Looking for the Future of Coordinated Healthcare Delivery in HIV Clinics

Andrew Kitchenman | May 22, 2014 | Health Care
Ryan White clinics use grant funding to combine behavioral care, other health services

Dr. Kemi Alli, chief medical officer at the Henry J. Austin Health Center.
A Trenton clinic for patients with HIV has been experimenting with a model of delivering care that may become common in the future — combining mental or behavioral healthcare with other types of services.

Traditionally, the two kinds of care are kept separate, both through billing systems and by regulations that require behavioral health and other healthcare to be located in separate facilities.

But Project ACCESS at the Henry J. Austin Health Center has been able to cross this divide through federal funding that has provided a psychiatric advanced practice nurse as part of a team that coordinates patient healthcare and social services.

This approach is drawing statewide attention because many of the patients with chronic conditions also have behavioral issues that make it difficult for them to maintain treatment. Services for these patients contribute a disproportionate share of healthcare expenses, so strategies to improve their health could have large implications for overall health costs.

Dr. Kemi Alli, chief medical officer at the health center, said the project allows each patient to receive individualized service. That means helping patients overcome barriers that prevent them from taking medication or completing scheduled appointments. Alli criticized the stance taken by healthcare providers in the past that many patients fail to comply with prescribed treatments. Instead, she emphasized that it’s the responsibility of providers to find ways to help patients.

“We haven’t designed the right program to meet their needs, to help them to get where they need to go,” Alli said.

That also means that providers must be aware of the social barriers that patients face. “There’s no point in me giving a prescription” for medication that needs to be refrigerated if a patient’s electricity has been cut off, Alli said.

Project ACCESS is funded under the federal Ryan White Program, the largest federal program designed specifically for those with HIV. The project was launched in 2001 with 35 patients and has grown to serve 355, most of whom have incomes below the federal poverty level and are either uninsured or receive Medicaid.

A 2012 federal grant was critical both to increasing the number of patients and to adding behavioral health services by hiring the psychiatric advanced practice nurse.

National success in reducing the spread of HIV/AIDS has obscured the importance of clinics like these, which continue to see many patients who have recently contracted HIV. Ensuring that these patients receive treatment is essential to reducing the amount of the virus that they carry, which makes them less likely to spread it.

Project ACCESS can point to successes: In April, the percentage of patients who stopped receiving needed treatment was less than one-quarter the state and national levels, while the percentage who successfully completed visits to providers was 92 percent for project patients, compared with 73 percent of patients statewide and 75 percent of patients nationally.

A central feature of this success is the “huddle,” in which members of the project’s care team meet to discuss the patients who will be visiting that day. They go over the patients’ histories, current needs and scheduled services.

These services are highly individualized. Staff members noted one patient who would only take a necessary test if it were offered outside of a hospital. That’s because a hospital would have required the patient to verify her family income, which would have led to her husband finding out that she had HIV. Staff members were concerned that the woman would be kicked out of her house and would stop seeking treatment if this occurred.

Patient Danisa Cathey credited Project ACCESS staff members with pulling her out of a downward spiral of poor health. In addition to HIV, she also has had Hepatitis C for 27 years.

Through treatment from the project, Cathey’s levels are now undetectable for both viruses. “They got me under control and healthy. Whenever I mess up Debra straightens me out,” Cathey said of project coordinator Debra Oliver, an advanced practice nurse.

Oliver expressed enthusiasm for a new service the project would be offering this summer — pain management, which faces a local shortage of providers. Pain management will be offered through Project ECHO, a New Mexico-based program that links pain management doctors with local clinics through the Internet.

Project ACCESS was recognized yesterday by the Good Care Collaborative, a statewide organization that is aiming to promote different models with a track record of successful healthcare delivery.

The collaborative members are aiming to attract state Medicaid funding for different models that focus on integrated, coordinated healthcare. They’ve also visited programs that provide services to residents with substance-abuse problems and home visits by nurses to first-time mothers.

Mark Humowiecki, legal counsel for the Camden Coalition of Healthcare Providers, said advocates are working on potential legislation that could make it easier for other providers to offer behavioral health services in the same facilities as other healthcare.