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Los Angles LGBT Center • Noah Kaplan MSW • Alex Adame MSW Los Angles LGBT Center How does the Center compare? Our Medical Home Services: A one-stop shop Comprehensive Mental Health Services Transgender Health Program Substance Abuse Services Medical Care Coordination Comprehensive Primary Care Domestic Violence Services Housing Referrals On-Site Pharmacy HIV and STI Testing and Treatment Partner Services Transportation Services Research Full Wrap-Around Services Health Education and Prevention Specialty Care Coordination Medical Care Coordination The Medical Care Coordination (MCC) model is a multi-disciplinary team approach, funded by the Los Angeles County Department of Public Health Division of HIV and STD Programs, that integrates medical and non-medical case management by coordinating behavioral interventions and support services with medical care to promote improved health outcomes. Los Angeles LGBT Center’s MCC team members are integrated into the patient’s medical home and deliver patient-centered activities that focus on: • addressing health status • engagement and retention in care • adherence to HIV medications, and • HIV risk reduction. Retention in Care Identify the social determinants that impact patient’s retention in care and medication adherence Intervene to help keep them in care or bring them back into care Engage patients who are at risk of falling out of care or out of care Retention in Care Demonstration Project Overview • Target Population 1. High risk of falling out of care 2. Out of care • How to identify target population 1. Internal reports using EHR records of last medical visit and/or VL 2. Care team case conference 3. Care team referral Retention in Care Intervention 1. Engage Retention in Care Intervention 2. Assess a) Risk b) Barriers to Care c) Needs Assessment done by a combination of medical records and interview Retention in Care Intervention 3. Intervene • Provide one on one psychosocial support • Incentives and transportation support • Navigate the client through the financial screening and appointment making process in a culturally sensitive way. Retention in Care Case Study Retention in Care Lessons Learned Discussion and Questions Noah Kaplan, MSW Manager of Psychosocial Case Management Health Services (323) 993-7486 Alexandra Adame, MSW Retention Care Manager Health Services (323) 993-8973 END
