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in+care Newsletter | June Newsletter

   Issue 8 

National Campaign to Improve Retention in HIV Care
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In This Issue
Heart Felt Thank You!
Upcoming Events
New Way to Share Strategies
Evaluating in+care
Provider Spotlight

32 days

until the next data submission deadline

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Data - National Averages
(as of 5/29/12)

Gap Measure
(n = 155 sites, 115,964 patients)
Visit Frequency Measure
(n = 160 sites, 91,715 patients)
New Patient Measure
(n = 178 sites, 7,862 patients)
Viral Load Suppression
(n = 176 sites, 135,685 patients)
Quick Links

Campaign Headquarters

National Quality Center (NQC)

New York State Department of Health AIDS Institute


90 Church Street, 13th floor
New York, NY 10007


Work: 212-417-4730
Fax: 212-417-4684


Heart Felt Thank You!


The in+care Campaign is continuing to evaluate its successes in ensuring that people living with HIV are consistently engaged in clinical relationships with medical providers, as well as how we can best support you in these efforts. During April, the Campaign team conducted several focus groups to get your input. Participants were selected on the basis of several key factors to make sure we had a sample that was reflective of Campaign participation. These factors included, HRSA health region, primary language, agency type, Part funding, size of client pool, level of experience working on retention projects, and whether the agency was in a rural or urban setting.


We would like to thank all the individuals and organizations that participated! We have a list of agencies that participated in focus groups available on the resources page of our website. Thank you for generously donating your time, and for helping this Campaign to make a positive impact in the health and lives of people living with HIV/AIDS across the United States and its jurisdictions!

Upcoming Events and Deadlines


+ in+care Campaign Office Hours

Every Monday and Wednesday 4-5pm ET

Office Hours allow in+care Campaign participants to directly communicate with NQC staff and consultants. Callers can ask general questions, request technical assistance or engage in dialogue about the Campaign. Upcoming discussion topics include:

  • Monday, July 2 - open format; no scheduled topic
  • Wednesday, July 4 - HOLIDAY - no office hours
  • Monday, July 9 - Developing Model Policy on using Social Media and texting to contact patients
  • Wednesday, July 11 - Designing and Implementing Retention projects

Dial-in#: 866.394.2346

Participant Code: 418 257 6142 #



+ Journal Club Webinar: Nikki Cockern

Wednesday, July 11, 2012 3pm ET

Nikki Cockern of Wayne State University will share her recent research findings on retaining youth in HIV care. 


Dial-in#: 866.394.2346
Participant Code: 397 154 6368 #

URL: http://www.nqcqualityacademy.org/incarecampaign



+ Improvement Update Form Submission Deadline  
Monday, July 16, 2012



+ Data Sumission Deadline
Wednesday, August 1, 2012
Keep up-to-date with the latest in+care events through our webpage: http://incarecampaign.org/index.cfm/75283  






New Way to Share Improvement Strategies!

Since the Campaign started, many of you told us that we needed a more streamlined way for Campaign participants to submit their improvement strategies. We have heard you and made an update to our website! You can now tell us your improvement stories with the click of a button on the homepage. Simply tell us your improvement stories in the upper left corner of the homepage!

Evaluating the in+care Campaign Part II

How well is the Campaign meeting its stated goals and objectives? We recently asked participants to complete an online survey to provide some feedback on Campaign activities so far. Thank you again to the 25% of all Campaign participants who completed the survey! Here are some of the general findings from the survey.

  • Campaign toolkits were rated as the top reason why participants joined the Campaign.
  • Word-of-mouth outreach by NQC, HIVQUAL and HRSA were also important to get teams involved.
  • Survey respondents have found the performance and improvement data reviews to be most impactful.
  • For those participating in content-driven webinars, topics related to improved communication across disciplines have been impactful.
  • Database benchmarking functionality has been very useful for Campaign participants.
  • The promotional video, the website, the newsletter and the FAQ document have also been useful.
  • Peer learning other than webinars (coaching, championing, office hours) has been less impactful.
  • Great new ideas for upcoming webinar topics. If you have ideas for additional webinar topics you would like to see, please send staff a note at Michael@NationalQualityCenter.org.

To see the full result-set from the survey, visit the resources page of our website. Stay tuned to the website for a report-back on focus group findings! Thanks again to all those who responded!! Please feel free to contact us with any questions, concerns or additional feedback! Michael@NationalQualityCenter.org.

Provider Spotlight | St. Luke's - Roosevelt Hospital Center, Center for Comprehensive Care (CCC)

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.


Retention Tools 

1.    ReminderPro

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.

Connect. With patients.
Collaborate. With a community of learners.
Change. The course of HIV. 

incareCampaign.org  |  212-417-4730