AHF JacksonvilleHealthcare Center

Ryan White Medical Outpatient and Medical Case Management

Quality ShowcaseMay 23, 2013

AHF Jacksonville HCC Health Care Team

AIDS Healthcare FoundationNCQA Accreditation

AIDS Healthcare Foundation

• Mission: Cutting edge medicine and advocacy, regardless

of ability to pay• Vision:

A healthier future for people living with HIV/AIDS• Core Values:

Patient centeredValue employeesRespect diversityNimbleFight for what’s right

Quality PrioritiesPatient-Centered Focus

• Systematic with Leadership, Accountability, Resources• Data and Measureable Outcomes to Determine Progress• Evidence-Based Benchmarks• Focus on Linkages, Efficiencies, Provider and Patient

Expectations/Satisfaction• Continuous Process Adaptive to Change. Fits Within

Framework of Other Activities, e.g., Medicaid• Data Feedback Loop to QI Process to Assure Goals Met

HRSA Quality Dimension Principles

• Accessibility of care Ease or difficulty of obtaining services when the patient needs

services• Continuity of care

Linkages to other resources--delivery of care does not occur in a vacuum

• Appropriateness of care Care delivered using state of the art technologies and includes

the best care that medical and social science judgment would prescribe

• Safety of care Procedures followed during delivery of care and services are

error free, i.e., avoids harm and actually helps

HRSA Quality Dimension Principles

• Timeliness of care Care is delivered at the right time

• Involvement in care Patients participate with clinicians/practitioners in making

decisions that affect their well-being• Effectiveness of care

The program is flexible so individuals can develop their own resources without counterproductive overdependence on the system (Salem, Seidman, & Rappaport, 1988)

• Efficacy of care Care is individually tailored to meet patient's needs

• Efficiency of care Care accomplishes the intended purpose

AHFQuality Dimensions for Improvement 2012

• Accessibility of Care

• Timeliness of Care

• Involvement in Care

AHF Quality Areas Addressed

• Core Clinical Area CD4 Count Viral Load Monitoring Medical Visits

• Medical Case Management Care Plan Medical Visits Outpatient Medical Care

• Systems-Level Waiting Time for Initial Appointment Outpatient Medical Care Quality Management Program

GoalsMedical O.P. and Medical Case Management

• Goals

Reduce No Show Rate For Medical Appointments

Reduce Risk of Patients Falling Out of Care

Bring Patients Back Into Care and Prevent Others From Falling Out of Care.

Adherence = Undetectable VL

AHF CQI PLANOUTPATIENT MEDICAL

• Outcome 1.1: Reduce % of No Shows by at least 2 pecentage points from 2011 annual no show rate

• No show rate for 2010 = 18.4%• No show rate for 2011 = 18.1%• No show rate for 2012 = 16.4%• Personal reminder calls the morning prior to their visit

aids in getting the patient to the office. A smiling voice is what it takes.

Monthly No Show Rates2012, 2011, 2010

Janu

ary

Februa

ryMarc

hApri

lMay

June Ju

ly

Augus

t

Septem

ber

Octobe

r

Novem

ber

Decem

ber

0%

5%

10%

15%

20%

25%

30%2012 2011 2010

% o

f No

Show

s

Monthly No Show Rates2012, 2011, 2010

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

2012 17.9 13.5 18.2 18.2 15.7 21.3 14.3 12.3 16.2 15.4 15.9 18.5

2011 17.5 14.5 12.8 16.6 15.7 21.3 22.2 20.1 15.9 18.9 24.1 17.4

2010 15.6 14.3 21.4 16.2 20.6 18.8 17.7 17.1 18.9 19.4 20.5 20.1

AHF CQI PLANOUTPATIENT MEDICAL

• Objective 1.2: Request updated contact information for 100% of patients upon check-in at the HCC

• Updated contact information requests with a smile and positive attitude increase the chance of patients continuing their care.

• AHF is piloting an HCC Patient Secret Shopper to evaluate the effect that customer service, whether negative or positive, has on retention of patients to the Healthcare Centers.

DEMOGRAPHICS

• 2012 is the first year the number of demographic changes have been reviewed.

• A report is being developed to determine the number of changes.

• Demographic changes for this baseline year are similar every month for an average of 4.5% each month.

• Based on the aggressiveness to obtain correct demographics, we will be able to compare the no show rate for 2013.

DEMOGRAPHIC CHANGEBY MONTH BASELINE

Month Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

%Change 7% 4% 5% 7% 3% 4% 3% 3% 4% 4% 6% 4%

AHF CQI PLANOUTPATIENT MEDICAL

• Outcome 1.3: Decrease no show rate by an additional 5 percentage points by sending appointment postcards

• Postcards were not used in 2012:1. Took too much time to fill out.2. Postcard thrown out as soon as it was received.3. Patient did not want anyone to see postcard andask questions (stigma).

AHF CQI PLANOUTPATIENT MEDICAL

• Objective 1.4: Send “Sorry We Missed You” cards to 100% of no shows.

