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A strong provider-patient relationship, the assistance of a multidisciplinary care team, and frequent office visits are key aspects of care.
Thus, chronic treatment and retention in care are important both for individual patients and for public health.HIV services often are provided to persons who have challenges in regard to participation in their own health because of discrimination, poverty, active substance use, or mental health disorders.
Through both the specific services they provide and their overall approach to patients, clinics can have a substantial impact on the quality of care for HIV-infected persons. The context of HIV care still is one of persistent stigma regarding HIV infection itself and discrimination against racial, ethnic, and sexual minorities who constitute the groups with the highest HIV prevalence and incidence.
For example, a patient-centered clinic environment in which education and supportive interventions are emphasized will greatly enhance patients' knowledge about HIV infection. At the same time, funding streams from federal, state, and local governments have created opportunities for treatment of uninsured and underinsured individuals and provide resources for creating innovative, effective programs. The Affordable Care Act creates new opportunities to provide care for previously uninsured persons through two insurance mechanisms and other benefits described below.
The delivery of effective care usually requires a strong provider-patient relationship, a multidisciplinary approach, and frequent office visits.The stigma associated with HIV places a major psychosocial burden on patients. Stigma and discrimination must be addressed through strong confidentiality protections, emotional support, and cultural sensitivity. It is important to inform all patients of their rights and responsibilities in a language or manner that is respectful and understandable.Underserved racial and ethnic groups are overrepresented among people with HIV. Centers for Disease Control and Prevention (CDC) estimates that up to 25% of HIV-infected persons in the United States are not aware of their HIV infection (Branson, 2006), so there is still much work to be done to diagnose those individuals and link them to care. Efforts to understand and acknowledge the beliefs of patients from a variety of cultural backgrounds are necessary to establish trust between providers and patients.
For newly diagnosed patients, studies show that there often is a substantial delay in attendance at an initial HIV care visit, with only 20-40% of them accessing care within 6 months of diagnosis (Mugavero, 2008).
Cultural competency is imperative in the field of HIV care.Providers play a key role in the public health system's HIV prevention strategy.
However, for the clinics, the number of newly diagnosed patients who present for care is substantial. Disease reporting, partner notification, and risk assessment are important aspects of care.
A recent survey of 15 HIV programs across the country (median of 1,300 active patients each year) showed that a median of 250 (range 60-730) new patients were enrolled in each clinic each year (Yehia, 2008).To facilitate linkage to care, every HIV clinic should 1) be linked to agencies that provide HIV testing and services for persons with HIV, and 2) make clinic access easy and comfortable for the clients of those outside services. Patients may see this as threatening and may need education and emotional support in order to participate in this process.
Many HIV clinics establish referral linkages with community HIV counseling and testing services (CTS), AIDS service organizations (ASOs), sexually transmitted disease (STD) treatment facilities, family planning agencies, drug treatment facilities, local health departments, regional HIV hotlines, and local hospitals and emergency rooms. Patients need to be informed of their rights under the Health Insurance Portability and Accountability Act (HIPAA) and understand the public health implications of HIV.Many patients have inaccurate information about HIV infection that can heighten their anxiety, sabotage treatment adherence, and interfere with prevention behaviors.
Many clinics also offer free confidential or anonymous CTS using state or federal funding.Clinic personnel should build personal relationships with agencies that may provide referrals, invite staff of community agencies to visit the clinic, or hold open houses. Patients need assurance that HIV is a treatable disease and that, with successful treatment, they can experience a normal life expectancy. Providers from ASOs, such as case managers, can be invited to accompany patients on clinic visits.
They also need to hear explicitly that HIV may be transmitted through sexual contact, injection drug use and other blood contact, and perinatal exposure, and that they can take specific measures to prevent transmission to others.Many patients need the support that only a peer can provide.
Referring agencies must know what services the clinic provides and which patients it serves, as well as those it cannot serve.Various approaches may help facilitate the patienta€™s entry into care. Peer educators should be available to help patients navigate difficult health care systems, medication regimens, and lifestyle changes.HIV-infected patients need to have an active voice in their health care. For example, the HIV clinic at the University of Alabama at Birmingham offers new patients an orientation visit in the HIV program within 5 days of their request for a new patient appointment. In this clinic, an HIV program staff member initiates a welcoming interaction during the patienta€™s first phone call requesting an appointment and invites the patient to an orientation visit.
Outline how appointments are scheduled and how prescription refill requests are managed.Arrange to see patients with acute problems quickly. During that visit, a psychosocial assessment is performed, specimens are taken for baseline laboratory tests, any immediate health issues are addressed, and referrals for mental health or substance use disorder care are initiated, if indicated. The orientation visit is used to give patients information on how to use the clinic effectively, provide other on-site nonmedical services, and start processes to access health insurance or AIDS Drug Assistance Program (ADAP) services as needed. Patient portals can provide quick and direct access to nonemergent information and can provide accurate answers to questions that arise between visits.Helping Patients Cope with Emotional IssuesPatients coming to terms with HIV infection often experience a range of emotions, including anger, fear, shock, disbelief, sadness, and depression.
Loss is a major issue for patients with HIV because health, employment, income, relationships with friends, lovers, and family, and hope all may be threatened. In a nonrandomized comparison, the no-show rate at that clinic dropped from 31% to 19% with that approach (Mugavero, 2008).Success in linking newly diagnosed persons to care may be enhanced through the participation of HIV-infected consumers as peer advocates and peer navigators (see chapter Supporting Patients in Care). Many patients feel overwhelmed, and even patients who seem to be adjusting reasonably well can find it difficult to keep all of the many appointments that may be scheduled as they initiate care.
Either volunteer or paid peer advocates can meet newlydiagnosed patients who have been referred to the clinic, help familiarize them with the clinic services and staff, and help them adjust to both the fact of their HIV infection and their role as a chronic care patient.
Providers need to recognize that patients' emotional states affect their ability to solve problems and attend to important medical or social issues. Providers can do the following:Assess each patient's emotional state and the availability of friends and family for emotional support. Some patients will need counseling to help them decide whether to disclose their diagnosis to friends, family, or employers as well as support in dealing with HIV infection. The peers must be trained and supervised (see below), and the patients must agree to participate with peers, either individually or in groups.Clinics differ in terms of the characteristics of people living in their catchment area and in regard to the levels of expertise of clinic staff members. Patients often feel hesitant about seeking emotional and practical support.Deliver important information in easily understood terms and in small amounts. Some successful clinics target a narrow but underserved population and concentrate on meeting the needs of that population. Reassess patient understanding of crucial information at subsequent visits, and repeat important information as necessary. The environment and services offered by the clinic may be tailored to the patient population. For example, a youth-friendly clinic may differ in these respects from one targeting the working poor.Retaining Patients in CareRetaining patients in care is an ongoing challenge (see chapter Supporting Patients in Care).
Patient self-management involves adopting new health behaviors and requires changes that will occur as a progression of motivational skills.
Among the 15 surveyed HIV clinics mentioned above, the median no-show rate for appointments was 28% (range 8-40%). Motivation is defined as the "probability" that a person will enter into, continue, and adhere to a specific change strategy. Across all the clinics there was a median annual loss-to-follow-up rate of 15% (range 5-25%) (Yehia, 2008). After patients have self-management skills, they still need help setting action plans for their health care.
Peer educators and patient advisory groups can help patients become more involved in their care.In order to best support patients, it is helpful to have peer educators available for them during initial and subsequent visits. Some patients believe that HIV was created in government laboratories to target African-Americans and may or may not believe that the clinic staff is part of the conspiracy. It is important that all staff members be trained to anticipate, recognize, and work with issues such as these.Patients may experience obstacles to care when there are cultural differences or language barriers between themselves and the staff members. The HIV program will listen to this group's suggestions and use them to improve patient satisfaction and clinic functionality. Patients always should be made to feel that they came to the right place (even in cases in which they must be referred on to another provider or clinic).
The PAG's role could involve identifying clinic problems, recommending changes in the care delivery system, and discussing new treatment approaches.
They must understand requirements for referrals from managed care providers, and new patients may need help with fulfilling such requirements. Some patients may feel ambivalent about seeking medical care if, by doing so, they risk disclosing their condition. Others may have learned from experience to expect rejection and therefore may not trust care providers. It is essential for providers to be supportive of patients who are dealing with the burden of stigma.Stigma of Fear of ContagionUnfortunately, patients and their families are often unaware that routine household contact with a person with HIV poses no risk of contagion. Patients who have had unpleasant experiences seeking medical care in the past, or those who are not used to engaging in medical care, may get better support from another consumer than from a nonpeer staff member. They should be educated about that, and also taught what to do in situations that do pose risk, such as when bleeding occurs. Youth especially may trust information from peers more so than from adult professional staff members.Peer advocates or peer navigators may work in this role part time or full time, as either volunteers or paid staff.
Often they work specifically to make new or recently returned patients comfortable in the clinic.
For example, gloves should be worn only as appropriate during physical examinations and as consistent with universal precautions.
Some programs designate consumers as peer navigators, emphasizing their role in helping new patients, or patients returning after being lost to care, in finding their way through the health care system and support systems. There should not be separate facilities or special procedures for HIV-infected patients.Stigma Associated with Being Gay, Lesbian, Bisexual, or TransgenderDemonstrating respect and providing excellent care to patients with various cultural backgrounds, beliefs, and sexual orientations are central to medical professionalism. Peer advocates also can help patients ask questions or make their needs known to the clinic staff. Providers should approach patients in an open and nonjudgmental fashion and be familiar with medical management issues unique to these populations, such as appropriate screening for sexually transmitted diseases for men who have sex with men (MSM) and hormonal treatment for transgender patients. Advocates or peer-support persons can be instrumental in helping patients build self-esteem and acquire new habits that will enable them to use health care services in a proactive manner. Clinic staff members also must be respectful and supportive; having a staff that is familiar with lesbian, gay, bisexual, and transgender (LGBT) cultures is a natural way to create a welcoming environment. Peers are especially helpful when they model good health behaviors, including adherence with appointments and medications and with avoiding unsafe sex or other HIV transmission activities. Providers and social workers should be aware of community agencies with resources available to people who are lesbian, gay, or transgender.

In some cases, peers have been the basis of a successful program, but in other cases peers model poor health behaviors and themselves become ill. In addition, providers and clinic staff members should be aware of special legal issues that affect these populations. Peers need to adhere to confidentiality rules and good work habits and need to provide accurate information to other clinic staff. For example, designating a durable power of attorney for medical decision making can be particularly important in states that do not recognize same-sex partners or spouses as legal next of kin.Other Special Cultural IssuesAfrican-Americans, Hispanics, and some immigrant groups are disproportionately affected by HIV, and many people of color with HIV infection have major socioeconomic problems such as poverty, homelessness, lack of medical insurance, lack of acculturation, and undocumented immigration status. This can be done through written materials such as posters and pamphlets, as well as through comments made by providers during clinic visits.
All these obstacles can make accessing health care difficult and attending to health problems less of a priority for the individual. These very inexpensive interventions have been shown to improve clinic attendance (Gardner, 2012).Patients should receive appointment reminders about 48 hours before each appointment. A patient's cultural background influences health-related beliefs and behaviors, and personal or historical adverse experiences may make some patients distrustful of medical care. Reminders typically are given by phone or mail, although text messaging or other forms of electronic communication may be more useful in some settings.
In addition, some patients' distrust of medical research can impede their willingness to access new drug therapies. It also may be effective to have a staff member contact patients who have missed appointments to find out what prevented them from attending, offer to reschedule, and try to eliminate barriers to clinic attendance.Factors such as child care needs, work schedules, and transportation problems can be substantial barriers to attending clinic appointments. Culturally competent communication between provider and patient may substantially affect adherence with therapies. Addressing these and other challenges may require coordinated efforts by the clinic staff, case manager, and others. The team of peer educators should be culturally diverse in order to be effective with all minority groups.Confidentiality and DisclosureConfidentiality of medical information is always mandatory, but the stakes are particularly high for patients infected with HIV, who risk losing medical insurance, employment, and the support of friends or family if their diagnosis is disclosed inappropriately.
These efforts are more successful when patients are asked for current telephone, address, and other contact information at every clinic visit.
Although people with HIV infection are protected against discrimination under provisions of the Americans with Disabilities Act, discrimination can be difficult to prove, and there are strict time limits after which charges of discrimination can no longer be made.Protecting Patient ConfidentialityAdherence to the HIPAA regulations is an important aspect of protecting patient confidentiality. Personnel policies should reinforce measures such as requirements that papers and computer screens containing patient-identifying information not be left unattended and should include provisions for documenting whether phone messages can be left for the patient, and if so, with whom.Helping Patients Disclose Their HIV StatusPatients who have a support network function better than those who are isolated.
However, patients' fears of disclosure are often well founded, and providers must find a balance between accepting patients' unwillingness to disclose their HIV status and the need to develop support networks. Outreach by medical professionals included efforts by physicians, nurses, or physician assistants to meet patients outside the HIV clinic setting, often in another part of a medical facility such as an inpatient unit.
Patients may find support groups or individual psychotherapy sessions beneficial in deciding when to disclose, and to whom.The sex and needle-sharing partners of people with HIV need to be informed about their possible exposure to HIV. These encounters were the most expensive type of outreach, but the most effective in engaging new patients in care.
Local health departments can either assist patients in making these disclosures or provide anonymous partner notification for them.A patient-centered clinic staff can help patients with disclosure.
Encounters with medical professionals did not increase adherence with medications, however.
For example, staff members could encourage patients to bring their partners to one of their clinic or counselor appointments in order to disclose their HIV serostatus in the context of the clinic visit.
Other types of outreach, either face-to-face or otherwise (by phone, email, or postal service), by professional, nonprofessional, or paraprofessional staff members, increased adherence with medications, but not with clinic attendance. This could allow the health care professional to answer the partners' questions and would provide a neutral environment for the disclosure discussion. More frequent encounters of this type were associated with greater improvements in adherence. Risk of intimate-partner violence should be assessed.Public Health Role of Providers in the HIV EpidemicPrimary care providers must consider their public health role in curbing the spread of HIV. The incidence of HIV remains unacceptably high, and may be increasing in some populations, especially in communities with relaxed adherence to safer sex recommendations.All AIDS diagnoses and, in some states, all positive HIV test results must be reported to the state health department.
State laws vary in reporting requirements and subsequent notification of potentially exposed individuals (see the Clinician Consultation Center Compendium of State HIV Testing Laws), but the name of the source contact is never divulged to the person being notified. This approach has been most highly developed for diabetes care, but it can apply equally well to a wide range of chronic illnesses. Providers should become familiar with the laws of their jurisdiction by contacting their health department. In contrast to the tradition of teaching patients the pathophysiology of their health condition in lay terms, with this model, training involves focused skills building so that patients can better monitor their health status, use their discretionary medications, and know when and how to contact the professionals for assistance. Assure them that their names are always kept confidential and are never given to potentially exposed individuals by the health department.Carefully assess patients' risk-taking behaviors, educate them regarding HIV transmission, and perform screening for sexually transmitted diseases. Frequent contact between patient and clinical staff, both face-to-face and through other means, both in clinics and in the community, usually are involved. Program-wide monitoring of process and outcome variables, such as frequency and results of CD4 cell counts and plasma HIV RNA levels, informs the practice as a whole as well as the quality of care for individuals. These interventions have been shown to improve outcomes, but do not necessarily reduce costs because the staff time required can be substantial.Patient-Centered Medical HomeThe chronic care model concept has been merged with the concept of a home to coordinate care and medical records for children to create the current model of the Patient-Centered Medical Home or PCMH. This concept usually is applied to primary care providers and practices; however, it potentially applies to a specialist who cares for the most prominent or demanding of a patienta€™s health problems as well as other primary care issues.
