AHF Jacksonville Healthcare Center Ryan White Medical Outpatient and Medical Case Management Quality Showcase May 23, 2013 AHF Jacksonville HCC Health Care Team

AIDS Healthcare Foundation NCQA Accreditation

AIDS Healthcare Foundation Mission: Cutting edge medicine and advocacy, regardless of ability to pay Vision: A healthier future for people living with HIV/AIDS Core Values: Patient centered Value employees Respect diversity Nimble Fight for what’s right

Quality Priorities Patient-Centered Focus Systematic with Leadership, Accountability, Resources Data and Measureable Outcomes to Determine Progress Evidence-Based Benchmarks Focus on Linkages, Efficiencies, Provider and Patient Expectations/Satisfaction Continuous Process Adaptive to Change. Fits Within Framework of Other Activities, e.g., Medicaid Data Feedback Loop to QI Process to Assure Goals Met

HRSA Quality Dimension Principles Accessibility of care Ease or difficulty of obtaining services when the patient needs services Continuity of care Linkages to other resources--delivery of care does not occur in a vacuum Appropriateness of care Care delivered using state of the art technologies and includes the best care that medical and social science judgment would prescribe Safety of care Procedures followed during delivery of care and services are error free, i.e., avoids harm and actually helps

HRSA Quality Dimension Principles Timeliness of care Care is delivered at the right time Involvement in care Patients participate with clinicians/practitioners in making decisions that affect their well-being Effectiveness of care The program is flexible so individuals can develop their own resources without counterproductive overdependence on the system (Salem, Seidman, & Rappaport, 1988) Efficacy of care Care is individually tailored to meet patient's needs Efficiency of care Care accomplishes the intended purpose

AHF Quality Dimensions for Improvement 2012 Accessibility of Care Timeliness of Care Involvement in Care

AHF Quality Areas Addressed Core Clinical Area CD4 Count Viral Load Monitoring Medical Visits Medical Case Management Care Plan Outpatient Medical Care Systems-Level Waiting Time for Initial Appointment Quality Management Program

Goals Medical O.P. and Medical Case Management Reduce No Show Rate For Medical Appointments Reduce Risk of Patients Falling Out of Care Bring Patients Back Into Care and Prevent Others From Falling Out of Care. Adherence = Undetectable VL

AHF CQI PLAN OUTPATIENT MEDICAL Outcome 1.1: Reduce % of No Shows by at least 2 pecentage points from 2011 annual no show rate No show rate for 2010 = 18.4% No show rate for 2011 = 18.1% No show rate for 2012 = 16.4% Personal reminder calls the morning prior to their visit aids in getting the patient to the office. A smiling voice is what it takes.

Monthly No Show Rates 2012, 2011, 2010

Monthly No Show Rates 2012, 2011, 2010 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 2012 17.9 13.5 18.2 15.7 21.3 14.3 12.3 16.2 15.4 15.9 18.5 2011 17.5 14.5 12.8 16.6 22.2 20.1 18.9 24.1 17.4 2010 15.6 21.4 20.6 18.8 17.7 17.1 19.4 20.5

AHF CQI PLAN OUTPATIENT MEDICAL Objective 1.2: Request updated contact information for 100% of patients upon check-in at the HCC Updated contact information requests with a smile and positive attitude increase the chance of patients continuing their care. AHF is piloting an HCC Patient Secret Shopper to evaluate the effect that customer service, whether negative or positive, has on retention of patients to the Healthcare Centers.

DEMOGRAPHICS 2012 is the first year the number of demographic changes have been reviewed. A report is being developed to determine the number of changes. Demographic changes for this baseline year are similar every month for an average of 4.5% each month. Based on the aggressiveness to obtain correct demographics, we will be able to compare the no show rate for 2013.

DEMOGRAPHIC CHANGE BY MONTH BASELINE Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec % Change 7% 4% 5% 3% 6%

AHF CQI PLAN OUTPATIENT MEDICAL Outcome 1.3: Decrease no show rate by an additional 5 percentage points by sending appointment postcards Postcards were not used in 2012: 1. Took too much time to fill out. 2. Postcard thrown out as soon as it was received. 3. Patient did not want anyone to see postcard and ask questions (stigma).

AHF CQI PLAN OUTPATIENT MEDICAL Objective 1.4: Send “Sorry We Missed You” cards to 100% of no shows. Cards were only used for a short time: Many cards were returned with unknown addresses. Patient did not want card coming to house (stigma). Phone calls from the peer navigators were much more efficient and cost effective.

AHF CQI PLAN OUTPATIENT MEDICAL Objective 1.5: Ensure that 90% of all new patients and returning to care patients see a medical provider within 3 days of contacting the HCC Overall we saw all of our new and return to care patients within 3.1 days. Jacksonville HCC is expanding so rapidly that we have been physically unable to see patients within 3 days and still care for our longtime patients.

AHF WAIT TIME

CONCLUSION OUTPATIENT MEDICAL Our 2012 No Show rate of 16.4% showed a decrease of 2 percentage points from 2010 and 1.7 percentage points from 2011. Reminder calls with a smiling voice increase the chance of patients continuing their care. Peer navigators calling no shows to assist them in rescheduling is very productive. Stressing the importance of a correct address and phone number from the patient is being achieved by the front desk. AHF will always strive to lower the patient wait time below 72 hours.

