Transcript Slide 1

Improving Patient Retention
National TA Call
December 2, 2009; 3:00pm – 4:00pm
Facilitator: Nanette Brey Magnani, Ed.D.,
NQC, HIVQUAL Quality Consultant
Funded by HRSA
HIV/AIDS Bureau
Guest Grantees
• Horizons for Youth – Nikki Cockern
Detroit Medical Center, Detroit, MI
• Clarion University – Jeff Curtis
Clarion, PA
• Scranton Temple Residency Program – Mary
Triano
Scranton, PA
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National Quality Center (NQC)
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.
• Plan a PDSA for improving patient retention.
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National Quality Center (NQC)
Agenda
Welcome
Defining retention
Testing and measuring interventions
Sustaining retention
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National Quality Center (NQC)
More Information on Retention
Prior presentations:
 2008 NQC TA Call (June, 2008) and AGM presentation
(August, 2008) strategies for improving patient retention.
 2009 NQC Part D Conference: Retention of Part D Clients -
Measurement and Interventions
For more information inclusive of summary of research
to support patient retention, download “Reflection on
Retention: Connecting To Care,” Bruce D. Agins,
Medical Director, NYSDOH AI, 6/12/09 from
www.nationalqualitycenter.org
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National Quality Center (NQC)
Continuum
Engagement in Care
Not in
Care
Unaware of
HIV Status
(not tested or
never received
results)
Fully
Engaged
Know HIV
Status
(not
referred to
care; didn’t
keep
referral)
May Be
Receiving
Other
Medical Care
But Not HIV
Care
Entered HIV
Primary
Medical Care
But Dropped
Out
(lost to followup)
Non-engager
In and Out
of HIV
Care or
Infrequent
User
Sporadic
User
Fully
Engaged in
HIV
Primary
Medical
Care
Fully
Engaged
Health Resources Service Administration (HRSA)
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National Quality Center (NQC)
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
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National Quality Center (NQC)
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.
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National Quality Center (NQC)
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
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National Quality Center (NQC)
Check-in on the Message Board
If you are working on a patient retention
QI Project, post your:
 retention measure or
 Identify issues in defining it.
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National Quality Center (NQC)
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?
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National Quality Center (NQC)
Defining performance measure and
resolving issues
• Clarion University – Jeff Curtis
• Horizons for Youth – Nikki Cockern
• Scranton Temple Residency Program (STRP)
– Mary Triano
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National Quality Center (NQC)
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
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National Quality Center (NQC)
Lost to Follow Up Definition - Horizons
• Missing any appointment places youth on list and
actively pursued for a year
• Medical team discusses next action
• Usually kept in database
• No longer actively pursued
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National Quality Center (NQC)
Retention Measure - Horizons
• Monthly
number of kept appointments
including walk-ins
______________________________
number of scheduled appointments including walkins
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National Quality Center (NQC)
HIVQUAL and NYS Retention Measure
and Scranton Temple Residency Program
Number of unique clients with at least 2 or more
visits during the past 12 months, one in each 6month period
Number of unique clients with at least 1 visit
during the past 12 months
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National Quality Center (NQC)
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
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National Quality Center (NQC)
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%
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National Quality Center (NQC)
Standard Measure: Tri-State
HIVQUAL Regional Group (Ohio, W.PA, W.VA)
• 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
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National Quality Center (NQC)
Next Step
Step 2: Establish your baseline
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National Quality Center (NQC)
Check-in on the Message Board
If you have begun work on patient
retention, please post your:
 Baseline data
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National Quality Center (NQC)
Baseline Data - STRP
• Engaged in QI Project to increase annual
cervical cancer screening rates. 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.
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National Quality Center (NQC)
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%
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National Quality Center (NQC)
QI Project Goal - Horizons
Of 68 youth (Jan-Aug 09) listed as missing
appointments, re-engage 70% in treatment
(based on no shows)
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National Quality Center (NQC)
Clarion Univ: Aggregate Data for Analysis and
Management
Erie
# of clinics per above date
Total Patients Scheduled
Total Patients Seen
Average patients per clinic
Number of No Shows
Number of Cancellations
Percent No Show
Percent Cancelled
Totals
# of clinics per above date
Total Patients Scheduled
Total Patients Seen
Average patients per clinic
Number of No Shows
Number of Cancellations
Percent No Show
Percent Cancelled
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1/1/07-3/31/07
4/1/07-6/30/07
7/1/07-9/30/07
10/1/07-12/31/07
1/1/07-12/31/07
3.5
38
26
7.43
11
1
29%
3%
4
40
35
8.75
4
1
10%
3%
4
43
33
8.25
10
0
23%
0%
3.5
36
35
10.00
0
1
0%
3%
15
157
129
8.60
25
3
16%
2%
1/1/07-3/31/07
4/1/07-6/30/07
7/1/07-9/30/07
10/1/07-12/31/07
1/1/07-12/31/07
8.5
83
65
7.65
16
2
19%
2%
12.5
113
94
7.52
14
6
12%
5%
11.5
110
77
6.70
21
4
19%
4%
10.5
105
87
8.29
13
5
12%
5%
43
411
323
7.51
64
17
16%
4%
National Quality Center (NQC)
Baseline – HIVQUAL Regional Groups (CA,AZ,NV)
*available as xml files for CAREWare users
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Grantee
UCSD Owen Clinic—San
Diego
Population
2300+/-
1/1/07-12/31/07
85.1%
7/1/07-6/30/08
85.2%
1/1/08-12/31/08
83.5%
7/1/08-6/31/09
84.9%
USC-MCA—Los
Angeles, CA
900+/-
78.1%
78.2%
74.1%
Sonoma Co—Santa Rosa
450+/-
82%
85%
79%
Venice Family Clinic—
Venice, CA
170+/-
77%
78%
85%
Community Medical
Centers—Stockton, CA
200+/-
74.8%
88%
Pace Clinic—Santa Clara,
CA
950+/-
X
85%
86%
85%
LA Gay & Lesbian
Center—Los Angeles, CA
1700+/-
82%
81%
78%
83%
Maricopa Health
Systems—Phoenix, AZ
1300+/-
81%
79%
77%
83%
Plumas Co., Northern CA
70+/-
84%
95%
87%
Santa Cruz Co, CA
164+/-
76%
80%
81%
84%
National Quality Center (NQC)
Next Step
Step 3: Investigate the Process
and Causal Analysis
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National Quality Center (NQC)
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.
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National Quality Center (NQC)
Check-in on the Message Board
If you have done your causal analysis,
list
 reasons why patients don’t come.
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National Quality Center (NQC)
How similar are your reasons
compared with those of other
grantee programs?
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National Quality Center (NQC)
Reasons identified for patients not being seen
every trimester – Tri-State HIVQUAL Regional
Group (9 Part C/D grantees) 2005-06
•
•
•
•
•
•
•
•
•
•
•
•
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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
National Quality Center (NQC)
Causal Analysis: Horizons for Youth
Why don’t they come?
In general, limited social support, insufficient structure, &
often in “survival mode”
 A small subset have legitimate life reasons
• Working, attending school, family demands
 Difficulties maintaining contact information
 Youth who are on their own; not disclosed to family




