Transcript - Welcome to the National Quality Center

National TA Call:
Where Are My Patients?
Strategies to Improve Retention in HIV Care
July 7, 2011
Facilitator: Johanna Buck, RN, MA
Senior Quality Consultant, NYSDOH AIDS Institute Office of the Medical Director,
Quality of Care Program
Learning objectives
• Briefly review the benefits of using QI
methodologies to improve retention in care
• Primer on measuring retention and the
importance of accurate patient case lists
• Learn about two programs' retention
initiatives and how measurement was
employed
• Preview the latest HRSA retention initiative
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Agenda
• Welcome
• Retention in care in 2011 and how can QI contribute to
improving retention
• Measuring retention in care – calculating a retention rate and
maintaining an accurate case list
• UHS Binghamton Primary Care HIV Clinic Kate Dodge, RN, MCM
• UC San Diego Medical Center Owen Clinic- Amy M.Sitapati,
MD, Assoc. Director, Owen Clinic
• Questions, answers and discussion
• HRSA initiative on retention – Sarah Cook-Raymond
3
Retention in care in 2011
• Linkages to care and retention in care will
become even more important as the number
of new patients requiring HIV treatment
increases.
• Why?
4
Retention in care in 2011
• Partially in response to:
 Center for Disease Control and Prevention HIV
Testing Recommendations ( opt out testing, 2006)
 National HIV/AIDS Strategy - one major goal is to
increase the proportion of Ryan White HIV/AIDS
program clients who are in continuous care (at
least 2 visits for routine medical care in 12
months) from 73 percent to 80 percent (Office of
National AIDS Policy, 2010)
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Continuum
Engagement in Care
Not in
Care
Unaware of
HIV Status
(not tested
or never
received
results)
Fully
Engaged
Know HIV
Status
(not
referred
to care;
didn’t
keep
referral)
May Be
Receiving
Other
Medical
Care But
Not HIV
Care
Entered HIV
Primary
Medical
Care But
Dropped
Out
(lost to
follow-up)
Non-engager
In and
Out of
HIV Care
or
Fully
Engaged
in HIV
Primary
Infrequent Medical
User
Care
Sporadic
User
Health Resources Service Administration (HRSA)
6
6
Fully
Engaged
Model for Improvement
What are we trying to
accomplish?
How will we know
that a change is an
improvement?
What change can we make
that will result in
improvement?
7
What can Quality Improvement
contribute?
• Focus on systems of care delivery
• Organization level vs. patient-level
• Systematize processes of measurement
• Routinize improvement of retention and manage
it at the clinic level
• Innovative (thinking “out of the box”) solutions
8
What does it really mean to be retained?
• The patient is engaged in care
 OR
• The clinic has the patient on its active roster
9
Select a retention measure
• New York State current retention measure:
2 visits during the year, at least one in each
six month half of the year
• Other sample measures:
No visit within three months
At least 2 visits in the year, separated by at
least 3 months
Many others….
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HRSA/HAB
• HRSA/HAB: Medical Visits
# of clients who had a medical visit with a provider
with prescribing privileges in an HIV care setting
two or more times at least 3 months apart during
the measurement year
Total number of clients who had a medical visit
with a provider with prescribing privileges at least
once in the measurement year
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To calculate an accurate
retention rate you Eligible Patients/Sample
need an accurate (Patients visiting the clinic known not to
active patient
have died or transferred out – CASE LIST
case list
Denominator
(patients with a visit in the
past 12 months)
Numerator
(patients with one visit in
each 6-month half of the year)
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Develop and manage an accurate patient
case list
Step 1 Identify all active patients that
visited the clinic during a given interval.
Example: all patients who visited Clinic A in the year
between January 2010 and January 2011.
Step 2 Define a retention measure and
determine how many patients are still
engaged in care.
Example: the number of active patients with a visit in
each half of a given year (NYS retention measure).
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Step 3 Explain why patients are not in care.
Gather the team and try to determine a cause: Died?
Transferred care? Only visits when in the area?
Analyze the list of those not accounted for and identify
common characteristics. Develop interventions to target
these patients.
