Practice Transformative Model for Care Integration

Brightpoint Health’s multifaceted Practice Transformative Model (PTM) is designed to address gaps in the agency’s existing Patient-Centered Medical Home model to improve the provision of care for people living with HIV/AIDS (PLWHA). This PTM is based on the identification of resources and workflow solutions, such as formalized communication structures that promote collaboration among providers, to improve care coordination and prevent high-risk HIV-positive clients from falling out of care. In response to Brightpoint Health’s current resource and workflow gaps, a Nurse Care Coordinator, Patient Navigator, and two Peer Escorts will be hired to increase capacity to achieve efficient and sustainable service delivery practices, ultimately leading to better health outcomes for PLWHA. The program will seek to increase access to care and enhance the quality of HIV care for PLWHA by facilitating improved collaboration among primary care, behavioral health and other service providers along the HIV care continuum.

These new staff positions will support four core components to facilitate a more enhanced model of care. First, the PTM will implement standardized systems for identifying and engaging high-risk HIV-positive patients, including the development of a patient registry that stratifies HIV-positive patients based on level of risk. Secondly, formalized communication among primary care and behavioral health providers will be established, including daily team huddles within the primary care team and bi-monthly HIV case conferencing between a representative from the primary care and behavioral health team. Third, an enhanced Health Information Technology Infrastructure will be implemented that creates a more streamlined process for providers to arrange referrals internally, as well as a cross-provider care plan for all HIV-positive patients. Finally, a client self-management program will be established to educate and empower patients to take a more active role in managing their health and to mitigate barriers to treatment adherence.