1. 1 in+care Campaign Webinar January 18, 2012

2. 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. 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. 5 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 TransportationSupport Systems Housing Stigma Mental Health & Substance use issuesHealth Literacy

6. 6 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

7. 7 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 2 nd 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.

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

9. 9 Binghamton Primary Care Updated 10/24/11 NATIONAL 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. 10 “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

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

12. 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. 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. 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. 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. 16 National Snapshot

17. 17 Improvement Update Submission Review A)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. 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. 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. 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. 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. 23 Medical Care Case Management

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

25. 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. 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. 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. 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. Client Problem (Must include measurable starting point) Treatments/ Interventions (Include whether individual and/or group intervention, and any out-of-center activities) Frequency of Treatment/ Intervention (e.g., 2x per week) Specific Objective/Goal of Treatment/ Intervention (must include measurable objectives/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 permanent housing application through agency XYX Outreach worker to assist pt. with appt. reminders and escort Medical provider to schedule regular medical appts and/or drop in days Case manager to refer pt. to behavioral health 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 housed as 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 of meth use and reduction of disabling PTSD sx in progress in progress Pt. declined referral INDIVIDUAL CARE PLAN - SAMPLE Client name: Jane Dx(s): HIV, Substance Dependence, PTSD Long Term Goal: Improve overall health and reduce viral load to undectable Service Dates 1/1/12 to /30/12

30. 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. 32

33. 33 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

34. 34 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…

35. 35 MCM Certificate: Key Topics Web 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

36. 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

37. 37 Opportunities for Shared Training Motivational Interviewing Trauma Informed Care Medical Knowledge & Health Literacy Case Conferencing

38. 38 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

39. 39 Time for Questions and Answers

40. 40 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 Montague March 14, 2012 at 3:00pm ET Next Steps

41. 41 Campaign Headquarters: National Quality Center (NQC) 90 Church Street, 13 th floor New York, NY 10007 Phone 212-417-4730 incare@NationalQualityCenter.org incareCampaign.org youtube.com/incareCampaign