PROJECT ABSTRACT Title: Practice Transformative Model: 2018 Applicant: Hektoen Institute on behalf of Ruth. M. Rothstein CORE Center Address: 2020 W. Harrison St., Chicago, Il, 60612 Project Director: Marisol Gonzalez, RN, MPH Contact Phone Numbers: 312-572-4831 Email:
[email protected] Program funds requested: $300,000 Year 1 ($1,200,000 total over four years) The Practice Transformative Model (PTM): 2018 will develop and implement the organizational infrastructure and operational procedures related to the health care of HIV positive patients based on the structures of the Healthcare Systemness Model. The Systemness Model (SM) refers to how well the components of an organization, or system collectively performs in achieving a common goal and, refers to the degree to which a collection of interconnected parts behave as a whole to predict and consistently produce results that are superior to the sum of the parts. i The PTM: 2018 goal is to establish a seamless health care delivery system, with high performing characteristics, for patients living with HIV/AIDS using a Patient-Centered Medical Home (PCMH) Model. This project will focus on retention in care, care coordination through multidisciplinary teams, improved CQI measures with consistent metrics and the development of organizational policies and procedures to guide the implementation of the PCMH model of care. The following four key change concepts will be used: 1) care coordination; 2) organized evidence-based care; 3) continuous team-based relationships; and, 4) a quality improvement strategy. The overall goal for this project is to establish a seamless health care delivery system with high performing characteristics for patients living with HIV/AIDS, while using a PatientCentered Medical Home (PCMH) Model. This will be achieved by 1) developing the organizational policies and procedures to guide the implementation of the PCMH Model of care, 2) facilitating early engagement and increase retention in an HIV Primary Care/PCMH, 3) improving health outcomes in HIV infected individuals by facilitating early engagement in and retention in care, and 4) improving CQI measures with consistent metrics. PTM: 2018 will facilitate the linkage and engagement of HIV positive patients into an HIV PCMH through a Clinical Transition Liaison (CTL). PTM: 2018 will provide funding for the CTL, the Community Health Workers and a Project Coordinator (PC) to facilitate the infrastructural systems development and coordination of policies, procedures, collection of patient metrics, process evaluation and CQI processes. In summary, the major gaps in service along the HIV continuum of care are linkage to care and retention in care, which can be addressed through improved care coordination and patient self-management strategies. These gaps do not reflect a shortage in the work force but are rather attributed to a need to create effective care coordination through care teams, a rapid CQI process, organizational P&P and leadership. i
Kizer, K.W. Population Health Management, Clinical Integration and Systemness. UC Davis:Institute for Population Health Improvement. Powerpoint presented at the California Area Indian Health Service Annual Medical Conference; May 21, 2013.
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