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. 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. 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. 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. 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. 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
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. 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. Key Concepts of PCMH
Comprehensive Care
Patient-centered
Coordinated Care
Accessible Services
Quality and Safety
13
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. 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
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. 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
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
Dates back to 1989
TAP and State of NJ under Commissioner Molly Coyle
Provide care to those underserved with HIV in NJ and across the country
Ryan White Programs
Funding for comprehensive programs
90’s and Millennium led to expansion of services at all levels
EIP replaced TAP
Outcomes resulted in fewer ED and hospital visits
Integration of care—multi-disciplined
Better control and better care
Original Medical Home Model
Medicaid expansion
Most have insurance for individual care
Wrap around services being challenged and gradual defunding
Last seven years have been tenuous for funding from Congress due to Medicaid expansion
More reliance on mainstreaming HIV than on programmatic development
Era of ACO’s and emergence of the Medical Home Model
Difficult period for programs across the country needing to adapt quickly to a changing landscape
ACO’s full risk models
Model takes risk for population to improve access, prevent complications and reduce cost
Variable success with some able to survive and others not able to bear the cost
Transitioning many practices to this model out of necessity
Medicare, Medicaid and Private Insurers
Fundamentals there in most HIV programs but how to transition to this model to get paid for the services previously provided by the Grant funding
Many Challenges