Collaborative Medical Case Management Team to Address Barriers to Adherence

Nationwide Children’s Hospital Center for Quality Improvement and Innovation (CQII)


Collaborative medical case management team called Tri-Pod (registered nurse, a social worker, non-medical case manager) utilizes a psychosocial assessment to identify barriers to adherence (e.g., lack of support/other priorities), facilitating collaboration among the medical case management team and allowing the MCM to provide patient-centered care, promote health and wellness, and assist in removing barriers to accessing health care.

Change Ideas

  • Initial informative session in November 2017.
  • Caseload review and assignment among medical case management team.
  • Documentation training.
  • Paired training within the pods.
  • Independent case management starting in March 2018.


A new medical case management (MCM) Tri-Pod approach was implemented through the Family AIDS Clinic Education Services (FACES) program, which provides more than 400 HIV-positive patients with comprehensive care and supportive services, since January 2018 to streamline the process of patient flow of youth ages 13-24 years and foster collaboration among the MCM team. This Tri-Pod approach to patient care allows for identification of barriers to care and assessment of 17 different functional areas by using the psychosocial assessment. This approach forms a multi-disciplinary team process where each Tri-Pod is comprised of a registered nurse (RN), a social worker (SW) and a non-medical case manager (NMCM). The RN’s, SW’s, and NMCM have individual caseloads with patients assigned to medical case managers (MCM) that reflect the needs of the patients while maximizing the MCM’s skills. A series of activities took place between November 2017 and March 2018 to implement this intervention. These activities included an informative session (November 29, 2017), case load review and assignment amongst the team (December 1-15, 2017), Documentation training (December 16-31, 2017), paired training within the pods (January to February 2018), and independent case management (March 2018). A Cause and Effect Diagram was used to identify the causes of not achieving viral suppression. This intervention addressed the barrier of lack of support/other priorities. Viral suppression among youth was 74% in January 2018 and increased to 85% in March 2019. During the period of July 2018 to March 2019, viral suppression for youth increased while viral suppression for the entire caseload of the FACES program (400 patients) decreased. The entire caseload remained stable throughout much of the time from July 2018 to March 2019, starting at 87% (354/409) and decreasing to 86% (351/408​). Viral suppression among youth increased from 80% (50/62) to 85% (47/55) during this same period. This approach improved team work and collaboration among the FACES team, allowed the MCM to provide patient-centered care, promoted health and wellness, and assisted in removing barriers to accessing health care.

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