Virginia Butler
Michael Allison
Teresa Castro-Rojas
Judy Griffin
Steve Mason
Robert Rutherford
William Saunders
Iva Stanley

The Monroe County Health Department Early Intervention Services/Primary Care Program will improve care to HIV/AIDS patients by making changes in the following areas:

• Self-management and adherence support
• Decision support for clinicians
• Clinical information systems
• Delivery system design
• Community linkages
• Leadership

• Percent of patients with at least one visit every 3 months (Goal: 100 percent)
• Percent of patients with a comprehensive physical exam at least annually (Goal: 100 percent)
• Percent of patients with documented HAART education/adherence counseling (Goal: 100 percent)
• Percent of patients with PCP/MAC prophylaxis as applicable (Goal: 100 percent)

• Implemented active and inactive clinics in HEMS Patient Data System
• Adapted HEMS for local use to record date of last rectal exam
• Generated HEMS reports useful to providers and case managers
• Generated HEMS report requested by providers listing patients with HCV co-infection within specific CD4 and viral load parameters

Self-Management and Adherence:

• Completed first edition of patient handbook; implement distribution plan November 
• Mailed clients Happy Birthday “wellness self-management” cards to schedule annual physical examination 
• Planned special “Lets Get Physical” day at outlying site
• Held Peer Program Kickoff: Trained 17 clients and planned next steps
• Conducted Mental Health Needs Assessment and Awareness Survey in English and Spanish; added two mental health providers to referral list
• Purchased new computer and Internet account for client access in the clinic

Delivery System Design:

• Made open appointment slots available weekly to assure new intakes will be scheduled within seven days
• Contacted lost-to-follow-up by certified mail
• Defined/systemized tracking procedures
• Redesigned client access to providers after hours/weekends
• Contracted case worker in clinic targeting hard-to-reach person
• Used HEMS reports for tracking patients not seen in three months

Decision Support:

• Implemented revised Standard Medication Sheet for patient medical records
• Had providers receive HEMS reports monthly to identify unmet patient needs
• Implemented systemized tracking to assure reports from referral providers
• Had BIA machine in clinic perform baseline assessments routinely
• Made annual comprehensive physical exam with rectal exam the standard of care; training was provided and this was accepted by all providers (a result of presenting HEMS reports at Providers’ Meeting)
• Neuropsychiatric training for medical director
• Purchased new computer for physician

Community Linkages:

• Collaborated with Florida AIDS Education and Training Center (AETC), University of Southern Florida, and the University of Miami for decision support and patient self-management support
• Established and incorporated the Consumer Advisory Board as a standing committee of the community planning body
• Had successful interagency collaboration which resulted in a 100 percent increase in the number of HIV tests performed on National Testing Day as compared with last year
• Obtained BIA machine from BTG Pharmaceuticals; technician trained to do patient assessments routinely

Leadership:

• Had MCHD Director actively participate regularly in bi-weekly CQI meetings, as well as weekly clinic staff meetings
• Had MCHD Director and AHI Director participate in two quarterly CQI full-day retreats
• MCHD Director assumed leadership responsibility to remove obstacles that have impeded improvement in delivery system design and information management

Spread of Change:

• Prepared booklet of all CQI planning and implementation documents and graphs for distribution at the Florida Planning Group meeting by a Consumer Advisory Board member
• Used Chronic Care Model as format for strategic planning at Community HIV Providers retreat
• Submitted proposal for the core team to present a CQI/Institute for Healthcare Improvement (IHI) workshop at Florida AETC Conference in March 2002
• Fully integrated outlying sites into CQI process and implementing changes
• Used IHI conference calls along with quarterly CQI Retreat to develop a community-wide patient self-management culture among network of HIV providers