• Cards were only used for a short time:1. Many cards were returned with unknown addresses.2. Patient did not want card coming to house (stigma).3. Phone calls from the peer navigators were much

more efficient and cost effective.

AHF CQI PLANOUTPATIENT MEDICAL

• Objective 1.5: Ensure that 90% of all new patients and returning to care patients see a medical provider within 3 days of contacting the HCC

• Overall we saw all of our new and return to care patients within 3.1 days.

• Jacksonville HCC is expanding so rapidly that we have been physically unable to see patients within3 days and still care for our longtime patients.

AHF WAIT TIME

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

3.9

3.1

3.73.9

2.93.1

3.3

2.8 2.8

3.3

2.72.4

2012

Ave

rage

num

ber o

f day

s

CONCLUSIONOUTPATIENT MEDICAL

• Our 2012 No Show rate of 16.4% showed a decrease of 2 percentage points from 2010 and 1.7 percentage points from 2011.

• Reminder calls with a smiling voice increase the chance of patients continuing their care.

• Peer navigators calling no shows to assist them in rescheduling is very productive.

• Stressing the importance of a correct address and phone number from the patient is being achieved by the front desk.

• AHF will always strive to lower the patient wait time below 72 hours.

LESSONS LEARNEDOUTPATIENT MEDICAL

• No show rate is fluid.• Time of year is not a factor.• Postcards not used in 2012 – not a factor.• Reminder calls to 100% of scheduled patients is a factor.• Correct and current demographic information is a factor.

Combined CQI Initiatives

AHF-LSS Mental Health• Conduct focus groups:

– Web-based versus telephonic-based support groups for newly diagnosed.

• 2012 Peer Navigator Training Initiatives.

• 2013 Develop and implement a web-based/ telephonic support group.

AHF-LSS Medical Case Management• Identifying patient barriers

to medical adherence.• Identify adherence

behaviors and characteristics that impact compliance.

Mental Health

Provided questionnaires to 10 newly diagnosed.

Results: 75% were interested in

group. 65% preferred an online/

telephone-based support group.

45% preferred a face-to-face group setting.

Trial Telephonic-Based Group5 members were pooled from existing support groups.

Pros and Cons:“I really enjoyed connecting with new people and would love to be a part of an ongoing group.”“Telephone provided Increased anonymity.”“I would be able to always attend, if it is on the phone.”“There has to be a way to lower background noise.”“I did not feel as connected as I do in a group meeting.”

Focus Group Interest

Mental Health Continued…

Training Curriculum with Peer Navigators

Training targeted to teach the basic principles of peer-run support groups.

Training included:o Ethics o Ethical Boundarieso Suicide Preventiono Preventing Secondary Traumao Best Practices: Group Facilitation

Medical Case Management Goals

Patient Ratio by Clinic

AHFBCCCUF CaresPrivate

Improving medical adherence through understanding the specific needs and barriers to care for those with high rates of non–adherence/loss to care.

1. Identify the current ratio of LSS patients in care with AHF.

2. Evaluate current rates of non-adherence/loss to care.

3. Perform MCM assessment of patient-specific needs.

4. Provide services geared towards barrier reduction.

Patient Non-Adherence Rates: Overall and LSS

Rates of adherence were gathered bi-monthly beginning August 2012 and ending February 2013.

AHF 104 day report displayed fluidity over this 7-month period.

The period ended with an overall 51% decrease in no show rates.

LSS represented 10% of those identified in the reporting period.

8 patients identified as frequently non-adherent (appeared more than 2 times on the 104 day report).

Aug 2012 Oct 2012 Dec 2012 Feb 2013

191

138

193

93

17 19 12 5

Overall RateLSS Rate

Non-adherence Rates

Identified Need/Stages for Change

Behaviors/ Barriers Identified

• 8 individuals targeted.• Provided with increased

medical case management to include: Appointment reminders Monthly calendars Adherence assessments Access to the Peer

Navigator Educational materials Behavioral assessments

Baseline

• 55% of those targeted showed to be in the contemplation stage of change in regards to their health.

• 68% had transportation listed as a barrier to care.

• 50% were listed as a MCM acuity level of 2 or higher, providing a history of either non-adherence to care or high need for care.

Change Happens

Current Change:• Over 7-month the rate of non-adherent

or lost to care LSS patients decreased 10% to 6% by identifying patients through use of the 104 day report.

• At the end, lost to care patients had returned through use of appointment reminders and access to gas cards or bus cards. The total number who were lost to care decreased by 85%.

• As patients became medically adherent their acuity decreased by 45% (more data still needs to be collected to ensure continued adherence).

• 65% of patients moved from contemplation to action and/or maintenance.

For the Future:• Acuity level 2 or higher patients should

receive appointment reminders to increase appointment adherence.

• Acuity 2, 3 and 4 patients should receive increased adherence counseling >2 times per year and should have regular access to peer navigators.

• The stages of change should be evaluated in regard to patient’s thoughts on their healthcare.

