- Welcome to the National Quality Center

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

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-

MD, Assoc. Director, Owen Clinic Amy M.Sitapati,

Questions, answers and discussion HRSA initiative on retention –

Sarah Cook-Raymond

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?

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)

Continuum

Engagement in Care

Not in Care Fully Engaged

Unaware of HIV Status (not tested or never received results) 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) In and Out of HIV Care or Infrequent User Fully Engaged in HIV Primary Medical Care Non-engager Sporadic

User Fully Engaged

Health Resources Service Administration (HRSA)

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?

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

What does it really mean to be retained?

• The patient is engaged in care 

• The clinic has the patient on its active roster

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 M any others….

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

To calculate an accurate retention rate you need an accurate active patient Eligible Patients/Sample ( Patients visiting the clinic known not to 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) 12

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).

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

ncorporate 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.

Example

Step 1: Identify your active patients Step 4: Adjust case lists 20 patients

REPEAT AT REGULAR INTERVALS

16 active 1 unknown Step 2: Determine how many patients are still engaged in care 16 active 4 unknown Step 3: Explain why patients are not in care 15 Transferred Care

Expire d

Still Unknown 3 accounted for 1 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

Improving Patient Retention UHS Binghamton Primary Care HIV Clinic

Presenter: Kate Dodge, RN, MCM

18 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: • • • • 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

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” & “No Show” letters In April, developed “Hot List” – patients with no visits in past 3 months.

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 2 nd 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.

PDSA 2008 Trial Results:

• December, 2008 data showed retention rate had increased from 50% to 85% during the calendar year.

Refinements in 2009:

• In 2009:     discontinued sending “Reminder letters” 2 weeks prior to 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%

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%

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

Results:

• Retention Rates:  December, 2007: 50%  December, 2008: 85%  June, 2009: 92%    December, 2009: 89% December, 2010: 87% May, 2011: 88%

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

Campaign Requirements

The following basic structure is suggested:  participation in the Campaign is voluntary  commitment  uniform Campaign-related indicators  highlight improvement strategies and challenges   participating grantees enroll for a 12-month routine reporting of performance data on 3 to 4 routine submission of a simple progress report to 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

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

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

•

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 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

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

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

Resources

• Summary of research to support patient retention in HIV care is available from: www.NationalQuality

Center.org

National Quality Center (NQC) NYSDOH AIDS Institute 90 Church Street —13th Floor New York, NY 10007-2919 212-417-4730 NationalQualityCenter.org