• Appointment reminders one week prior to visit - phone and mail
• Patient list reviewed by both nursing and case managers monthly to identify those out of care and initiate contact
• No-show patients are contacted immediately after the failed appointment (phone and mail) to reschedule
• When necessary, our dedicated program patient transport person will attempt to locate the patient by visiting last address, known areas that patient frequents, etc.
• Patients are always given an appointment date and a date to have labs drawn prior to that visit. Provider schedules are reviewed to determine who is scheduled for an appointment in the next week and if the labs have been drawn. This allows us to contact patients to remind them of the need for labs and identify potential or ongoing problems that could affect followup.
• Every morning prior to the start of patient hours, our team (providers, nursing/medical assistant, case managers, driver and receptionist) holds a fifteen minute "huddle" meeting. This allows all of us to plan for the day,. identify specific challenges or issues affecting care, and strategize solutions to these.
• Many of our patients have underlying psychiatric and/or substance abuse issues; while very few are homeless, many are in temporary housing or staying with friends, relatives, etc. It is often difficult for them to follow through the care.
• With the closure of a local EIS and recent outreach efforts, we have had an influx of approximately 60 patients in a very short period of time - some are newly diagnosed, many have had no primary care in many years, and most are uninsured or underinsured. Moreover, the backlogs in local specialty clinics
• Our new grant allows us to add an additional case manager, medical assistant, and a psychiatric nurse practitioner based within our unit. Both the case manager and medical assistant have been hired. However, it will take some time for them to become fully oriented. The psychiatric piece has been even more difficult due to a shortage of psych APNs. However, our medical director is meeting with a psychiatric service the second week of June and we have interviewed a psych APN who is experienced in the needs of the HIV population; she is ready to join our program if we are able to work out the necessary details with the outside consultant group.
• All of the above have put a tremendous strain on our program as we attempt to incorporate these patients into our program. It will take some time to fully integrate these patients and engage them in care..