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Integrated Care at a Community

Health Clinic Setting Specializing

in the Treatment of HIV/AIDS

Tracy Murphy, MHANatalie Perkins, PharmD, AAHIVPSession 38July 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.

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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 PracticeInternal MedicinePediatricsHIV / AIDS Treatment, Education and InterventionHealth Care for the HomelessImmunizationsNurse Midwifery ServicesObstetrics 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 TeamThe 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%

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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

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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 overcoming barriers to adherence.

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Club 95

• GoalTo 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??