouri-Kansas City, including schools of medicine, nursing, pharmacy, dentistry and social work • Hospital provides adult-only care - Children’s Mercy Hospital across the street • Over the past 18 months our clinic has served 780 unduplicated clients with 4, 546 encounters

6. History of Retention efforts • In 2007 TMC leadership announced that “shadow” charts would be eliminated within 3 years • At around that same time additional funding allowed for hiring FT retention assistant • Bilingual retention assistant hired in 2007

7. History, cont… • For the next 12 months the RA conducted a chart review and found 405 patients not seen for more than 6 months. The RA then searched for those patients by • Calling patients at last known phone number • Sending certified letters to last known address • Collaborating with surveillance staff at the KCHD • Contacting case managers for additional contact info

8. Also during that time frame clinic and case management staff worked together to: • Improve communication regarding status of patients • Create tools within EMR to help identify reasons patients drop in and out of care • Create a spreadsheet for RA to track in “real time” appt status of all patients

10. Role of Retention Assistant • Tracks all appointments in real time • Contacts patients after “no show” • Contacts patients who are close to being “poorly engaged” or not seen for more than 6 months. Works with case managers as needed. • Works with case managers and KCHD surveillance staff in finding patients who are “lost to care” or not seen for more than 12 months. • Is contact person for Spanish speaking clients

11. In+Care Campaign • Kicked off “our” campaign at all-staff clinic retreat held December, 2011 • 3 workgroups were formed *new patient orientation *retention and satisfaction *poorly engaged/out of care

12. Steps we have implemented • Daily satisfaction surveys • Focus groups to obtain information re why patients not engaged or miss appointments • Revised scheduling codes within EMR to identify when patient returning to care • Extra clinics added during the summer to accommodate ASAP those clients returning to care

13. Creation of new patient orientation packets • Created team response to patients returning to care ie role of RN, CM, peer educator • Creation of “retention tab” in EMR so all staff can document and easily find updated info re location of clients ie “moved to New Mexico” • Peer Educators making daily reminder phone calls • Grand Rounds presentation re Cost of Care when Patients not Engaged

14. Next Steps • Awaiting IRB approval to do interviews with clients who have experienced periods of non-engagement in care: • newly diagnosed people who delayed engaging in care • patients who are just now returning to care after an absence of at least 6 months • patients who are currently engaged in care but who have previously had periods of non-engagement

15. Next Steps • Awaiting IRB approval to do interviews with clients who have experienced periods of non-engagement in care: • newly diagnosed people who delayed engaging in care • patients who are just now returning to care after an absence of at least 6 months • patients who are currently engaged in care but who have previously had periods of non-engagement

16. Focusing on Patients “At-risk” for Falling Out of Care P. Justin Goforth, RN Director of Medical Adherence Whitman-Walker Health 09/25/2012

17. Three Strategies for Recruitment/Retention/Recapture • Red Carpet Access Program • Breaking down barriers to entering care • Identification of patients most at-risk for falling out of care • Focusing resources on those who are most at-risk for serious health consequences of not being in care • Building a Recruitment/Retention/Recapture program in the ever changing world of healthcare

18. Red Carpet Access Program • History of accessing care: • HIV testing was disconnected from direct linkage to care • The message in delivering an HIV positive result was apologetic • The journey from receiving an HIV positive rapid result to an appointment with an HIV care provider to discuss treatment options was long and arduous! • Waiting for that magical “confirmatory test” in order to move forward • Way too many chances along the way to drop into denial, despair, and/or just give up!

19. Red Carpet Access Program • Changing the delivery of an HIV positive result: • This test is extremely accurate and most likely means you ARE HIV positive • HIV can be a manageable, chronic disease and you have the potential for living a healthy life with a relatively normal lifespan • BUT…it is imperative that you immediately engage in care with a provider that has expertise in HIV care • We will help you with that process! • Your first set of labs will include tests that will let us know the status of your immune system, how much virus is in your system and will also include another test we need to confirm this diagnosis

20. Red Carpet Access Program • Linkage to care (tested on-site): • Patients are immediately handed off to a RN case manager • The RN continues the emotional stabilization • RN begins educational process of understanding what this diagnosis means from a health perspective and helps identify immediate resources for support • If a patient is unwilling or unable to engage in care at WWH, concrete resources that match the needs of the patient are identified and appointments are made with partner organizations if possible • Confirmatory test is obtained

