Transcript Slide 1

in+care Campaign
Webinar
September 25, 2012
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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
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Rose Farnan, RN, BSN, ACRN
Infectious Diseases Program Manager
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Only safety-net hospital for Kansas City, MO
Located in the urban core
Teaching hospital for University of MissouriKansas 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
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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
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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
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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
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
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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
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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
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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
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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
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Awaiting IRB approval to do interviews with
clients who have experienced periods of nonengagement 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
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Awaiting IRB approval to do interviews with
clients who have experienced periods of nonengagement 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
Focusing on Patients “At-risk” for Falling
Out of Care
P. Justin Goforth, RN
Director of Medical Adherence
Whitman-Walker Health
09/25/2012
Three Strategies for
Recruitment/Retention/Recapture
1. Red Carpet Access Program
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Breaking down barriers to entering care
2. Identification of patients most at-risk
for falling out of care
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Focusing resources on those who are most at-risk
for serious health consequences of not being in
care
3. Building a
Recruitment/Retention/Recapture
program in the ever changing world of
healthcare
Red Carpet Access Program
• History of accessing care:
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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!
Red Carpet Access Program
• Changing the delivery of an HIV positive
result:
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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
Red Carpet Access Program
• Linkage to care (tested on-site):
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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
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Confirmatory test is obtained
Red Carpet Access Program
• Linkage to care (tested on-site):
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If patient is willing and able to engage in care at
WWH:
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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
Red Carpet Access Program
• Linkage to care (diagnosed offsite or
transferring care):
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No appointment necessary, just walk in
All local referral partners know to tell patients to
walk-in and ask for “Red Carpet”
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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
Red Carpet Access Program
• Why we believe this works:
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A sense of both great hope and urgency is relayed
in the delivery of positive results
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Relationships are immediately established with
key members of the patient’s new care team
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Patients walk away understanding the seriousness
of the diagnosis but also understanding their ability
to take control and live well
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
Red Carpet Access Program
• So does this actually work??
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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
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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
Red Carpet Access Program
• DC data on engagement in care:
Red Carpet Access Program
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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!
A Focus on Those At-Risk for Falling
out of Care
• With limited resources we wanted to
get the best “bang for the buck”
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Our experience at recapturing patients who have
already fallen out of care shows this is extremely
resource intensive
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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)
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
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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!)
A Focus on Those At-Risk for Falling
out of Care
• Identifying who these patients are:
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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
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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
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
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
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
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
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
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!
Discussion/Questions
• Who else is experiencing these
challenges?
• What solutions have you developed?
• What questions do you have?
• Thank you for participating!
Improvement
Strategies Exercise
Michael Hager, MPH MA
NQC Manager
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in+care Campaign National Data Snapshot
December – August
as of 09/25/2012
Data
Dec
Feb
Apr
Jun
Aug
Dec
Feb
Apr
Jun
Aug
Average
Average
Average
Average
Average
Sites
Sites
Sites
Sites
Sites
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
Measure 1:
Gap Measure
16.17%
(123,603)
204
16.18%
(128,935)
198
14.71%
(127,359)
201
15.06%
(114,218)
179
14.10%
(105,674)
160
Measure 2:
Visit Frequency Measure
63.39%
(83,697)
153
65.71%
(86,504)
150
62.09%
(102,503)
172
64.09%
(91,687)
163
64.21%
(87,809)
149
Measure 3:
New Patient Measure
55.80%
(7,761)
192
58.18%
(8,759)
187
58.64%
(8,297)
190
59.33%
(7,066)
174
59.95%
(6,610)
157
69.69%
(134,926)
196
69.46%
(146,562)
190
70.43%
(153,754)
194
71.83%
(137,384)
178
72.31%
(123,904)
157
Measure 4:
Viral Suppression Measure
Coming Soon – new analyses!
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Improvement Strategies Discussion
Interventions Discussed on Today’s Program
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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
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
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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
 Community Priorities
 Planning Councils, CPGs, Part B CABS / Community Forums
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New Way to Submit Improvement Updates!
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Time for Questions
and Answers
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Upcoming Events and Deadlines
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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 Retention
Date Pending – to be announced!
•
Next Partners in+care Webinar: HIV, Stigma and Me
Date Pending – to be announced!
•
Next Meet-the-Author Webinar: Topic to be announced
Date Pending – to be announced!
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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
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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 [email protected] 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)
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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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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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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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