Two goals of the National HIV/AIDS Strategy, reducing HIV incidence, and increasing access to care/optimizing outcomes, can be strongly and positively affected by engaging and retaining HIV-infected patients in clinical care. Why has this been so challenging? A glance at the Spectrum of Engagement in Care Cascade shows dramatic decreases from the number of people diagnosed with HIV to those engaged in clinical care, taking antiretroviral therapy, and achieving undetectable viral loads.
A recent CDC study, A Low-Effort, Clinic-Wide Intervention Improves Attendance for HIV Primary Care, addressed the challenge of retaining patients in care in 6 large HIV urban-area clinics. The study was conducted in two parts. First, a low-cost, low-effort intervention with several components was implemented. Clinic staff watched a short video with “good” and “bad” (relationship building vs. alienating) enactments of interactions with patients by a receptionist, social worker, nurse, and physician. In order to create warm and welcoming clinic environments, all staff received training on the importance of treating patients like consumers, greeting them by name, and saying, “Thank you for coming in today; it’s good to see you.” Healthcare providers were instructed to remind patients at every visit, “People who keep their clinic appointments live longer and do better than those who don’t, so it’s great that you came in today.” In addition, posters with a see-saw graphic demonstrating the goal of care (keep CD4 counts high and viral loads low) were placed in exam rooms. Clinicians and patients were also given pocket guides with care tips. Clinician guides had messages specifically tailored for new patients, inconsistent attenders, and regular attenders to care. Patient guides provided strategies to help them be successful in care: problem solving, getting organized, and communicating with care providers.
In the second part of the study, each clinic hired two case managers, called Retention Interventionists (RIs), whose focus with patients was to help them overcome barriers that kept them from clinic appointments. The RIs were trained in Basic HIV Biology, Motivational Interviewing, Strengths-Based Counseling, and given the mantra “My job is to get the patient to come back.” The importance of building rapport with patients was emphasized throughout the training. Patients had up to 3 one-hour sessions with the RI, and received brief check-in calls between visits to see how they were doing, as well as personal (rather than automated) reminder calls before their clinic appointments. Based on individual patient needs, RIs used sessions to enhance patient self-efficacy to help them overcome barriers to attendance. This was accomplished by teaching the basic biology of HIV, and skills building in 3 areas: getting organized, learning problem-solving techniques, and improving communication skills with healthcare providers, an expansion of skills discussed in the patient pocket guide.
Have you considered ways to improve engagement/retention in care in your clinic? For more ideas, and to read about the study outcomes, register for the "Introducing the Engagement in Care Toolkit: Resources to Employ Evidence-based Interventions" training exchange on February 26, and be sure to take a look at some of the tools and publications described in this blog.