21. Red Carpet Access Program • Linkage to care (tested on-site): • If patient is willing and able to engage in care at WWH: • Once initial emotional stabilization and brief education is completed, the RN hands off the patient to an eligibility specialist who verifies payer source or begins applications to public benefits as needed/as eligible • RN monitors the provider’s schedules and identifies available provider based on pre-existing “HIV Rapid” appointment blocks • Patient meets with provider who briefly again validates the patient’s ability to remain healthy if they stay engaged in care and explains what tests will be obtained in their “new patient panel” of labs

22. Red Carpet Access Program • Linkage to care (diagnosed offsite or transferring care): • No appointment necessary, just walk in • All local referral partners know to tell patients to walk-in and ask for “Red Carpet” • Important partnership with DOH • First step flips to meeting with eligibility specialist to ensure best access to care • Patient then meets with the RN case manager • Rest of process remains the same

23. Red Carpet Access Program • Why we believe this works: • A sense of both great hope and urgency is relayed in the delivery of positive results • Patients walk away understanding the seriousness of the diagnosis but also understanding their ability to take control and live well • Relationships are immediately established with key members of the patient’s new care team • The RN will become your medical case manager • The provider will become your new doctor • Information is obtained that first day that provides an incentive to return (patients want to know the status of their immune system and general health) • Important education has already begun • System is simple and easy for patients to follow

24. Red Carpet Access Program • So does this actually work?? • We do not have good internal data from our previous model of engagement in care so it is difficult to compare, but… • The DC DOH saw the power of this model of engagement and pushed it out to all RW funded providers in the city • Each organization has adapted this model to their specific resources • Each organization chooses their own code word for patients to use when walking in for care • DOH publishes and disseminates a brochure on “Red Carpet Access to Care” so that patients know what organizations they can walk into and what word to use

25. Red Carpet Access Program • DC data on engagement in care:

26. Red Carpet Access Program • Latest data from DOH suggests we are now meeting or exceeding the President’s National AIDS Strategy goal of 85% engagement in care within three months of diagnosis! • We even got a shout-out by President Clinton at the AIDS 2012 conference!

27. A Focus on Those At-Risk for Falling out of Care • With limited resources we wanted to get the best “bang for the buck” • Our experience at recapturing patients who have already fallen out of care shows this is extremely resource intensive • We do not have accurate contact information on a great percentage of these patients • “Recapture Blitz” pilot showed an average of 14 telephone calls were necessary to connect with a patient lost to follow up when we DO have accurate telephone contact information • Feet on the street were necessary to connect with many of these patients and WWH does not have this capacity (but more to come on how we might)

28. A Focus on Those At-Risk for Falling out of Care • Hypothesis: Keeping patients who are at-risk for falling out of care in+care will take less resources than tracking down patients who already have • We have a better chance of having correct contact information • They have not had a chance to solidify their internal message about whatever barrier they are experiencing about staying engaged in care • They most likely have a relationship with someone currently employed at WWH (we can leverage that!)

29. A Focus on Those At-Risk for Falling out of Care • Identifying who these patients are: • Not JUST who is at-risk for falling out of care, but… • Who is most at-risk for immediate serious health consequences if they become lost to care • With 3000 HIV positive patients in medical care we needed to prioritize • We created four indicators, reflecting four levels of priority • Monthly data runs from QID are delivered to the Medical Adherence Department • Medical Adherence staff will follow up to address potential barriers and re-engage patients

30. The Four Indicators • Highest priority • Numerator: HIV+ Patients with CD4 count <200 and medical visit from month beginning 7 months before measurement month and month ending 1 month before measurement month (6 months prior) with a N/S in a medical visit within measurement month • Denominator: HIV+ Patients with CD4 count <200 and medical visit from month beginning 7 months before measurement month and month ending 1 month before measurement month (6 months prior) • In other words…we are MOST worried about patients who have less than 200 CD4 cells and miss a medical appointment

31. The Four Indicators • High priority • Numerator: HIV+ Patients prescribed ARVs with VL >20 and medical visit in the 6 months prior to measurement month that N/S for a medical visit in the measurement month • Denominator: HIV+ Patients prescribed ARVs with VL>20 with a medical visit in the 6 months prior to measurement month • In other words…we are VERY worried about patients who are on ARVs and have a detectable viral load and missed a medical appointment

32. The Four Indicators • Medium priority • Numerator: HIV+ Patients not prescribed ARVs with CD4 <350 and medical visit in the 6 months prior to measurement period and N/S for medical visit in measurement month • Denominator: HIV+ Patients not prescribed ARVs with CD4 <350 and medical visit in the 6 months prior to measurement period • In other words…we are worried about patients who have a compromised immune system who are not on ARVs who have missed a medical appointment

