1 Pender Community Health Centre

2 Back in the old days (Before the collaborative) We didn’t know who all of our HIV patients were We didn’t have a sense of how many had gaps in care We didn’t have an organized way of keeping track of blood work, visits, outcomes Irregular case conferences and very limited outreach resources

3 “Ah Ha!” An up to date registry which automatically populates “Gaps in Care” and generates a patient list which we review and triage at monthly interdisciplinary meetings Ability to track our complex patients and implement case management with outreach team support

4 “Oh No!” Jan 2012 team reduced from 7 -> 2 Sub-optimal technical support Based on new reality we had to redefine how to sustain our patient care goals Reassess our ability to achieve collaborative goals for data and narrative reporting

5 Ongoing challenges Increasing complexity of patients Trying to function with a smaller group and limited time resources Need to continue efforts for patient input (i.e surveys) and self-management Maintaining updated registry, data collection and quarterly reporting

6 Why we can’t be stopped! We know we are providing better care We are developing a clearer understanding of how to improve our patient care outreach NP or RN patient satisfaction survey for all primary care patients low barrier counseling for those “hard to engage” patients