Transcript Slide 1

AHF Jacksonville
Healthcare Center
Ryan White
Medical Outpatient and Medical Case Management
Quality Showcase
May 23, 2013
AHF Jacksonville HCC Health Care Team
AIDS Healthcare Foundation
NCQA Accreditation
AIDS Healthcare Foundation
• Mission:
 Cutting edge medicine and advocacy, regardless
of ability to pay
• Vision:
 A healthier future for people living with HIV/AIDS
• Core Values:
 Patient centered
 Value employees
 Respect diversity
 Nimble
 Fight for what’s right
Quality Priorities
Patient-Centered Focus
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Systematic with Leadership, Accountability, Resources
Data and Measureable Outcomes to Determine Progress
Evidence-Based Benchmarks
Focus on Linkages, Efficiencies, Provider and Patient
Expectations/Satisfaction
• Continuous Process Adaptive to Change. Fits Within
Framework of Other Activities, e.g., Medicaid
• Data Feedback Loop to QI Process to Assure Goals Met
HRSA Quality Dimension Principles
• Accessibility of care
 Ease or difficulty of obtaining services when the patient needs
services
• Continuity of care
 Linkages to other resources--delivery of care does not occur in
a vacuum
• Appropriateness of care
 Care delivered using state of the art technologies and includes
the best care that medical and social science judgment would
prescribe
• Safety of care
 Procedures followed during delivery of care and services are
error free, i.e., avoids harm and actually helps
HRSA Quality Dimension Principles
• Timeliness of care
 Care is delivered at the right time
• Involvement in care
 Patients participate with clinicians/practitioners in making
decisions that affect their well-being
• Effectiveness of care
 The program is flexible so individuals can develop their own
resources without counterproductive overdependence on
the system (Salem, Seidman, & Rappaport, 1988)
• Efficacy of care
 Care is individually tailored to meet patient's needs
• Efficiency of care
 Care accomplishes the intended purpose
AHF
Quality Dimensions for Improvement 2012
• Accessibility of Care
• Timeliness of Care
• Involvement in Care
AHF Quality Areas Addressed
• Core Clinical Area
 CD4 Count
 Viral Load Monitoring
 Medical Visits
• Medical Case Management
 Care Plan
 Medical Visits
 Outpatient Medical Care
• Systems-Level
 Waiting Time for Initial Appointment
 Outpatient Medical Care
 Quality Management Program
Goals
Medical O.P. and Medical Case Management
• Goals
 Reduce No Show Rate For Medical Appointments
 Reduce Risk of Patients Falling Out of Care
 Bring Patients Back Into Care and Prevent Others
From Falling Out of Care.
Adherence = Undetectable VL
AHF CQI PLAN
OUTPATIENT MEDICAL
• Outcome 1.1: Reduce % of No Shows by at least 2
pecentage points from 2011 annual no show rate
• No show rate for 2010 = 18.4%
• No show rate for 2011 = 18.1%
• No show rate for 2012 = 16.4%
• Personal reminder calls the morning prior to their visit
aids in getting the patient to the office. A smiling
voice is what it takes.
Monthly No Show Rates
2012, 2011, 2010
2012
30%
25%
% of No Shows
20%
15%
10%
5%
0%
2011
2010
Monthly No Show Rates
2012, 2011, 2010
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
2012
17.9 13.5 18.2 18.2 15.7 21.3 14.3 12.3 16.2 15.4 15.9 18.5
2011
17.5 14.5 12.8 16.6 15.7 21.3 22.2 20.1 15.9 18.9 24.1 17.4
2010
15.6 14.3 21.4 16.2 20.6 18.8 17.7 17.1 18.9 19.4 20.5 20.1
AHF CQI PLAN
OUTPATIENT MEDICAL
• Objective 1.2: Request updated contact information
for 100% of patients upon check-in at the HCC
• Updated contact information requests with a smile
and positive attitude increase the chance of patients
continuing their care.
