Using EHR and Coordinated Outreach to Increase Retention in HIV Care


The Cooper Early Intervention Program Expanded Care Clinic observed that the gap in retention in care among patients with HIV was reduced from 15% to 10% over a span of 3 months.

A notable challenge in HIV treatment is retention in care. Most of the currently available and approved antiretroviral therapy (ART) regimens require at least 1 pill to be taken daily. People living with HIV are also recommended to have more frequent visits with health care providers to evaluate viral load and ART adherence.

The Cooper Early Intervention Program (EIP) Expanded Care (CEEC) Clinic in Camden, New Jersey, is a Ryan White-funded clinic that provides primary care for individuals living with HIV. In January 2019, the CEEC Clinic launched a data-driven initiative with the intention of reducing the number of patients living with HIV who did not have a medical visit within the last 6 months.

The purpose of the initiative was to assure ongoing retention in HIV care services among patients. Representatives from Cooper University Health Care discussed the initiative in a poster presentation at the Association of Nurses in AIDS Care Conference (ANAC 2019).

At the conference, Contagion® spoke to Pamela Gorman, RN, ACRN, administrative director of the EIP, and presenter of the poster.

The clinic sought to increase retention in care from the 2018 year-end percentage of 85% of 15% of people living with HIV having a > 6-month gap between care appointments. The team derived a list of patients from performance measure search filtering criteria by scanning the Ryan White CAREWare database.

From there, each patient’s chart in the electronic medical record system was scanned manually for contact information and last appointment status. The gap database was then updated with a comment describing the circumstances of the patient’s gap status and the patient’s status is then prioritized based on need for outreach.

The database was then distributed to the outreach staff, case management, screen/identify/linkage to care staff, and clinical staff in an effort to make contact with the patient and schedule an appointment for a primary care visit.

Through using this process, the investigators observed that the gap measure was reduced from 15% to 10% over a span of 3 months. This indicates that retention in care statistics at this particular clinic have improved from a baseline of 85% to 89.3%.

“Reducing the gap between medical care visits will lead to improved health care outcomes for prescribing of ART and viral load suppression,” the investigators concluded.

The abstract, Data Search Tool Implementation, Patient EHR Root-Cause Analysis, and Coordinated Outreach Activities Dramatically Improve Retention in Care for PLWH at a Hospital Based HIV Clinic, was presented in a poster session on Thursday, November 7, at ANAC 2019 in Portland, Oregon.

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