1. 1 Pender Community Health Centre

2. 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. 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. 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. 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. 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