Ryan White Part C: Outpatient Early Intervention Services to HIV Positive Persons 2015-2017

Model of Care: The Bluegrass Care Clinic (BCC) is a university-affiliated clinic which has served as the safety net for HIV medical care in Kentucky since 1990. The BCC proposes to use a patientcentered, multidisciplinary team model of care. PLWHA served: Since receiving Ryan White funding in 2002 the BCC has seen a 175% increase in the number of patients seen annually; increasing from 425 (2001) to 1027 (2011), 1133 (2012) and 1181 (2013). In 2013 the BCC enrolled a record number (177) new patients into care. BCC Service Area: The BCC proposes to continue providing comprehensive HIV services to the entire 20,054 square mile service area, encompassing 63 counties in central and eastern Kentucky. Of the 63 counties served, 51 are designated as Appalachian, 38 are federally recognized as economically distressed, and 43 have been identified as medically underserved areas. Target population to be served: Of the patients served in 2013, 69% were white, 21% African American, and 8% Hispanic; 71% were below 200% of poverty. The BCC is providing care to an increasing percentage of patients ages 45 and older, increasing from 33% of the patient population in 2002 to 50% in 2013. Kentuckians have among the highest US rates of co-morbid conditions (i.e., cardiovascular disease, obesity, diabetes, and cancer), making patient care complex and time consuming. Unprotected sex is the most common risk factor for HIV/AIDS within the BCC’s service area with the majority of cases diagnosed among men who have sex with men (MSM - 58%) followed by heterosexual transmission (27%). In 2013 66% of the new patients reported a risk factor of MSM; 15% were diagnosed with concurrent syphilis. The proposed project targets persons at-risk for HIV disease in the 63-county service area, including persons of color, migrant farm workers, and medically underserved, rural residents. The project is designed to address unmet needs and to overcome barriers to care. Key Ryan White Part C Services: The BCC proposes in this application to continue to provide HIV care by a multidisciplinary care team, including on-site services of: 8 board certified infectious disease physicians, 3 internists, a clinical pharmacist; a mental health counselor; a registered dietician; three Patient Service Coordinators (PSC); and a Health Educator. The BCC receives Ryan White Part B from the Commonwealth of Kentucky which funds nine on-site Part B HIV Care Coordinators to provide medical case management. In addition to comprehensive Infectious Disease care, as part of the larger University of Kentucky Healthcare Enterprise patients seeking care at the BCC have access to an additional 40 specialty referral clinics onsite. Ryan White Part C - Quality Improvement Measures: The BCC has an active Quality Management Program that meets monthly and has representation from members of the multidisciplinary care team including: three HIV physicians, one infectious disease fellow, one Primary care physician, the ambulatory practice clinic manager, a patient services coordinator, 2 program coordinators, and 2 medical case managers. The BCC’s CQM team is actively involved in assessing and improving many of HRSA/HABs recently released performance measures. Current quality goals include: increasing the percentage of patients with suppressed viral load to 88% (currently 83%) and increasing the percentage of patients with at least 2 medical appointments every 12 months to 92% (currently 89%). Additional quality goals including increasing the percentage of patients receiving the following services: annual pap smears; adherence assessment and counseling; annual lipid screening; and annual STD screening