This Special Projects of National Significance (SPNS) initiative, System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Health Care Settings, is a multi-site demonstration and evaluation of system-level changes in staffing structures to improve health outcomes along the HIV Care Continuum. This initiative is funding 15 demonstration sites for four years to promote the design, implementation, and evaluation of innovative strategies to increase organizations' workforce capacities and achieve efficient and sustainable service delivery practices that both optimize human resources and improve quality outcomes. The University of California at San Francisco is serving as the Evaluation and Technical Assistance Center (ETAC) for this initiative. The ETAC will coordinate the multi-site evaluation provide programmatic technical assistance to the demonstration sites and lead publication and dissemination efforts of best practices and lessons learned.
This initiative seeks to enhance the capacity and readiness of funded organizations in making structural changes to their workforce systems to improve the provision of quality care to people living with HIV (PLWH). The demonstration projects will implement and evaluate innovative Practice Transformative Models (PTMs) for the delivery of HIV treatment and comprehensive care services in order to better respond to the changing health care landscape, marked by shortages of HIV primary care physicians and increasing demand for access to quality HIV services. Evaluation of these innovative PTMs will identify best practices and methods to support other organizations to adapt and re-align their workforces, as well as factors that increase the potential for successful integration of HIV care into primary care and community health care settings serving vulnerable populations.
Structural workforce changes employed by the PTMs include physician extension or task shifting (i.e., transferring specific tasks from the physician-level to mid-level providers or other health workers), restructuring staff to meet the standards of Patient-Centered Medical Home, integration of community health workers and patient navigators into the medical team, and inter-professional team-based practice coordination or co-management (such as a generalist physician overseeing HIV care while in regular consultation with an HIV expert).
The overall goals of these proposed PTMs is to increase the number of HIV care providers in their organization, increase the potential for successful integration of HIV care into primary care, and enhance the capacity and readiness of the organization's workforce to identify, link, and retain people living with HIV towards a path of achieving viral suppression.
Grants for this initiative have been awarded to the following organizations, and brief descriptions of their project and practice transformative models are below. Funding is anticipated for four years.
Access Community Health Network, Integrating HIV Care into a Patient Centered Medical Home: Practice Transformation in a Federally Qualified Health Center Network, Chicago, IL
Access Community Health Network (ACCESS) provides HIV care and treatment services in Cook and DuPage Counties of Illinois. Their providers must divide their time between five sites geographically distributed across more than 1,000 square miles. As the number of HIV patients has increased over time and those diagnosed with HIV are living longer, ACCESS' ability to provide continuous care has been stretched to capacity. ACCESS Practice Transformative Model will fully integrate its HIV care into their primary care system using the Patient Centered Medical Home model. HIV patients will be treated by a care team, including primary care providers and infectious disease specialists, with their care coordinated by Registered Nurse-trained Care Coordinators. In this way, they will expand the capacity of their system to take care of HIV patients who are living longer and facing a full range of health issues.
Centro de Salud de la Comunidad De San Ysidro, Inc., Innovation in Meeting HIV-positive Patient Needs across the Spectrum of Care: A System-Level Approach to Service Integration and Workforce Capacity Building in San Diego, California
San Ysidro Health Center's project has two overarching goals. The first is to provide a seamless continuity of a full spectrum of care for persons living with HIV. This includes establishing a team-based care model that will promote improved communication between HIV and non-HIV providers to support continuity of patient care including full-spectrum service utilization and improved patient health outcomes. It also includes the implementation of a service integration model that uses a systems-based approach to foster communication between HIV and non-HIV providers to support continuity of patient care including full-spectrum service utilization. The second goal is to develop a sustainable clinical workforce pipeline that secures medical resident capacity to serve HIV-positive patients in primary care settings. This will be accomplished by establishing a residency rotation that will systematically engage family medicine residents into primary care environments to develop their capacity and self-efficacy to deliver primary care to people living with HIV.
Coastal Bend Wellness Foundation, Inc., Corpus Christi, TX
Coastal Bend Wellness Foundation (CBWF) proposes a Practice Transformative Model for delivery of HIV care and treatment that will increase its capacity to achieve efficient and sustainable service delivery practices that both optimize human resources and improve health outcomes. The main goal of their project is to develop interdisciplinary team-based strategies that include the realignment of the agency workforce systems to improve its provision of quality HIV primary care. CBWF's PTM seeks to transform its current clinical care practice into an interdisciplinary team-based approach using an integrated Patient-Centered Medical Home model of care to provide HIV positive patients with primary care, HIV care, and behavioral health services. The PTM's principal components are task shifting and physician extension, restructuring staff to meet the standards of a Patient-Centered Medical Home, development of an inter-professional team-based practice coordination, and capacity building. The project will provide integrated primary care, HIV and behavioral health services utilizing a health home model to manage disease and address other healthy behavior concepts.
