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in + care Campaign Webinar January 18, 2012

in + care Campaign Webinar January 18, 2012. 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)

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in + care Campaign Webinar January 18, 2012

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  1. in+care CampaignWebinar January 18, 2012

  2. 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

  3. 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

  4. Improving Patient Retention Kate Dodge, RN, MCM UHS Binghamton Primary Care HIV Clinic

  5. 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 United Health Services Binghamton Primary Care “Snapshot”

  6. 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 UHS Patient Retention Project

  7. 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. PDSA Trial: Begun April, 2008

  8. Retention Rates: December, 2007: 50% December, 2008: 85% June, 2009: 92% December, 2009: 89% December, 2010: 87% May, 2011: 88% Results:

  9. 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

  10. (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 “Un-retained” patients 2010

  11. Review of December Campaign Data and Improvement Update Michael Hager, MPH MA NQC Manager

  12. 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%

  13. 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%

  14. 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%

  15. 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%

  16. National Snapshot

  17. Improvement Update Submission Review • 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. This is not the way to care for people CaseManagement MedicalCare

  24. Quality Consumers Case managers Medical Providers Working together improves engagement, retention, and outcomes

  25. 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

  26. 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

  27. How we deal with these challenges: 1. Morning Huddles 2. Weekly Case Conferencing 3. Outreach 4. Monthly Administrative Meetings 5. Master Care Plan

  28. 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

  29. INDIVIDUAL CARE PLAN - SAMPLE Client name:  Jane                            Dx(s): HIV, Substance Dependence, PTSDLong Term Goal: Improve overall health and reduce viral load to undectable    Service Dates 1/1/12 to /30/12

  30. 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

  31. Matt Bennett, MBA, MA bennett@diversemanagementsolutions.com 303.258.3523 diverse management solutions www.diversemanagementsolutions.com/resources

  32. 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

  33. 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…

  34. MCM Certificate: Key Topics Web Based Trainings In person Trainings Best Practices in MCM Positioning Clients to Succeed – Trauma Informed Approach Motivational Interviewing Medical Self Management Thrive • Motivational Interviewing • HIV 101 • Service Planning & Monitoring • Approaches to Difficult Situations • Harm Reduction • Helper as Person • HIPAAMandatory Reporting • Multiculturalism • Stages of Change • Therapeutic Communication

  35. 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

  36. Opportunities for Shared Training • Motivational Interviewing • Trauma Informed Care • Medical Knowledge & Health Literacy • Case Conferencing

  37. 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

  38. Time for Questions and Answers

  39. 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 MontagueMarch 14, 2012 at 3:00pm ET

  40. Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floor New York, NY 10007Phone 212-417-4730 incare@NationalQualityCenter.orgincareCampaign.org youtube.com/incareCampaign

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