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2012 HSR&D/QUERI National Conference Abstract

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2012 National Meeting

3126 — How do PACT Hallmarks Apply to Patients Receiving Primary Care in Specialty Clinics?

Fix GM, Center for Healthy Quality, Outcomes, and Economic Research (CHQOER); HIV/Hepatitis & eHealth QUERIs; Asch SM, VA Palo Alto Healthcare System; HIV/Hepatitis-QUERI; Saifu HNFletcher MD, and Knapp H, VA Greater Los Angeles Healthcare System; HIV/Hepatitis-QUERI; Bokhour BG, CHQOER; HIV/Hepatitis-QUERI;

Many patients receive primary care from specialists. PACT medical home elements are tailored to primary care clinics, but the relationship between PACT and specialty care remains unclear, as is indicated by the Office of Specialty Care Services. Because of the complexity of managing HIV, patients have historically received primary care in HIV clinics. We used the consolidated framework for implementation research (CFIR) to understand the extent to which HIV care in the VA conforms to the hallmarks of PACT.

We conducted semi-structured, qualitative interviews with a convenience sample of 42 HIV providers and staff from 7 geographically diverse VAMCs, including clerks, nurses, social workers, psychiatrists, psychologists, pharmacists, physician assistants, nurse practitioners, and physicians. The interview guide elicited information about the current clinic functioning and provider perspectives on PACT. Detailed fieldnotes were recorded by a trained research assistant, and reviewed by the research team. We conducted grounded thematic analysis to identify key aspects of care, and simultaneously coded for specific PACT elements to ascertain perceptions of adherence to PACT principles.

Four themes emerged as key variants. 1) Clinic composition: Clerks and PAs played essential roles in some clinics, but were absent in others. 2) Integrated care: Highly integrated clinics offered social work and psychiatry during the appointment, while others made referrals. 3) Provision of primary care: Some providers reported responsibility for all of the patient's primary care needs while others saw themselves as responsible only for HIV related care. 4) Team work: Some clinics functioned as highly cooperative and interlinked teams, while others did not. Interviewees identified ways to make their care conform more to PACT principles, such as offering support groups or increasing access.

PACT elements’ presence in HIV clinics varies greatly. Understanding the inner context and individuals involved in HIV care is critical to ascertaining the relationship of HIV care to PACT.

Several national initiatives strive to incorporate medical home principles into specialty care. Even in a specialty that has historically embraced primary care, there is much variation in those principles’ expression in care organization. Understanding this variation is critical to building the relationship of HIV care to PACT.

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