Transcript Slide 1

in+care Campaign
Webinar
January 18, 2012
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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
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Agenda
• Welcome & Introductions, 5min
• Peer Success Stories, 10min
• December Campaign Data and Improvement
Updates Review, 15min
• Improving Communication between Medical and
Medical Case Management Providers, 25min
• Q & A Session, 5min
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Improving Patient
Retention
Kate Dodge, RN, MCM
UHS Binghamton Primary Care
HIV Clinic
United Health Services Binghamton Primary Care
“Snapshot”
• Busy Internal Medicine clinic serving approximately 10,000 patients
annually
• HIV Clinic within BPC is only HIV specialty clinic in greater
Broome County area, serving approximately 300 patients
• Clinic located in Binghamton, a semi-urban area surrounded by
suburban & largely rural population
• Patient barriers to retention:
• Poverty
• Transportation
Support Systems
• Housing
Stigma
• Mental Health & Substance use issues
Health
Literacy
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UHS Patient Retention Project
• Retention monitoring begun in March, 2007 to
establish baseline
• Data: December, 2007: 50% Retention rate
• “Retention” is defined as:
At least 1 clinic visit every 3 months, annually
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PDSA Trial: Begun April, 2008
• Mailed “Appointment Reminder Cards” 2 weeks prior
to appointment;
• Followed up with “Reminder Calls” 24 hours prior to
appointment;
• If patient failed to keep appointment, mailed “Missed
Appointment letter”, from HIV Team;
• If patient failed to keep 2nd appointment, mailed
“Missed Appointment letter” from Provider;
• Monthly, sent “Visit Reminder letter” – not seen within
last 3 months -- to each patient on “Hot List”
• Sent “Discharge letter” to patients who had not been
seen in past 12 months.
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Results:
• Retention Rates:
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December, 2007: 50%
December, 2008: 85%
June, 2009: 92%
December, 2009: 89%
December, 2010: 87%
May, 2011: 88%
Binghamton Primary Care Updated 10/24/11
NATIONAL HIV QUALITY INDICATORS REPORT, 2010 Data
• Patient RETENTION:
• 252 Patients with @ least 1 visit in both 6-month periods of 2010
• 304 Patients with @ least 1 visit in 2010
• 84% Retention Rate
• Patient MONITORING:
• 239 Patients with 2 or more CD4 & VL tests done at least once in
each 6-month period of 2010
• 252 patients with @ least 1 visit in both 6-month periods of 2010
• 95% Monitoring Rate
• Patient VIRAL LOAD SUPPRESSION:
• 169 Patients on ART with VL<48 within last 6 months of the year
• 252 patients with @ least 1 visit in both 6-month periods of 2010
• 67% Patient Viral Load Suppression
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“Un-retained” patients 2010
(Patients with @ least 1 visit in 2010, but only in 1 6-month period)
• #52 Patients:
• Moved from area = 13
• New to BPC = 12
• Incarcerated = 7
• Limited Cognition/Needed Support = 5
• Non-compliant/Lack of motivation = 3
• Transportation Issues = 3
• Denial = 3
• Substance Use/Diminished Capacity = 2
• Lost to Care = 2
• Insurance Issues = 1
• High-functioning/Well controlled = 1
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Review of December
Campaign Data and
Improvement Update
Michael Hager, MPH MA
NQC Manager
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Data Review – Measure 1: Gap
Data Points:
• 154 organizations submitted data
• 86,943 patients in sample
Data Results:
• 17.70% patients experienced gap in care
• Top 10%: 3.14%; Top 25%: 5.15%
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Data Review – Measure 2: Visit Frequency
Data Points:
• 91 organizations submitted data
• 52,347patients in sample
Data Results:
• 61.28% patients retained in care for 2 yrs
• Top 10%: 90.56%; Top 25%: 86.69%
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Data Review – Measure 3: New Patients
Data Points:
• 146 organizations submitted data
• 7,456 patients in sample
Data Results:
• 57.17% new patients retained in care for yr
• Top 10%: 99.19%; Top 25%: 90.42%
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Data Review – Measure 4: Viral Suppression
Data Points:
• 143 organizations submitted data
• 91,830 patients in sample
Data Results:
• 68.03% patients virally suppressed at last viral load
test
• Top 10%: 86.86%; Top 25%: 82.65%
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National Snapshot
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Improvement Update Submission Review
A) Interventions
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Reports created identifying those out of care
Outreach via phone and letters
Outreach to shelters, streets, and homes
Reminder phone calls and texts
Hiring of staff to deal specifically with retention
Formation of peer navigation systems
Consent to contact other providers to ensure patients are
consistently in care
• Follow-up call 2 weeks after intake
• Asking patients for preferred method of communication
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Improvement Update Submission Review
B) Barriers
• Transportation
• Correct/up-to-date
contact info
• Mental health issues
• Substance abuse
• Socio-economic barriers
• Undocumented
consumers
• Unstable childcare
• Medical co-morbidities
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Limited resources
Understaffed
Long wait times
No system in place to easily
track retention
• Systematic insurance
coverage issues
• Language and cultural
barriers
Improvement Update Submission Review
C) Lessons Learned
• Collaboration and
communication with other
agencies is key
• Important to address nonHIV related issues
• Patients should feel
acknowledged and welcome
• Decrease wait time and
increase same-day appts
• Use volunteers
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• Engage community partners in
assisting with retention efforts
• Check Social Security death lists
• Provide or link to
transportation services
• Mental and substance abuse
screening to link patients to car
• Important to understand patient
population demographics
Improvement Update Submission Review
D) Training/Assistance Needs
• Would like to hear more about interventions other
organizations have found to be effective
• Tips on how to gather data more efficiently
• How do large organizations use tools to track reengagement of clients
• Data entry assistance needs
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Communication Between Medical Case
Managers and Primary Care Providers
Deborah Borne, MSW, MD, San Francisco Department of
Public Health
Kim Gilgenberg, LCSW, Clinical Supervisor, Tenderloin
Health, SF, CA
Matthew Bennett, MBA, MA , Diverse Management
Solutions, Denver, CO
What we will be discussing
• Using Quality Improvement Tools and Principles
for interdisciplinary communication and case
conferencing
• Structuring case conference
• Master Care Plan
• Panel Management in case conferencing
• Interdisciplinary training and case management
certification
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Medical Care
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Case
Management
Quality
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Working together improves engagement, retention, and outcomes
Our Two Agencies
• Tenderloin Health: Community based Multi-Service
agency in the Tenderloin of San Francisco
• Serve Homeless and Marginally Housed Clients with
significant Mental health and Substance issues
• Lead Agency in Part A and Part C
• Tom Waddell Health Center: DPH clinic
• Multiple sites
• 50, 000 visits annually
• Medical and Social issues other then HIV
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Communication Challenges:
• Not co-located
• Do not have access to same electronic information system
• Can not send ephi electronically
• Several medical providers working part time and not always on
the same day
• Clinic is a satellite of a larger organization, staff often pulled
• Turn over of case management staff
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How we deal with these challenges:
1. Morning Huddles
2. Weekly Case Conferencing
3. Outreach
4. Monthly Administrative Meetings
5. Master Care Plan
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Case Conferencing
•Acute issues - Morning Huddle
•Twice a week Case Conference : Each discipline
takes a turn at facilitating a meeting once a month
Tuesdays: Monthly run through of all current patients.