• AHF is piloting an HCC Patient Secret Shopper to
evaluate the effect that customer service, whether
negative or positive, has on retention of patients to
the Healthcare Centers.
DEMOGRAPHICS
• 2012 is the first year the number of demographic
changes have been reviewed.
• A report is being developed to determine the number of
changes.
• Demographic changes for this baseline year are similar
every month for an average of 4.5% each month.
• Based on the aggressiveness to obtain correct
demographics, we will be able to compare the no show
rate for 2013.
DEMOGRAPHIC CHANGE
BY MONTH BASELINE
Month
%
Change
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
7%
4%
5%
7%
3%
4%
3%
3%
4%
4%
6%
4%
AHF CQI PLAN
OUTPATIENT MEDICAL
• Outcome 1.3: Decrease no show rate by an additional 5
percentage points by sending appointment postcards
• Postcards were not used in 2012:
1. Took too much time to fill out.
2. Postcard thrown out as soon as it was received.
3. Patient did not want anyone to see postcard and
ask questions (stigma).
AHF CQI PLAN
OUTPATIENT MEDICAL
• Objective 1.4: Send “Sorry We Missed You” cards to
100% of no shows.
• Cards were only used for a short time:
1. Many cards were returned with unknown addresses.
2. Patient did not want card coming to house (stigma).
3. Phone calls from the peer navigators were much
more efficient and cost effective.
AHF CQI PLAN
OUTPATIENT MEDICAL
• Objective 1.5: Ensure that 90% of all new patients
and returning to care patients see a medical provider
within 3 days of contacting the HCC
• Overall we saw all of our new and return to care
patients within 3.1 days.
• Jacksonville HCC is expanding so rapidly that we
have been physically unable to see patients within
3 days and still care for our longtime patients.
AHF WAIT TIME
4.5
4.0
3.5
Average number of days
3.0
3.9
3.7
3.1
3.9
2.9
3.1
3.3
3.3
2.8
2.8
2.7
2.4
2.5
2.0
1.5
1.0
0.5
0.0
2012
CONCLUSION
OUTPATIENT MEDICAL
• Our 2012 No Show rate of 16.4% showed a decrease
of 2 percentage points from 2010 and 1.7 percentage
points from 2011.
• Reminder calls with a smiling voice increase the
chance of patients continuing their care.
• Peer navigators calling no shows to assist them in
rescheduling is very productive.
• Stressing the importance of a correct address and
phone number from the patient is being achieved by
the front desk.
• AHF will always strive to lower the patient wait time
below 72 hours.
LESSONS LEARNED
OUTPATIENT MEDICAL
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No show rate is fluid.
Time of year is not a factor.
Postcards not used in 2012 – not a factor.
Reminder calls to 100% of scheduled patients is a factor.
Correct and current demographic information is a factor.
Combined CQI Initiatives
AHF-LSS Mental Health
• Conduct focus groups:
– Web-based versus
telephonic-based support
groups for newly
diagnosed.
• 2012 Peer Navigator
Training Initiatives.
• 2013 Develop and
implement a web-based/
telephonic support
group.
AHF-LSS Medical Case Management
• Identifying patient barriers
to medical adherence.
• Identify adherence
behaviors and
characteristics that impact
compliance.
Mental Health
Focus Group Interest
Trial Telephonic-Based Group
Provided questionnaires to 10
newly diagnosed.
5 members were pooled from existing
support groups.
Results:
 75% were interested in
group.
 65% preferred an online/
telephone-based support
group.
 45% preferred a face-to-face
group setting.
Pros and Cons:
“I really enjoyed connecting with new
people and would love to be a part of an
ongoing group.”
“Telephone provided Increased
anonymity.”
“I would be able to always attend, if it is
on the phone.”
“There has to be a way to lower
background noise.”
“I did not feel as connected as I do in a
group meeting.”
Mental Health Continued…
Training Curriculum with Peer Navigators
Training targeted to teach the basic principles of
peer-run support groups.
