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

1. Modernizing the HIV Care
Delivery Model
David Condoluci, D.O., M.A.C.O.I.
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2. Timeline of Kennedy’s HIV Care Model
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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
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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
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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
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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
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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
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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
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9. The Quadruple Aim
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10. OVERVIEW OF THE PATIENT
CENTERED MEDICAL HOME

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.
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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
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13. Key Concepts of PCMH
 Comprehensive Care
 Patient-centered
 Coordinated Care
 Accessible Services
 Quality and Safety
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14. Patient-Centered Medical Neighborhood
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15. Team-Based – Flatten the Hierarchy
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16. Patient-Centered Care
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17. Volume to Value
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18. Health Care not Sick Care
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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
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20. FEATURES OF INTEGRATED,
PATIENT-CENTERED MODELS

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. 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. 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. 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. 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. 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

27. TRANSFORMING HIV CARE
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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
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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
29http://www.medicalhomesummit.com/readings/practice_transformation_guide_pcpcc.pdf

30. Get comfortable with feedback
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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
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32. 32aidsetc.org