Using a Multidisciplinary Approach to Improve Retention in HIV Care

MacGregor Infectious Diseases (MacGregor), a hospital-based clinic affiliated with the Hospital of the University of Pennsylvania, implemented a multidisciplinary approach to strengthen outreach to Ryan White HIV/AIDS Program (RWHAP) clients and improve care retention. As compared to clients in standard care, clients served with the multidisciplinary approach had higher rates of retention in care, particularly among clients who were not virally suppressed.

Philadelphia, PA

Implementation Guide
Emerging Intervention
Emerging Intervention
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Clinical service delivery model
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Retention in HIV medical care; Viral suppression
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People with HIV
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University-based clinic
Need Addressed

Retention in medical care is essential for the overall health and wellness of people with HIV. MacGregor completes an annual quality improvement project, and selected retention in care as the focus to identify and engage clients with HIV who were not virally suppressed.

Core Elements
Early identification of clients in need of follow-up

MacGregor reviews data to identify clients who are at risk of falling out of care, including: clients who do not have recent labs or medical visits in CAREWare or Epic, the electronic health record system; clients who missed three notification calls from the pharmacy for medication delivery; clients whose insurance has lapsed as identified in a quarterly review; and clients identified by the health department surveillance team.

Multidisciplinary approach to follow-up contact

When a client is identified through the data review, MacGregor and Penn Specialty Pharmacy staff coordinate to identify the best staff person to lead outreach, based on who has a connection with the client. Outreach is conducted by all staff people including the pharmacy, case management, social work, behavioral health, medical providers, and administrative staff (e.g., medical assistants who have access to the scheduling system). If clients cannot be reached, the outreach effort shifts to the program manager and eventually to the surveillance team at the health department. Results from outreach are tracked continuously in Epic, using flags to alert other teams of outreach efforts.

Increased access to services 

MacGregor also increased access to services by setting aside a day a week for walk-in appointments. A second medical case manager was hired which also allowed a doubling in the number of clients who were able to access those services. Clients aged 18-29 were also able to access financial and benefits counseling and social work services.

“Trust the relationships that all different kinds of people have with your patients. Sometimes the person that knows them best is the pharm tech that calls them, or is their case manager, or is the provider that only sees them to treat their STDs, but doesn't see them for everything else. Sometimes those people know things about [patient’s] lives or their situation that may give a lot of insight... Those little insights really give a lot to the provider patient relationship.”


Outcomes data are tracked in Epic. Data for around 900 RWHAP-eligible clients were manually entered in CAREWare for analysis and quality improvement projects.

Measure Multidisciplinary Approach Standard Approach
Retention in care for overall population 80% 76%
Retention in care for clients who are not virally suppressed 82.5% 56%
Viral suppression for overall population 90% 88%

Source: Communication with the Best Practices Compilation team. 2020–2021.

Planning & Implementation
  • Infrastructure. Key infrastructure for this project, including support for quality improvement, was provided by the RWHAP Part A health department that funds MacGregor.
  • Co-location and collaboration. Penn Specialty Pharmacy is co-located in the same building as MacGregor, and several pharmacy staff work within MacGregor. The pharmacy technicians also have access to Epic and can pull data on medication fills, and maintain a spreadsheet for when client refills are coming due. MacGregor collaborated extensively with the Penn Specialty Pharmacy for this program. Though MacGregor had worked for years with the on-site pharmacy, the teams were siloed in terms of outreach before this project.
  • Communication. Epic is used to track outreach and allows the pharmacy team and MacGregor to communicate easily with each other. The program manager also maintains an Excel list of clients, and cases are discussed at weekly quality improvement meetings that include pharmacy staff, case management, social work, behavioral health, and a nurse practitioner.
  • Streamlined outreach. MacGregor learned that the pharmacy team had also been doing several rounds of outreach to clients around medication refills, so they streamlined the process to reduce the overall number of calls going out to avoid “alert fatigue.”

“We have dedicated pharmacy technicians down in the pharmacy who kind of get to know our patients and make all of the refill calls every month…I love that we get messages [in Epic] that say they've tried three times to reach the patient on this phone number and haven't been able to go through.”

  • This intervention brings together a multidisciplinary team to coordinate and conduct outreach, all of whom are already involved in client care. Streamlining the outreach call process led to a reduction in the total number of calls conducted, which saves staff time. Having a staff coordinator for outreach who can refer to other patient navigator services as needed is beneficial.
  • Given the changes needed to Epic and the many data sources that go into creating the follow-up list, it is helpful to have an on-site IT person to build interfaces and manage the data pieces of the program.

Photo Source: HRSA Ryan White HIV/AIDS Program Photo Library

Lessons Learned
  • Clients respond to different types of outreach. Providers should consider alternate methods of follow-up beyond phone calls, including email, text messaging, communication through a patient portal, and letters. Collecting emergency contact information can be effective in reaching clients who change their phone number.
  • Outreach is most effective when it includes a multidisciplinary team. Good communication across the team (e.g., in the weekly meeting) is key to matching the best outreach person to each client.
  • Though smaller clinics may already have coordinated outreach across departments, larger providers may have some duplication because they are not aware of the outreach processes of other departments. Streamlining processes and instituting communication across departments can better leverage staff time and relationships.

“For me [our advice] would be definitely leveraging as many resources as you can, working with as many providers, different disciplines, different practices that you can. That would be my key takeaway."

Hospital of the University of Pennsylvania
Morgan Curran
Program Manager, MacGregor Infectious Diseases

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