HIV programs often act as the primary care provider, especially for patients who do not have insurance and therefore have limited access to other providers, whether the practice is otherwise a primary care or specialty clinic.
Many HIV clinics have the capacity to organize and implement a chronic care approach and to coordinate services across other specialties and providers in order to be a true medical home. Several national organizations provide certification of PCMH status to clinicians and practices.
One organization is the National Center for Quality Assurance or NCQA (see details on its PCMH certification process on its website). NCQA will certify individual providers and practices even when they are located within larger institutions.
Another organization is the Joint Commission, which usually certifies PCMH status within an organization that has Joint Commission accreditation for other purposes. General information about the concept and other agencies that provide certification is available online at the National Center for Medical Home Implementation. In some states or localities, insurers such as Blue Cross and Aetna have their own certification process.
Some health plans provide additional payment to primary care clinicians and practices that are certified as medical home providers, to support the health informatics infrastructure, care coordination, teaching and skill building, and follow-up outside of office visits that are required to manage panels of patients in a proactive manner.
The PCMH approach also will provide financial opportunities for practices that become involved in Accountable Care Organizations (ACO), as pay-for-performance models of reimbursement are implemented across the United States.
HRSA provides technical assistance to Ryan White grantees interested in being certified as a medical home, and to those interested in learning the lessons of this process even if not seeking certification. Additional information regarding training, resources, and webinars is available on the HRSA Target Center website.PCMH NeighborThis is a concept for specialty practices who do not wish to or are not able to take up full care coordination for a patient, or who may not be eligible as specialists to become certified as a PCMH (see "References," below).
With this concept, a specialist participates in timely and thorough sharing of information and care coordination with a patienta€™s primary care medical home, so that the full array of PCMH services is available without duplication but with the added expertise of the specialty practice. However, implementing this enhanced level of care coordination with the patient centeredness, proactive approach, and skill building that characterize a PCMH, is expected to improve outcomes and may create opportunities for enhanced reimbursement in the future. This coordination also will be useful for specialist participation in ACOs.This is a concept for specialty practices who do not wish to or are not able to take up full care coordination for a patient, or who may not be eligible as specialists to become certified as a PCMH (see "References," below). With this concept, a specialist participates in timely and thorough sharing of information and care coordination with a patient's primary care medical home, so that the full array of PCMH services is available without duplication but with the added expertise of the specialty practice. Most patients will need additional primary care and specialty health care and support services; it is often more effective and more convenient when these are available on-site rather than by referral.
For health interventions to be successful, many patients will need assistance with health behavior change.The services ideally provided by the HIV clinic include those on the list that follows. Detailed information on most of these topics is available in other chapters in this manual. After the initial screening, new standards promote periodic screening for acquisition of hepatitis C in persons at risk.Assessment of ongoing sexual or drug-use behaviors associated with HIV transmission, and counseling or other interventions to reduce transmission behaviors.
Interventions regarding sexual transmission behaviors should be linked with family planning.General health screening for hypertension, diabetes, dyslipidemia, and cardiovascular risks, and cervical, breast, and colon cancer. The role of anal cytology in screening for anal cancer remains uncertain because of limited data on effective management of anal dysplasia.Care of common general medical illnesses including hypertension, dyslipidemia, uncomplicated diabetes, obesity, asthma, and chronic obstructive pulmonary disease. Care of a wider range of disorders, such as congestive heart failure and chronic kidney disease, will vary by practice.Evaluation and care of common comorbidities including hepatitis B and C infection and latent and active tuberculosis (TB).
