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2019 HSR&D/QUERI National Conference Abstract

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1088 — How should we organize care for Veterans with HIV and comorbidities in VA? A multisite qualitative study of HIV care

Lead/Presenter: Barbara Bokhour,  COIN - Bedford/Boston
All Authors: Bokhour B (Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA; Boston University School of Public Health), Fix G (Center for Healthcare Organization and Implementation Research (CHOIR), , Edith Nourse Rogers Memorial Veterans Hospital; Department of Health Law Policy and Management, Boston University School of Public Health) Asch S (Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System) Bolton R (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; Brandeis University Heller School for Social Policy and Management) Dvorin K (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital) Gifford A (Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System; Department of Health Law Policy and Management & Section of General Internal Medicine, Boston University) Hyde J (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; Section of General Internal Medicine, Boston University) McInnes DK (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; Department of Health Law Policy and Management, Boston University School of Public Health) Midboe A (Center for Innovation to Implementation (Ci2i), VA Palo Alto Healthcare System; Department of General Medicine, Stanford University) Parker V (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; Peter T. Paul College of Business & Economics, U. of New Hampshire) Skolnik A (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital; University of Massachusetts Amherst) Wu J (Center for Healthcare Organization and Implementation Research (CHOIR), Edith Nourse Rogers Memorial Veterans Hospital) Ohl M (Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA; Department of Medicine, University of Iowa)

Objectives:
HIV is a chronic manageable condition, however as patients age co-morbidity management often becomes the highest priority. In VA, care for Veterans with HIV is shifting from solely within HIV clinics towards co-management with primary care and should align with PACT principles. We sought to understand how variation in the organization, structure and processes of care for Veterans with HIV related to HIV and comorbidity care quality.

Methods:
We selected a purposive sample of 8 VAMCs high and low in key quality indicators for HIV (viral control), physical comorbidity care (e.g. HbA1C) and mental health care (e.g. guideline concordant depression care) based on medical record data. We conducted in depth qualitative site visits, blinded to sites' quality designation, including: 1) patient interviews (n = 60); 2) HIV care team interviews (n = 60); 3) direct observation of clinic processes and team interactions (n = 22) and 4) direct observations of patient-provider clinical encounters (n = 45). We coded all using both a priori constructs from PACT principles and emergent codes. We constructed individual site templates to reflect extent of PACT-principled care, and observed processes and structures of care. After removing blinding to quality designations, we examined relationships between templated descriptions and levels of quality.

Results:
Sites highest and lowest in both HIV and comorbidity quality demonstrated clear differences in provision of PACT-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs, either via HIV clinic team-based care or through coordination with other psychosocial services. Sites that had consistent processes of care for comorbidities, whether in HIV or primary care clinics, had higher quality of comorbidity care.

Implications:
Different aspects of the structures and processes of care are important to providing high -HIV and comorbidity quality of care for Veteran's with HIV. Attention to psychosocial needs and consistency in comorbidity management were most important for high quality care.

Impacts:
When considering organization of care for Veterans with HIV, medical centers should focus on providing care aligned with PACT principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.