Transcript shopping los angeles

Los Angles LGBT Center
• Noah Kaplan MSW
• Alex Adame MSW
Los Angles LGBT Center
How does the Center compare?
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
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.
Retention in Care
Identify the
social
determinants that
impact patient’s
retention in care
and medication
adherence
Intervene to help
keep them in care
or bring them
back into care
Engage
patients who
are at risk of
falling out of
care or out of
care
Retention in Care
Demonstration Project Overview
• Target Population
1. High risk of falling out of care
2. Out of care
• How to identify target population
1. Internal reports using EHR records of last
medical visit and/or VL
2. Care team case conference
3. Care team referral
Retention in Care
Intervention
1. Engage
Retention in Care
Intervention
2. Assess
a) Risk
b) Barriers to Care
c) Needs
Assessment done by a combination of
medical records and interview
Retention in Care
Intervention
3. 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.
Retention in Care
Case Study
Retention in Care
Lessons Learned
Discussion and Questions
Noah Kaplan, MSW
Manager of Psychosocial Case Management
Health Services
(323) 993-7486
Alexandra Adame, MSW
Retention Care Manager
Health Services
(323) 993-8973
END