VHA transformed primary care through implementation of Patient-Aligned Care Teams (PACT), based on core principles including patient-centered, team-based and well-coordinated care. It's less clear how PACT can be extended to specialty care, such as HIV. Understanding variations in HIV care across VA is critical to the development and spread of initiatives to ensure Veterans living with HIV receive the best care possible for all their health needs.
1) Characterize patterns and structures of HIV care at low and high patient volume sites, and examine associations between structures of care, adherence to PACT principles, and outcomes of care for HIV and comorbidities. 2) Qualitatively characterize how different types of sites and corresponding structures of care achieve integration, coordination, and team functioning to generate a typology of HIV care.
We conducted an observational, mixed methods study. Using administrative data from a cohort of HIV patients in VA care, risk-adjusted patient-level measures were constructed to examine quality of care for HIV and common comorbidities across VA sites. HIV clinicians were surveyed regarding structures and processes of care and adherence to PACT principles in their clinics. A confirmatory factor analysis was conducted to identify PACT domains. Mixed effect models were used to evaluate the association between these patient and site-level variables.
We conducted a qualitative study, visiting 8 VA facilities varying on adherence to PACT principles and quality of care. Data collected includes ethnographic observations and qualitative interviews of patients and providers. Field notes and interviews were coded to capture themes related to clinic structures and processes and PACT principles. Site-level summaries were created. Using a constant comparison method we examined common themes among sites with similar levels of comorbidity and HIV care quality.
Site and individual variation in quality: VA performance is very high for quality measures of HIV care, while performance for comorbidity care measures is similar to that of the population of Veterans in care. We found substantial variation in viral, hypertension, and diabetes control across VA HIV clinics but these were not highly correlated at the clinic level. We identified important racial disparities. African American Veterans were less likely than Caucasians to receive cART, have lipid monitoring, or have viral, hypertension, or diabetes control. Disparities in viral control were explained by lower adherence to cART and location of care clinic where HIV care was received.
Adherence to PACT is associated with quality: The majority of Veterans with HIV receive HIV and comorbidity care in Infectious Disease (ID)/HIV clinics and there is variation in adherence to PACT principles across clinics. Hypertension control was higher for patients managed in HIV clinics alone than for patients co-managed in HIV and Primary Care. Positive associations were found between Population Health and Prevention and being on cART; Care Coordination/Continuity of Care and viral control; Patient-Centered Care and receipt of depression care; and Continuous Improvement and initiation of substance abuse treatment.
Organization of care and quality-Qualitative findings: We found important variation in care approaches across ID/HIV clinics. The optimal structure of HIV and comorbidity care may vary based on size of HIV population. Sites with better comorbidity outcomes had clear, formalized guidelines and protocols for comorbidity care, whether it was provided in the ID/HIV Clinic or Primary Care. This includes guidelines about where comorbidities will be managed and how care coordination will occur. Sites without a clear strategy for addressing multiple health needs of Veterans with HIV identified fragmentation and inconsistencies in care quality as concerns. Sites with better HIV outcomes had integrated care and adequate resources and supports to address psychosocial needs, especially around adherence.
Clinician conceptualizations of patients were embedded in organizational contexts. Clinics with team processes and resources to address life stressors viewed patient behaviors as embedded in sociocultural contexts, while clinics with limited support services viewed behavior as individual responsibility. An analysis of themes related to PrEP found that prescribing is in an early adoption phase with ID clinicians expressing a range of attitudes from support of PrEP to clinical concerns about prescribing complexities and patient non-adherence.
Findings identified care structures, processes and PACT elements to target in improvement initiatives for Veterans with HIV. Specifically, findings have implications for how ID/HIV clinics structure and enact protocols around comorbidity management; develop team processes; and allocate resources to address patients' psychosocial needs. Disparities in HIV outcomes persist and our VA partners have begun to use these findings to address them, including formation of a working group. Conceptualizations of patients have implications for care planning and may be influenced by addressing the organizational context of individual clinics.
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Treatment - Observational