The Practice Transformative Model (PTM): 2018
Core Center’s Practice Transformative Model will develop and implement the organizational infrastructure and operational procedures relating to the health care of HIV positive patients based on the structures of the Healthcare Systemness Model. The Systemness Model refers to how well the components of an organization or system collectively performs in achieving a common goal, and to the degree to which a collection of interconnected parts behave as a whole to predict and consistently produce results that are superior to the sum of the parts. Their PTM’s goal is to establish a seamless health care delivery system, with high performing characteristics, for patients living with HIV/AIDS using a Patient-Centered Medical Home model. This project will focus on retention in care; care coordination through multidisciplinary teams; improved continuous quality improvement measures with consistent metrics; and the development of organizational policies and procedures to guide the implementation of the PCMH model of care. Four key change concepts will be used, including care coordination; organized evidence-based care; continuous team-based relationships; and a quality improvement strategy.
The PTM will facilitate the linkage and engagement of HIV positive patients into an HIV PCMH model through a Clinical Transition Liaison (CTL). In addition to the CTL, Community Health Workers and a Project Coordinator will facilitate the infrastructural systems development and coordination of policies, procedures, collection of patient metrics, process evaluation and CQI processes. Through improved care coordination and patient self-management strategies, this PTM will address the major gaps in service in linkage to care and retention in care along the HIV continuum of care.