Internal (Harris Health System) Patients - PowerPoint Presentation

Internal (Harris Health System) Patients
Internal (Harris Health System) Patients

Internal (Harris Health System) Patients - Description


Track 1 Scheduled Current or out of care homeless TSHC patients Hospital Inpatients Less urgent patients from HHS HIV testing programs Track 2 Rapid Response New or previous diagnoses from HHS testing programs ID: 911096 Download Presentation

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patient cmt patients intervention cmt patient intervention patients goals interested services tshc hiv linkage met health homeless appointment care

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Slide1

Internal (Harris Health System) Patients

Track 1 – ScheduledCurrent or out of care homeless TSHC patientsHospital InpatientsLess urgent patients from HHS HIV testing programs

Track 2 – Rapid ResponseNew or previous diagnoses from HHS testing programsHIV+ encountered elsewhere in HHS & in poor health and/or unstably housed

CMT continues with linkage process and is still eligible to receive services

HHS Staff notify CMT

CMT meet patient at patient location before patient leaves

CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services

CMT schedule TSHC screening appointment

Not interested

Interested

CMT plan and goals developed

CMT continue to provide services until patient goals are met and HIV is managed

CMT work on transitioning patient to shelter clinic if patient so chooses

DM generates list weekly

DM generates list monthly

Have upcoming appointment?

No

Yes

CMT review list to identify patients to approach

CMT review list to identify patients to approach

CMT continue with re-linkage process

CMT try to locate patient and schedule a TSHC appointment

When patient is at TSHC, CMT present intervention and perform brief assessment

Not interested

Interested

CMT present intervention

CMT

f

lag selected patients in EMR to be notified when the patient arrives

Graduate from intervention to 90-day transition period

Goals remain met

Goals met

Standard Care

Yes

Yes

No

No

 

This publication is part of a series of manuals that describe models of care that are included in the HRSA SPNS Initiative

Building a Medical Home for HIV Homeless Populations

. Learn more at

http://cahpp.org/project/medheart/models-of-care

Slide2

Referring agency informs CMT

CMT meet patient at patient location before patient leavesReferring agency informs CMT

CMT schedule TSHC screening appointment

CMT continue with re-linkage process

Interested

Not Interested

External (non- Harris Health System) Patients

Track 1 – Scheduled

Less urgent

HIV+ homeless patients referred by

external agencies serving homeless and/or HIV populations

Track 2 – Rapid Response

Urgent patients from external agencies serving homeless and/or HIV populations (poor health

and/or unstably housed)

When patient is at TSHC CMT present intervention and perform brief assessment

CMT continues with linkage process and is still eligible for services

Not interested

Interested

CMT presents Intervention and performs brief assessment

CMT: Case Management Team

DM: Data Manager

MH: Mental Health

SA: Substance Abuse

TSHC: Thomas Street Health Center

CMT complete contact info & initiate linkage and intervention services including housing and MH/SA services

CMT schedule TSHC screening appointment

CMT plan and goals developed

CMT continue to provide services until patient goals are met and HIV is managed

CMT work on transitioning patient to shelter clinic if patient so chooses

Graduate from intervention to 90-day transition period

Goals met

Standard Care

Yes

Yes

No

No

Goals remain met

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