Nurse Care Manager Model HCV, HIV & MAT Programs North Shore

Nurse Care Manager Model HCV, HIV & MAT Programs North Shore Community Health May 2018

How did Partnership for Care stimulate the concept of nurse care manager driven services? Prior to P4C, NSCH had no in-house services to assist individuals diagnosed with HCV or HIV. HIV patients were referred to infectious disease specialists resulting in inconsistent follow up care and data monitoring. P4C’s goal to have PCPs have their own panel of HIV patients, with referrals to local ID specialist for patients with complicated resistance

Partnership for Care & North Shore Community Health Through outreach, utilization of EMR capacity, and communication with PCPs the RN Care Manager created a directory of current pts diagnosed as HIV . . Once developed, our NCM continued outreach to review our patients’ SDOHs, medication compliance, and communicated with patient and provider to create continuity of care. NCM established communication with local ID specialists in order to act as a liaison between specialists and PCPs at NSCH, which previously did not exist, to allow for a more impactful coordination of care.

Where We Are May 2018 NCM provided HIV education to primary care providers regarding CDC HIV testing recommendations Increased HIV screening rates from 20% (2015) to 60% (2018) HIV Provider Champion MAVEN Project – ID/HIV specialist

HCV Treatment NCM model expanded to include in-house HCV treatment and Nurse Care Management Homeless outreach and Care Management ECHO Program-GI specialist Currently have treated 87 patients- 58 pt’s achieved HCV SVR 31 pts currently being treated or waiting for HCV SVR testing 5 patients lost to follow up incomplete tx 1 reinfection currently being retreated

Medicated Assisted Treatment M.A.T Started four years ago, modeled after Boston Medical Center’s RN Care driven Model of care Team: Program Director, Program manager, 4 full-time MAT RNCM, PCPs NCMs see 80% of visits All new patients have weekly visits with NCM Relationship building, education, support, relapse prevention Assess SDOH with referrals as needed

Medicated Assisted Treatment M.A.T 300 patients across 3 sites on the North Shore of Boston 70% have 1 year in the program

Medicated Assisted Treatment M.A.T Harm Reduction Model Narcan and Overdose training Behavioral Health referrals (in-house) Utilizing in-house services we are able to provide comprehensive specialized services to our patients with the goal of meeting the needs of all of our patients needs in one location

North Shore Community Health & Partnership For Care Overview The relationship between the patient and the NCM is our driving force. NCM services, done properly, decrease outside provider referral, enhance engagement in care, and lessen load of PCPs. NCM services also improve care, decrease provider burn out, and help to keep all care centered at the medical home of our patients Due to the success of this model, we are investigating expanding our program and assigning specific NCM for primary care teams to strengthen our coverage for additional special populations and MAT

Thank You!