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members
Intermittently homeless
Life chaotic
Drifting – not in school, not working
Many don’t feel badly & taking care of health is not a
priority
National Quality Center (NQC)
Contd. Causal Analysis: Horizons for Youth
 Residence often dependent upon on who they are in
relationship with
 Psychotic – hospitalized/untreated
 Incarcerated – under 18 can’t check system
 Developmental issues
• Trust
• Lack of impulse control
• Rebel against prescriptive approaches; forming own identity
 Mental health issues
• Depression/Anxiety




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Substance Use
Acquisition of STIs
High frequency of literacy issues
Routine health care is not a priority
National Quality Center (NQC)
Fishbone Diagram –
Causal Analysis (ClarionUniv.)
Access
Facility
No Clinic in my Area
No Clinic in my area
No Insurance
Poor Parking
Don’t' like the
location
No Transportation
I don't trust the staff,
I heard them talking
about other patients
Lack of
Retention of
Care
Didn't get Labs done
Hate the Doctor
Didn't want to get 00B
I don't want to know the results
I didn't want to go
I might see someone I know
I forgot
the staff doesn't really
care about me
Don't like Needles
Don't like needles
Anxiety
Patient / Support
system
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Procedures
Staff
National Quality Center (NQC)
Next Step
Step 4: Select, Test, and
Measure Interventions
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National Quality Center (NQC)
Check-in On the Message Board
If you have started testing your
intervention, please post your
 QI intervention and
 results if QI Project is completed.
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National Quality Center (NQC)
Interventions and Outcomes: Clarion
Time Period
Sep - Dec 2005
Jan - Apr 2006
May -Aug 2006
Sep - Dec 2006
Jan - Apr 2007
May - Aug 2007
Jan - Dec 2008
Mar -Feb 2008/9
May - Apr 2008/9
Jul - Jun 2008/9
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Intervention
Initiated post cards in January
Retention Rate
74%
88%
79%
80%
Initiated more frequent follow-up calls January 2007
Initiated scripted/assertive calls March 2007
83%
84%
Key position vacant for part of this timeframe
90%
91%
Position filled right before this timeframe
94%
91%
National Quality Center (NQC)
Improvement in No Show 2006 – 2008
Clarion Univ.
Totals
2006
2007
# of c linic s per above date
Total P atients S c heduled
Total P atients S een
A verage patients per c linic
Number of No S hows
Number of C anc ellations
P erc ent No S how
P erc ent C anc elled
48
472
329
6.85
103
36
21.8%
7.6%
43
411
323
7.51
64
17
15.6%
4.1%
Change
-5.00
-61.00
6.00
0.66
-39.00
-19.00
-6.25%
-3.49%
2009
Good
Good
Good
Good
Good
44.5
479
359
8.07
73
45
15.24%
9%
Change
1.5
68
36
0.56
9.00
28.00
-0.33%
5.26%
Good
Good
Conservative estimate of cost savings due to
reduction in no shows is $10,000 annually since 2006
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National Quality Center (NQC)
Improvement Process-Missed Appointment Process - Horizons
1. Maintain List
Identify youth who
missed clinic
appt. & not
able
to reschedule
5.
Contact made w/
Client & clinic
visit scheduled
Or
Repeat
2.
month after
missed clinic
visit. Advocate
attempts
contact
1st
4.
3rd month
Home Visit
3.
month
Mail post
card
2nd
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National Quality Center (NQC)
Plan/Do - Horizons
• Initially, we only monitored:



