Combining EHR and Outreach to Promote Retention in Care

Segment Description: Pamela Gorman, RN, ACRN, administrative director of the Cooper Early Intervention Program Expanded Care Clinic in Camden, New Jersey, discusses how electronic health data and coordinated outreach can be combined to increase retention in care.

The Cooper Early Intervention Program Expanded Care (CEEC) Clinic in Camden, New Jersey, is a Ryan White-funded clinic that provides primary care for individuals living with HIV. In January 2019, the CEEC Clinic launched a data-driven initiative with the intention of reducing the number of patients living with HIV who did not have a medical visit within the last 6 months.

The purpose of the initiative was to assure ongoing retention in HIV care services among patients. Representatives from Cooper University Health Care discussed the initiative in a poster presentation at the Association of Nurses in AIDS Care Conference (ANAC 2019).

Interview transcript: modified slightly for readability)

We've been watching and observing the qualitative improvement in patient’s care related to this model and I should tell you that historically it started just with outreach navigation back in 2009. We implemented some enhanced outreach techniques in order to get patients that were identified as injection drug users and they were going to addiction medicine programs. At this time, we didn't have this service in our clinic so we relied heavily on the outreach navigators to work with these individuals in order to connect them to care.

In 2017 we were really concerned that we found out if we waited for this 6-month period of time, it was more likely that [the patients] were going to get lost to care, or they were not going to come back in for their routine laboratory assessments. It was difficult for us to monitor or gauge how well they were adhering to their treatment plan.

We also knew that the treatment plan was not being adhered to because they weren't showing up for their appointments. What we noticed was we had a gap in care of 17%, and this is based on the HIV/AIDS Bureau Performance Measure, I think it's the core 4 for those of you that work with HAP measures for HIV care and treatment. What we do is we look at them, we have a measurement period of 12 months. Like I said, these individuals have a visit within the first 6 months, but they're missing an appointment within the last 6 months and based on that 17% of our patients were not receiving that visit within the second half of the 12-month measurement period.

We saw that we would get down to about 15%, but we really weren't making a dent in improving that measure. So, we felt that it was necessary to really ramp up our strategies, and that's what we did. The ramping up of strategies really was the data analysis piece. That's really what was key in order to identify that there was an issue. And then we've identified that we needed to more frequently look at this data. We couldn't wait until 6 months to when the patient was out of care, we had to start looking at this data and we started evaluating it monthly.

Sometimes doing it more frequently can give you a false impression of whether or not there's a problem because you're looking at it too frequently. But we felt that it was necessary to get a sense for that. And then, even though we were looking at it monthly, we were evaluating the quarterly milestones over the 12-month measurement period.

We found that we were just fluctuating between 14% and 15% and that was our best effort until we started enhancing utilizing data to influence finding patients and then getting them in care. Now, the Careware database allows you to look at persons that are in the numerator and not in the numerator. This is the advantage to importing your electronic health record information on patients into a software database platform.

So we import this information and we run the performance measures that are on the Careware software platform, specifically the gap measure, and it allows us to generate a client list of those are in the numerator—meaning that these are the people that are in the gap measure—they have a 6 month gap in their visits. That allows us to target specific individuals and have our staff work frequently to find these patients and figure out how to get them back in care. With each of these individuals, we do intake assessments, because the individual care plans for retention and care and finding patients to get them in care is per person. So everybody is unique—they all have their own set of circumstances, and based on those circumstances we identify what strategies will work best for getting those persons in care.