2. Los Angles LGBT Center
Noah Kaplan MSW
Alex Adame MSW

3. How does the Center compare?
Los Angles LGBT Center
How does the Center compare?

4. Our Medical Home Services: A one-stop shop
Comprehensive Mental Health Services
Transgender Health Program
Substance Abuse Services
Medical Care Coordination
Comprehensive Primary Care
Domestic Violence Services
Housing Referrals
On-Site Pharmacy
HIV and STI Testing and Treatment
Partner Services
Transportation Services
Research
Full Wrap-Around Services
Health Education and Prevention
Specialty Care Coordination

5. Medical Care Coordination
The Medical Care Coordination (MCC) model is a multi-disciplinary team approach, funded by the Los Angeles County Department of Public Health Division of HIV and STD Programs, that integrates medical and non-medical case management by coordinating behavioral interventions and support services with medical care to promote improved health outcomes.
Los Angeles LGBT Center’s MCC team members are integrated into the patient’s medical home and deliver patient-centered activities that focus on:
addressing health status
engagement and retention in care
adherence to HIV medications, and
HIV risk reduction.
The goals of MCC are to:
Streamline care coordination to improve HIV+ patients’
Access to medical care
Adherence to care and treatment regimens
Health Outcomes
Empower patients to self-manage care and reduce dependence on care system
Reduce HIV transmission
The primary objectives of MCC are to:
Support patients in adhering to medical care and antiretroviral therapy (ART)
Promote sexual risk reduction to reduce patient acquisition of sexually transmitted infections (STIs) and transmission of HIV infection
Facilitate access and linkage to appropriate services in the continuum of care
Increase patient self-efficacy by reducing acuity level
Eliminate duplication of services by integrating medical and non-medical case management for HIV+ patients
Increase coordination among providers

6. Retention in Care
Identify the social determinants that impact patient’s retention in care and medication adherence
Engage patients who are at risk of falling out of care or out of care
Intervene to help keep them in care or bring them back into care

7. Demonstration Project Overview
Retention in Care
Demonstration Project Overview
Target Population
High risk of falling out of care
Out of care
How to identify target population
Internal reports using EHR records of last medical visit and/or VL
Care team case conference
Care team referral

8. Intervention Engage Retention in Care
Phone, , txt, meeting in the community i.e. coffee shops

9. Assessment done by a combination of medical records and interview
Retention in Care
Intervention
Assess  
Risk
Barriers to Care
Needs
Assessment done by a combination of medical records and interview
Determine their level of risk for falling out of care and/or rate of non-adherence to HIV meds
Identify social determinants such as behavioral issues, life circumstances, and/or systemic barriers that are barriers to their care

10. Intervention Intervene Provide one on one psychosocial support
Retention in Care
Intervention
Intervene
Provide one on one psychosocial support
Incentives and transportation support
Navigate the client through the financial screening and appointment making process in a culturally sensitive way.  
Alex – Training ARTIS, MI, MSW

11. Retention in Care
Case Study

12. Lessons Learned Retention in Care Creating fast track FS appt.
Creating fast track RN, MCC appt.
Incentives

13. Discussion and Questions
Noah Kaplan, MSW Manager of Psychosocial Case Management Health Services (323) Alexandra Adame, MSW Retention Care Manager Health Services (323)

14. END