Implementing QI in HIV Clinics to Improve Retention in Care

Amy M. Sitapati, MD


November 29, 2012

In This Article

Key Elements of a Successful HIV Quality Improvement Initiative

The medical home offers an important framework for thinking about how to organize clinical services. It focuses on easy access, comprehensive care, coordination of care, and personal relationships and aims to transform a medical practice to provide improved individual and population health.[3]

One strategy shown to be effective in improving retention within the HIV medical home is the implementation of a new position: the retention specialist. In a project conducted at the University of California, San Diego,[4] a retention program was developed to address large numbers of patients who were identified as lost to care during open-access implementation. While the open-access scheduling did not worsen retention, a significant number of patients were identified as having poor retention.

The retention specialist underwent training within the clinic to improve the ability to help patients navigate the healthcare system, schedule appointments, and motivate engagement. In addition to extensive multidisciplinary team and system cross-training, the retention specialist was given a new set of tools for tracking poorly retained patients. Specifically, using a database, the retention specialist was able to track patient retention including missed, cancelled, and kept appointments and was able to document outreach contacts, reasons for missed visits, and pertinent barriers to care. Most important, the retention specialist had the support of the continuous quality improvement committee through which members were able to strategize ways to improve internal clinic operations to improve care delivery (Table 1).

Table 1. Building a Retention Specialist Program

Step 1 Calculate baseline retention rate
Step 2 Cross-train retention specialist with multidisciplinary team
Step 3 Develop tools for retention: algorithms, scripts, and tracking database
Step 4 Implement retention program
Step 5 Use quality improvement committee to refine retention specialist work by addressing internal retention barriers
Step 6 Recalculate improved retention rate

By the end of the project, use of a retention specialist, algorithms, a tracking database, an active continuous quality improvement committee, and other quality improvement initiatives resulted in identification of 628 of 716 (87.7%) poorly retained patients, which improved the clinic's overall retention rate from 74.4% to 95.2%.[4]

Achievement of this goal was partially attributable to reconciliation of the true active patient population, which is a critical first step in defining who cannot be accounted for by subsequent visits, death, incarceration, or relocation. Others have shown that even a low-cost, low-effort initiative can yield improvements in retention rates. In a study by the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care Group,[5] 6 HIV specialty clinics disseminated brochures, posters, and messages that conveyed the importance of regular clinic attendance for 1 year among their 10,000+ patients. Improved clinic attendance, defined as keeping 2 consecutive visits, was 7% higher post-intervention and was 3% higher for the mean proportion of all visits kept.[5] The success of this program demonstrates that targeted messages on staying in care, even those delivered at minimal effort and cost, can have a substantial impact on the rate of retention in HIV care.