Taking Better Care of HIV, AIDS Patients with Population Health Management Technology

ARCW meets the needs of the HIV community with trustworthy data, improved outreach and accurate measures

A few months ago, I stood at the podium of the 30th Make-a-Promise Gala – the annual fund raising event for the AIDS Resource Center of Wisconsin (ARCW). There were more than 900 people in attendance that night, all of them committed to our long-standing promise: to aggressively help people at greatest risk stay free of HIV and to successfully manage the HIV disease so that our patients can live a long and healthy life. The support of our donors that night gives us the opportunity to be at the forefront of HIV prevention and to provide quality medical, dental, behavioral and social service for all people with HIV. We made that promise more than 30 years ago and having been making good on it ever since. Now, better than ever.

We’re better at keeping that promise because we now have powerful, new tools. This includes innovative prevention strategies, robust medications, advanced care management techniques and, vitally important, our own data – clean, fully-aligned data that points the way to improved outcomes. We are now providing comprehensive population health management, and it’s the smart use of our data that is driving our organization to new heights.

The HIV healthcare community is a forerunner of today’s patient-centered medical home. At ARCW, we are the first and still only CMS-approved HIV Medical Home. Our unique integrated care system is achieving great clinical outcomes and is informing and leading payment reform initiatives. We’re a one-stop shop providing more than 3,500 patients with comprehensive medical, behavioral, pharmacy and dental care that is relationship, whole-person-based. In addition to this high quality healthcare, we are overcoming the social determents of health through our housing, food, legal and case management staff working in with physicians in clinics throughout Wisconsin. We provide tightly, integrated care that is fully coordinated across a broad system. We’re accessible and providing care regardless of our patients’ ability to pay, all the while maintaining our patient’s safety and privacy.

It is access to good data that differentiates us. Our EHR, up and running since 2011, has been a valuable tool, but setting clinical goals and monitoring progress was difficult. The data was going into the system but it was difficult for our physicians and care teams to get it out, to see what was going on with our patients.

With the good, clean data we’ve harvested in our embrace of population health management technology, we can very effectively communicate the value of their investments. We can show them we continue to keep our promise.

Undetectable Viral Load

The most important health outcome related to HIV disease is for a patient to achieve an undetectable viral load. This measure shows how well a patient’s HIV is managed. An undetectable level number means a patient’s HIV is managed as effectively as possible – HIV is still present, but even the most advanced tests cannot detect it and the virus is not degrading the patient’s immune system. Nationally, about 30 percent of HIV patients have undetectable viral load. Advanced HIV care centers, the best in the nation, can deliver results well around 75%. At ARCW, with our advanced approach to the data, our ability to see the data and measure our progress, we’ve improved from 78% when we started in 2013 to 90% today. That’s an excellent, powerful number.

This number helps ARCW generate revenue and satisfy stakeholders by enabling us to demonstrate that we are delivering improved outcomes. It also enables ARCW to expand its range of services to meet more of our patients’ needs, such as our move into advanced dental and mental health programs. Before, we were not screening for depression. Now we are.

But a clinic helping 90% of patients reach an undetectable viral load is not the same as 100%. As you might expect, going from 90% to 100% will be extraordinarily difficult. Here’s how we are going to do it.

Most At-Risk Patients

With population health management technology, we are able to design personalized, customized care plans for our patients. Identifying our most at-risk patients is important. Good, clean data makes it possible. We’re not talking some dreary PDF, or old-fashioned report. We’ve moved beyond that. We ask a lot of questions. Who’s most at-risk? What other conditions are our patients facing? Diabetes? Hypertension? Depression?

With a few simple but powerful visualizations, our population health solution identifies these patients, allowing us to quickly zero in on the co-morbid center, those most at-risk. In the not-so-distant old days, that would have been terribly difficult to see, and certainly not quickly. Now we can get them into the clinic, reach out to them and produce a plan, one patient at a time.

Competing Docs

All doctors compete; all want to be the best. An unexpected result of population health management is the confirmation that no physician wants to show up near the bottom of a performance measure. But doctors (or nurses or case managers) must trust the data. They must believe that it is accurate and real. Right there on the screen, “Oh, I’m in seventh place in hypertension, but look, I’m near the top in behavioral measures…” – This is powerful stuff, a great motivational tool.

Suddenly, we found conversations going on, “What’s your practice standard? How do you do it?” People began competing with the medical director, and this competitive spirit began to spread throughout the system. It’s all good.

Patients as Stakeholders

Patients have choices. They want to be served by the best providers. With trustworthy data, improved outreach and accurate measures, ARCW can clearly demonstrate how we are meeting the needs of the HIV community. And we can measure quality, continuously. How can a CEO not love that?

Dive In

Population health management based on good, clean data is a catalyst for quality improvement at ARCW. We’re going for 100% undetectable viral load, and we have a real shot at it. With accurate measurement, we can better control costs. We can meet the needs of our stakeholders, payors and investors, and drive expanded services.

Best of all, we can take better care of our patients. We are keeping our promise. And for us, nothing could be more important.

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