The Center for Comprehensive Care (CCC) of St. Luke's-Roosevelt Hospital Center in New York City was founded in 1986 to provide a continuum of care to HIV-infected and affected individuals and their families. In 2011, the CCC served 5,218 living with HIV/AIDS. The CCC, while caring for New York City's most vulnerable and at-risk populations, has achieved marked improvements through quality improvement efforts in viral load suppression with approximately 68% of patients with a viral load under 200, and approximately 71% with a viral load under 400.
Eighty-eight percent of patients have a CD4 count quarterly, and 87% of patients have a viral load test quarterly. CCC currently retains 86% of patients in care. Retention efforts and lessons learned by the staff at St. Luke's-Roosevelt Hospital Center are described below.
a.) An automated appointment reminder call system is fed a daily report of patients to be called; this is run from CCC's electronic medical record system.
b.) The day after patients miss a scheduled appointment, the tool calls patients and encourages them to reschedule.
2. Outreach Mail and Phone Calls: The activities below are conducted quarterly.
a.) A report is generated through an EMR data extraction with a list of:
* Lost to follow-up patients defined by having at least one primary care visit in the past two years at the practice but not seen in nine months
* Poor immunological state patients defined with a CD4 T-cell count less than 200 cells/mm3 or HIV RNA level of greater than 100,000 copies/mL.
b.) Peers contact the clients by phone calls and letters. If the peers are able to reach the patients, they follow-up within one week to make sure the patients were able to schedule an appointment with a primary care provider. All outreach attempts and outcomes are logged in a tracking form that is closely monitored and reviewed by the program coordinator on a daily basis.
3. "No Patient Left Behind" Database:
a.) Each provider is given a list of patients who are out of care.
b.) Providers are responsible for making outreach efforts in 30 days for medically unstable patients and in 90 days for medically stable patients.
c.) The outreach efforts and outcomes are documented in a database that is monitored regularly by the Management Information Systems team.
Lesson Learned about Improving Retention in HIV Care
1. Comprehensive care services: Patients are likely to engage and remain in medical care if the clinic provides ancillary specialized services such as dental care, mental health, social work, and co-located services.
2. Contact information: Accurate documentation of patient contact and alternate contact information is extremely useful for outreach. CCC has launched several initiatives to keep an accurate record of patients' contact information.
3. Flexibility in communication methods: Patients have preferred methods of communication. For example, the patients in CCC's Young Adult Program rely heavily on text messaging for reminders about their group meetings. The CCC has an alert system in their EMR to notify them of the preferred method of communication for each patient.
Advice for Starting Improvement Activities to Retain Patients in Care
1. Know patient population demographics (gender, race/ethnicity, age, income, residential location, and health literacy): Create programs that reduce the underlying barriers that prevent engagement and retention in medical care.
2. Engagement of all staff: Include all staff in the process and offer regular feedback on retention efforts of patients.