National TA Call: Improving Patient Retention May 13, 2010 Facilitator: Nanette Brey Magnani, Ed.D., NQC and HIVQUAL Qua

1. National TA Call: Improving Patient RetentionMay 13, 2010 Facilitator: Nanette Brey Magnani, Ed.D., NQC and HIVQUAL Quality Consultant

2. Learning Objectives • Review evidence for working on retention • Discuss several retention performance measures for your HIV program • Review key questions to ask when improving retention • Discuss how to coordinate efforts across grantees

3. Agenda • Welcome • Defining retention • Considerations in measurement • Key questions • Coordinating efforts across grantees

4. More Information on Retention Prior presentations: 2008 NQC National TA Call (June, 2008) and AGM presentation (August, 2008) strategies for improving patient retention • 2009 NQC Part D Conference: Retention of Part D Clients - Measurement and Interventions • 2009 NQC National TA Call (December, 2009) “Improving Patient Retention”

5. For more information inclusive of summary of research to support patient retention, download from www.NationalQualityCenter.org : • Presentation “Reflection on Retention: Connecting To Care,” Bruce D. Agins, Medical Director, NYSDOH AI, 6/12/09 and • Article by Horstmann, Brown, Islam, Buck and Agins, “Retaining HIV-Infected Patients in Care: Where Are We? Where Do We Go from Here?” Clinical Infectious Diseases, 2010:50, March 2010, pp. 752-761 from

6. Defining Retention

7. ContinuumEngagement in Care Not in Care Fully Engaged Non-engager Sporadic User Fully Engaged Health Resources Service Administration (HRSA) 7

8. Who Misses Appointments? Clinical Higher CD4 count (Catz, 1999; McClure, 1999; Arici, 2002) Not having an AIDS diagnosis (Israelski, 2001; Arici, 2002) Detectable viral load and AIDS-defining CD4 count (Berg, 2005) Other History of or current IDU (McClure, 1999; Arici, 2002; Kissinger, 1995; Lucas, 1999) Lower perceived social support (Catz, 1999) Less engagement with health care provider (Bakken, 2000) Shorter follow-up since baseline (Arici, 2002)

9. Why is it important?

10. Health Care The heart of the patient-provider relationship: The patient identifies the provider team (clinic) as his or her provider The team identifies the individual as their patient

11. Patient Care and Public Health Retention has now been proven to correlate with improved biological outcomes that improve quality of life for patients and reduce the likelihood of further transmission of HIV to others

12. Healthcare Cost Retained patients more likely to receive preventive care, use emergency services less, and keep overall healthcare utilization and costs lower

13. Hypothesis Retention in care promotes improved adherence to treatment which results in lower viral loads, prevention of drug-resistance and improved health outcomes. Is there evidence to support the hypothesis?

14. The Evidence Base Rastegar, AIDS Care 2003: Missed appointments associated with detectable viral load. Chart review 1997-99. Lucas, Ann Intern Med 1999: Missed appointments associated with failure of suppression. JHU. 1996-8. Valdez, Arch Intern Med 1999: Missing <2 appts per year associated with virologic success defined as <400 copies. Sethi, Clin Infect Dis 2003:Missed appointments associated with viral rebound and clinically significant resistance at JHU 2000-1. Nemes, AIDS 2004: Missing 2 appointments associated with decreased adherence among >1900 patients in Brasil.

15. How do you measure retention?

16. Measurement What is the extent of the problem? No-shows Retention rates But, why??

17. No-Show Rates: aka “DNKA” No-show rates range from 25% to >40% in published studies Limitations: Patients may be counted for multiple visits Type of clinic visit not uniform Time frame accepted for prior cancellation Rescheduling: does it count? What about walk-ins?

18. Retention Rates Require precise definitions of expected number of visits during a specified time interval Eligible population required for the denominator which requires determination of visit type and determination of active caseload of the clinic

19. Where do you start? Numerator: define expected number of visits during a specified time interval Denominator: determine eligible patients (population), visit type and active caseload of the clinic

20. Questions in Defining and Selecting a Measure • What is the best measure for your population? Do different populations require different measures? • What does the measure allow you to know? • What are you not picking up by using this measure? • How frequently do we measure retention? • What is the capability of your EMR?

21. Retention Measures Examples

22. HRSA/HAB • HRSA/HAB: Medical Visits # of clients who had a medical visit with a provider with prescribing privileges in an HIV care setting two or more times at least 3 months apart during the measurement year Total number of clients who had a medical visit with a provider with prescribing privileges at least once in the measurement year

23. CT HIVQUAL Regional Group • Baseline • Fairhaven CHC – 95% • Community Health Center, Inc at Meriden (3 sites) • 99% • 98% • 90% • Torrington – 88% • CT Part D Network – 77%

24. HIVQUAL and NYS Retention Measure Number of unique clients with at least 2 or more (clinician) visits during the past 12 months, one in each 6-month period Number of unique clients with at least 1 (clinician) visit during the past 12 months 24

25. Baseline Data – Scranton Temple Residency Program Engaged in QI Project to increase annual cervical cancer screening rates. The team increased rates from 16% to 70%. To further improve, the team realized there was a retention in care problem. 46 of 128 or 36% of female patients did not meet the HIVQUAL definition of one medical visit in the first six months of the year and one in the second six months; thus, a 64% retention rate.

