HIV ACCESS Patient-Centered Medical Home
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: HIV ACCESS is a Ryan White Program Part C-funded HIV health care system that provides comprehensive primary care and related services to low-income, medically underserved people living with HIV. Founded in 1991, HIV ACCESS’ mission is the provision of coordinated, comprehensive, quality HIV primary care services for Alameda County's underserved communities. Tri-City Health Center (TCHC), based in Fremont, California, is the grantee and fiscal agent; Alameda Health Consortium provides program coordination for HIV ACCESS. HIV ACCESS’ Patient Centered Medical Home proposal features the orderly implementation of a set of service delivery changes, each of which builds on the last. We propose first to expand information exchange between the clinics and with key service providers. Then, we will establish an HIV disease registry and related patient care management reports. Building on this, team-based panel management is put in place. Finally, with the population approach made possible by the electronic health record (EHR), registry and panel management, patients can be supported in self-management. With a population-based approach, higher-functioning patients can be empowered to manage their own care in a more informed way, and limited staff resources can be targeted to patients who need more support in order to stay engaged in care. GOAL #1 To use EHR to improve health outcomes and support coordinated care for HIV ACCESS patients by establishing electronic information exchange for providers caring for patients-in-common: within each clinics’ multidisciplinary care teams; between HIV ACCESS clinics; and among providers of specialty and support services. OBJECTIVES 1.1 Establish joint access to electronic patient data among HIV ACCESS clinics, in order to identify common patients, improve their care, and help with reducing loss to follow-up. 1.2 Two-way information exchange, electronic where possible, will be established with selected providers of high-priority services including: dental, mental health and substance treatment, testing &amp; linking to care, housing, and specialty medical care providers. 1.3 All sites will achieve a level of capacity that enables multi-disciplinary care teams to use electronic health information efficiently for population-based care/panel management and coordinated care. GOAL#2 To improve health outcomes and support coordinated care for HIV ACCESS patients by instituting a population-based panel management program and strengthening and expanding patient self-management support. OBJECTIVES 2.1 All sites will incorporate panel management strategies to manage their entire population for optimum health in a manner that is compatible with their existing resources. 2.2 Using the disease registry, sites will pro-actively identify patients who will most benefit from additional health education, action-planning and other behavior change supports, and support the individual patient in achieving his or her health goals. Significance for HIV/AIDS in California This demonstration project will be useful to other programs because - it does not require the addition of on-going staff—we are making the changes within the resources we have. - Panel management can be tried as a small pilot, so an “early adopter” could do a test in their clinic, and demonstrate its success to their colleagues and administrators.