LA County Patient-Centered HIV Medical Home Project
Creators: name: University Of California Office Of The President
Publisher: name: University of California Office of the President
publisherIdentifier: https://ror.org/00dmfq477
publisherIdentifierScheme: ROR
Year: 2024

description: The Los Angeles County Office of AIDS Programs and Policy (OAPP) and the Rand Schrader Clinic at the Los Angeles County/University of Southern California Medical Center will collaborate on a project to enhance and evaluate electronic data-sharing in order to assess the efficacy of a medical care coordination service model for nearly 2,300 patients enrolled in an HIV medical home at LAC USC Rand Schrader Clinic. Using the AFFINITY electronic health record at LAC USC Rand Schrader Clinic, medical care coordination partners will have access to medical, social service, and utilization data, to develop and measure comprehensive medical and social service treatment plans for people with HIV disease, in order to maximize coordinated care, assess health outcomes, and promote retention in and adherence to HIV care and treatment. Specifically, the project intends to create, test and evaluate an Electronic Data Interface (EDI) between the OAPP Ryan White care data system and the LAC USC Rand Schrader Clinic AFFINITY system. This will include bi-directional sharing of clinical and social service data for the purposes of enhancing medical care coordination. We will evaluate the electronic enhancements’ impact on overall health care coordination among medical and social service providers, access to and retention in HIV care, HIV treatment adherence, and additional health outcomes and service effectiveness. This demonstration project at Rand Schrader Clinic will serve as a prototype for successful implementation of the Patient-Centered Medical Home (PCMH) model and the Los Angeles County medical care coordination (MCC) framework in the Ryan White care system. Medical care coordination, as a service model, has been developed through a partnership between OAPP and the Los Angeles County Commission on HIV. The MCC framework utilizes a multidisciplinary team approach led by a combination of registered nurses and licensed clinical social workers to assess patients’ medical and psychosocial needs, determine treatment plans, coordinate service linkages, and continually assess patient health to promote active coordination of services. The primary goals of MCC include increased service efficiency and effectiveness, improved patient health outcomes, and improving patient self-management skills. Established in 1986, the Rand Schrader Clinic is one of the largest providers of HIV medical care in Los Angeles County, with approximately 30,000 - 40,000 patient visits each year. The clinic provides comprehensive primary and subspecialty medical care, along with coordination of support services through a network of community social service providers. OAPP is responsible for coordinating the County’s response to the HIV/AIDS epidemic. OAPP is the administrative agency for Ryan White Part A, Minority AIDS Initiative, and Part B consortium funds in Los Angeles County, as well as the administrator for the County’s Cooperative Agreement with the Centers for Disease Control and Prevention, along with other grants and demonstration projects from federal, state and local entities. As the administrator for much of the public HIV/AIDS resources coming to Los Angeles County, OAPP is in a unique position to implement the PCMH model across its HIV/AIDS primary care network (currently 23 medical outpatient providers in 34 service sites), if the model is proven to increase access, improve retention and foster better health outcomes.