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in+care CampaignWebinar

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

Improving Patient Retention

Kate Dodge, RN, MCMUHS Binghamton Primary Care HIV Clinic

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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:

• December, 2007: 50%• December, 2008: 85%• June, 2009: 92%• December, 2009: 89%• December, 2010: 87%• May, 2011: 88%

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Binghamton Primary Care Updated 10/24/11NATIONAL 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 MANQC Manager

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Data Review – Measure 1: Gap

Data Points: • 154 organizations submitted data• 86,943 patients in sampleData 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 sampleData 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 sampleData 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 sampleData 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 ReviewA) Interventions

• 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

• Limited resources• Understaffed• Long wait times• No system in place

to easily track retention

• Systematic insurance coverage issues

• Language and cultural barriers

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Improvement Update Submission Review

C) Lessons Learned• Collaboration and

communication with other agencies is key

• Important to address non-HIV related issues

• Patients should feel acknowledged and welcome

• Decrease wait time and increase same-day appts

• Use volunteers

• 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

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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 re-engagement of clients• Data entry assistance needs

Communication Between Medical Case Managers and

Primary Care Providers Deborah Borne, MSW, MD, San Francisco

Department of Public HealthKim Gilgenberg, LCSW, Clinical Supervisor,

Tenderloin Health, SF, CAMatthew Bennett, MBA, MA , Diverse Management Solutions, Denver, CO

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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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This is not the way to care for people

Medical Care

Case Managemen

t

24Working together improves engagement, retention, and outcomes

Quality

Consu

m

ers

Med

ical

Prov

ider

s Case

managers

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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 

Client Problem(Must include measurable starting point)

Treatments/ Interventions (Include whether individual and/or group intervention, and any out-of-center activities)

Frequency ofTreatment/Intervention(e.g., 2x per week)

Specific Objective/Goal ofTreatment/ Intervention(must include measurableobjectives/goals)

Quarterly Evaluation

1. Pt. reports non-compliance with med tx due to lack of stable housing and forgetting med. appts. 

other potential risk factors: Viral may be impacted by substance use and untreated symptoms of PTSD

1. Case manager to facilitate referral to ER housing and assist pt. in permanenthousing application through agency XYX Outreach worker to assist pt. with appt.reminders and escort Medical provider to schedule regularmedical appts and/or drop in days 

Case manager to refer pt. to behavioralhealth for substance use and PTSD assessment

Behavioral health to provide assessment and treatment

1x/mo and as needed  @ each appt.  1x/mo and as needed 

1x/mo and as needed

1x/week and as needed

1. Pt. will be adequately housedas documented by case manager Pt. will be compliant with medical treatment per self report, provider observation and lab results 

Pt. will be referred to behavioral health specialist

Pt. will self report  a reduction ofmeth use and reduction of disabling PTSD sx

in progress   in progress  

Pt. declined referral

INDIVIDUAL CARE PLAN - SAMPLE Clien t name:  Jane                            Dx(s) : HIV, Sub st ance Dep end ence, PTSD

 Long Term Goal: I mp rove overall health and red uce viral load to undect ab le    Service Dat es 1/1 /1 2 t o /30 /1 2

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Panel Management in Case Conference

• Assignments• Case Manager• Behavioral Health• Medical provider

• Frequency of Visits• Last visit

• CD4• Viral Load• ARV• Prophylaxis• Adherence

• Housing• SSI

Matt Bennett, MBA, MAbennett@diversemanagementsolutions.com303.258.3523

diverse management solutions

www.diversemanagementsolutions.com/resources

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Best Practice = Health Outcomes

• Acuity

• Coordination of Care

• Self Management• Health Literacy• System Navigation

• Adherence

• Psychosocial Support

• Resource Knowledge

• Training in Evidenced Based Care

• Supervision

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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 TopicsWeb 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

In person Trainings• Best Practices in MCM

• Positioning Clients to Succeed – Trauma Informed Approach

• Motivational Interviewing

• Medical Self Management

• Thrive

Partnerships are Critical to Health Outcomes

MCM Expertise: Resource to overcome barriers to care

Medical Expertise: Treatment & Care

Combined Expertise: Psychosocial Support; Behavioral Change; Self Management; Health Literacy; Adherence

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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. Deboarh.Borne@sfdph.org

• Kim Gilgenberg, LCSW, Tenderloin Health,

Kim.Gilgenberg@tlhealth.org

• Matthew Bennett, MBA, MA bennett@diversemanagementsolutions.com

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Time for Questions and Answers

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• 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

MontagueMarch 14, 2012 at 3:00pm ET

Next Steps

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign