Patient-Centered Health Home

HIV ACCESS Patient-Centered Medical Home Demonstration Project

Visit with Dr. Frances Herb at LifeLong Medical Care

The PCMH Project is using technological innovation and collaborative Communications Boxlearning to support HIV ACCESS clinics in the journey toward Patient-Centered Medical Home transformation. Funded by the California HIV/AIDS Research Program, the PCMH Demonstration Project leverages the HIV ACCESS network’s long history of partnership.  Implementing the project in the context of an existing network adds value to existing relationships and information-sharing processes with technical assistance, coaching, and shared learning. Our project is led by a Steering Committee consisting of representatives from all five HIV ACCESS clinic sites:

The HIV ACCESS PCMH Demonstration Project builds on the longstanding patient-centered model of care of the HIV ACCESS program by implementing several key service delivery changes. The goals of the project are: (1) To support optimal use of health information technology; (2) To build capacity at HIV ACCESS sites to prepare for recognition from the National Committee for Quality Assurance as Patient-Centered Medical Homes; (3) To use electronic health records and other technology to implement population-based panel management

at three intervention clinic sites. These goals aim to improve health

outcomes as well as continuity of care for patients.

In June of 2012, Alameda County Medical Center (ACMC) at Highland Hospital launched a panel management pilot in the Adult Immunology Clinic using the existing LabTracker system and a Microsoft Access database. Please click on the video link below for more detail to hear from ACMC staff about their successes and challenges so far.

Panel Management Pilot at ACMC

This pilot will be scaled up to multiple providers at ACMC, as well as expanded to Tri-City Health Center and Lifelong Medical Care, in early 2013. We anticipate continued improvement in process and outcome measures for patients who receive panel management interventions through these pilot activities.  Panel management practices can help serve as a form of benefits advocacy as people living with HIV in Alameda County transition from Ryan White to the Low Income Health Program (LIHP).  As medical assistants and other support staff become more skilled at reaching out to patients who are out of care, and all patients are seen more regularly and treated more effectively using decision support tools, we anticipate seeing clear improvement on our long-term goal: a healthier population of patients who are actively involved with managing their own wellness.

Principal Investigator Dr. Kathleen Clanon presents to the PCMH Steering Committee

Principal Investigator Dr. Kathleen Clanon presents to the PCMH Steering Committee

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For more information on the HIV ACCESS PCMH Demonstration Project, contact Erin Gael Friedman at



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