HIV ACCESS Patient Centered Medical Home Demonstration Project

Principal Investigator: Kathleen Clanon, M.D.
Tri-City Health Center

Patient-Centered Medical Home Demonstration Project
Awarded: 2010

Project Description: The HIV ACCESS Patient Centered Medical Home Demonstration Project is situated in the context of an existing network of HIV primary care providers based at five different clinic sites in Alameda County. Originally formed in 1992, HIV ACCESS is a Ryan White Part C-funded primary care network consisting of four Federally Qualified Health Centers as well as two outpatient HIV clinics at Alameda County Medical Center. Serving a total of 1392 HIV-positive clients, participating clinics include:

  • Alameda County Medical Center - Highland and Fairmont clinics
  • Asian Health Services
  • La Clínica de La Raza
  • LifeLong Medical Care
  • Tri-City Health Center

The mission of HIV ACCESS is to provide coordinated, comprehensive, quality HIV primary care services for Alameda County's underserved communities. With program coordination support from Alameda Health Consortium, the clinics collaborate on various activities, including training and technical assistance, data systems, quality improvement, and reporting.

The HIV ACCESS network's long history of collaboration will be leveraged to implement the PCMH Demonstration Project. The project will add value to existing relationships and information-sharing processes to engage the clinics in the PCMH transformation process. Implementing the project in the context of an existing network has the advantage of drawing on established relationships between partners, which will facilitate peer learning throughout the duration of the intervention.

The HIV ACCESS PCMH Demonstration Project has two goals:

  • To use Electronic Health Records to improve health outcomes and support coordinated care for HIV ACCESS patients by establishing electronic information exchange for providers caring for patients-in-common on three levels: (1) within each clinic's multidisciplinary care teams; (2) between HIV ACCESS clinics; and 3) among providers of specialty and support services.
  • To improve health outcomes and support coordinated care for HIV ACCESS patients by instituting a population-based panel management program and strengthening and expanding patient self-management support.

To support these overlapping goals, a disease registry for HIV will be established at each clinic, along with related patient care management reports. Building on this, team-based panel management pilots will be conducted and evaluated. Finally, with the population-based approach made possible by the EHR, registry and panel management, patients can be supported in self-management. With a population-based approach, higher-functioning patients can be empowered to manage their own care in a more informed way, and limited staff resources can be targeted to patients who need more support in order to stay engaged in care. The clinics in which the HIV programs are embedded will be able to use these documented protocols and procedures to move toward PCMH recognition.

Contact: Erin Gael Chambers, Project Director
(510) 297-0277