LifeLong was featured in this article on HealthyCal.org’s California Health Report. Click here to view the article.

LifeLong West Berkeley has been recognized with the Preservation Award by the Berkeley Architectural Heritage Association. Click here to see award.

We are pleased to announce that the Spring 2014 edition of our quarterly newsletter, the Lifelong Times, is now available. Click here to read the full newsletter.

A demonstration project aimed at improving patient care for people with HIV and AIDS has reduced the number of hospital re-admissions at one Bay Area hospital by 44 percent.

The new approach — jointly funded by the California HIV/AIDS Research Program (CHRP) at the University of California, the Alameda County Health Care Services Agency, the Gordon and Betty Moore Foundation and Alameda Health System — puts primary care physicians at the helm of an integrated care team that includes social workers, psychologists and medical specialists.

These collaborative teams form virtual "patient-centered medical homes" that work together to ensure that patients come to appointments, take their medications and get the care they need.

“The HIV epidemic has had a history of clients being advocates for their own care,” said John Mortimer, CHRP health policy and health services research program officer. “Our goal is to make medical care even more client-centered to help improve patient outcomes.”

Promising results

Early results are promising. Highland Hospital in Oakland looked at how many patients were re-admitted to the hospital in 2010 before the demonstration project started and compared it to re-hospitalizations during the pilot program.

As a result of Patient-Centered Medical Home care strategies, which included support for care transitions from hospital to outpatient care, the number of re-admissions fell significantly. Of 89 patients admitted in 2010 for HIV-related treatment, 35 were readmitted within a month. From October 2012 to September 2013, 63 patients were admitted, and only 14 of them were readmitted within 30 days.

“This shows that our system is working,” says Dr. Kathleen Clanon, medical director of the Health Program of Alameda County. “The supports are successfully in place outside the hospital.”

In addition to Oakland's Highland Hospital, four other community clinics are participating: the Tri-City Health Center in Fremont, Lifelong Medical Care in Berkeley, and La Clínica and Asian Health Services, both in Oakland.

“UC is happy to have supported this innovative and effective pilot research program,” said Dr. George Lemp, director of CHRP.

Meeting patient needs

Patients with HIV are especially in need of the kind of wrap-around services offered by the patient-centered medical homes project.

Only half of Californians with HIV consistently receive medical care. There are many reasons for this: lack of insurance, homelessness, lack of transportation and the stigma of the disease, among others.

And tracking every person who tests positive for the virus is like following a needle as it sifts through a haystack. This poses both individual and public health hazards.

HIV can only be suppressed — and rendered non-transmissible — if anti-retroviral medication is taken every day.

At the heart of the pilot project are tools that help clinics capture and centralize patient care information to better track individual needs. Highland uses the software system Lab Tracker and a customized database.

Centralized patient information

The tools, called registry reports and decision support sheets, give each physician’s team a detailed history: the last lab report, any missed appointments and unfilled prescriptions, but also, reports of depression or lack of adequate food and transportation.

Clinic staff work closely with patients, providing information about why tests are needed and reminding them, if need be, to get them done.

“I’m paying attention and want to be more involved,” said Monica Chadwick, a medical assistant at Highland’s Adult Immunology Clinic — a key implementer in the Highland pilot. “And I want the patient to be more involved as well.”

If a patient misses an appointment or does not refill a prescription, Chadwick is on the phone. And it’s not just a friendly reminder.

“A significant number of Monica’s calls involve cussing on the patient’s part and hang-ups,” Clanon says. “People are frightened we will reveal their diagnosis. They’re frightened in general. But we work to connect with people who don’t know what they need.”

It takes an average of 10 phone calls from the clinic before a person who has tested positive in Highland’s emergency department comes in for his or her first visit.

Time is a challenge. Clanon and Chadwick block out two appointment slots every month for a “team huddle” where they review their patient group and see what follow-ups are needed. That means other patients wait longer to see the doctor so that the team can track down people who haven’t come in.

Changing clinic culture

Clinic culture has also changed. Staff use the new tools to care for the patients they see regularly as well as the ones they do not: A telephone number on a computer screen for someone who has missed appointments is as important as the person sitting in the waiting room.

“I get a lot of support services here,” says one patient, who chose not to give his name. “The people here are very knowledgeable. They know about legal aid, transportation, and housing. They encourage you to take advantage of other services.”

The good news is that people with HIV are living long enough to make health and well-being a tangible goal.

“Because I’m working with patients who haven’t been seen in the clinic for a while, I tend to spend more time with people around the things that make accessing care hard for them,” Clanon says of the provider experience. “But I also get to work with them on what they need to do to stay well, like preventing pneumonia and going to the dentist. Bringing those two things together is the power of this program.”

We are pleased to announce that the Fall 2013 edition of our quarterly newsletter, the Lifelong Times, is now available. Click here to read the full newsletter.

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Congressman George Miller

Standing up for California’s 7th District

FOR IMMEDIATE RELEASE

MAY 11, 2012

202-225-2095

Miller Congratulates LifeLong Medical Care on Health Care Innovation Award

LifeLong Medical Care to use award to create local jobs and improve health care outcomes

Washington, D.C. – An award made possible by the Affordable Care Act could help create jobs, lower health care costs and improve the well being of residents in several East Bay communities, Rep. George Miller (D-CA) said today. 

