August 2011

Slides from: Amy M. Sitapati, M.DAt the UCSD Owen Clinic

ANCHORING INTO THE MEDICAL HOMEEngagement in Care

Continuity ofcare(5)

Quality andsafety

(5)

Healthinformationtechnology

(5)

Practiceservices

(5)

CareManagement

(4)

PATIENTCENTEREDMEDICAL

HOME

Access to careand

information(6)

Practicemanagement

(5)

Practicebased care

(4)

The 39 Core Components C.R. Jaen, et al. Ann Fam Med. 2010;8(Suppl 1):s57-67

Engagement in care(one component of care management)

A pilot “lost to follow up” project: 2009

STEP 1: Pilot RETENTION

• May-June 2009 collaboration with AVRC Bridge Program

• Inclusion: one visit in past 12 months, no visits in past 6 mo

• Greeting script with decision tree to determine best method to get patient back into care

• “I’m so grateful someone thought of me.”

Collaborative Pilot: Owen Clinic and the AVRC Bridge Program targeted 492 patients: Resulted in 33 patients returning to care

Lost to Follow Up Pilot Summary 2009Outcome # %Deceased 1 0.2%New Insurance - Remaining in Care 35 7.1%Incarcerated 7 1.4%Moved out of Area 24 4.9%In Care - Other UCSD Provider 8 1.6%In Care - San Ysidro with Owen Provider 3 0.6%In Care Other Provider - Change Not Insurance Related 15 3.0%Returned to Owen Prior to Contact 105 21.3%Returned to Owen - Assisted with Appointment 33 6.7%Unable to Reach/Phone Disconnected/Homeless 261 53.0%Total     492 100.0%

STEP 2:

Moving Engagement into ACTION! By getting involved in an organized quality improvement project

Objectives: outreach interventions engaging HIV patients back into primary care

Aimed to get patients unable to follow up back into careDevelop innovative methods to target the 53% unable to reach by telephone aloneDetermine methods to prevent future loss to follow up

Creation of Project PUFF: Patients unable to follow-up…FOUND

One person can make a difference

Previous phone political/non-profit workHIV science and research exposureVolunteer in communityRead articles on backgroundCross-training to navigate barriers:

4 system training & all staff roles (MA/ desk/ phones/ adhere/ enroll/ edu/ case mgt)

Tool 1: Creation of a NEW Job

Tool 2: Making algorithms/flyers

Flow diagram for re-engagementCheck Lab Tracker:

Return on Own? No

Search:- EMR for Hospitalization/Death - Sheriff Inmate Loghttp://apps.sdsheriff.net/wij/wij.aspx - Social Security Death Index http://ssdi.rootsweb.ancestry.com/ - County Health

NoReason Why?

Moved, etc.

Call-LM-Message not returned in 2 days Call Again

EmailSend Same day as 2nd call w/ no contact

Call Emergency Contact/Case Manager-3 days after mail w/ no contact

Mail Letter to known address-Send 2 days after email w/ no contact

Search Facebook/Myspace

Call Emergency Contact/Case manager – Call again after two days

-Send message via website messenger-- Use contact information

Consider other resources:-Support groups-Centers-etc

Search Google

Contact Pharmacy

Search ADAP

Consider Patient LOST

 

Posted outreach: Flyer creation

Tool 3: Track in Access database

PUFF: Access: patient search

•Dedication of a singular VIP phone line with after hours messages•Many calls to same phone when appeared to be correct; then called frequently to leave messages•Got to know the client from chart/phone

Tool 4: Calls, calls, and calls

61/70 lost patients with e-prescribingCalled 20 pharmacies, looking for:

Date of last refillNewest phone #Other pt info Message left at pharmacy for pt upon next refill“Please call your doctor’s office at the Owen Clinic to schedule an appointment xxx-xxxx” (PUFF program phone #)

Tool 5: Untapped pharmacy link

Inclusion CriteriaHIV+

At least one clinic visit in past 12 monthsExcluded subspecialty and consult only visits

Over 6 months since last visit478 patients in first 6 mo(716 patients identified for the

year in 2 separate 6 mo cycles)

Persistence in calling was keyGetting to know the patientA bit of help with mail & pharmacyLimitations with myspace/facebook due to access restraints institutionalConfidentiality restricts intervention into community outreach of Homeless programs, etc. for referrals

