HIV ACCESS PCMH Demonstration Project:
Home Improvement Bulletin
May 2013
CHRP Meeting Recap
May 2013 CHRP meeting
PCMH Project Team, from left to right: Nadia Salibi, Lois Bailey Lindsey, Erin Gael Friedman, Megan Crowley, Paloma Pavel, and Dan Clanon


The PCMH Project team met with our funders at the California HIV/AIDS Research Program and statewide cohort in May to share findings and best practices.  There were several shared themes to the presentations: the challenges and benefits of empanelment, and what it takes to create system-wide change.


The Alameda County PCMH Project team shared our successes in expanding panel management within our network and bringing patients back into care, along with the challenges of keeping momentum going in an environment where clinics have many competing priorities.  Our full presentation can be viewed by clicking here (Flash plugin required).


UCSD's presentation explored the idea of breaking down silos, particularly by including IT staff in the clinical care teams.  They also talked about DSRIP V and its contributions to empanelment and added staff.  


The Los Angeles team at OAPP described the beginning stages of implementing a "PCMH Prototype", which consists of Medical Care Coordination and population management using i2iTracks.  One of the main topics of their talk was what a huge challenge it can be to implement change on a large systems scale, especially as employees of an outside organization.  


UCSF discussed strategies for recruiting geriatric HIV patients into the Silver Project. They described the challenge of implementing team-based care and encouraging physicians to let go of tasks that can be handled by other clinic staff.


The team from the C.A.R.E. Program in Long Beach shared the process of connecting their Electronic Dental Record to the EHR, and the challenge of creating seamless information sharing between the two systems.  

It was inspiring to hear how each of the five statewide projects has evolved and continues to improve care for HIV patients throughout California. 
NACHC PCMH Accelerator Webinar Series


The National Association of Community Health Centers (NACHC) is currently delivering a series of free webinars on several major EHR systems (NextGen, eClinicalWorks, GE Centricity, and SuccessEHS). Each two-part webinar provides guidelines and tips for maximizing the use of the EHR system for PCMH recognition. These sessions are targeted towards health center leadership as well as any other staff involved in PCMH project teams. 


For more information on the series, or to register for remaining sessions, visit NACHC's website

East Bay Linkage to Care Advisory Group 


Earlier this year, staff from various organizations serving HIV-positive individuals in the East Bay began meeting to identify strategies for improving linkages between agencies in order to enhance care coordination. Goals of the group include:
  • Create warm hand-off procedure and protocol draft
  • Maintain an updated care clinic linkage contact list online
  • Work on a region-wide linkage surveillance system, first within the Alameda/Contra Costa TGA
  • Support and training on building linkage teams within and between agencies
These goals are very consistent with the PCMH model, and the work of the Linkage to Care Advisory Group will no doubt improve patient care in the East Bay. At the most recent meeting, held earlier this month, the group drafted a "warm hand-off" algorithm to guide staff in ensuring that referrals are successful. 
To join the East Bay Linkage to Care Advisory Group, contact Shailey Merchant Klinedinst at The next meeting is scheduled for September 5th at the East Bay AIDS Center (EBAC). 
In This Bulletin
CHRP Meeting Recap
NACHC PCMH Accelerator Webinar Series
East Bay Linkage to Care Advisory Group
CPCA PCHH Lunch & Learn Series
East Bay HIV Update
Assistance with PCMH Applications is available for AHC/CHCN Clinics

PCMH Project staff are available to assist AHC/CHCN health centers applying for NCQA PCMH Recognition. We can help you to:
  • Clarify NCQA PCMH 2011 Standards and documentation requirements
  • Review a selection of documents, including all Must Pass Elements, to verify they are sufficient and appropriately labeled
  • Provide feedback on potential opportunities to improve your score before submission
Contact Project Coordinator Megan Crowley at 510.297.0425 or to get started! 
CPCA PCHH Lunch & Learn Series
As part of their Patient-Centered Health Home Initiative, the California Primary Care Association hosts monthly "Lunch & Learn" webinars on topics related to PCMH transformation and recognition. The series takes place on the third Thursday of each month from 12:15-1:15pm. Visit CPCA's registration calendar to register for future sessions. 
The next Lunch & Learn session will take place on Thursday, June 20th at 12:15pm and will focus on NCQA PCMH Standard 2 (Identify and Manage Patient Populations). The facilitator will be our own PCMH Program Coordinator Megan Crowley, who also serves as a PCHH Practice Coach for CPCA. To register for this session, click here

Upcoming Event: East Bay HIV Update


The 26th Annual East Bay HIV Update is scheduled for all day Friday, June 7th at Samuel Merritt University in Oakland. This event is for providers of medical care and supportive services for HIV-positive individuals in the East Bay. 


The event will include presentations and workshops on various topics, including: new scientific updates, ethical issues, health care reform and PLWHA, current controversies, and reproductive health. 


Click here to download the flyer from the East Bay AETC's website. To register for the event, click here.

Next Steering Committee Meeting: June 12, 2013


The next PCMH Demonstration Project Steering Committee meeting is scheduled for Wednesday, June 12th, 1:00pm - 3:00pm at Alameda Health Consortium. More information will follow soon.

Want to know more about the PCMH Project?


For more information about our program, check out our webpage.


To view past Home Improvement Bulletins and Voices from the Field videos, please visit our Communications Archive.


For more information on our grant, view California HIV/AIDS Research Program's website.


Check out our Evernote Notebook, which we've compiled to keep track of all the tools, articles, and other PCMH-
related resources we've come across. For help finding a resource, or to suggest an addition to the Notebook, contact
Megan Crowley.

Contact Us:

Erin Gael Friedman, Project Director


Megan Crowley, Project Coordinator


Dan Clanon, IT Systems Specialist


Lois Bailey Lindsey, HIV Program Director


Kathleen Clanon MD, Principal Investigator

View our videos on YouTube