Training included:
o Ethics
o Ethical Boundaries
o Suicide Prevention
o Preventing Secondary Trauma
o Best Practices: Group Facilitation
Medical Case Management Goals
Improving medical adherence
through understanding the
specific needs and barriers to
care for those with high rates
of non–adherence/loss to care.
1. Identify the current ratio of LSS
patients in care with AHF.
2. Evaluate current rates of nonadherence/loss to care.
3. Perform MCM assessment of
patient-specific needs.
4. Provide services geared
towards barrier reduction.
Patient Ratio by Clinic
AHF
BCCC
UF Cares
Private
Patient Non-Adherence Rates: Overall and LSS
Rates of adherence were gathered bimonthly beginning August 2012 and
ending February 2013.
AHF 104 day report displayed fluidity
over this 7-month period.
Non-adherence Rates
Overall Rate
LSS Rate
193
191
The period ended with an overall 51%
decrease in no show rates.
LSS represented 10% of those
identified in the reporting period.
8 patients identified as frequently nonadherent (appeared more than 2 times
on the 104 day report).
138
93
17
19
Aug 2012
Oct 2012
12
Dec 2012
5
Feb 2013
Identified Need/Stages for Change
Behaviors/ Barriers Identified
• 8 individuals targeted.
• Provided with increased
medical case management
to include:
 Appointment reminders
 Monthly calendars
 Adherence assessments
 Access to the Peer
Navigator
 Educational materials
 Behavioral assessments
Baseline
• 55% of those targeted
showed to be in the
contemplation stage of
change in regards to their
health.
• 68% had transportation listed
as a barrier to care.
• 50% were listed as a MCM
acuity level of 2 or higher,
providing a history of either
non-adherence to care or
high need for care.
Change Happens
Current Change:
• Over 7-month the rate of non-adherent
or lost to care LSS patients decreased
10% to 6% by identifying patients
through use of the 104 day report.
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At the end, lost to care patients had
returned through use of appointment
reminders and access to gas cards or
bus cards. The total number who were
lost to care decreased by 85%.
As patients became medically adherent
their acuity decreased by 45% (more
data still needs to be collected to
ensure continued adherence).
65% of patients moved from
contemplation to action and/or
maintenance.
For the Future:
• Acuity level 2 or higher patients should
receive appointment reminders to
increase appointment adherence.
•
Acuity 2, 3 and 4 patients should receive
increased adherence counseling >2
times per year and should have regular
access to peer navigators.
•
The stages of change should be
evaluated in regard to patient’s thoughts
on their healthcare.
The identification of behaviors and barriers
and setting goals may lead to decreased
rates of non-adherence and patients
becoming lost to care.
Continuous Efforts towards Change
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AHF
Measures rate
Identifies need
Provides specific support
to patients by medical case
managers use of case
conferencing and peer
support
Ensures a team approach
to care
LSS
• Assesses need
• Identifies targeted patients
• Evaluates Barriers/Behaviors
• Implements strategic
interventions
• Works as a team with the
medical provider to decrease
barriers to care
RN-MCM Actions To Reduce Risk of
Falling Out of Care
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Conducts Patient Assessments to formulate Plan of Care
Addresses Issues and Needs in POC
Peer Navigators outreach to and Link to Medical Care
Patient Education on “How to Conduct Your Medical Visit”
Peer Navigators Attend Medical Visits With New and Returning
to Care Patients
Patient Adherence Education on ARV and Chronic Condition
Medications
Appointment for follow up after medical visits with Peer or
RNMCM
Collaborative Interdisciplinary Meetings With PCP
Embedded Staff to Support PCP and Medical Treatment Plan
focusing on Patient-Centered Care Delivery
AHF CQI Goal 2.2.1 and 2.3.1
Follow-up Appointments, Lost to Care, and Barrier Analyses
Follow-up visit scheduled
Lost to care (no follow-up visit scheduled)
Barrier
80
75
70
# of patients
60
49
50
44
40
40
40
34
30
22
20
10
22
15
20
19
16
15
9
8
5
5
4
4
1
2
Sep 2012
Oct 2012
1
5
5
Dec 2012
Jan 2013
5
3
5
0
Jul 2012
Aug 2012
Nov 2012
Feb 2013
Note: November spike most likely due to influx of patients from River Region that did not return after 2 initial visits
(becoming lost to care).
