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IIR 12-385 – HSR&D Study

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IIR 12-385
Integrating HIV Care in VA: Extending PACT Principles to Specialty Care
Barbara G. Bokhour PhD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: February 2014 - January 2018

BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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.

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Fix GM, Hyde JK, Bolton RE, Parker VA, Dvorin K, Wu J, Skolnik AA, McInnes DK, Midboe AM, Asch SM, Gifford AL, Bokhour BG. The moral discourse of HIV providers within their organizational context: An ethnographic case study. Patient education and counseling. 2018 Dec 1; 101(12):2226-2232.
  2. Vaughan Sarrazin MS, Ohl ME, Richardson KK, Asch SM, Gifford AL, Bokhour BG. Patient and Facility Correlates of Racial Differences in Viral Control for Black and White Veterans with HIV Infection in the Veterans Administration. AIDS Patient Care and Stds. 2018 Mar 1; 32(3):84-91.
  3. Yakovchenko V, Gifford AL, Matthews KL, Greenstone CL, Tsai J, McInnes DK. Improving VHA's Approach to Community Care: Lessons Learned From an Imperfect Hepatitis C Choice Program. Medical care. 2018 Mar 1; 56(3):274-276.
  4. Swan H, Reisman JI, McDannold SE, Glickman ME, McInnes DK, Gifford AL. The relationship between gastrointestinal symptom attribution, bothersomeness, and antiretroviral adherence among adults with HIV. AIDS Care. 2018 Aug 1; 30(8):997-1003.
  5. Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open forum infectious diseases. 2017 Feb 3; 4(1):ofx005.
  6. Richardson KK, Bokhour B, McInnes DK, Yakovchenko V, Okwara L, Midboe AM, Skolnik A, Vaughan-Sarrazin M, Asch SM, Gifford AL, Ohl ME. Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care. Journal of the National Medical Association. 2016 Sep 22; 108(4):201-210.e3.
Conference Presentations

  1. Appenheimer AB, Bokhour BG, McInnes DK, Richardson K, Midboe A, Gifford AL, Asch S, Dvorin K, Thurman A, Vaughan-Sarrazin M, Ohl M. Testing Un-learning and Substitution Strategies to De-implement Antipsychotics in Nursing Homes. Poster session presented at: ID Week Annual Conference; 2016 Oct 26; New Orleans, LA.
  2. Richardson LM, Bokhour BG, Ohl M. Racial Disparities Extend to Common Comorbidities among Persons in Care for HIV Infection. Paper presented at: ID Week Annual Conference; 2015 Oct 26; San Diego, CA.
  3. 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.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Care Coordination, HIV/AIDS, Hepatitis C, Management and Human Factors, Organizational Structure, Practice Patterns/Trends
MeSH Terms: none

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