Number of kids on list
Number of Phone calls made, postcards sent and
home visits
Number of youth returning to care monthly
• Increased discussion and monitoring of list to
weekly meetings with Clinical Care Team
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National Quality Center (NQC)
Plan/Do (continued)- Horizons
• QI interventions: Added




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Call clients during clinic if late
Discuss missing clients at weekly meeting
Track the number of youth confirmed vs. those
not confirmed with clinic show rates
Text messaging, email and facebook
National Quality Center (NQC)
Study/Results - Horizons
Total: 38 out of 68 (Jan-Aug 09) on list returned
to care, 56%
• Home visits did not yield significant return to
care 4 out of 11 or 36% returned
• 34 returned (89% of the 38)
 Phone calls and post card
 Added texting, email, and Facebook
• 30 still being pursed
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National Quality Center (NQC)
Contd. Study - Horizons
• Youth contacted during missed appointment
are more likely to reschedule and attend next
appointment
• Youth who were contacted prior to
appointment and confirmed are more likely to
keep appointment
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National Quality Center (NQC)
Another view, a different result - Horizons
• Using HIVQUAL retention measure
 2008 = 95%
 7/1/08-6/30/09 = 98%
• Plan to track quarterly visits
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National Quality Center (NQC)
Next Steps
Step 4/5: Next PDSA (Plan, Do,
Study, Act) Cycle
and
Step 6: Sustaining Gains
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National Quality Center (NQC)
Check-in on the Message Board
If you have 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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National Quality Center (NQC)
Learning – Future QI Project
Horizons for Youth
Next PDSA (Plan, Do, Study, Act) cycle:
• To prevent missed appointments
 New Intervention
 Motivational Interviewing
• Youth newly entering care
• To make home visits more effective – on the
spot interview & intervention
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National Quality Center (NQC)
To sustain gains – Horizons for Youth
48
•
Continue to make efforts to contact youth prior to
and during their clinic appointments to increase
attendance & reschedule quickly if needed
•
Continue to meet weekly (check-in) with clinical
team members about missing youth, as well as
having monthly more in depth discussions re list of
youth
•
Continue to track attendance statistics
•
Texting and communicating on Facebook deemed
effective & continue
National Quality Center (NQC)
Next Steps – Clarion University
• A significant number of no-shows in 2008 still due to:
“not that important to them”
• Therefore, must get patients to change attitude
Next PDSA Cycle:
• Stage-Based Behavioral Counseling - helps patients move from:
 Pre-contemplative:
 Contemplative:
 Ready for action:
 Action:
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“don’t care”
“want to, but…”
“ready to try”
“doing it”
National Quality Center (NQC)
Moving Forward: Next Steps
Discussion and agreement on retention
measure (include IT staff in meeting)
Data collection for baseline
Causal analysis
QI Project Plan
Implementation
Measure
Act
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National Quality Center (NQC)
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
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National Quality Center (NQC)
Addendum
Retaining New Patients in Care
Use of flow diagram
Grantee contact information
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National Quality Center (NQC)
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; [email protected]
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National Quality Center (NQC)
Process Map: Follow-Up to No-Show
Clarion
At Clinic Patient
NS
Ask CM why
don't know
Does MSC &
CM have time
yes
Call while at
clinic
reach
Ask if want to
come
know
no
call patient
within week
not reach
yes
not coming
not reach
reach
Not a
NS!
ready to ask
for help
Ask why
NS
Is there time
Schedule for
later in day
yes
yes
no
no
Record
reason
CM reaches:
handle/
refer
Ask CM to
help
refer
Refer to MSC
Ask why
NS
handle
record
tell MSC
Chronic
Chronic NS
Give lecture
(few)
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yes
reschedule
no
National Quality Center (NQC)
Contact Information
Nanette Brey Magnani, EdD, [email protected]
Special Thanks to Presenters and Resource Persons
Nikki Cockern, PhD, LLP, Clinical Care Manager, Horizons
Project, Detroit Medical Center, [email protected],
[email protected], 313-924-8229
Jeff Curtis, NW Pennsylvania Rural AIDS Alliance
Clarion University
814- 764-6066
[email protected]
Mary LawhonTriano, CRNP-C, Scranton Temple Residency
Program, Scranton, PA
[email protected] 570-343-2383
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National Quality Center (NQC)
National Quality Center (NQC)
212-417-4730
NationalQualityCenter.org
[email protected]
Funded by HRSA
HIV/AIDS Bureau