Supporting Engagement and Retention in Care Using the PCMH Model

Supporting Engagement and Retention in Care Using the PCMH Model

December 16, 2013
HIV/AIDS Medical Homes Resource Center (HIV-MHRC)

Best Practices from a California HIV/AIDS PCMH Demonstration Project

According to the CDC only about 50% of persons diagnosed with HIV receive regular HIV care. Of those retained in care, 89% are prescribed antiretroviral therapy and 77% achieve viral suppression. Establishing the infrastructure and services to support long-term retention and engagement in medical care is a key component of the PCMH model.

This HRSA HIV Medical Homes Resource Center webinar reviewed best practices and lessons learned from the University of California San Diego Health System and HIV ACCESS as they share their continued efforts to engage and retain patients in care. Additional topics will include ideas for promoting provider commitment to team-based care and the team’s roles in care coordination and panel management.

Upon completion of this activity participants should be able to:

  • Recognize how key concepts of the PCMH model support sustainable improvement in the HIV Treatment and Care Cascade
  • Employ effective strategies for population and panel management to retain patients after empanelment
  • Recognize specific challenges/solutions in engagement and retention from the UCSD and HIV ACCESS (CHC) perspective
  • Discuss the role of team-based care in supporting clients’ access to wraparound services
  • Identify engagement and patient retention deliverables specific to PMCH recognition.


  • Amy Sitapati MD, UCSD
  • Kathleen Clanon MD, Alameda Health System
  • Steve Bromer MD, HRSA MHRC

Supporting Files