Step 4 Incorporate improvements,calculate
new case list and repeat.
Calculate updated case list by removing any inactive
patients accounted for and keeping all remaining patients;
add new patients; re-calculate retention rate. If a lost patient
returns, re-classify as active.
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Example
Step 1: Identify your active patients
Step 4: Adjust case lists
Step 2: Determine how many
patients are still engaged in care
20 patients
16 active
REPEAT AT REGULAR
INTERVALS
16 active
1 unknown
Step 3: Explain why patients are not
in care
Still
Transferred Expire
d
Unknown
Care
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3 accounted for
1 unknown
4 unknown
After your first cycle
• Remember to refresh your active case list,
adding in “found” patients and new patients
• Develop process to flag “unknown” patients in
case list
• Maintain the cohort to monitor retention over
longer periods of time
• Keep in mind that successful retention
interventions often require “bundles” of
strategies
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Improving Patient Retention
UHS Binghamton Primary Care HIV Clinic
Presenter: Kate Dodge, RN, MCM
IMPROVING PATIENT RETENTION
United Health Services Binghamton Primary Care “Snapshot”

Busy Internal Medicine clinic serving approximately 10,000 patients
annually
 HIV Clinic within BPC is only HIV specialty clinic in greater Broome
County area, serving approximately 300 patients annually
 Clinic located in Binghamton, a semi-urban area surrounded by
suburban & largely rural population
 Patient barriers to retention:
•
•
•
•
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Poverty
Transportation
Housing
Mental Health & Substance use issues
Literacy
Support Systems
Stigma
Health
UHS Patient Retention Project
• Retention monitoring begun in March, 2007 to
establish baseline
• Data: December, 2007: 50% Retention rate
• “Retention” is defined as:
At least 1 clinic visit every 3 months,
annually
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UHS Patient Retention Project
January, 2008 PDSA Retention Project:
• Analyzed appointment reminder system
• Reviewed “Active Patient list” & inactivated patients who
were deceased, transferred or lost to follow-up
• Developed & began disseminating “Follow-up” & “NoShow” letters
• In April, developed “Hot List” – patients with no visits in
past 3 months.
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PDSA Trial: Begun April, 2008
• Mailed “Appointment Reminder Cards” 2 weeks prior to
appointment;
• Followed up with “Reminder Calls” 24 hours prior to
appointment;
• If patient failed to keep appointment, mailed “Missed
Appointment letter”, from HIV Team;
• If patient failed to keep 2nd appointment, mailed “Missed
Appointment letter” from Provider;
• Monthly, sent “Visit Reminder letter” – not seen within last 3
months -- to each patient on “Hot List”
• Sent “Discharge letter” to patients who had not been seen in
past 12 months.
21
PDSA 2008 Trial Results:
• December, 2008 data showed retention rate
had increased from 50% to 85% during the
calendar year.
22
Refinements in 2009:
• In 2009:
 discontinued sending “Reminder letters” 2 weeks prior to





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appointment
Continued doing “Reminder calls” 24 hours prior to
appointment
Continued sending “Hot List letters”
Continued sending “Visit Reminder letter” from Provider if no
appointment in past 6 months, or more
Prior to reordering patient medications, HIV Team would
ensure appointments & labs were up-to-date
Notified Pharmacy if patient due for an appointment &
appointment reminder would be placed directly on
medication bottle
PDSA 2009 Results:
 June, 2009: Retention rate reached 92%
 December, 2009: Retention rate was 89%
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Patient Retention Project, 2010
• January, 2010:
 Continued “Reminder calls”
 Continued “Hot List letters”
 Continued “Missed Appointment letters” from Team &
Provider
 Continued “1-year Discharge letters”
 Began utilizing Southern Tier AIDS Program (STAP) & UHS
Outpatient Mental Health for assistance with transportation,
support
 December, 2010: Retention rate was 87%
25
Refinements in 2011
• Enhanced 1-on-1 Medical Case Management opportunities
allowing patient & Medical Case Manager to meet regularly on
behavior change issues and/or barriers to patient’s visit
retention, including Service Planning
• ‘RESPECT’ DEBI started in late 2010, prompts intensive case
management to address behaviors that could impact visit
retention. Incentives
• Continued utilizing STAP & UHSOPMH support services
• HIV Team assists with coordinating transportation to visits
(Medicaid trans, STAP)
• In addition to contacting pharmacy, Team contacting patients
and/or family members, care providers, case managers to
coordinate scheduling of quarterly clinic visits & lab work
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Results:
• Retention Rates:
 December, 2007: 50%
 December, 2008: 85%
 June, 2009: 92%
 December, 2009: 89%
 December, 2010: 87%
 May, 2011: 88%
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Update on HRSA HIV/AIDS
Bureau-funded quality
improvement campaign
Campaign Framework
• This National HIV Campaign is designed to
facilitate local, regional, or even state-level
efforts on retention in care. This involves
bringing patients back to care and keeping
others from falling out of care.
