Chase Brexton Health Services, Inc.

Program Name: Expanding Access to Support Team Services for Patients with Chronic Illnesses: The Healthy Outcomes through Patient Empowerment (HOPE) Project

Grant Amount: $250,000/2 years

Chase Brexton Health Services, Inc.

Chase Brexton Health Services, Inc. has four clinic locations and has evolved from a gay health clinic into an FQHC that provides care to disenfranchised, high risk patients through primary care, diabetes management, HIV-targeted case management, substance abuse and mental health services.

The Healthy Outcomes through Patient Empowerment (HOPE) Project is an integrated, multidisciplinary model of care to provide adherence assessment, education, support and drug regimen review. The most common chronic diseases in this population are HIV, hypertension, diabetes, and asthma. Specifically this grant will expand the Medication Support Team (MST) to provide increased patient access to an interdisciplinary treatment team (MST nurse and clinical pharmacist) for all patients diagnosed with at least one chronic illness, and add a QI nurse to be responsible for clinical quality performance activities. In addition, Chase Brexton will hire navigator to provide additional support to chronically ill patients referred to the program. The grant will support MST Coordinator, clinical pharmacist, patient navigator and quality improvement nurse.

The program will measure the number of patients with chronic illness seen for intake and evaluations; number of patients’ visits for medication review; adherence, education, self-care planning, management of chronic illness; number of Club Med (a group that fills pill boxes and provides a forum for group discussions for HIV+ patients) group visits; number of patient visits with behavioral medicine clinician; patient progress on clinical quality measures for key health indicators; electronic registry for HOPE program patients to allow tracking and reporting on both an individual and aggregate basis.

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