26. Baseline Data for Men - STRP September 1, 2008 through August 30, 2009 183 active male patients 111 / 183 met HIVQUAL criteria of medical visit in the first six months and once in the second six months 111 / 183 = 60% Retention rate Combined rate for female and male patients - 62%

27. HIVQUAL Regional Groups’ Retention Measure (CA,AZ,NV) Inclusive of: • UCSD Owen Clinic – San Diego • USC-MCA – Los Angeles • Sonoma Co – Santa Rosa • Venice Family Clinic – Venice, CA • Community Medical Centers – Stockton, CA • Pace Clinic – Santa Clara • LA Gay & Lesbian Center • Maricopa Health Systems - AZ • Plumas Co., Northern CA • Santa Cruz Co., CA

28. Retention Measure Numerator: Patients with a visit in 1st and 2nd half of year Denominator: Patients with a visit in 1st half of year Exclusion: patients who enter care in 2nd half of year Example: Numerator: 135 (number of pts from 1/1/07 – 6/30/07 and 7/1/07 – 12/31/07 Denominator: 175 (number of pts with at least one visit from 1/1/07 – 6/30/07 Retention rate: 77%

29. Baseline – HIVQUAL Regional Groups (CA,AZ,NV)*available as xml files for CAREWare users

30. Why do HIV patients not come? Patients at a community based clinic: conflicts with work schedules, lack of child care, no transportation, family illness and hospitalization (Norris, 1990) Women patients: forgetting the appointment, having a conflicting appointment and feeling too sick to attend the visit (Palacio, 1999) NYC clinic: no specific explanation, forgot, meant to cancel, unexpected social reasons (Quinones, 2004)

31. Why do patients not come? Not HIV disease-specific studies Forgetting the appointment Feeling too ill to attend Resolution of symptoms (Cashman, 2004; Moore, 2001; Waller, 2000; Barron, 1980) Negative emotions about seeing doctor; perceived disrespect of beliefs and time; distrust; lack of understanding about the scheduling system (Lacy, Ann Fam Med 2004)

32. Part C/D Grantees Additional Reasons • Mental health issues • Substance use • Homeless • Confidentiality concerns • Health literacy

33. Act Locally • Determine reasons why your patients are not being retained

34. Looking Beyond the Clinic Patients may seek care from multiple providers in different locations. Is a patient who receives care from another provider “retained”? How should we define quality of care in the context of retention when a patient receives care outside of the clinic?

35. Presentation “Recapture the Blitz”

36. Summary Retention in care is associated with improved health outcomes Practical strategies can improve retention rates involving healthcare providers and community based organizations. Addressing patient needs and barriers to care improves retention. Measurement is the key to investigating the problem and identifying effective solutions Limited data about “at-risk” patients – “drill down” to learn more about those not retained

37. Addendum • List of QI Interventions that have successfully improved retention rates • Retaining New Patients in Care Storyboard • Grantee contact information

38. Improving Retention QI Strategies Improvement strategies Clinic operation & information systems Consumer involvement to identify barriers & solutions Increasing staff & patient awareness Focused case management (internal & external)

39. Clinic Operation & Information System Strategies Clinic Organization Ensure coverage for provider vacations and time-off to avoid canceling or re-scheduling appointments Establish patient database to track adherence with appointments Pre-Appointment Reminder cards with date/time/location of visit mailed to patients Reminder calls made 48 hrs prior to appointment to allow patient time to make arrangements, if needed Reminder calls to patients made by providers, case managers or other staff closely involved w/ patient's care Schedule labs to be done prior to visits to maximize time spent w/ provider

40. Clinic Operation & Information System Strategies After a Missed Appointment Follow-up calls no later than 24 hours after missed appointment During Clinic Visit Update patient contact information at EACH clinic visit Cross reference all sources of patient contact information to consolidate and update Schedule labs for the next visit Improve visit/cycle time

41. Consumer Involvement Convene focus group of established patients to provide feedback on retaining new patients Survey patients who have missed appointments to identify common reasons and barriers Routinely share results of patient satisfaction surveys w/ Consumer Advisory groups to elicit feedback Survey new patients immediately following initial visit for satisfaction w/ services Develop patient satisfaction surveys targeted to patient groups w/ different levels of experience - patients w/ less than 3 visits, patients w/ more than three clinic visits, etc.

42. Retention of New Patients in Care Download story board from www.nationalqualitycenter.org Ana Lapp, RN, QI Coordinator Esperanza Health Center 3156 Kensington Ave. Philadelphia, PA 19134-2400 Member of: Phila. Regional HIVQUAL Group 215-831-1100 x227; aml@esperanzahealth.com

43. Contact Information • Nanette Brey Magnani, EdD, HIV Quality Consultant, breymagnan@aol.com • Dr. Shannon Hader, Senior Deputy Director of the HIV/AIDS, Hepatitis, STD and TB Administration (HAHSTA) for the District of Columbia, Shannon.hader@dc.gov • Angela Fulwood Wood, Chief Operations Officer, Family and Medical Counseling Service, Inc. afulwood@fmcsinc.org • Dr. Nnemdi Kamanu-Elias, Chief Medical Officer, HAHSTA, nnemdi.kamanuelias@dc.gov • Justin Goforth, Director; Medical Adherence Unit at Whitman Walker Clinic, jgoforth@wwc.org • Annie LaTour, Manager for Monitoring and Evaluation, HAHSTA, annie.latour@dc.gov

44. National Quality Center (NQC)NYSDOH AIDS Institute90 Church Street—13th FloorNew York, NY 10007-2919212-417-4730NationalQualityCenter.org