Table 3.

Interventions Adopted by Sites, by Chronic Care Model Domain

Chronic Care Model Domain	Interventions
Health system	• Integration of cascade into existing HIV quality management plan and program • Interprofessional team rounds • Referrals and service programs and agencies • Expanded clinic hours • Inclusion of community health workers and peers in case management and QI teams • Coordination with other service delivery areas and departments to identify and refer PLWH to HIV care • Implementation of memoranda of understanding with other agencies to share information and establish care referral policies
Delivery system	• Rearrangement of clinic flow • Spacing of clinic visits based on need • Home visits • Care navigation for clinic appointments • Intensified screening for mental health and substance use • Reminder strategies • Flexible appointment scheduling for new and unengaged patients • Telemedicine and e-visits • Adherence counseling at first clinic visit • Individualized care plans for ART initiation • HIV lab testing for patients receiving care in other service delivery areas • Directly observed therapy • Transition plans for adolescent patients transferring to adult care
Patient-centered care	• Patient involvement in care planning and case conferencing • Shared decision-making • Involvement of consumer advisory groups to identify effective interventions and participate in QI activities • Implementation and use of online patient portals • Use of visuals and videos to address health literacy • Use of adherence tools • Implementation of self-management programming • Motivational interviewing • Peer support groups • Personal cascade narratives • Use of social media to communicate adherence promotion strategies
Knowledge management and decision support	• Education of HIV program staff on cascade methodology • Sensitization of staff in other service delivery areas and departments about unengaged PLWH • Data transparency policies • Education of HIV program staff about HIV-related stigma • Referral resources guide • Formal policy and training on same-day ART initiation • Training of HIV program staff on entitlement programs • Education of providers about refill standards
Information systems and performance measurement	• Updated patient contact information • Frequent and automated report generation to track virally unsuppressed patients • Previsit patient reports for care coordination planning • Structured templates in EMRs • Structured fields in EMRs for care coordination • Monitoring of prescription refill rates • Daily alert system with updates on new patients and test results • Tracking time from diagnosis to first clinic visit • Monitoring of staff compliance to linkage-to-care policies • Routine reporting of missed appointments and labs within specified interval • Provision of tracking information to case management team • Integration of visit tracking systems into EMRs
Community	• Engagement of community partners to promote linkage and VLS • Linkage of patients to community services • Inclusion of community partners in care planning • Referral of LTFU patients to health department • Routinized communication with community partners to confirm linkage to care • Partnership with insurance companies to facilitate care enrollment • Linkage to transportation services • Outreach community groups catering to specific at-risk subpopulations
Financial	• Incentives for retention and viral load suppression

Abbreviations: ART, antiretroviral therapy; EMR, electronic medical record; LTFU, lost to follow-up; PLWH, people living with HIV; QI, quality improvement; VLS, viral load suppression.