• Ryan White grantees across all funding streams
are invited to join
• participating grantees have access to faculty for
support and coaching
• consumers will be involved in this Campaign
wherever possible
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Campaign Requirements
The following basic structure is suggested:
 participation in the Campaign is voluntary
 participating grantees enroll for a 12-month
commitment
 routine reporting of performance data on 3 to 4
uniform Campaign-related indicators
 routine submission of a simple progress report to
highlight improvement strategies and challenges
monthly conference calls/webinars are held to
provide content expertise and promote peer
earning
where possible, regional/local meetings of NQC
Campaign participants will be held and grantees
are encouraged to come if possible
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in+care Campaign
Determination of Campaign Theme and Logo
• Campaign Name
 in+care Campaign
• Campaign Slogan
 Connect…with patients
 Collaborate… with a community of
learners
 Change… the course of HIV
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Recruitment
• NQC, HRSA Part directors, and
HRSA project officers to send out
email invitation to Ryan White
grantees
• Recruitment brochure and resources
CD to be mailed to grantees
• Recruitment video to be posted on
YouTube, NQC Facebook page, etc.
• Campaign information to be
disseminated via HRSA channels
(e.g. e-newsletter, TARGET Center
Website, at meetings)
• HRSA to inform CDC’s12-Cities
contacts, Part B SPNS System
Linkages grantees, DC
Collaborative, and Cross-Part
Collaborative to encourage
involvement and emphasize synergy
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Recruitment Brochure
• Recruitment brochure
 Will include invitation to join
campaign, retention in care
statistics, and campaign
information
 Draft has been written and
reviewed; currently in
editing/layout
“My clinic fed me when I was hungry. They helped me
get an apartment when I was homeless. They gave me
good care when I had nowhere else to go. They cared
for me first as a person and then as a patient. They
treated me like family. That’s why I stayed in care.
That’s why I keep coming back. And that’s why I’m alive
today.”
Ronald, HIV-positive patient at Ryan White Part A 33 funded clinic
Recruitment Video
Development of a Recruitment
Video
• to highlight the importance of
retention in HIV care and its
affect on health outcomes and
patient quality of life
• to increase awareness about the
Campaign
• to link those who are interested
in joining the Campaign with
recruitment information
Development Phases
• Video has been created and
music has been purchased,
currently in editing
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Campaign Website
• Website copy: written
• Website design:
under revision
• Website database: in
development
• Resources section:
will continue to be
populated with new
information pertinent
to grantees and,
hopefully, consumers
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Prior presentations
Prior presentations:
2010 NQC National TA Call (June, 2010): Improving
Patient Retention
2009 NQC Part D Conference: Retention of Part D
Clients - Measurement and Interventions
2009 NQC National TA Call (December, 2009)
“Improving Patient Retention”
2008 NQC National TA Call (June, 2008) and AGM
presentation (August, 2008) strategies for improving
patient retention
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Resources
• Summary of research to support patient retention in
HIV care is available from:
www.NationalQualityCenter.org
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National Quality Center (NQC)
NYSDOH AIDS Institute
90 Church Street—13th Floor
New York, NY 10007-2919
212-417-4730
NationalQualityCenter.org