Thursdays: Intensive discussion of 3-4 Patients
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INDIVIDUAL CARE PLAN - SAMPLE
Client name: Jane
Dx(s): HIV, Substance Dependence, PTSD
Long Term Goal: Improve overall health and reduce viral load to undectable
Service Dates 1/1/12 to /30/12
Client Problem
(Must include measurable
starting point)
Treatments/ Interventions
(Include whether individual and/or group
intervention, and any out-of-center
activities)
Frequency of
Treatment/
Intervention
(e.g., 2x per
week)
Specific Objective/Goal of
Treatment/ Intervention
(must include measurable
objectives/goals)
Quarterly
Evaluation
1. Pt. reports non-compliance
with med tx due to lack of
stable housing and forgetting
med. appts.
1. Case manager to facilitate referral to
ER housing and assist pt. in permanent
housing application through agency XYX
1x/mo and as
needed
1. Pt. will be adequately housed
as documented by case manager
in progress
Outreach worker to assist pt. with appt.
reminders and escort
@ each appt.
Pt. will be compliant with medical
treatment per self report, provider
observation and lab results
in progress
Medical provider to schedule regular
medical appts and/or drop in days
1x/mo and as
needed
Case manager to refer pt. to behavioral
health for substance use and PTSD
assessment
1x/mo and as
needed
Pt. will be referred to behavioral
health specialist
Pt. declined
referral
other potential risk factors:
Viral may be impacted by
substance use and untreated
symptoms of PTSD
Behavioral health to provide assessment and 1x/week and as
treatment
Pt. will self report a reduction of
needed
meth use and reduction of disabling
PTSD sx
Panel Management in Case Conference
• Assignments
• Case Manager
• Behavioral Health
• Medical provider
• Frequency of Visits
• Last visit
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CD4
Viral Load
ARV
Prophylaxis
Adherence
• Housing
• SSI
Matt Bennett, MBA, MA
[email protected]
303.258.3523
diverse management solutions
www.diversemanagementsolutions.com/resources
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Best Practice = Health Outcomes
• Acuity
• Psychosocial Support
• Coordination of Care
• Resource Knowledge
• Self Management
• Training in Evidenced
Based Care
• Health Literacy
• System Navigation
• Supervision
• Adherence
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MCM Certificate Program
• Partnership Boston College, Denver Office of HIV
Resources and others.
• Change in MCM Definition: HRSA Definition
Change (10-02): Medical case management services
must be provided by trained professionals, including
both medically credentialed and other health care
staff…
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MCM Certificate: Key Topics
Web Based Trainings
• Motivational Interviewing
• HIV 101
• Service Planning & Monitoring
• Approaches to Difficult
Situations
• Harm Reduction
• Helper as Person
• HIPAA
Mandatory Reporting
• Multiculturalism
• Stages of Change
• Therapeutic Communication
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In person Trainings
•
Best Practices in MCM
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Positioning Clients to
Succeed – Trauma Informed
Approach
•
Motivational Interviewing
•
Medical Self Management
•
Thrive
Partnerships are Critical to Health Outcomes
Combined Expertise: Psychosocial Support; Behavioral
Change; Self Management; Health Literacy; Adherence
MCM Expertise: Resource to
overcome barriers to care
Medical Expertise: Treatment
& Care
Opportunities for Shared Training
• Motivational Interviewing
• Trauma Informed Care
• Medical Knowledge & Health Literacy
• Case Conferencing
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Questions?
• Deborah Borne, MSW, MD, San Francisco Department
of Public Health.
[email protected]
• Kim Gilgenberg, LCSW, Tenderloin Health,
[email protected]
• Matthew Bennett, MBA, MA
[email protected]
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Time for Questions
and Answers
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Next Steps
• Office Hours: Every Monday and Wednesday,
4-5pm ET
• Improvement Update Submission Deadline:
January 17, 2012
• Data Submission Deadline: February 1, 2012
• February Webinar: TBA
• Webinar on Incarceration: Dr. Brian Montague
March 14, 2012 at 3:00pm ET
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Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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