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Treatment Update - Modernizing the HIV Care Delivery Model


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Dr. David Condoluci presented a treatment update at the May 2017 meeting of the HIV Integrated Planning Council.

Published in: Health & Medicine
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Treatment Update - Modernizing the HIV Care Delivery Model

  1. 1. Modernizing the HIV Care Delivery Model David Condoluci, D.O., M.A.C.O.I. 1
  2. 2. Timeline of Kennedy’s HIV Care Model 2
  3. 3. Developing an HIV Care Model  Care Model used at Kennedy dates back to 1989  Two primary funding mechanisms  Treatment Assessment Program (TAP) under Commissioner Molly Coyle  Aimed at providing care to underserved living with HIV in NJ  Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990  Allowed for the development of comprehensive programs to address the AIDS epidemic 3
  4. 4. Evolution of HIV Care  1990s and 2000s led to expansion of services at all levels  Early Intervention Program (EIP) replaced TAP  Programmatic expectations of integrated, multi- disciplinary care  The “original” adult medical homes – HIV clinics  Focus on core and supportive services  Integrated care and improved therapy resulted in fewer ED and hospital visits  HIV Programs had better control and provided better care  HIV became a chronic manageable disease 4
  5. 5. Healthcare Expansion  Patient Protection and Affordable Care Act of 2008 (ACA or Obamacare)  Offered states the opportunity to expand Medicaid  Established insurance marketplaces with consumer protection measures  Shift to insurance-based care meant wrap-around services became more difficult to provide  Reliance on Ryan White funded services to maintain comprehensive programs  Medicaid expansion has slowed public health funding  Emphasis on mainstreaming HIV programs 5
  6. 6. Emerging Challenges  Medicaid Expansion  Medicaid does not cover the supportive services meaning even with “full” coverage there are gaps  Patients with supportive service needs are still accessing Ryan White services  Medicaid programs have different formularies  Marketplace Coverage  Coverage brings co-pays and deductibles  Low insurance literacy  Multiple care models in use with no clear “winner”  Persons Living with HIV still need the integrated care that the RWHAP provides 6
  7. 7. Transformation  Adoption of the Medical Home Model in Primary Care  Value-based models replaces fee-for-service models  Complex and rapid changes in care models  Requires total health care system transformation  Not all care sites will survive  Accountable Care Organizations (ACO) developed to provide better care to Medicare beneficiaries  Drives the model across the system  Model assumes risk for a whole population (community)  Improves Access, Prevents Complications, and Reduces Cost 7
  8. 8. Medical Home Model  Practices are being pushed to adopt integrated models; particularly the medical home model  Driven by Medicaid, Medicare, and Private Insurers  HIV programs are prepared for transformation  History of integration, care management, and population health  Challenge – how can HIV programs continue to provide the same level of care with the expanded access to insurance  Health Information Technology (HIT) integration is costly and time-consuming 8
  9. 9. The Quadruple Aim 9
  11. 11. Definition The Patient Centered Medical Home is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand. 11
  12. 12. Joint Principles of PCMH Adopted by AAFP, ACP, AAP, AOA:  Personal Physician  Physician Directed Medical Practice  Whole Person Orientation  Care is Coordinated and Integrated  Quality and Safety are Hallmarks  Enhanced Access  Payment Reform 12
  13. 13. Key Concepts of PCMH  Comprehensive Care  Patient-centered  Coordinated Care  Accessible Services  Quality and Safety 13
  14. 14. Patient-Centered Medical Neighborhood 14
  15. 15. Team-Based – Flatten the Hierarchy 15
  16. 16. Patient-Centered Care 16
  17. 17. Volume to Value 17
  18. 18. Health Care not Sick Care 18
  19. 19. Population Health Management 1. Define the Population 2. Identify Care Gaps 3. Stratify Risks 4. Engage Providers and Patients 5. Manage Care 6. Measure Outcomes 19
  21. 21. Same Day Appointment Scheduling  Promotes continuity of care and helps patients avoid unscheduled medical visits  Patients with enhanced access are less likely to seek care from other providers  Benefits  Reduces unnecessary use of the ER  Decreases patient use of retail clinics (fractured care)  Provides continuity of care which is associated with better health outcomes  Increases patient satisfaction 21South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  22. 22. Daily Huddles (Clinical Team Meetings)  Care teams hold regular meetings to review upcoming scheduled patient visits (“visit pre-planning”)  Typically held daily, in advance of patient visits, and include the following activities:  Identifying gaps-in-care and establishing plans to address needs during visit  Review of specialist reports  Review of lab and imaging reports  Benefits  More robust patient visits 22South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  23. 23. Population Health Management  The ability to identify groups of patients by condition and/or services needed  Outreaching to patients who need care (letters, phone calls)  Benefits  Prevents inactive patients from “falling through the cracks”  Improves performance on measures 23South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  24. 24. Enhanced Care Plan Development  Providing patients with a written/electronic copy of their care plans and treatment goals  Providing education, tools and resources to help patients better manage their conditions  Tracking goals and progress with patients at each relevant visit  Assessing and addressing barriers when patients are not meeting their goals 24South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  25. 25. Referral and Test Tracking  Formalized processes for tracking referrals and tests to ensure:  Results and reports are received timely  Abnormal results are reviewed by clinicians  Results are shared with patients  Benefits:  Safety!  Prevents “lost” results 25South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  26. 26. Continuous Quality Improvement  Capturing data that can be used to track performance on important measures such as:  Patient satisfaction  Clinical measures (Viral Load Suppression,Cd4/Cd8)  Preventive measures (Vaccines, Screenings)  Having access to useful and accurate data helps practices identify areas for improvement AND measure the success of improvement activities.  Benefits  Improved performance 26South Carolina Blue Cross/Blue Shield – PCMH Overview, “The Basics of PCMH” Access from: on September 18, 2015
  28. 28. Future IS Now  Well-organized & On-time Visits  Enhanced Access with their own provider & care team for continuity  same day appointment availability, 24/7 telephone access, alternatives to the 1:1 visit  Proactive Care Management  Evidence-based clinical care, panel management, reminder systems, registries  Care Coordination Across Settings  Assistance with referrals, tracking for tests & referrals; care during transitions  Patient Activation, Engagement & Participation in Care Decisions  Patient-centered, customer-driven  Connections to Community Resources  Focus on Health Outcomes & goals for improvement  Data-Driven use of Health IT  Supports the achievement of advanced primary care practice 28
  29. 29. Factors to Guide Transformation  Leadership Team from Start to Finish  Staff Engagement (at ALL levels)  Constant and Active Monitoring  Framework for Measurement  Solicitation of HONEST Feedback 29
  30. 30. Get comfortable with feedback 30
  31. 31. Moving Forward  No crystal ball to predict what the future brings  Proposed Changes  Changes to Pre-Existing Conditions and Access  Medicaid Changes to Block State Grants  Establishment of alternative high risk pools  Current proposals may change access while maintaining coverage 31
  32. 32.