Tool 6: Inside TIPs/what didn’t work

Impact Summary

Final Outcome # %Returned on Own 205 28.6%Returned with Intervention 116 16.2%Lost, Unable to Contact 88 12.3%In Care Elsewhere 98 13.7%Still Clinic Patient but No Return Visit 26 3.6%Future Return Visit Scheduled 8 1.1%Expired 41 5.7%Moved out of Area 101 14.1%Incarcerated 28 3.9%No Longer Clinic Patient Unknown if In Care 4 0.6%Dismissed from Clinic - Status Unknown 1 0.1%Total 716 100.0%

Sitapati, unpublished data, 1/2011

A. No hx prolonged absences or missed visits. Always did 3 to 4 month F/U. He just forgot.

B. Pt has new insurance; recovering from met cancer, contacts Dr. by phone; RW; many cancels & no shows

C. Phone #'s bad in 2 databases; letter returned; medical records detail govt persecution perception; needs to renew RW/ADAP 

D. Phone #'s in PCIS and LT and IDX no good; moved to New Orleans per case manager

Patient calls and outreach:

Dx HIV 1990 & clinic pt since1995 Last appt 3/27/20097 phone calls and 1 letter: multiple attempts. Calls taken by a housemate claimed B would get messg and call right back… but never didOn the 8th call, B answered. Explained lost insurance, MediCal; upon asking if knew about Ryan White funding, pt B“who is that”. Did not detail health. Return visit given 2 days.B direct admitted from clinic to hospital and now well.

 

Oh, my God, I think you just saved my life….- B

Reasons Patients Gave for Missing Care

Reason # %Jail/Prison 30 15.2%Too Busy 25 12.6%I'll know when it's time 24 12.1%Other 24 12.1%Out of Town Split Work 16 8.1%Not Sick 14 7.1%Insurance or Referral Issue 14 7.1%Forgot 11 5.6%No Reason Given 9 4.5%Psychological Issues 8 4.0%Residential Care 5 2.5%No Insurance 4 2.0%Don't know when to Schedule Appt 3 1.5%Transportation Issues 2 1.0%Office Hours 2 1.0%Don't want to think about being sick 2 1.0%Interresearch Study 2 1.0%Tired/ Needed Break 2 1.0%Perceived Maltreatment 1 0.5%Total 198 100.0%Sitapati, unpublished data, 1/2011

This is a project requires a ½ time employee at low cost Community Health Program Representative and is an affordable option.

PUFF is afforbable

Med refills may tie patients to their providers. How utilize without risking interruptions in therapy?How do we changing pt health beliefs and goals for care?What better contact pro-active info gathering is needed?

Unanswered Questions:Improving FUTURE engagement

PUFF “Toolbox” of Retention Resources:

• Work flow diagrams for Retention Specialist

• Retention Patient Letter• Retention Community Flyer• Patient engagement Hand out• Access Database tool

HEALTHCARE IS UNDERGOING A REVOLUTION

• The Patient Centered Medical Home (PCMH)• encompasses this fundamental change.

• Construction requires thoughtful allocation of processes/people/and data.

• A formalized engagement program is a necessary addition to the HIV medical home

and is entirely achievable.

PUFF is Supported by:– Health Resources and Services Administration Funding Opportunity:  HRSA 5-H76-10-003- San Diego HIV Funding Collaborative of San Diego Human Dignity Foundation:  Grant No.

09-00009(CAT)

Jan Limneos for PUFF data support Stephanie Moody-Geissler & Sara King; PUFF Retention SpecialistsSusan Benson for staff/project oversight

A Special Thanks to:

The ANCHOR Medical Home is Supported by:- University of California; California HIV/AIDS Research Program: Award No. MH10-UCSD-640

Suggested Reading:1. M Mugavero. Improving Engagement in HIV Care: What can we do? IAS-

USA Topics in HIV Medicine Vol 16(5); December 2008: 156-161.2. KB Ulett, et al. The Therapeutic Implications of Timely Linkage and Early

Retention in HIV Care AIDS Patient Care and STDs Vol 23(1); 2009: 41-49.3. MJ Mugavero, et al. Missed Visits and Mortality among Patients Establishing

Initial Outpatient HIV Treatment Clin Infect Dis 48; Ja 15 2009: 248-256.4. LW Cheever Engaging HIV-Infected Patients in Care: Their Lives Depend

on It. Clin Infect Dis 44; June 1, 2007: 1500-1502.5. TP Giordano, et al. Retention in Care: A Challenge to Survival in HIV

Infection Clin Infect Dis 44; June 1, 2007: 1493-1499.6. DR Rittenhouse, SM Shortell The Patient-Centered Medical Home: Will It

Stand the Test of Health Reform JAMA 2009; 301(19): 20038-407. Linkage, Engagement and Retention in HIV care Clin Inf Dis 2011; 52(2)