Family Health Centers of San Diego, Inc., Practice Transformative Model to Build San Diego's Primary Care Capacity to Provide HIV Treatment and Comprehensive Care Services, San Diego, CA
Family Health Centers of San Diego's Practice Transformative Model will train a minimum of three primary care providers each year to provide HIV care to address the growing shortage of HIV care providers and an increasing patient caseload. Training will include a rotation at the HIV clinic, the Ciaccio Memorial Clinic, in-clinic shadowing with an HIV specialist physician, specialist consultation, and workshop trainings. This PTM also includes training primary care-based staff, including health educators, mental health staff, clinical support staff (medical assistants, case managers, patient service representatives) in HIV-related topics specific to their job functions, including treatment adherence counseling, Ryan White HIV/AIDS Program enrollment, and Trauma-Informed Care practices. In addition to workforce training, an interdisciplinary care team will provide coordinated, wrap-around services (case management, care coordination, substance abuse counseling, and treatment adherence counseling) to HIV patients seen in the primary care setting. A Patient Navigator will ensure ongoing coordination between the interdisciplinary care team, primary care providers, and the primary care team and will standardize patient follow-up processes to improve patient follow-up and retention in care.
Florida Department of Health, Kissimmee, FL
The Florida Department of Health in Osceola County (OCHD) operates the Primary Care Medical Services of Poinciana Federally Qualified Health Center (FQHC). Their Practice Transformative Model seeks to integrate their current public health HIV clinical services program into their FQHC network's primary care services, using the Primary Care Medical Home model. This team-based approach will increase their capacity to serve more patients, sharing patient care responsibilities among members of an inter-professional care team. OCHD seeks to transform the limited practice capability of its current HIV program into a systematic, comprehensive, inter-professional health care system that improves capacity and quality of primary care for its patients. The Primary Care Medical Home model has been shown to provide better care through well-organized teams that collectively have the skills and time to comprehensively meet the needs of patients, to address health disparities, and to improve health outcomes.
FoundCare Inc., West Palm Beach, FL
FoundCare Inc., a Federally Qualified Heath Center (FQHC) located in Palm Beach County, FL, is implementing a project composed of four evidence-based practice models. These are Practice Transformation, Patient-Centered Medical Home, HIV Care Model, and Model for Improvement. This PTM seeks to implement and integrate an interdisciplinary care team comprised of medical professionals, case managers, and peer para-professionals in an effort to better engage patients in care and improve outcomes. This care team will be supported by practice improvements, including task shifting, designed to ensure greater workforce efficiency and increased capacity in each discipline. The PTM will assess and improve organizational capabilities along the HIV care continuum and close gaps between the stages of the care continuum for patients. The goals of this PTM are to enhance FoundCare's capacity and readiness to implement a practice transformative model, to develop and integrate a team approach to increase testing, to create seamless linkage to care, to increase retention in care, to promote viral suppression; and to fully integrate HIV care into primary care.
Hektoen Institute for Medical Research (Core Center), The Practice Transformative Model (PTM): 2018, Chicago, IL
Core Center's Practice Transformative Model will develop and implement organizational infrastructure and operational procedures relating to the health care of HIV positive patients based on the health care Systemness Model. The Systemness Model refers to how well the components of an organization or system collectively perform in achieving a common goal, and to the degree to which a collection of interconnected parts behave as a whole to predict and consistently produce results that are superior to the sum of the parts. The PTM's goal is to establish a seamless health care delivery system for patients living with HIV using a Patient-Centered Medical Home model. This project will focus on retention in care, care coordination through multidisciplinary teams, continuous quality improvement measures with consistent metrics, and the development of organizational policies and procedures to guide the implementation of the PCMH model of care. Four key change concepts will be used, including care coordination, organized evidence-based care, continuous team-based relationships, and a quality improvement strategy. Through improved care coordination and patient self-management strategies, this PTM will address the major gaps in service in linkage to care and retention in care along the HIV care continuum.