Mar 2013
Barriers to Care Identified
AHF CQI Goal 2.2.1 and 2.3.1: Types of Barriers to Care*
Ineligibility Issues
6.1%
Work
4.9%
Deceased/Coma
8.5%
Incarcerated
4.9%
New/Changing
provider
Refused svc/
3.7%
care
3.7%
In nursing home/
hospitalized
3.7%
Family/
Personal issues
3.7%
Homeless
2.4%
Transportation
1.2%
No mode of
contact
1.2%
Transferred/
Using other svc
18.3%
Moved
37.8%
*Barrier data were collected from a sample of patients lost to care.
AHF MCM: in+care Campaign
Medical Visits
AHF CQI Goal 3.2.1: #1 Gap Measure
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who did not have a medical visit
with a provider with prescribing privileges in the last 180 days of measurement year.
20%
National
Jacksonville
10%
10.47%
10.58%
Lower is better
Rate
15%
11.15%
9.36%
9.12%
8.68%
9.14%
9.56%
9.03%
7.82%
5%
0%
Jun 2012
Jul 2012
Aug 2012
Sep 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
AHF MCM: in+care Campaign
Medical Visits
AHF CQI Goal 3.2.2: #2 Medical Visit Frequency
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS who had at least one medical visit with a provider
with prescribing privileges in each 6‐month period of the 24‐month measurement period with a minimum of 60 days apart.
95%
Jacksonville
National
90%
86.96%
Rate
85%
86.27%
85.82%
85.67%
86.11%
86.65%
Oct 2012
Nov 2012
Dec 2012
Jan 2013
87.16%
85.01%
82.69%
80%
75%
70%
65%
60%
Jun 2012
Jul 2012
Aug 2012
Sep 2012
Feb 2013
Mar 2013
Higher is better
88.75%
AHF MCM: in+care Campaign
Viral Load Suppression
AHF CQI Goal 3.2.4: #4 Viral Load Suppression
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with a
viral load less than 200 copies/mL at last viral load test during the measurement year.
90%
Jacksonville
National
85.71%
83.97%
83.95%
86.49%
86.27%
83.69%
83.53%
83.85%
82.55%
80%
Rate
80.93%
75%
70%
65%
Jun 2012
Jul 2012
Aug 2012
Sep 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
Higher is better
85%
Summary of Patient-Centered Quality Care
Measures
AHF CQI Goal 2.2.1, 2.3.1, 3.2.1, 3.2.2, 3.2.4: Summary - Follow-up Visit
Scheduled/Lost to Care Comparison to JAX in+care Measures Scores
100%
90%
Follow-Up Visit Scheduled
Lost to Care
Gap Measure
Medical Visit
VL Suppression
94%
Medical Visit
80%
80%
79%
76%
VL Suppression
70%
Rate
60%
59%
56%
55%
52%
52%
48%
50%
48%
45%
44%
41%
40%
30%
24%
21%
20%
20%
Gap Measure
10%
6%
0%
Jul 2012
Aug 2012
Sep 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb 2013
Mar 2013
MCM Conclusions and Lessons Learned
• Patient-Centered Assessment and Interdisciplinary
Team are Effective in Increasing Medical Visit and
Medication Adherence.
• Barrier Mitigation and/or Removal Increases Patient
Success for Adherence.
• Multi-Level (PCP, RNCM, Peer) Continual Education
on HIV, Chronic Conditions, Medical System
Navigation Increases Medical Literacy, Treatment
Adherence and Patient Self Management Skills.
• Each Patient is Unique and Use of Persistence and
Tailored Measures Is Necessary For Success.
QUESTIONS?
Thank You!