The identification of behaviors and barriers and setting goals may lead to decreased rates of non-adherence and patients becoming lost to care.

Continuous Efforts towards Change

AHF• Measures rate• Identifies need• Provides specific support

to patients by medical case managers use of case conferencing and peer support

• Ensures a team approach to care

LSS• Assesses need• Identifies targeted patients• Evaluates Barriers/Behaviors• Implements strategic

interventions • Works as a team with the

medical provider to decrease barriers to care

RN-MCM Actions To Reduce Risk of Falling Out of Care

• Conducts Patient Assessments to formulate Plan of Care• Addresses Issues and Needs in POC• Peer Navigators outreach to and Link to Medical Care • Patient Education on “How to Conduct Your Medical Visit”• Peer Navigators Attend Medical Visits With New and Returning

to Care Patients• Patient Adherence Education on ARV and Chronic Condition

Medications• Appointment for follow up after medical visits with Peer or

RNMCM• Collaborative Interdisciplinary Meetings With PCP• Embedded Staff to Support PCP and Medical Treatment Plan

focusing on Patient-Centered Care Delivery

AHF CQI Goal 2.2.1 and 2.3.1

Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 20130

10

20

30

40

50

60

70

80

22

5

15

2219

44

34

5

40

15

41

20

75

40

9

16

49

5 41 2

85 5

35

Follow-up Appointments, Lost to Care, and Barrier AnalysesFollow-up visit scheduledLost to care (no follow-up visit scheduled)Barrier

# of

pat

ient

s

Note: November spike most likely due to influx of patients from River Region that did not return after 2 initial visits (becoming lost to care).

Barriers to Care Identified

Moved37.8%

Transferred/Using other svc

18.3%

Deceased/Coma8.5%

Ineligibility Issues6.1%

Work4.9%

Incarcerated4.9%

New/Changingprovider

3.7%Refused svc/

care3.7%

In nursing home/hospitalized

3.7%Family/

Personal issues3.7%

Homeless2.4%

Transportation1.2%

No mode ofcontact1.2%

AHF CQI Goal 2.2.1 and 2.3.1: Types of Barriers to Care*

*Barrier data were collected from a sample of patients lost to care.

AHF MCM: in+care CampaignMedical Visits

Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 20130%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

9.12%

10.47% 10.58%11.15%

9.36%8.68% 9.14% 9.56%

7.82%9.03%

AHF CQI Goal 3.2.1: #1 Gap MeasurePercentage of patients, regardless of age, with a diagnosis of

HIV/AIDS who did not have a medical visit with a provider with prescribing privileges in the last 180 days of measurement year.National

Jacksonville

Rat

e

Low

er is

bet

ter

AHF MCM: in+care CampaignMedical Visits

Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 201360%

65%

70%

75%

80%

85%

90%

95%

88.75%86.96% 86.27%

82.69%

85.82% 85.67% 86.11% 86.65% 87.16%85.01%

Jacksonville

Rat

eR

ate

AHF CQI Goal 3.2.2: #2 Medical Visit FrequencyPercentage of patients, regardless of age, with a diagnosis of HIV/AIDS who had at least one medical visit with a provider with

prescribing privileges in each 6‐month period of the 24‐month measurement period with a minimum of 60 days apart.

Hig

her i

s be

tter

AHF MCM: in+care CampaignViral Load Suppression

Jun 2012 Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 201365%

70%

75%

80%

85%

90%

82.55%83.97% 83.95% 83.53%

85.71%86.49% 86.27%

83.69% 83.85%

80.93%

AHF CQI Goal 3.2.4: #4 Viral Load SuppressionPercentage of patients, regardless of age, with a diagnosis of

HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during

the measurement year.Jacksonville

Rat

e

Hig

her i

s be

tter

Summary of Patient-Centered Quality Care Measures

Jul 2012 Aug 2012 Sep 2012 Oct 2012 Nov 2012 Dec 2012 Jan 2013 Feb 2013 Mar 20130%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

59%56%

94%

52%

20%

52%

79%

24%

45%41%

44%

6%

48%

80%

48%

21%

76%

55%

Follow-Up Visit ScheduledLost to CareGap MeasureMedical VisitVL Suppression

Medical Visit

VL Suppression

Gap Measure

Rat

e

AHF CQI Goal 2.2.1, 2.3.1, 3.2.1, 3.2.2, 3.2.4: Summary - Follow-up Visit Scheduled/Lost to Care Comparison to JAX in+care Measures Scores

MCM Conclusions and Lessons Learned

• Patient-Centered Assessment and Interdisciplinary Team are Effective in Increasing Medical Visit and Medication Adherence.

• Barrier Mitigation and/or Removal Increases Patient Success for Adherence.

• Multi-Level (PCP, RNCM, Peer) Continual Education on HIV, Chronic Conditions, Medical System Navigation Increases Medical Literacy, Treatment Adherence and Patient Self Management Skills.

• Each Patient is Unique and Use of Persistence and Tailored Measures Is Necessary For Success.

QUESTIONS?

Thank You!