HELP/PSI Services Corp., Practice Transformative Model for Care Integration, Bronx, NY
HELP/PSI's multifaceted Practice Transformative Model (PTM) is designed to address gaps in the agency's existing Patient Centered Medical Home model to improve the provision of care for people living with HIV. This PTM is based on the identification of resources and workflow solutions, such as formalized communication structures that promote collaboration among providers, to improve care coordination and prevent high-risk HIV-positive clients from falling out of care. In response to HELP/PSI's current resource and workflow gaps, a Nurse Care Coordinator, Patient Navigator, and two Peer Escorts will be hired to increase capacity to achieve efficient and sustainable service delivery practices, ultimately leading to better health outcomes for PLWH. The program will seek to increase access to care and enhance the quality of HIV care for PLWH by facilitating improved collaboration among primary care, behavioral health and other service providers along the HIV care continuum.
La Clínica del Pueblo, Transforming Latino HIV Care, Washington, DC
La Clínica del Pueblo, a Federally Qualified Health Center, proposes to develop, implement, and evaluate an innovative, culturally-appropriate Practice Transformation Model that will enhance La Clínica's HIV workforce's capabilities to optimize patient health outcomes for Latino women and men living with HIV in metropolitan Washington, DC. Its PTM is grounded in the Patient Centered Medical Home (PCMH) Model, an evidence-based practice that emphasizes care coordination and service integration to transform primary care into a quality and patient outcome-oriented care approach. The PCMH model combines core tenets of primary care (e.g., continuous, comprehensive, and coordinated care) with recent evidence-based practice innovations such as electronic information systems, population-based management of chronic illness, and continuous quality improvement. La Clínica seeks to implement a cultural and linguistically-appropriate team-based delivery of care model that focuses on care coordination and strengthening provider communication, creating stronger synthesis between behavioral and medical care, increasing patient engagement in their own care and the integration of community health workers into the health care team. It is anticipated that the strategies identified by this project will improve organizational capacity to successfully integrate sustainable and replicable service delivery practices, which will enhance La Clínica's HIV model of care, strengthen its workforce, and optimize patient health outcomes along the HIV care continuum.
The MetroHealth System, MetroHealth System (MHS) HIV - Implementation of a Collaborative Care Model, Cleveland, OH
MetroHealth System (MHS)'s Practice Transformative Model will provide integrated primary HIV care and behavioral health care to people living with HIV. The Collaborative Care Model for Depression will transform MHS' HIV primary care delivery by integrating depression screening and treatment into the medical infrastructure, by task shifting of responsibility for depression screening and monitoring response to therapy to non-physician providers, and by decreasing overall healthcare utilization and costs for PLWH. Implementing the model will in turn optimize HIV outcomes by improving rates of engagement in care, optimizing HIV medication adherence and result in sustained viral suppression. Essential training will be provided to the medical and support staff on how to manage mental illness and enable a team approach to challenging patients. This project's design, implementation, and evaluation of a Collaborative Care Model for Depression in the MHS HIV clinic will lead to better depression treatment and, in turn, lead to increased rates of viral suppression.
New York and Presbyterian Hospital, STaR Project (Stimulating Transformation of Technology and Team structure to Reach PLWH), New York, NY
Through resource transformation, the Comprehensive Health Program of New York Presbyterian/Columbia (NYP-CHP)'s STaR Project will increase NYP-CHP's patient capacity, improve efficiency, and optimize patient outcomes via three main initiatives. First, NYP-CHP staff will be restructured into clinical care teams that are united in purpose to care for shared panels of patients. Secondly, team coordination and enhanced linkage and retention will be implemented through a dedicated clinical care coordinator and outreach worker. Third, innovative health information technology will be used to support population and individual level care coordination efforts and practice efficiency. NYP-CHP's electronic medical record system will be linked to the local Regional Health Information Organization (RHIO) and will be enhanced to provide the care teams with novel panel management tools capable of driving practice transformation. NYP-CHP staff will be organized into four coordinated teams, each led by social worker-registered nurse co-captains to manage a shared panel of patients. Each team will consist of a multidisciplinary group that embodies the medical home model including a social worker and registered nurse, clinicians, a care coordinator, a behavioral health specialist, a linkage and retention specialist, and a peer educator. The team approach will enhance communication and permit safe, supervised task shifting which will increase patient capacity for clinicians.