Clinics with access to Ryan White Treatment Extension Act funding must accept patients regardless of health insurance status or ability to pay. Federally qualified health centers also can accept uninsured patients and have an important role in expanding access to care. Every state receives Ryan White Part B funds for an ADAP to pay for antiretroviral agents and often other drugs for the uninsured or other eligible persons with HIV. Clinics planning to serve a moderate-to-high volume of HIV patients can apply for a Ryan White Part C planning grant. Clinics serving women, pregnant women, youth, and families are eligible to apply for Ryan White Part D funding. Other individual providers or small clinics may be eligible for Part B reimbursement for medical care of uninsured persons, by working with local case management agencies.The ACA created online insurance marketplaces or exchanges, at which persons and families with incomes between 100% and 400% of the Federal Poverty Level (FPL) can purchase affordable insurance using tax rebates (for 250-400% of FPL) and other subsidies (for 100-250% of FPL). In addition, many states are expanding Medicaid eligibility, for example to persons and families with annual incomes up to 138% of FPL. Another benefit of the ACA for persons with HIV is the requirement that core health benefits, including evidence-based preventive services, are provided by all health plans.
HIV patients will benefit from the fact that preexisting conditions no longer disqualify persons from obtaining individual health insurance at competitive rates, and that more employers are now expected to provide health insurance for employees. Ryan White Part B Drug Assistance Program (DAP) funds may be used to assist patients with the costs of health plans if doing so is less expensive than providing direct benefits to DAP beneficiaries. Details about the plans available on the exchanges, their costs and benefits, the role of DAP, and Medicaid eligibility vary by state.
HIV provider organizations will need to contract with some of the new plans available on their state exchanges, and providers will need to educate themselves on details of their plans.

Local organizations have been designated as Certified Application Counselors (CACs), which allows trained staff to assist patients with enrollment on the exchanges and to certify that hardcopy documentation provided by patients, if needed in the course of online enrollment, is accurate. Other help may be provided by ACA navigators, who can assist clients with enrollment decisions but are not able to certify clientsa€™ documentation. Specific details and mechanisms for this interaction between ACA insurance benefits and Ryan White benefits are still evolving. An apparatus for pulse oximetry is very useful in assessing patients with respiratory symptoms. Easy access to facilities for collecting venous blood, urine, and stool specimens should be available. On-site access to rapid tests that do not require Clinical Laboratory Improvement Amendments (CLIA) certification may be useful, such as urine pregnancy tests, fingerstick blood glucose tests, and perhaps the rapid HIV antibody screening tests.
Laboratory certification to perform urine analysis and microscopic examination of vaginal fluid specimens is very useful.
One important resource is the AETC National Resource CenterA and the local performance sites of the AETCs funded by HRSA to provide training and technical assistance to clinics.
The NRC, local AETCs, and the website of the Clinician Consultation Center provide detailed and patient-specific education to assist clinicians in making treatment decisions. Written educational materials for staff, such as national and regional treatment guidelines, may be obtained free of charge via the Internet and are updated regularly.
Assistance with enhancing and implementing systems of care, including instituting a quality management program, also is available from the AETCs. Ideally, members of the staff can meet for a few minutes prior to each clinic session to anticipate special needs and allocate personnel resources.
Some clinics place a checklist on each chart at each visit to indicate which team members a patient is meant to see that day and to confirm that all intended interactions have occurred.The teama€™s potential can be best utilized if there is a regular opportunity to meet and discuss patients outside clinic sessions, in multidisciplinary team meetings. When all members participate, the discussions can range from the selection of antiretroviral regimens for a patient to addressing the patienta€™s adherence issues or chronic mental illness. Services for infected and affected family members also can be coordinated at these meetings.Table 1.
