DCHC MAT/ STOP HIV
Collaborative Team
Improvement:
Lost To Care Engagement
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Improvement relates to: identifying, referring and re-engaging those lost to care.
How we are succeeding:
Increased staffing to MAT’s outreach team (1 outreach worker and 1 nurse) from
Memorandum Of Understanding with STOP
Hold regular meetings to discuss the “Lost to Care” List.
Weekly MAT team meetings to discuss client engagement strategies (i.e. food
security, housing, social support, etc)
Track the most recent dates of blood work and primary care visits on the DCHC
collaborative database.
Data to back up method:
MAT Team Referral Tracking Sheet (To track referrals on our “radar”)
Collaborative Database including blood work and primary care visits
Review older versions of MAT/ Pharmacy databases, to capture those who
are not yet linked to another primary care provider - “Lost to Care” list.
Social work piece- keep record of clients needs/ interests/ quality of life/ challenges/
etc. for engagement
Case Example
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Jane is a 37 year-old female, diagnosed with HIV 1999, has
difficulty staying on ARVS, off treatment for years.
Referred to MAT through her family doctor and the STOP team in
April with a viral load of 24,220 on April 20th, 2011. Had pneumonia
and wouldn’t go to hospital.
Not on ARVs due to substance abuse, depression, personal
relationship and housing issues.
Jane moved into supportive housing for women in April.
MAT outreach team found she was chaotic, struggling with her
addiction, wasn’t initially interested being involved with MAT.
MAT outreach team started their relationship by building trust and
bringing her food (i.e. yogurt, Ensure, ginger ale, vitamins). Food
security was her identified major issue.
Jane expressed that she valued the constant contact through
outreach and was very grateful for the daily visits. She was worried
she was going to wake up dead and no one would know.
Eventually Jane went to the hospital for her pneumonia and was
reconnected with her family then.
Outreach team referred her to A Loving Spoonful, offered to help
with caring for her cat, i.e. food, neutering, and reconnected with
the Food Bank and AIDS Vancouver.
Case Example
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Jane agreed to start ARVs and her regimen was started on June
30th, 2011.
MAT STOP Outreach Team deliver ARVs daily to Jane.
July 16th, 2011 her viral load decreased to 9,775.
Today Jane states she feels her depression is now better
managed. As her ARV adherence is 97%, and we’re waiting for the
results of her latest viral load.
Jane comes in to MAT from time to time, she is less sedated and
so grateful for the care she is receiving. She is more open to the
outreach team being involved with her medication management.
We know that because of additional supports and services her
quality of life has improved.
Jane needed to be validated and listened to. MAT Outreach team
had the time to spend with her and be flexible. They’ve enhanced
her self directed nature.
Through weekly case conferencing, social work accessibility,
outreach, communication with other agencies (i.e. supportive
housing team) and her primary care provider, we have been able to
create a suitable care plan for engagement with Jane.
Continuing Challenge:
Recalling Patients Overdue for
Bloodwork
Challenge Relates to: Recalling patients overdue for Blood work.
Tools that didn’t work:
Creating a list of patients who have not had blood work completed in the last 4
months, printing the list for each physician, and calling the patients in to the clinic
or sending out a letter.
Challenges with this tool:
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Physician not at DCHC
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Contacting patients because of lack of addresses or phone numbers
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Incorrect address or phone number
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Confidentiality issues regarding patient verification
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Patients who know they are due, but will not come in for various reasons
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Not clear who’s responsibility it would be to contact the patient
Next Steps…
Use Process Mapping to create a new PDSA cycle.
Lessons Learned
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Maintenance of the Collaborative Registry Database is
essential to tracking individual patient needs.
Using PDSA cycles to explore new tools is effective.
Holding multidisciplinary meetings are necessary for
ongoing communication and implementing positive
change in clinic procedures.
Using outreach teams to engage difficult to reach
patients helps prevent them from becoming lost to care.
Change is a slow process.