In large cities, persons with HIV often receive care in high volume HIV specialty clinics that employ co-located interdisciplinary care teams. Approximately 18% of the 24,000 veterans in care for HIV infection in the United States live in rural areas and have limited access to this form of specialized health care. Our prior work demonstrated that, compared to their urban counterparts, rural veterans with HIV infection enter care with more advanced illness, are less likely to be early adopters of important advances in HIV therapy, and experience higher mortality.
The long term research objective of this career development award is to develop, evaluate, and implement an innovative delivery model to improve the accessibility, quality, and outcomes of care for rural veterans with HIV. Specific research aims are: 1) further determine rural - urban variation in HIV care quality and intermediate outcomes, and identify specific 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 using qualitative methods; and 3) develop and evaluate an innovative delivery model for rural veterans with HIV that employs existing VA telehealth resources.
We will employ a series of mixed methods over the course of three incremental projects to achieve these aims. In aim 1 we will apply secondary analysis of extant VA HIV Clinical Case Registry (CCR) data to provide a detailed description of gaps in care for rural veterans with HIV. Dependent variables will include a series of process and outcome measures of HIV care tracked in VA. In aim 2 we will employ qualitative methods and semi-structured interviews with veterans, VA providers, and administrators to identify opportunities to improve care for rural veterans with HIV. Interviews will focus on perceived needs for care among rural veterans with HIV, enabling resources that influence care access, needs for additional resources in low HIV-volume sites serving rural areas, and specific opportunities to improve care. In aim 3 we will apply these findings to develop and pilot test an innovative, telehealth-based delivery model to close gaps in care for rural veterans with HIV.
Rural veterans in care for HIV infection in 2010 had poor geographic access to VA infectious disease specialty care (median travel time to nearest ID clinic 86 minutes for rural veterans vs. 23 minutes for urban veterans, p < 0.001) and were somewhat less likely than their urban counterparts to use ID specialty care (82.4% rural vs, 87.8% urban, p < 0.001). Despite travel burdens, the majority of rural veterans who used ID specialty care received antiretroviral therapy (95.0%) and had an undetectable viral load on therapy (83.4%). The approximately 18% of rural veterans with HIV who did not receive ID specialty care were less likely to receive antiretroviral therapy (67.7%) or have an undetectable viral load on therapy (75.5%). These findings further support the need for novel models for delivering care for rural veterans that ensure access to both specialized HIV care and comprehensive primary care.
In the past year, we completed a mixed-methods evaluation of the Specialty Care Access Network - Extension for Community Health Outcomes (SCAN-ECHO) telemedicine model for improving access to specialized care for Veterans with HIV in rural settings. In three VA facilities, this model had limited adoption in Community Based Outpatient Clinics (CBOCs) serving rural areas (9 of 21 clinics adopting, 43%) and limited reach among rural veterans (5.3% of rural Veterans with HIV offered SCAN ECHO participated). Qualitative analysis of interviews with program stakeholders identified barriers to implementing SCAN-ECHO in HIV care, including a sense of HIV exceptionalism that made it difficult to engage primary care providers in the HIV care mission, and insufficient learning loops in HIV care to drive the ECHO model. In contrast, pilot work has demonstrated the feasibility of a telehealth collaborative care model for delivering care for rural veterans with HIV who have poor access to specialty clinics. Telehealth collaborative care integrates HIV specialty care delivered by veteran-level clinical video telehealth visits, with primary care delivered by local Patient Aligned Care Teams (PACTs) in VA Community Based Outpatient Clinics (CBOCs) serving rural areas.
This work is increasing our understanding of gaps in care for rural veterans. We are applying this knowledge to design and test an innovative care system that uses VA telehealth resources to extend interdisciplinary-team-based specialty care for veterans with HIV in rural settings. 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.
- 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. 2016 Aug 24; 33(3):323-331.
- 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.
- Ohl ME, Rosenthal GE. Advancing telecare for pain treatment in primary care. JAMA : the journal of the American Medical Association. 2014 Jul 16; 312(3):235-6.
- 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.
- 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.
- 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.
- 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.
- 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.
Health Systems, Infectious Diseases
Epidemiology, Technology Development and Assessment