Example One:

Aim: The clinic will improve care of HIV/AIDS patients by making changes in the following areas: self-management and adherence support; decision support for clinicians; clinical information systems; delivery system design; community linkages; and leadership. Focusing on education, prevention, and early intervention, our goals include:

Guidance:

The clinic will focus on the current active caseload of HIV/AIDS patients who are seen in the HIV/AIDS Early Intervention Services program at three of the center’s sites (approximately 350 patients).

Team:

System/Team Leadership: Primary Care Physician and Nursing Director

Technical Expertise: Senior Physician

Day-to-Day Leadership: Program Manager

Additional team members: Community Health Nurse, Case Manager, Clerical Staff

Example Two:

Aim: Redesign and coordinate services provided at the health center in order to achieve quality clinical and functional outcomes, improve patients’ perceptions of their health status, and improve the overall care provided at the center. To achieve these goals, we will implement changes using the Chronic Care Model and measure the following to gauge our success:

Guidance:

Focus initially on the existing panel of patients with HIV/AIDS seen by two of our clinicians. After implementing changes locally, spread the changes to the rest of the clinicians in the health center.

Team:

System/Team Leadership: Vice President of Ambulatory Services

Technical Expertise: Family Medicine Physician

Day-to-Day Leadership: Nurse Manager

Additional team members: Biostatistician, Social Services Counselor, Nurse Practitioner