LESSONS LEARNED OUTPATIENT MEDICAL No show rate is fluid. Time of year is not a factor. Postcards not used in 2012 – not a factor. Reminder calls to 100% of scheduled patients is a factor. Correct and current demographic information is a factor.

Combined CQI Initiatives AHF-LSS Medical Case Management AHF-LSS Mental Health Conduct focus groups: Web-based versus telephonic-based support groups for newly diagnosed. 2012 Peer Navigator Training Initiatives. 2013 Develop and implement a web-based/ telephonic support group. Identifying patient barriers to medical adherence. Identify adherence behaviors and characteristics that impact compliance.

Mental Health Focus Group Interest Trial Telephonic-Based Group Provided questionnaires to 10 newly diagnosed. Results: 75% were interested in group. 65% preferred an online/ telephone-based support group. 45% preferred a face-to-face group setting. 5 members were pooled from existing support groups. Pros and Cons: “I really enjoyed connecting with new people and would love to be a part of an ongoing group.” “Telephone provided Increased anonymity.” “I would be able to always attend, if it is on the phone.” “There has to be a way to lower background noise.” “I did not feel as connected as I do in a group meeting.” 2011-2012 Total MH Referrals 29 2012-2013 Total MH Referrals 43 Total patients that received at least one service 36. Total patients that are currently enrolled 16 Total graduated: 14 Total MH patients 157 27% of referrals from AHF

Mental Health Continued… Training Curriculum with Peer Navigators Training targeted to teach the basic principles of peer-run support groups. Training included: Ethics Ethical Boundaries Suicide Prevention Preventing Secondary Trauma Best Practices: Group Facilitation

Medical Case Management Goals Improving medical adherence through understanding the specific needs and barriers to care for those with high rates of non–adherence/loss to care. Identify the current ratio of LSS patients in care with AHF. Evaluate current rates of non-adherence/loss to care. Perform MCM assessment of patient-specific needs. Provide services geared towards barrier reduction.

Patient Non-Adherence Rates: Overall and LSS Rates of adherence were gathered bi-monthly beginning August 2012 and ending February 2013. AHF 104 day report displayed fluidity over this 7-month period. The period ended with an overall 51% decrease in no show rates. LSS represented 10% of those identified in the reporting period. 8 patients identified as frequently non-adherent (appeared more than 2 times on the 104 day report). Non-adherence Rates

Identified Need/Stages for Change Behaviors/ Barriers Identified Baseline 8 individuals targeted. Provided with increased medical case management to include: Appointment reminders Monthly calendars Adherence assessments Access to the Peer Navigator Educational materials Behavioral assessments 55% of those targeted showed to be in the contemplation stage of change in regards to their health. 68% had transportation listed as a barrier to care. 50% were listed as a MCM acuity level of 2 or higher, providing a history of either non-adherence to care or high need for care.

Change Happens Current Change: Over 7-month the rate of non-adherent or lost to care LSS patients decreased 10% to 6% by identifying patients through use of the 104 day report. At the end, lost to care patients had returned through use of appointment reminders and access to gas cards or bus cards. The total number who were lost to care decreased by 85%. As patients became medically adherent their acuity decreased by 45% (more data still needs to be collected to ensure continued adherence). 65% of patients moved from contemplation to action and/or maintenance. For the Future: Acuity level 2 or higher patients should receive appointment reminders to increase appointment adherence. Acuity 2, 3 and 4 patients should receive increased adherence counseling >2 times per year and should have regular access to peer navigators. The stages of change should be evaluated in regard to patient’s thoughts on their healthcare. The identification of behaviors and barriers and setting goals may lead to decreased rates of non-adherence and patients becoming lost to care.

Continuous Efforts towards Change AHF Measures rate Identifies need Provides specific support to patients by medical case managers use of case conferencing and peer support Ensures a team approach to care LSS Assesses need Identifies targeted patients Evaluates Barriers/Behaviors Implements strategic interventions Works as a team with the medical provider to decrease barriers to care

RN-MCM Actions To Reduce Risk of Falling Out of Care Conducts Patient Assessments to formulate Plan of Care Addresses Issues and Needs in POC Peer Navigators outreach to and Link to Medical Care Patient Education on “How to Conduct Your Medical Visit” Peer Navigators Attend Medical Visits With New and Returning to Care Patients Patient Adherence Education on ARV and Chronic Condition Medications Appointment for follow up after medical visits with Peer or RNMCM Collaborative Interdisciplinary Meetings With PCP Embedded Staff to Support PCP and Medical Treatment Plan focusing on Patient-Centered Care Delivery

AHF CQI Goal 2.2.1 and 2.3.1 Note: November spike most likely due to influx of patients from River Region that did not return after 2 initial visits (becoming lost to care).

Barriers to Care Identified

AHF MCM: in+care Campaign Medical Visits

AHF MCM: in+care Campaign Medical Visits

AHF MCM: in+care Campaign Viral Load Suppression

Summary of Patient-Centered Quality Care Measures

MCM Conclusions and Lessons Learned Patient-Centered Assessment and Interdisciplinary Team are Effective in Increasing Medical Visit and Medication Adherence. Barrier Mitigation and/or Removal Increases Patient Success for Adherence. Multi-Level (PCP, RNCM, Peer) Continual Education on HIV, Chronic Conditions, Medical System Navigation Increases Medical Literacy, Treatment Adherence and Patient Self Management Skills. Each Patient is Unique and Use of Persistence and Tailored Measures Is Necessary For Success.

QUESTIONS? Thank You!