Session Goals Present an integrated care and interdisciplinary - - PDF document

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Integrated Care at a Community Health Clinic Setting Specializing in the Treatment of HIV/AIDS

Tracy Murphy, MHA Natalie Perkins, PharmD, AAHIVP Session 38 July 17, 2014

Session Goals

• Present an integrated care and interdisciplinary

approach to the delivery of HIV/AIDS care

• Discuss specific aspects of care team
• Provide an overview of the Patient Centered

Home criteria

– Compare integration vs co-location

• Discuss peer support and its use

Overview of El Rio Community Health Center

• Established 1970
• Provides accessible and affordable healthcare

primarily to underserved populations

• Serving the greater Tucson area and southern

Arizona

• Special population groups, including: women

at risk, children, the homeless, individuals with HIV/AIDS, teen parents

El Rio Community Health Center is

A Federally Qualified Health Center

– Organization that receives a grant under section 330 of the Public Health Service.

A non-for-profit

– Managed by a Community Board of Directors, CEO/Executive Director and Senior Staff. – Multicultural organization imbedded in the community – 16 languages spoken other than English

The 14th largest community health center in the nation.

6/24/2014 2 El Rio Community Health Center is

A nationally recognized organization. National Committee for Quality Assurance

• NCQA is a private, non-profit organization dedicated to

improving health care quality.

The Joint Commission

• An independent, not-for-profit organization, accredits and

certifies more than 19,000 health care organizations and programs in the United States .

Overview cont.,

• Medical Services (Primary Care)

Family Practice Internal Medicine Pediatrics HIV / AIDS Treatment, Education and Intervention Health Care for the Homeless Immunizations Nurse Midwifery Services Obstetrics and Gynecology (OB/GYN) Optometry

Overview cont.,

• Dental services
• Pharmacy services
• Radiology services
• Lab services

Overview cont.,

• El Rio serves primarily low-income and

medically underserved people.

• In 2013, El Rio Community Health Center

served 80,987 patients and provided over 330,000 medical and dental visits.

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El Rio Locations

17 locations throughout Tucson.

SIA is immediately West of St. Mary’s Hospital

EL Rio Demographics

Of the 80,987 patients served in FY 2013

– 54% were at or below the federal poverty line – 46% were on Medicaid – 26.5% were uninsured

Demographics by Age

14% 27% 29% 22% 8%

Age

Under 5 5-19 years 20-44 years 45-64 years Over 65 years

Stage of Engagement in HIV Care

Clin Infect Dis. 2011 March 15; 52(6): 793–800

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El Rio SIA Health Center

• Special Immunology Associates

– Provides quality comprehensive health care to people living with HIV/AIDS & affected family members – Integrated care – Interdisciplinary approach – Aftercare support to affected family members

El Rio Special Immunology Associates Treatment Team

The SIA Treatment Team

• Medical providers
• Behavioral health providers
• Care coordinators
• Substance abuse counseling/groups
• Specialty pharmacy
• Nationally recognized adherence program
• Nutritionist & Diabetes Educator
• Lab services
• Coming soon, peer support!

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Logistics

• Immediate communication and collaboration
• Wraparound supports to patients
• Shared EHR

– Treatment plan – Medication list – Progress notes – Real time follow up

SIA Demographics

• Total patients in care: 1101
• Males served: 84%
• Females: 15%
• Transgender: 1%
• By diagnosis:

*Living with HIV: 48% *Living with AIDS : 51%

SIA Demographics by Age

• 13 -24 years of age: 1%
• 25-44 years of age: 28%
• 45-64 years of age: 64%
• 65+ years of age: 7%
• SIA provides care to those ages 18+, however

we occasionally treat transition age youth*

SIA Demographics by Ethnicity

• White: 56%
• Hispanic: 30%
• African American: 9%
• Native American/Pac. Islander: 3%
• Asian: 1%

6/24/2014 6 SIA Demographics by Insurance

• Medicaid: 31%
• Medicare Part A/B: 29%
• Private: 25%
• No insurance: 10%
• Other: 5%

Funding

• Grants
• Health Resources & Services Administration

(HRSA)

– Ryan White HIV/AIDS Program

• Part B
• Part C Supplemental
• Part C EIS
• Lutheran Medical Center community Based

Dental Partnership Program

Funding

• Contracts
• Community Partnership of Southern AZ (CPSA)
• Non-CPSA BH Third Party Revenue
• Clinic-based Medical Third Party Revenue

(including patient fees)

• Mona Private Foundation

Viral Suppression Outcomes

• Viral suppression treatment goal of  200
• In December 2013, 91.09% of patients met this goal

