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Delivery System Design

Effective management of HIV/AIDS requires more than simply adding interventions to an existing system focused on acute care. Rather, it necessitates basic changes in delivery system design. These changes require a shift of emphasis to "planned" visits instead of acute visits. Effective management often requires expansion of staff member roles and responsibilities. These changes include all professionals (e.g., nurses, case managers, health educators) who have the knowledge and time to carry out the range of tasks required to manage complex chronic conditions. Staff members also need timely access to key clinical data, enough time to interact with patients, and regular, planned follow-up with patients. Meeting these needs often requires innovation in the scheduling and organization of care, such as group or individual planned visits.

 

Related Measures
Percent of Patients with Primary Care Visit(s) in the Last Three Months


Changes for Improvement
Describe and Document the New Delivery System Design
Assign Roles, Duties, and Responsibilities for All Tasks Within the Delivery System Design, Especially for Planned Visits to a Multidisciplinary Care Team
Educate Patients about Delivery System Design
Use the Registry to Proactively Review Care and Plan Visits
Include Planned Visits in the Individual and Group Setting in the Delivery Model
Make Designated Staff Responsible for Follow-up by Various Methods, Including Outreach Workers, Telephone Calls, and Home Visits