Alameda County pilot program decreases hospital readmission for HIV/AIDS patients

Michael Bailey/Staff

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A UC-funded pilot program tasked with providing higher-quality care to HIV and AIDS patients in Alameda County has reduced hospital readmission rates at one hospital in Oakland.

Operating under a comprehensive health care model, the program has decreased readmission rates by 44 percent at Highland Hospital since its implementation, according to George Lemp, director of the California HIV/AIDS Research Program through the University of California. Lemp and other program directors plan to expand the model to treat patients with other chronic diseases.

The program — patient-centered medical homes, or PCMH — is not a physical space but a health care system that aims to reorganize primary care within a model that centers on individual needs. The new system has been piloted at five Bay Area medical centers, including LifeLong Medical Care in Berkeley.

“Alameda County is one of, if not the first, system in the country to examine the PCMH model in serving HIV/AIDS patients,” Lemp said.

Kathleen Clanon, a physician and director of Health Care Services Agency of Alameda County, meets with clinicians and other team members to discuss progress and follow-up needs for patients on a monthly basis. In the program, a primary-care doctor leads a customized team of psychologists, social workers, educators, nutritionists and specialists.

“The U.S. is still fee-for-service,” Clanon said in an email. “This model doesn’t allow much flexibility … The patient-centered medical home model allows for wrapping a variety of effective services around a patient, depending on what they need.”

Prior to the program’s initiation, Highland saw 89 patients admitted for HIV treatment, with 35 needing to be readmitted within a month. After the implementation of the program, 63 patients were admitted, with only 14 readmitted within a month.

“Patients with HIV/AIDS benefit from the PCMH approach because it helps clinics centralize patient care information and better track individual patient needs,” Lemp, whose agency funds the program, said in an email.

Funding from Lemp’s UC research program has allowed for the expansion of what specialists call a “panel-management” approach in the program. The practice helps doctors track their patients’ progress and assess their need for follow-up care.

Highland’s HIV program serves about 800 patients, according to Nancy Halloran, an administrator for Alameda Health Systems, which oversees PCMH at the hospital.

Halloran said Alameda Health Systems will continue offering the program for at least another year. In the coming months, the health care provider will conduct a cost analysis of the program.

Currently, the program administers only to targeted HIV/AIDS patients, but it is projected to serve  individuals suffering from other chronic diseases. According to Lemp, Alameda County has invested an additional $5 million to expand the PCMH program to other diseases.

Staff writer Heyun Jeong contributed to this report.

Contact Brennan MacLean at [email protected].

A previous version of this article incorrectly stated that readmission rates decreased by 17 percent. In fact, readmission rates decreased by 17 percentage points. Hospital readmission rates declined by 44 percent.