1. DCHC MAT/ STOP HIV Collaborative Team

2. Improvement: Lost To Care Engagement  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: 1) MAT Team Referral Tracking Sheet (To track referrals on our “radar”) 2)Collaborative Database including blood work and primary care visits 3) Review older versions of MAT/ Pharmacy databases, to capture those who are not yet linked to another primary care provider - “Lost to Care” list. 4) Social work piece- keep record of clients needs/ interests/ quality of life/ challenges/ etc. for engagement

3. Case Example 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 20 th, 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.

4. Case Example Jane agreed to start ARVs and her regimen was started on June 30 th, 2011. MAT STOP Outreach Team deliver ARVs daily to Jane. July 16 th, 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.

5. 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: 1) Physician not at DCHC 2)Contacting patients because of lack of addresses or phone numbers 3)Incorrect address or phone number 4)Confidentiality issues regarding patient verification 5)Patients who know they are due, but will not come in for various reasons 6)Not clear who’s responsibility it would be to contact the patient Next Steps… Use Process Mapping to create a new PDSA cycle.

6. Lessons Learned 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.