Excellent case managers also help motivate patients.Traditionally, case managers should perform periodic assessments of clientsa€™ needs and update their comprehensive care plans at least every 6 months. With the evolution of the PCMH concept, and a stronger need to have health care coordination for patients with multiple complex medical conditions, the approach to HIV case management is evolving.
A new, and perhaps more useful, model is one in which community-based case managers provide linkage and follow-up for community-based services such as health insurance, transportation, housing, food security, income, and psychosocial support generally. At the same time, medical case managers, usually nurses, provide coordination of medical care services, with support for appointment and medication adherence, side-effect management, self-care, and clinical monitoring between office visits.Close coordination between clinic staff and case management is important for avoiding duplication of efforts and services. Written communication, for example, when sharing case management care plans, can be useful. Case management agencies and clinical sites need to obtain written consent from patients to share the information that allows coordination.Creating useful linkages with community-based servicesClinics can develop relationships with community-based case managers or directly with providers of specific services, such as mental health, substance abuse, or housing services. Personal contact between staff members of clinics and outside agencies is important for establishing the relationship, and ongoing contacts are necessary for coordination.
Community organizations often are pleased to give in-service education to clinic staff personnel in order to streamline the referral process. Clinics can function as advocates to ensure that their patients receive the attention and services for which they were referred.
Periodic interdisciplinary meetings of clinic staff with representatives of community-based agencies, including case managers, are very useful.Consumer involvement in HIV clinical careMany clinics have created patient (consumer) advisory groups to participate in planning and quality management.
The role these groups take depends on the specific clinic; some advisory boards educate themselves about clinic issues and provide expert input to clinic processes.
Many clinics display HIV-related education materials, including information on safer sex practices and birth control; many also provide male and female condoms with instructions about their use. In some clinics, a separate area for educational materials may help clients maintain confidentiality. Free educational materials are available from federal and state HIV websites, and the pharmaceutical industry also produces some appropriate materials.Many ASOs and clinics host support groups for interested patients. Participation must be voluntary, and only patients who are comfortable with revealing their status to other patients will be willing to participate. Groups may be more effective if an experienced counselor or mental health provider leads them.Some clinics hold classes on HIV and adherence.
Clinics serving pregnant women and parents may include classes on birth preparation and parenting. For clinics that have a community advisory board, the board can be the organizing force for these community updates.
Both public grants and funds from the pharmaceutical industry may be used to support these events.Some youth-oriented clinics arrange social events and outings for their patients. These three types of software may be available as a suite or as separate products that can be linked, although the linkage of separate products sometimes is challenging. Software products may be designed to run on one desktop computer in a small practice or on a computer server that can be accessed by many users simultaneously, or they may be based on the Internet and managed by the vendor. This is very useful in tracking clinic productivity and patient adherence with visits, and in developing an overview of a patient population and understanding the finances of a practice.
PMS software can provide data regarding some quality measures, because services such as vaccinations and procedures performed within the practice can be tracked easily.EHR refers to software used for clinical care, as a substitute for or supplement to a paper medical record. Providers enter their notes into these systems, and clinic staff document procedures and interventions performed in the office. With many systems, prescriptions may be written within the system and sent to pharmacies electronically or by fax, diagnostic tests may be ordered, and test results may be sent electronically into the EHR for clinician review and action. Paper documents often can be scanned into the system so that hard copies of outside reports can be included in the medical record. EHRs that substitute for paper records can reduce issues of storage, retrieval, and access to paper charts once the transition is complete.EHR refers to software that the patients can access to see part or all of their medical record.