33. The Four Indicators • Lower priority • Numerator: HIV+ Patients with a medical visit in 6 month period beginning 12 months before measurement month and ending 7 months before measurement month with a N/S for medical visit in 7 month period ending at end of measurement month • Denominator: HIV+ patients with a medical visit in 6 month period beginning 12 months before measurement month and ending 7 months before measurement month • In other words…we are worried about patients who were in care with us within the last year but have recently missed a medical appointment

34. Creating a Recruitment Retention Recapture Program • Current considerations for WWH: • Multiple changes in funding opportunities • Linkage models like ARTAS were designed to be incentive based but funding for incentives is hard to come by! • RW medical case management funding is increasingly focused on licensed providers (RN or LICSW) who are expensive • Large HIV focused clinics have evolved to FQHC Community Health Centers • Community Health Centers are moving to Patient Centered Medical Homes (PCMH) with important implications to what is medical case management • RW funding will continue to change as healthcare reform evolves

35. Creating a Recruitment Retention Recapture Program • How we believe we can maximize RW funding for our RRR program: • CBO funding is at-risk as RW funding continues to consolidate on organizations that provide direct primary medical care to large numbers of patients • CBOs have the best access to the community, best ability to put “feet on the street”, and best ability to reach specific target populations like young black MSMs, transgender women, or AA women • Creating contractual, accountable relationships (not just MOUs) with these CBOs can make our RW applications stronger and secure maximum funding for RRR programs • In other words, creating community level patient centered medical homes!

36. Discussion/Questions • Who else is experiencing these challenges? • What solutions have you developed? • What questions do you have? • Thank you for participating!

37. Improvement Strategies Exercise Michael Hager, MPH MA NQC Manager

38. in+care Campaign National Data Snapshot Coming Soon – new analyses!

43. Improvement Strategies Discussion Interventions Discussed on Today’s Program • Formation of dedicated staff work groups to explore domains of retention and barriers • EMR configuration – encounter types for re-engagement and patient status information • Expanded MOUs and subcontracting with community partners to create networks • Creation of new patient orientation packets • Created team response to patients returning to care i.e., role of RN, CM, peer educator • Grand Rounds presentation re Cost of Care when Patients not Engaged • Daily (continuous) satisfaction surveys • Focus groups to learn why patients not engaged or miss appointments • Discovery interviews with patients • Extra clinics added during the summer to accommodate ASAP clients returning to care • Red carpet access program • Peer Educators making daily reminder phone calls – for larger centers, prioritize calling lists

44. Improvement Strategies Discussion Interventions Submitted Through in+care • Make it a regional priority – Planning Council discussions based on workplan reports for each service category • Clinic walk through and patient cycle time measurement as a method to reimagine patient flow • CAB inputs on clinic forms and verbiage used in reminder/FU calls • CAB inputs on patient experience issues and possible solutions • Encounter, laboratory, adherence counselor notes data mining • Train navigators to gather information on barriers/challenges faced by individuals and communities that the clinic can work around

45. Improvement Strategies Discussion Lessons Learned • Operational Changes • Workgroups, EMR configuration, External networking • Staff Educational Opportunities (financial + community health costs) • Grand Rounds, All-staff meetings • Increased Patient Support • Expanded hours, retention advocates, reminder systems • Quality Improvement Approaches • Focus groups, surveys, EMR data management, Discovery interviews • CommunityPriorities • Planning Councils, CPGs, Part B CABS / Community Forums

46. New Way to Submit Improvement Updates!

47. Time for Questions and Answers

48. Upcoming Events and Deadlines • Campaign Office Hours: Mondays & Wednesdays 4-5pm ET • Data Collection Submission Deadline: October 1, 2012 • Improvement Update Submission Deadline:October 15, 2012 • Next Campaign Webinar: Mental Health and RetentionDate Pending – to be announced! • Next Partners in+care Webinar: HIV, Stigma and MeDate Pending – to be announced! • Next Meet-the-Author Webinar: Topic to be announcedDate Pending – to be announced!

49. MedScape Retention in HIV Care Series • Technical Working Group working on articles for a new Medscape Today News Series. • Bruce Agins, MD MPH, New York State Department of Health AIDS Institute Medical Director, wrote the opening article in the series • We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series! • http://www.medscape.com/index/section_10285_0

50. Partners in+care • Partners in+care Private Facebook Group is live! • Share tips, stories and strategies • Join a community of PLWH and those who love them • Email michael@nationalqualitycenter.org for more details • Partners in+care website is live! • http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB Group)