ANCHORING INTO THE MEDICAL HOME
Engagement in Care
August 2011
Slides from: Amy M. Sitapati, M.D
At the UCSD Owen Clinic
Engagement in care
(one component
of care management)
The 39 Core Components
C.R. Jaen, et al. Ann Fam Med. 2010;8(Suppl 1):s57-67
STEP 1: Pilot RETENTION
 A pilot “lost to follow up” project: 2009
• 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 2009
Outcome
#
%
Deceased
1
0.2%
35
7.1%
7
1.4%
24
4.9%
In Care - Other UCSD Provider
8
1.6%
In Care - San Ysidro with Owen Provider
3
0.6%
15
3.0%
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%
New Insurance - Remaining in Care
Incarcerated
Moved out of Area
In Care Other Provider - Change Not Insurance
Related
Returned to Owen Prior to Contact
STEP 2:
Moving Engagement into
ACTION! By getting involved in an
organized quality improvement
project
Creation of Project PUFF: Patients
unable to follow-up…FOUND
One person can make a difference
Objectives: outreach interventions
engaging HIV patients back into primary
care
Aimed to get patients unable to follow up back into
care
Develop innovative methods to target the 53% unable
to reach by telephone alone
Determine methods to prevent future loss to follow up
Tool 1: Creation of a NEW Job
Previous phone political/non-profit work
HIV science and research exposure
Volunteer in community
Read articles on background
Cross-training to navigate barriers:
4 system training & all staff roles (MA/ desk/
phones/ adhere/ enroll/ edu/ case mgt)
Tool 2: Making algorithms/flyers
Flow diagram for re-engagement
Check Lab Tracker:
Return on Own?
No
Reason Why?
Moved, etc.
No
Search:
- EMR for Hospitalization/Death
- Sheriff Inmate Log
http://apps.sdsheriff.net/wij/wij.aspx
Email
Send Same day as 2nd
call w/ no contact
Call
-LM
-Message not returned in
2 days Call Again
- Social Security Death Index
http://ssdi.rootsweb.ancestry.com/
- County Health
Mail Letter to known
address
-Send 2 days after
email w/ no contact
Search Google
Consider Patient
LOST
Call Emergency
Contact/Case Manager
-3 days after mail w/
no contact
Consider other
resources:
-Support groups
-Centers
-etc
Call Emergency
Contact/Case manager –
Call again after two days
Search
Facebook/Myspace
-Send message via
website messenger
-- Use contact
information
Contact
Pharmacy
Search ADAP
Posted outreach: Flyer creation
Tool 3: Track in Access database
PUFF: Access: patient search
Tool 4: Calls, calls, and calls
•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 5: Untapped pharmacy link
61/70 lost patients with e-prescribing
Called 20 pharmacies, looking for:
Date of last refill
Newest 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 #)
Inclusion Criteria
 HIV+
 At least one clinic visit in past 12 months
Excluded subspecialty and consult only visits
 Over 6 months since last visit
478 patients in first 6 mo
(716 patients identified for the
year in 2 separate 6 mo cycles)
Tool 6: Inside TIPs/what didn’t
work
Persistence in calling was key
Getting to know the patient
A bit of help with mail & pharmacy
Limitations with myspace/facebook due to
access restraints institutional
Confidentiality restricts intervention into
community outreach of Homeless programs,
etc. for referrals
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%
8
1.1%
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%
716
100.0%
Future Return Visit Scheduled
Expired
Total
Sitapati, unpublished data, 1/2011
Patient calls and outreach:
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
Oh, my God, I think you just saved
my life….- B
Dx HIV 1990 & clinic pt since1995
Last appt 3/27/2009
7 phone calls and 1 letter: multiple attempts. Calls
taken by a housemate claimed B would get messg
and call right back… but never did
On 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.
Reason
Reasons
Patients Gave
for Missing
Care
#
%
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%
198
100.0%
Total
Sitapati, unpublished data, 1/2011
PUFF is afforbable
This is a project requires a ½ time
employee at low cost Community Health
Program Representative and is an
affordable option.
Unanswered Questions:
Improving FUTURE engagement
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?
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)
The ANCHOR Medical Home is Supported by:
- University of California; California HIV/AIDS Research Program:
Award No. MH10-UCSD-640
A Special Thanks to:
Jan Limneos for PUFF data support
Stephanie Moody-Geissler & Sara King; PUFF Retention
Specialists
Susan Benson for staff/project oversight
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): 20038-40
7. Linkage, Engagement and Retention in HIV care Clin Inf Dis
2011; 52(2)