While this potential is real, substantial effort and investment is required to deploy and maintain systems that are useful to clinicians, administrators, and payers. An EHR for a small office or one that is deployed only in an HIV program can be managed fairly easily, and some products developed specifically for HIV care are available. An EHR for a large organization, such as a multispecialty group, is more complex and requires much more planning, training, maintenance, and sometimes customization to meet the needs of all the users.Success in EHR implementation is greater when the users are involved in the selection and implementation of the system. Text-based systems are often quicker to learn; however data-based systems may provide more information for quality and program management and reporting needs and may be more useful for billing functions. Some EHR software packages are available at no cost (such as the Veterans Health Administration system and other open-source software) whereas others are available commercially and are maintained by vendors.Once fully implemented, EHRs are expected to improve quality by improving communication and coordination among clinicians, reminding clinicians about standards of care and the timing of health maintenance or monitoring, avoiding errors associated with handwritten notes or prescriptions, documenting prescriptions, and providing warnings on potential drug interactions or hazards associated with specific diagnoses.
EHRs are expected to lower costs by reducing the expense of maintaining paper records and by reducing duplication by sharing prescriptions, test orders, and test results among all users.
EHRs can provide both process and outcome data for monitoring and for quality improvement activities (see chapter Quality Improvement), and data for Ryan White grantee reports. EHRs are not simply replacements for paper records; effective use involves changes in the work habits of clinicians. Successful implementation of an EHR system requires working with the end users as the system is developed so that reasonable compromises and accommodations can be made. An EHR system that must share data with another system such as a hospital EHR or a laboratory reporting system can be very complex and require substantial investment of time and money, even when the different software systems use compatible data standards.
Implementation of EHR systems is not a panacea and will not solve all health care system problems, but use of EHRs is likely to be a necessity for functioning in the evolving systems of health care finance and reimbursement, as well as an essential tool for monitoring and assuring quality of care for the individual patient and at a population level.Ensuring that patients receive necessary services at clinics without EMRsAt clinics in which paper charts are in use, forms, checklists, and flow sheets can be designed to remind providers of care standards, simplify data collection, and serve other purposes as well. Staff members may find it challenging to adjust to using new forms; however, using checklists often saves time by listing required elements of the visit and by reducing the amount of writing. Including representatives from clinical, data, and quality management staffs in the process of designing forms increases the acceptability of new forms or procedures.Effective Management of HIV ProgramsManaging a program with all the components described in this chapter is challenging.
For enhancing communication and advancing the clinica€™s objectives, staff meetings are important. Smaller organizations may include the entire staff at monthly meetings, whereas larger organizations may have staff meetings less often, such as on a quarterly basis.
Some larger organizations find it useful to have a monthly interdisciplinary meeting of program leadership, with representation of the different disciplines or program components, such as nursing or clinical care, psychosocial support, data and quality management, behavioral health, research, finance, administration, satellite services, and consumers. These coordinating meetings provide an opportunity for personnel from each discipline to update others on current activities, challenges, successes, and initiatives. They also provide a regular forum for updates on fulfilling grant-related work plan tasks and reviews of financial reports. In smaller programs, quality management may be part of monthly staff meetings whereas in larger programs it is more practical to have a separate quality management committee (see chapter Quality Improvement).HIV programs often are contained within larger health organizations, and may be outliers with regard to the patients they serve and other features. It is important for program leadership to build and maintain support within the host institution. Where applicable, this may involve reminding the host institution of the grant or other funding the program generates. HIV programs often are on the forefront of innovative health care delivery, for example, in adopting quality management approaches and using other data to assist program management, incorporating EMR and PHR systems, implementing interdisciplinary care that integrates medical care with behavioral health, using a chronic care model or providing a medical home for patients, and linking with community-based programs. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. Incorporating HIV prevention into the medical care of persons living with HIV: Recommendations from CDC, the Health Resources and Services Administration, the National Institutes of Health, and the HIV Medicine Association of the Infectious Disease Society of America. Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition. Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care. Improving health outcomes for youth living with the human immunodeficiency virus: a multisite randomized trial of a motivational intervention targeting multiple risk behaviors.

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