New York City Health and Hospitals Corporation, Pay it Forward: Building New Opportunities for Success by Replicating the NYC SPNS Jail Linkages Model in Puerto Rico and the Bronx, Riker's Island, NY
The New York City Health and Hospital Corporation's Correctional Health Services (CHS) is responsible for the provision of health care to all those held in NYC jails. CHS's Transitional Health Care Coordination (THCC) will implement its HIV Continuum of Care Model (HCCM), an innovative evidence-based Practice Transformative Model (PTM) model, to enhance linkages to HIV care for people living with HIV and returning home after incarceration. CHS will collaborate with Montefiore Medical Center in the Bronx, and with One Stop Career Center of Puerto Rico, to expand their medical care, case management capacity, and ability to care for their HIV patients. THCC will provide technical assistance to address the gaps in their service delivery systems needed to implement the HCCM. This will include how to establish relationships with incarcerated persons living with HIV prior to release from jail, facilitating their linkages to community care after incarceration, and supporting their maintenance in care and adherence to ART medication. The project seeks to achieve a "warm transition" for those returning home from jail to increase the number achieving viral suppression, as well as sustaining improved community health.
Special Health Resources for Texas, Inc., Longview, TX
Special Health Resources for Texas (SHRT) is an AIDS Service Organization serving people living with HIV in rural Northeastern Texas. SHRT will implement a Practice Transformative model that will promote changes in the agency's structure, increasing capacity, restructuring resources, and integrating care in order to improve health outcomes for its HIV patients. Their PTM will develop interdisciplinary team-based strategies that include the realignment of the agency workforce systems to improve the provision of quality care. The project's goals are to engage in task shifting and physician extension, to increase the number of persons receiving HIV and primary care services, to increase the agency's ability to track, assess and document project objectives and activities and monitor HHS indicators, and to develop an inter-professional and interdisciplinary team-based approach to the delivery of clinical services. The five principal components of their PTM are task shifting and physician extension, restructuring staff to meet the standards of a Patient-Centered Medical Home, integration of Patient Navigators into the interdisciplinary team, development of inter-professional team-based practice coordination, and capacity building.
University of Miami, Comprehensive Practice Transformation Model to Enhance Capacity and Improve Quality of Care in PLWHA in Miami-Dade County, Coral Gables, FL
The University of Miami will implement a system-level Practice Transformation Model to incorporate the core components and broad concept changes of a Patient Centered Medical Home (PCMH) to enhance capacity and improve quality of care in persons living with HIV in Miami-Dade County, FL. The project will build upon the recognized strengths of existing interdisciplinary HIV care, and incorporate strategic structural changes to optimize access, retention, and clinic capacity for PLWH. The implementation and evaluation of the proposed PTM will be carried out by a Practice Transformation Team and an Evaluation Team, both to be incorporated into the existing clinic infrastructure. The Practice Transformation Team will include recruitment of new staff (Patient Navigator and Medical Assistants) under the direction of the Principal Investigator, who serves as the Clinical Director of the UM/JMMC Adult HIV Outpatient Clinic. The purpose of the Practice Transformation Team is to transform care in the clinic to be more patient-centric, while the Evaluation Team will collect data pertaining to the impact of the PTM, including clinic and quality improvement metrics, and provide ongoing feedback to the Practice Transformation Team.
University of Pittsburgh Medical Center - Presbyterian Shadyside, Screen. Engage. Treat. Train. Building HIV Capacity Today and for Tomorrow (SETT), Pittsburgh, PA
The UPMC Presbyterian Shadyside HIV/AIDS Program will partner with the UPMC Latterman Family Health Center in McKeesport, PA to expand HIV care capacity in McKeesport and southeastern Allegheny County. The project will transform a community health center's operations through practice improvements across all disciplines; enhancing HIV screening and reducing barriers to testing; expanding HIV education and improving cultural competency in all clinic disciplines, strengthening formal HIV training for residents and providers establishing HIV family medicine physician champions, and creating and fully integrating an HIV track in the Family Medicine residency program. The project's overarching goals are to train the next generation of family medicine physicians and mid-level practitioners to care for people living with HIV in primary care settings, particularly in medically underserved areas.
University of California at San Francisco, San Francisco, CA - Evaluation and Technical Assistance Center
The University of California at San Francisco (UCSF) will serve as the Evaluation and Technical Assistance Center (ETAC) for this initiative. The ETAC will coordinate the multi-site evaluation, provide programmatic technical assistance to the demonstration sites, and lead publication and dissemination efforts of best practices and lessons learned. UCSF will work with the SPNS Program to support 15 demonstration sites in all aspects of the development, implementation, and evaluation of the projects funded under this initiative. Efforts will be informed by extensive experience and expertise in the training and evaluation of practice transformative models and other health systems innovations. UCSF will provide leadership and support to demonstration sites implementing practice transformative models (PTMs) to improve health outcomes along the HIV care continuum.
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