91.09% 8.91% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% <200 Over 200

Lowest Viral Load - 2013

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Retention in Care Outcomes

• Retention & adherence is key
• Retention rate as of December 2013: 89.81%

80% 82% 84% 86% 88% 90% 92%

Retention Rate Percentage

Outcomes

• Patient satisfaction

– 127 El Rio Providers – SIA Providers Rank in the top 10

• SIA consistently ranks highest in patient

satisfaction among all El Rio health centers

6/24/2014 8 Treatment Adherence Program Special Immunology Associates

Importance of Adherence

• Suboptimal adherence has been associated

with:

– Incomplete viral suppression – Emergence of resistant strains – Decrease in CD4 count – Increase in mortality and progression to AIDS – Public health concern

Pharmacist’s Role Pharmacist’s Role

• Importance of adherence

– pharmacy refills – medication routine – identify barriers to adherence

• ARV combination complete

– Guidelines – Drug-interactions

• Assist with ADEs
• Decrease stigma

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Pharmacist’s Role

• OI prophylactics
• Interpreting lab values
• Interpret resistance tests
• Collaborative practice
• Drug information resource
• Chart reviews

Treatment Adherence Program

Individual Consults – Disease state counseling – Medication counseling

• “Show and tell”

– Side effect management – Readiness to start ART

Treatment Adherence Program

• Support between patients through:

– Club Medbox – Club 95 – Patients who are non-adherent with treatment are identified and referred to adherence program for engagement

Appetite for Adherence: Club Medbox

• Goal:

Assist patients in developing skills to increase medication adherence through identifying and

• vercoming barriers to adherence.

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Club 95

• Goal

To provide patients who have achieved at least 95% adherence to their antiretrovirals and medical appointments for a period of three months with an incentive to foster continued adherence.

Treatment Adherence Program Results

• 20 out of 26 patients enrolled in Club Med Box have

Viral Loads of  50 (77%)

• 17 out of 19 patients enrolled in Club 95 have Viral

Loads of  50 (89%)

• 901 of 1102 total SIA patients have Viral Loads of

 50 (82%)

• Patients brought into adherence program are

brought in line with rest of patients re: Viral suppression rates.

Patient Centered Medical Home

What is it?

• Team based comprehensive integrated care
• Focus on needs of patients
• Treats whole person, physical and behavioral health

needs

• Coordinated, accessible care focused on quality
• Patients as partners in their care

Patient Centered Medical Home

• Integration versus Co-location: what’s the difference?
• Integration is:

* Shared electronic health record (EHR) * One common treatment plan * Verbal communication between providers * Behavioral health as embedded member of primary care team * Warm hand offs to providers * Shared physical space & patient population

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Patient Centered Medical Home

• Co-located care is:

* Ancillary service provider on site * Maintains separate treatment plan * Access services via referral * Written communication between providers predominant

Patient Centered Medical Home

“Whole Person” Model:

• Improved patient care experience
• Reduced hospitalization rates/ER visits
• Healthcare cost savings
• Higher quality of care
• Reduce stigma/increase likelihood of patient

accessing behavioral health services

Patient Centered Medical Home Eligibility

• Practice must demonstrate “whole person”

care model:

• Comprehensive care
• Self management support of health conditions
• Emphasizes spectrum of care
• Preventive care focus
• Must meet other elements for majority of patients

(75%)

Peer Support Why?

• Many benefits to implementing peer support

including:

Impact of the shared personal experience Shared experience fosters trust, credibility Promotes & role models wellness and healthy coping skills Bridges the gap that can exist between provider & patient Benefit to both peer provider and recipient of support

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Peer Support in Mental Health

• Recognition of value of shared lived

experience in recovery process

• Mutual respect
• Role model recovery, resiliency, coping skills
• Credibility based on having “been there”

Peer Support in HIV Settings

• Decrease isolation
• Increase access to medical/social services
• Increase understanding of HIV
• Increase medication adherence
• Increased collaboration between providers

and patients

Implementing Peer Support Potential Challenges

• Is the peer support person also receiving

services at your center?

• Staff views & perceptions
• Staff understanding of peer support
• Peer as patient/provider/employee &

boundaries

Improving Patient Outcomes

• What care delivery model are you currently

utilizing?

• How can you enhance your current model of

care?

• Is peer support being used at your health

center?

• How can it be implemented?

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Thank You!

• Tracy Murphy, MHA

Behavioral Health Program Manager TracyM@elrio.org & Natalie Perkins, PharmD, AAHIVP Treatment Adherence Coordinator NatalieP@elrio.org

Questions??