1. Dr. Sarah Stone, IDC Physician Julie Kille, Operations Leader Brynn Grierson, MSN, Clinical Nurse Leader Nancy Chow, RN Elizabeth Barrett, Administration Coordinator Neil Fowler, Project Assistant Immunodeficiency Clinic St. Paul’s Hospital

2. “Aha Moment” Realization that many, if not most, of our patients are already self managed Peer navigators, pharmacy support and adherence, nursing education (i.e. CD4, VL) are all interventions that were already in place that promote self management How do we know?: HIV quality indicators are high Decreased number of patient ‘no-shows’ Anecdotal reports and clinician experience

3. “Oh No” Moment Realizing that the most complex (medically and psychosocially) patients consumes most of the interdisciplinary teams time and resources i.e. 10-15% of our patients (110/1100) require complex case management In terms of HIV, our complex patients are quite stable, however many have complex needs based on addictions Realization that a more comprehensive and innovative restructuring of already existing addictions team needs to occur

4. Moving Ahead Addictions team to meet regularly New strategies to be implemented to improve engagement in care (i.e. groups) Improved group space Addictions team to work with QI team on planning and evaluation measures (PDSA)