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Building a Medical Home for Patients with HIV/AIDS

People diagnosed with HIV/AIDS have complex health care needs. They require closely coordinated care that may include multiple providers, an expensive medication regimen, the need to prevent and identify secondary and opportunistic infections  and the need to identify and treat common behavioral health issues. 

Patients who have no (or not enough) health insurance often face additional challenges. 

An integrated approach to care can help patients over the hurdles that daily life presents, which is why the AIDS Resource Center of Wisconsin (ARCW) (a HRSA Ryan White HIV/AIDS program grantee) has adopted the AIDS/HIV medical home model of care. Combining high tech with high touch, they are finding that they can improve the quality of care they provide, attain better health outcomes and reduce costs in the process.

Medical Home = Coordinated Care

ARCW provides to all of its patients: Winsome Panton, DNP of ARCW visiting with a patient

  • Direct health care services, including medical, dental, and behavioral health visits and
  • Services that enhance their health and lives, such as care management and social services.

High Tech

Providing comprehensive, coordinated care requires substantial sharing and management of information. To facilitate this, ARCW uses an electronic health record (EHR) to track medical care and social services. By the end of the year, ARCW plans to add a dental moduleNicole Martin, DDS and dental assistant Cindy Rodriguez, both of ARCW.

Though the EHR facilitates tasks requiring individual patient level data, it is limited in its ability to make population health data accessible to providers. 

For this reason, ARCW partnered with an external group to configure its population health management tool. This tool allows providers to better manage their patient populations. With population health data, ARCW can also measure quality and outcomes to evaluate the performance of its medical home.

High Touch

Rick Fons, RPh of ARCW providing adherence counselingAt ARCW, each patient has a dedicated primary care provider. In addition to medical care, patients can come to ARCW for their oral health and behavioral health care.

Recognizing the major influence of factors outside of the clinic on outcomes, ARCW works to address both the physical and social determinants of health. Onsite at ARCW, patients can meet with pharmacists, legal experts and social service providers and access services such as:

            • Medication management
            • Housing support
            • Food pantries, and
            • Case management.

The primary care provider is responsible for leading the multidisciplinary care team. Consistent care from a team that intimately understands an individual patient’s multidimensional needs is the pillar supporting quality care.

Improving Outcomes and Ensuring Quality

Since implementing the medical home, ARCW has seen improvements in outcomes. Currently, 76 percent of ARCW patients on HIV medication have an undetectable viral load (the national average is about 25 percent). 

But ARCW is not resting on their laurels. Committed to ensuring quality care and continuously improving quality, ARCW is continuing to engage all members of the care team in quality improvement activities and preparing to report on various clinical quality measures related to the medical home:

  1. The percentage of health home patients, with a CD4 count of ≤350 cells per microliter (μL), who initiate antiretroviral therapy (ART)
  2. The percentage of health home patients with an undetectable viral load within 6 months of ART initiation
  3. The percentage of patients with at least two preventive medicine visits during the measurement year, one visit for each six month period of enrollment
  4. The percentage of patients who had at least one dental visit during the measurement year
  5. The percentage of health home enrollees with one or more avoidable hospitalizations during the report year
About ARCW

The AIDS Resource Center of Wisconsin (ARCW) is the largest HIV health care system in Wisconsin, serving more than 3,300 patients living with HIV and offering prevention services for at-risk individuals.

ARCW’s medical home received approval from the Centers for Medicare and Medicaid Services, providing ARCW with enhanced Medicaid reimbursement. The National Committee for Quality Assurance has recognized ARCW as a patient-centered medical home.

AIDS Resource Center of Wisconsin Exit disclaimer website