1. LEARNING SESSION 5 Portland Clinic Rapid Fire Presentation

2. ISSUE: IDC REFERRAL  Clients’ of the Portland Clinic who not on ARV’s are referred to IDC for consult.  This is best practice; however wait times to be seen at the IDC can be long, depending on time of year and availability of specialists  When clients’ have appointments they often go AWOL or refuse to go to appointment. Even with planning it can be difficult to get the clients’ to their appointments.

3. INNOVATION: ADDITIONAL PHYSICIAN SUPPORT  In consultation with the STOP team and the Portland Clinic team it was agreed that an HIV specialized GP would be added to the clinical rotation at the rate of 1hour per week/4hours per month.  This addition allowed for the clients’ to be seen in their own environment effectively lowering any barriers to accessing care  Also the addition of an HIV specialized GP provides clinical staff access to support for any HIV care related questions/concerns

4. OUTCOMES AND PLANS  The addition of the HIV specialized GP to the Portland team has allowed for 4, difficult to engage clients’, to be seen and started on ARV’s.  The new HIV specialized GP will see HIV+ clients, provide help with side effect management, adherence concerns, review clients’ current regimes and change or update meds if needed.

5. ISSUE: CURRENT REGISTRY  The Portland clinic team has done an excellent job keeping clients’ up to date with their blood-work and engaging clients’ in care.  Lists are updated manually and require a great deal of detective work to find the details regarding everything from clients’ current meds to their vaccination records.  Current collaborative data set provides limited clinical information

6. INNOVATION: COLLABORATION  Regional Practice Support Leader Swati Thakkar kindly offered her assistance and expertise with building a new registry for a complete clinical snapshot of the Portland Clinic HIV+ clients  The new registry is designed so that alerts will show up in the different tabs allowing the user to easily identify client needs and gaps in care. Swati has created a registry that uses the excel software to populate the cells according to a pre-set criteria thus reducing data entry time and error.  Thank you Swati for all of your help!!!

7. OUTCOMES AND PLANS  The registry is a work in progress, further data is being compiled to complete the registry for use.  The registry will become a part of the Portland Clinics’ data base and allow the user a snapshot of the clinical data regarding the current HIV+ clients’  It will be a tool for monitoring clients’ status and needs, and an easy application for which to add new clients’ and move client’s who are MOOGE to another tab where they can be retrieved easily if they return to the clinic for care.

8. TEAM BUILDING: WHO WE ARE & WHERE WE ARE AT  0.5 STOP HIV RN, Stephanie C., in place  0.25 STOP HIV Outreach worker, Meenakshi, in place  0.5 STOP HIV MOA, Ashley, in place  4hrs per month HIV specialized GP, Hand over from current provider Dr. Tu to new provider Dr. Deans in progress.  Current Portland Clinical staff: Physicians Dr. Jafari and Dr. Joe, Clinic RN (Kirsten), and Clinic Manager: Ashley, supporting the STOP initiative every step of the way.

9. THINGS TO WORK ON  Continue to collect data and update registry  Work with Portland team, the STOP team and the current outreach HIV specialized GP to provide care to HIV+ clients and to develop a model that would allow for easy assimilation of outreach Physicians at the Portland clinic or at other sites.  Continued client engagement and adherence initiatives.  Evaluate clients’ current medication regimes and alter if client would benefit from newer regime.

10. ANY ADVICE?  If you have any advice on anything that has worked for you and your team on any of the above issues and especially on the topics of continued engagement strategies and adherence motivation please come and chat with me at the break