An Alameda County pilot program has shown promising early results, reducing the number of hospital re-admissions for HIV/AIDS patients at one hospital by 44 percent.
The model of care — known as a “patient-centered medical homes” — creates comprehensive care teams led by primary care physicians and including support staff, medical specialists, social workers and psychologists who work together to ensure patients go to their appointments, take their medications and get the treatment and support they need. For people living with HIV, consistent treatment means a longer life and a reduced risk of transmitting the virus.
At Highland Hospital in Oakland, the number of hospital re-admissions for patients with HIV and AIDS dropped significantly as a result of the program. Of the 89 patients admitted in 2010 for HIV-related treatment, 35 were re-admitted within a month. Meanwhile, from October 2012 to September 2013, 63 patients were admitted and only 14 were readmitted within 30 days.
“This shows that our system is working,” says Dr. Kathleen Clanon, medical director of the Health Program of Alameda County. “The supports are successfully in place outside the hospital.”
Four other community clinics in the Bay Area are also participating in the project: Tri-City Health Center in Fremont, Lifelong Medical Care in Berkeley, La Clínica in Oakland and Asian Health Services in Oakland.
HIV can only be suppressed — and rendered non-transmissible — if anti-retroviral medication is taken every day. Only half of Californians with HIV receive medical care consistently, in part because of lack of insurance, homelessness, lack of transportation or the stigma associated with the disease.
Patients with HIV/AIDS benefit from a patient-centered medical home approach because it helps clinics centralize patient care information and better track individual needs. In addition to traditional medical care, the pilot project provides tools that give doctors a detailed patient history and information, such as the date of the last lab report, missed appointments or unfilled prescriptions, reports of depression, or lack of adequate food or transportation.
The project is jointly funded by UC’s California HIV/AIDS Research Project, the Alameda County Health Care Services Agency, the Gordon and Betty Moore Foundation and Alameda Health System.