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CDP 12-253 – HSR&D Study

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CDP 12-253
Improving Access and Outcomes for Rural Veterans with HIV (CDA 11-211)
Michael Ohl MD MSPH
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: October 2012 - September 2017

BACKGROUND/RATIONALE:
Approximately 12-16% of the 27,000 veterans in care for HIV infection in the United States live in rural areas and have limited access to specialized health care. Our prior work demonstrated that, compared to their urban counterparts, rural veterans with HIV infection entered care with more advanced illness and experienced higher mortality.

OBJECTIVE(S):
The long term research objective of this career development award was to develop, evaluate, and implement innovative delivery models to improve the accessibility, quality, and outcomes of care for rural veterans with HIV. Specific aims were to: 1) further determine rural - urban variation in HIV care quality and intermediate outcomes, and identify gaps in care for rural veterans; 2) identify barriers to care for rural veterans with HIV and obtain stakeholder input on design of an improved delivery model; and 3) develop and evaluate an innovative delivery model for rural veterans with HIV that employs existing VA telehealth resources.

METHODS:
We employed a series of mixed methods during three incremental projects to achieve these aims. In aim 1 we applied secondary analysis of VA HIV registry and other administrative data to identify gaps in care for rural veterans with HIV. In aim 2 we employed qualitative methods and interviews with veterans, VA providers, and administrators to identify opportunities to improve care for rural veterans with HIV. In aim 3 we applied these findings to develop, pilot test, and evaluate innovative, telehealth-based delivery models for rural veterans with HIV.

FINDINGS/RESULTS:
Findings on rural - urban variation in care included later care entry for rural compared to urban Veterans with HIV and lower rates of retention in HIV care among rural Veterans. Findings form aim 2 included Veteran and provider preferences for telehealth models that involved co-management between HIV specialists and primary care providers (i.e. "shared care"), as opposed to models that shift care more completely to primary care teams (i.e. SCAN-ECHO). Interviews with key stakeholders identified factors associated with limited uptake of HIV SCAN ECHO programs, in comparison to SCAN ECHO programs for hepatitis C care. We pilot tested an alternative, telehealth collaborative care model for Veterans with HIV in rural areas, which was well-accepted by Veterans and provider. In years 3-5 we undertook a randomized program evaluation to evaluate the effectiveness of the Telehealth Collaborative Care Model for Veterans with HIV in four facilities serving rural areas. Results from this evaluation are pending.

IMPACT:
This work increased our understanding of gaps in care for rural veterans, and strategies for overcoming these gaps. In addition to improving access and outcomes of care for rural veterans with HIV, this may inform care systems for rural veterans with other chronic conditions requiring ongoing specialized care. Thus, this work directly addresses the VA operation mandate and HSR&D research priority to improve access to care for rural veterans.

PUBLICATIONS:

Journal Articles

  1. Moeckli J, Stewart KR, Ono S, Alexander B, Goss T, Maier M, Tien PC, Howren MB, Ohl ME. Mixed-Methods Study of Uptake of the Extension for Community Health Outcomes (ECHO) Telemedicine Model for Rural Veterans With HIV. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2017 Jun 1; 33(3):323-331.
  2. Ohl ME, Richardson KK, Goto M, Vaughan-Sarrazin M, Schweizer ML, Perencevich EN. HIV quality report cards: impact of case-mix adjustment and statistical methods. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Oct 15; 59(8):1160-7.
  3. Ohl ME, Rosenthal GE. Advancing telecare for pain treatment in primary care. JAMA. 2014 Jul 16; 312(3):235-6.
  4. Ohl ME, Richardson K, Kaboli PJ, Perencevich EN, Vaughan-Sarrazin M. Geographic access and use of infectious diseases specialty and general primary care services by veterans with HIV infection: implications for telehealth and shared care programs. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2014 Apr 6; 30(4):412-21.
  5. Ohl M, Dillon D, Moeckli J, Ono S, Waterbury N, Sissel J, Yin J, Neil B, Wakefield B, Kaboli P. Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Journal of general internal medicine. 2013 Sep 1; 28(9):1165-73.
Conference Presentations

  1. Ohl M, Richardson KK, Swan H, McInnes K, Yakovchenko V, Okwara L, Midboe A, Bokhour B. HIV Viral Control and Comorbidity Control are not Highly Correlated at the Level of the HIV Clinic. Paper presented at: ID Week Annual Conference; 2015 Oct 9; San Diego, CA.
  2. Richardson KK, Swan H, McInnes K, Yakovchenko V, Okwara L, Midboe A, Bokhour B, Ohl M. Racial Disparities Extend to Common Comorbidities among Persons in Care for HIV Infection. Paper presented at: ID Week Annual Conference; 2015 Oct 9; San Diego, CA.
  3. Moeckli J, Ono SS, Stewart K, Alexander B, Ohl M. Does the Specialty Care Access Network-Extension for Community Health Outcomes (SCAN-ECHO) Model Apply to HIV Care? Experience from Three Facilities. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.


DRA: Health Systems, Infectious Diseases
DRE: Technology Development and Assessment, Epidemiology
Keywords: Career Development
MeSH Terms: none