Transcript Slide 1

ANCHORING INTO THE MEDICAL HOME
Engagement in Care
July 7, 2011
Amy M. Sitapati, M.D
Associate Clinical Professor
Associate Director, Owen Clinic
Engagement in care
The 39 Core Components
C.R. Jaen, et al. Ann Fam Med. 2010;8(Suppl 1):s57-67
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.”
Collaborative Pilot: Owen Clinic and the AVRC
Bridge Program targeted 492 patients:
Resulted in 33 patients returning to care
Lost to Follow Up Pilot Summary 2009
Outcome
#
%
Deceased
1
0.2%
35
7.1%
7
1.4%
24
4.9%
In Care - Other UCSD Provider
8
1.6%
In Care - San Ysidro with Owen Provider
3
0.6%
15
3.0%
105
21.3%
Returned to Owen - Assisted with Appointment
33
6.7%
Unable to Reach/Phone Disconnected/Homeless
261
53.0%
Total
492
100.0%
New Insurance - Remaining in Care
Incarcerated
Moved out of Area
In Care Other Provider - Change Not Insurance
Related
Returned to Owen Prior to Contact
STEP 2:
Moving Engagement into
ACTION! By getting involved in an
organized quality improvement
project
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
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)
Tool 2: Making algorithms/flyers
Flow diagram for re-engagement
Check Lab Tracker:
Return on Own?
No
Reason Why?
Moved, etc.
No
Search:
- EMR for Hospitalization/Death
- Sheriff Inmate Log
http://apps.sdsheriff.net/wij/wij.aspx
Email
Send Same day as 2nd
call w/ no contact
Call
-LM
-Message not returned in
2 days Call Again
- Social Security Death Index
http://ssdi.rootsweb.ancestry.com/
- County Health
Mail Letter to known
address
-Send 2 days after
email w/ no contact
Search Google
Consider Patient
LOST
Call Emergency
Contact/Case Manager
-3 days after mail w/
no contact
Consider other
resources:
-Support groups
-Centers
-etc
Call Emergency
Contact/Case manager –
Call again after two days
Search
Facebook/Myspace
-Send message via
website messenger
-- Use contact
information
Contact
Pharmacy
Search ADAP
Posted outreach: Flyer creation
Tool 3: Track in Access database
PUFF: Access: patient search
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
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 #)
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)
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
Working with Homeless programs for
referrals
Impact Summary
Final Outcome
#
%
Returned on Own
205
28.6%
Returned with Intervention
116
16.2%
Lost, Unable to Contact
88
12.3%
In Care Elsewhere
98
13.7%
Still Clinic Patient but No Return Visit
26
3.6%
8
1.1%
41
5.7%
Moved out of Area
101
14.1%
Incarcerated
28
3.9%
No Longer Clinic Patient Unknown if In Care
4
0.6%
Dismissed from Clinic - Status Unknown
1
0.1%
716
100.0%
Future Return Visit Scheduled
Expired
Total
Sitapati, unpublished data, 1/2011
SUMMARY of patient
experiences in Retention
“I really appreciated the call from the office in person, you calling
and saying we have not seen you in a while, it means a lot to me”
“Is there anything else I can do for you”, “No you just made my day”
A patient who had not been seen in 7 months and is currently on
ARVs: “I’m not going to take a day out of my schedule, come in and
wait in that office if I don’t have to and don’t need to.”
Even if a provider has informed the patient of the need for a 3-4
months follow up a patient may feel the need to have a direct call
from there provider to come in for a visit: "I don't go in unless
something is wrong or he (Provider) tells me too"
Patient calls and outreach:
A. No hx prolonged absences or missed visits. Always
did 3 to 4 month F/U. He just forgot.
B. Pt has new insurance; recovering from met cancer,
contacts Dr. by phone; RW; many cancels & no shows
C. Phone #'s bad in 2 databases; letter returned; medical
records detail govt persecution perception; needs to
renew RW/ADAP
D. Phone #'s in PCIS and LT and IDX no good; moved to
New Orleans per case manager
“oh, my God, I think you just saved
my life…”- B
Dx HIV 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.
Reason
Reasons
Patients Gave
for Missing
Care
#
%
Jail/Prison
30
15.2%
Too Busy
25
12.6%
I'll know when it's time
24
12.1%
Other
24
12.1%
Out of Town Split Work
16
8.1%
Not Sick
14
7.1%
Insurance or Referral Issue
14
7.1%
Forgot
11
5.6%
No Reason Given
9
4.5%
Psychological Issues
8
4.0%
Residential Care
5
2.5%
No Insurance
4
2.0%
Don't know when to Schedule Appt
3
1.5%
Transportation Issues
2
1.0%
Office Hours
2
1.0%
Don't want to think about being sick
2
1.0%
Interresearch Study
2
1.0%
Tired/ Needed Break
2
1.0%
Perceived Maltreatment
1
0.5%
198
100.0%
Total
Sitapati, unpublished data, 1/2011
Pharmacy link results
20 DIFFERENT PHARMACIES TO FIND 61 PTS
19/20: provided info last refill date, contact # and other
10/20 (50%): accepted provider messages
1/20 did not share info, but called 10 pts (8 bad #/2 mg)
33/61 pts WITH NEW PHONE NUMBERS
22/33 were already listed in our EMR; 1 new bad #
10/33 were new good contact numbers
4/61 pts found with the new contact #’s:
1 return visit kept; 1 appt. pending; 1 moved; 1
changed provider
Additional 2/61 ID as moved/incarc from pharm
Preliminary data 7/10: Sitapati, unpublished.
PUFF is afforbable
This is a project requires a ½ time
employee at low cost Community Health
Program Representative and is an
affordable option.
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?
PUFF “Toolbox” of Retention
Resources:
• Work flow diagrams for Retention
Specialist
• Retention Patient Letter
• Retention Community Flyer
• Patient engagement Hand out
• Access Database tool
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.
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
Suggested Reading:
1. M Mugavero. Improving Engagement in HIV Care: What can we
do? IAS-USA Topics in HIV Medicine Vol 16(5); December 2008:
156-161.
2. 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.
3. MJ Mugavero, et al. Missed Visits and Mortality among Patients
Establishing Initial Outpatient HIV Treatment Clin Infect Dis 48;
Ja 15 2009: 248-256.
4. LW Cheever Engaging HIV-Infected Patients in Care: Their Lives
Depend on It. Clin Infect Dis 44; June 1, 2007: 1500-1502.
5. TP Giordano, et al. Retention in Care: A Challenge to Survival in
HIV Infection Clin Infect Dis 44; June 1, 2007: 1493-1499.
6. DR Rittenhouse, SM Shortell The Patient-Centered Medical
Home: Will It Stand the Test of Health Reform JAMA 2009;
301(19): 20038-40
7. Linkage, Engagement and Retention in HIV care Clin Inf Dis
2011; 52(2)