Miller congratulated LifeLong Medical Care on their $1.1 million Affordable Care Act award to further integrate care and encourage healthy behavior among certain Medicaid populations and their plan to train an estimated 60 health care workers over the next three years. The award was announced this week and is one of 26 health care innovation awards made across the country.

The awards made this week represent the first batch of organizations to receive Health Care Innovation awards that were made possible by the Affordable Care Act, the health care reform law that Miller helped to pass in Congress. The program is estimated to save $254 million in health care costs and improve health care.

“Congratulations are in order to LifeLong Medical Care,” Miller said of the announcement. “I look forward to seeing this innovative program put into place and the impact it will have on our community.”

“This unique partnership with the Center for Independent Living and the Alameda Alliance for Health is a great opportunity to implement practices that will positively impact the health of many high risk patients, and therefore ultimately benefit our entire community. This innovative triple aim program is a model that can be implemented throughout our nation, and we are very grateful that health care reform-the Affordable Care Act has made it possible to further LifeLong’s mission of delivering high quality medical care to those who are most in need,” said LifeLong Medical Care CEO Marty Lynch, Ph.D.

LifeLong will use its $1.1 million award to further integrate care and encourage healthy behavior, among 3,250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid-eligible beneficiaries.  The intervention will train adults with disabilities to support adoption of healthy behaviors among their peers and encourage self management, with the support of a team of nurse care managers. The goal is to reduce avoidable emergency room and hospital visits.  Improved care and better health for high risk patients will lower costs, with estimated savings of approximately $1 million. LifeLong will partner with Berkeley’s Center for Independent Living and the Alameda Alliance for Health to achieve program goals.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services at HHS administers the awards through cooperative agreements over 3 years. During that period, LifeLong Medical Care’s program will train an estimated 60 health care workers, while creating an estimated 60 new jobs.  These workers will include peer health coaches and nurse care managers who will facilitate integrated care for seniors and for low-income adults with disabilities.

LifeLong Medical Care is an innovative, nonprofit Federally Qualified Health Center serving Alameda, Contra Costa, and Marin Counties. LifeLong has served northern California communities for over 35 years, providing medical, dental, and social services to patients of all ages at multiple sites, including nine primary care medical centers, two dental centers, two adult day health centers, two school based health centers and a supportive housing program.

# # #

  Health and Human Services (HHS) Secretary Kathleen Sebelius has announced that LifeLong Medical Care is among three California awardees to receive the CMS Health Care Innovation awards, that included a total of $122.6 million,  with more than $11.5 million coming to California organizations. LifeLong will use its 1.1 million dollar award to further integrate care and encourage healthy behavior, among 3250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid-eligible beneficiaries.  The intervention will train adults with disabilities to support adoption of healthy behaviors among their peers and encourage self management, with the support of a team of nurse care managers. The goal is to reduce avoidable emergency room and hospital visits.  Improved care and better health for high risk patients will lower costs, with estimated savings of approximately $1 million. LifeLong will partner with Berkeley’s Center for Independent Living and the Alameda Alliance for Health to achieve program goals. 

  “This unique partnership with the Center for Independent Living (CIL) and the Alameda Alliance for Health (AAH) is a great opportunity to implement practices that will positively impact the health of many high risk patients, and therefore ultimately benefit our entire community. This innovative triple aim program is a model that can be implemented throughout our nation, and we are very grateful that health care reform-the Affordable Care Act has made it possible to further LifeLong’s mission of delivering high quality medical care to those who are most in need,” said LifeLong CEO Marty Lynch, Ph.D.

  “We are thrilled to have the opportunity to work with the Center for Independent Living and Alameda Alliance for Health to help low income adults with disabilities achieve a higher quality of life, while at the same time improving health care and reducing cost, “ commented LifeLong Strategic Planning Director Nance Rosencranz.

  "For 40 years, CIL has said that people with disabilities are the best experts on our own lives, that any programs or services to help our community achieve independence must be developed with us, rather than for us,'' said Yomi Wrong, Center for Independent Living's Executive Director. "This new partnership with LifeLong Medical Care will bring CIL's philosophy of consumer-controlled services into a medical setting -- a place not traditionally open to such a concept. But we know that LifeLong is not your traditional health center. Like CIL, Lifelong is an outgrowth of community advocacy. The hope is that the natural synergies between our organizations will allow us to succeed in meeting the challenge of this grant."

  “An interdisciplinary health care model not only expands an organization’s capabilities and resources, it also can greatly enhance patient outcomes,” said Ingrid Lamirault, Chief Executive Officer of Alameda Alliance for Health. “The Alliance is excited at the prospect of collaborating with LifeLong Medical Care and the Center for Independent Living under the CMS grant to improve outcomes for Alameda County’s low-income seniors and persons with disabilities. Innovative partnerships such as this advance us toward our shared goal, to improve quality of life for our community’s most vulnerable populations.”

  The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services at HHS administers the awards through cooperative agreements over 3 years. During that period, LifeLong Medical Care’s program will train an estimated 60 health care workers, while creating an estimated 60 new jobs.  These workers will include peer health coaches and nurse care managers who will facilitate integrated care for seniors and for low-income adults with disabilities.

  LifeLong Medical Care is an innovative, nonprofit Federally Qualified Health Center serving Alameda, Contra Costa, and Marin Counties. LifeLong has served northern California communities for over 35 years, providing medical, dental, and social services to patients of all ages at multiple sites, including nine primary care medical centers, two dental centers, two adult day health centers, two school based health centers and a supportive housing program.