Patient-Centered Medical Home Demonstration Project

In September 2010, the California HIV/AIDS Research Program awarded grants totaling $6.3 million over three years to five California health care provider organizations to establish the Patient-Centered Medical Home Demonstration Project. The focus of this project is to conduct collaborative research to evaluate the effectiveness of Patient-Centered Medical Homes (PCMH) for persons with HIV/AIDS. The research is examining cost, quality, patient satisfaction, and patient self-management.

The Obama Administration identified PCMH as a key element in the 2010 National HIV/AIDS Strategy for the United States and PCMH has been repeatedly cited in federal and private sector health care reform discussions as having the potential to result in a more effective and efficient model of health care delivery, especially for those with chronic diseases.

This is the first PCMH research project in the US focused on persons with HIV/AIDS. This research can provide tremendous value to HIV care providers, policy makers, and health care system planners and administrators in California and throughout the US, and will have significant implications in the design and delivery of care to persons with other chronic diseases.

The five grantees for this project are:

  • The Los Angeles County Office AIDS Programs and Policy in collaboration with the Rand Schrader Clinic at the University of Southern California Medical Center.
  • The San Francisco Department of Public Health in collaboration with the University of California, San Francisco (UCSF) Positive Health Program at San Francisco General Hospital, and 360: The Positive Care Center at UCSF. This project will exclusively focus on PLWH aged 50 and over.
  • St. Mary Medical Center Foundation in Long Beach.
  • Tri-City Health Center (Alameda County) in a consortium with Alameda County Health Center, Asian Health Services, La Clinica de La Raza, and LifeLong Medical Center
  • The University of California, San Diego.

Collectively, these organizations provide medical and social services for over eight percent of Californians reported to be living with HIV/AIDS. The percentages among African Americans, Latinos and women are 9.8, 9.9 and 11.7, respectively. It is estimated that over 25% of persons with HIV/AIDS 50 and over will be served by these grantees.

The grantees are testing a number of strategies through their PCMH models. Examples include:

  • Evaluate the impact of enhanced electronic medical data sharing on care coordination among medical and social service providers, access to and retention in HIV care, and HIV treatment adherence.
  • Improve patient health literacy and access to health information.
  • Use innovative encounters (telephone, texting, and e-visits) to improve communication between patients and providers.
  • Test new models of integrated HIV and aging care services to address the complex needs of persons 50 years and older living with HIV.
  • Pilot a new messaging portal for local HIV testing sites to alert the HIV clinic when a new HIV-positive client has been identified and referred to the agency.
  • Pilot a computerized pharmacy electronic interface that allows the clinic to ascertain when a prescription has not been filled.
  • Improve health outcomes by establishing electronic information exchange within multidisciplinary care teams and among providers of specialty and support services.
  • Incorporate panel management strategies to manage populations for optimum health.

The grantees are evaluating the impact of their models and strategies through a collaborative research effort coordinated by the Center for AIDS Prevention Studies at the University of California, San Francisco.

Project Descriptions:

Project Dissemination:

Retention: Building a Patient-Centered Medical Home in HIV Primary Care through PUFF (Patients Unable to Follow-up Found)
Sitapati, Amy M., Jan Limneos, Militza Bonet-Vázquez, Moira Mar-Tang, Huifang Qin, and W. Christopher Mathews. "Retention: Building a Patient-Centered Medical Home in HIV Primary Care Through PUFF (Patients Unable to Follow-up Found)." Journal of Health Care for the Poor and Underserved 23, no. 3 (2012): 81–95.

HIV ACCESS PCMH Demonstration Project
YouTube Channel for the Tri-City Health Center: HIV ACCESS Patient Centered Medical Home Demonstration Project

CHRP-Funded Research Presented at the HRSA Ryan White All Grantee Meeting: November 27-29, 2012