1. Pender CHC STOP HIV Team

2. Improvement Developed case management for HIV + patients with identified “Gaps in Care” “Gaps in care” defined as no Primary visit or Viral load > 4/12, CD4 200 on ARVT >6/12 Started process with PDSA in May/11 with new form for 1-3 case reviews/meeting. Data showing improvement?

4. Continuing Challenge Keeping HIV registry updated and monthly reporting. Patient Satisfaction Survey Next Steps…..Need ongoing computer support from STOP Project Team. Need to improve process to include front staff for data entry. Will need revision of patient survey.

5. Lessons Learned Focus on computer skills Positive impact of involving Outreach Team Need to start measuring Numbers of Gaps in Care patients and impact of case management Start developing plan for sustainability Need ongoing work on self-management and patient involvement.