SPNS/Fax: An Electronic Report from HRSA/HAB's SPNS Cooperative Agreements:
Volume 2, Issue 13 (June 27, 1997)

Information dissemination from 27 Innovative Models of HIV Care projects funded as Special Projects of National Significance by the HIV/AIDS Bureau (HAB) of the Health Resources and Services Administration (HRSA).

Introduction

Welcome to SPNS/Fax: An Electronic Report from HRSA/HAB's SPNS Cooperative Agreements. In each issue of SPNS/Fax, we will highlight findings from the HRSA Special Projects of National Significance Program Cooperative Agreements. The projects have been funded to develop innovative models of HIV/AIDS care. SPNS/Fax reports are distributed every two weeks by fax machine to all subscribers. All issues of SPNS/Fax are also available at this Web site. Due to slight differences in the media, issues distributed by fax machine may appear slightly different from those posted on this Web site, but the content is identical.

East Boston Neighborhood Health Center

HIV-positive individuals living within the Boston areas of Chelsea, Revere, East Boston and Winthrop (CREW), are often disengaged or underserved by the healthcare system. Fragmentation of care, the need for a linguistically and culturally sensitive environment, lack of support for families, and high rates of disorienting and expensive hospitalizations are issues addressed by the East Boston Neighborhood Health Center (EBNHC) SPNS Program project. Its target population is high-risk individuals who are traditionally underserved, including active and recovering substance abusers and their sexual partners, sex workers, HIV-positive prisoners, gays/bisexuals, and Latinos in the CREW area. The major project goals of EBNHC are:

• to develop a community-based, coordinated, non-fragmented, comprehensive care plan for patients with HIV infection;

• to evaluate the cost of care for patients at three stages of infection—asymptomatic, symptomatic, and AIDS; and

• to establish appropriate capitated rates and explore risk-sharing arrangements with service providers and payers.

A key element of this project is comprehensive managed care in outpatient, inpatient, and home care settings. Client care is coordinated by a multidisciplinary team consisting of a primary care physician, HIV nurse/nurse practitioner, home care nurse, HIV case manager, social worker, and infectious disease consultant. The services provided include outreach, primary and specialty care, inpatient and home care, case management, social and mental health services, substance abuse treatment, client support services, and HIV testing and counseling. EBNHC is developing strategies for illness prevention including: medical standards for antiretroviral therapy and prophylaxis of opportunistic infections and an associated quality improvement assessment; use of creative compliance strategies with patients taking combination antiretroviral therapy that may involve the home care nurse, outreach worker or volunteers; and integration of mental health and substance abuse treatment into primary care. EBNHC provides efficient, well-coordinated care that maximizes the use of community and home-based services.

In order to meet the changing needs of health care under capitation, EBNHC has made several changes to its clinical practice. These include: 1) expanding urgent care site roles; 2) ensuring full management of all in-patient care; 3) developing tight primary care physician/specialist teaming; 4) building a community-based infrastructure for alternatives to hospitalizations; 5) developing and using practice-based systematic strategies for illness prevention; 6) performing routine case reviews to learn from experience and to re-acculturate physicians as to practicing under capitated care; and 7) evaluating service utilization, costs and outcomes to adjust clinical practice accordingly. Such changes in clinical practice have resulted in decreased hospitalizations and lengths of stay while still ensuring high quality, safe alternatives to care.

In building on eight years of experience in providing high quality care for frail elders under total, at-risk capitation, EBNHC has spent the past year moving to a restructured system of care that is built upon the assumption that financing for all patients is globally capitated. The underlying assumption in this restructured delivery system is that the primary care provider group is at risk for the total cost of care. Coupled with this restructuring, and of equal importance, is the utilization of other funding sources that allow for the provision of the same level of care for the under- or uninsured populations.

EBNHC believes that with improved health maintenance, case management, integrated mental health/substance abuse services, and increased utilization of community resources, hospitalizations will be reduced and costs contained. Freed from the restrictions of fee-for-service reimbursement, EBNHC has been able to respond creatively to the needs of its patients in order to ensure high quality care for even higher quality of life.

For more information, contact Judith Steinberg, M.D., East Boston Neighborhood Health Center, 10 Gove Street, East Boston, MA 02128,

SPNS/Fax is produced by The Measurement Group–PROTOTYPES Evaluation and Dissemination Center (EDC). Editorial comments should be made to The Measurement Group at 5811A Uplander Way, Culver City, California 90230, 310.216.1051, 310.670.7735 (fax).
 

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