SNP Alliance Member Success Story

HIV/AIDS Chronic Conditions SNP Success Story

• PHC members are assigned a consistent Registered Nurse Care Manager (RN-CM)
• RN-CM responsible for health risk assessment (HRA), development of an individualized Plan of Care (POC) in collaboration with the member, the member’s HIV expert Primary Care Provider (PCP) and other care team members
• RN-CM responsible for assuring POC implementation and monitoring
• POC addresses whole person care, including comorbid conditions in the context of HIV conjunction with HIV

A very recent PHC enrollee, Jim, was hospitalized for failure to thrive and a serious infection.  At the hospital, RN-CM learned John had not been taking his Antiretroviral medications and, because of this, was highly susceptible to catastrophic opportunistic infections, opportunistic cancers and death. After inpatient stabilization, the RN-CM worked to ensure smooth transition to an appropriate skilled nursing facility and then home. While at the Skilled Nursing Facility, Jim’s Plan of Care (POC) was updated.  As part of this process, the RN-CM learned Jim was frustrated with the array of pills, multiple physicians’ offices and poor physician office communication.

With RN-CM support, Jim began taking his meds and streamlined his primary care physician (PCP) and other physician visits.   During a routine visit, PCP detected a second infection.  PCP contacted RN-CM to request assistance with an Emergency Department visit. RN-CM met Jim at the ED and coordinated a telehealth meeting between PCP and ED. With this clear communication, Jim was successfully treated with an appropriate IV antibiotic to target the infection and avoided an inpatient admission.  Since this challenge, Jim continues to engage with the RN-CM and actively participates in his POC.