Patient-centered medical home to target poor adherence to antiretroviral therapy and retention in care for patients with HIV

Issues: As we prepare for the Accountable Care Act in 2014, we created a staffing plan for a community HIV non-profit agency. High adherence to antiretroviral therapy is the key to maintaining suppressed HIV viral load and better health outcomes. In the Gardner cascade, poor retention in care also leads to low rates of suppressed viral load in populations of patients. We evaluated this cascade for our patients to determine where patients are lost to care and to design a patient-centered medical home. Description: We measured 30 day pharmacy fill rates (number of days supply/number of days between fills) for the primary antiretroviral medication in each patient's regimen with a 95% cut off for inclusion in the intervention. Retention in care was measured using the number of visits with a cut off of two visits per year. Lessons learned: Our analysis demonstrated overall low rates of adherence and retention in care. We designed an integrative, interdisciplinary, co-located, patient-centered medical home offering primary care, behavioral health services, and dental care. The model utilizes patient navigators and psychotherapists to motivate patients with low adherence or poor retention in care using a problem-solving approach to improve outcomes. Based on our current data, the team should include a medical provider, a medical assistant, 2 psychotherapists, and 4 patient navigators. Recommendations: Patients with less than 95% adherence or less than two visits per year should be targeted to participate in an integrative, interdisciplinary, collaborative, co-located primary care/behavioral health patient-centered medical home to improve outcomes.