Reported care quality in federal Ryan White HIV/AIDS Program supported networks of HIV/AIDS care

Strengths and Challenges of Implementing a Learning Collaborative in the Ryan White HIV/AIDS Program

Learning collaboratives (LCs) are a popular tool for supporting collaboration and shared learning among health programs. Many variations of LCs have been reported in the literature. However, descriptions of key LC components and implementation lack standardization, making it hard to compare and contrast different LC approaches. To advance the field's understanding of how primary elements of LCs are implemented, we describe the implementation of an LC in the Ryan White HIV/AIDS Program using a recently established taxonomy of four primary elements of LCs-innovation, social systems, communication, and time. Additionally, we explain the strengths and challenges we encountered with regard to each of these elements when implementing this LC. We then offer recommendations to others on how to leverage LC facilitators and mitigate challenges in future projects. This information can guide other programs to replicate beneficial practices and avoid pitfalls in future LC projects.

Impact of Availability of Telehealth Programs on Documented HIV Viral Suppression: A Cluster-Randomized Program Evaluation in the Veterans Health Administration

Background

Telehealth may improve care for people with HIV who live far from HIV specialty clinics. We conducted a cluster-randomized evaluation to determine the impact of availability of HIV telehealth programs on documented viral suppression in Veterans Administration clinics.

Methods

In 2015-2016, people who previously traveled to HIV specialty clinics were offered telehealth visits in nearby primary care clinics. Patients were cluster-randomized to immediate telehealth availability (n = 925 patients in service areas of 13 primary care clinics offering telehealth) or availability 1 year later (n = 745 patients in 12 clinics). Measures during the evaluation year included telehealth use among patients in areas where telehealth was available and documented HIV viral suppression (viral load performed and <200 copies/mL). Impact of telehealth availability was determined using intention-to-treat (ITT) analyses that compared outcomes for patients in areas where telehealth was available with outcomes for patients where telehealth was not available, regardless of telehealth use. Complier average causal effects (CACEs) compared outcomes for telehealth users with outcomes for control patients with equal propensity to use telehealth, when available.

Results

Overall, 120 (13.0%) patients utilized telehealth when it was available. Availability of telehealth programs led to small improvements in viral suppression in ITT analyses (78.3% vs 74.1%; relative risk [RR], 1.06; 95% confidence interval [CI], 1.01 to 1.11) and large improvements among telehealth users in CACE analyses (91.5% vs 80.0%; RR, 1.14; 95% CI, 1.01 to 1.30).

Conclusions

Availability of telehealth programs improved documented viral suppression. HIV clinics should offer telehealth visits for patients facing travel burdens.

Ryan White HIV/AIDS Program Assistance and HIV Treatment Outcomes

BACKGROUND

The Ryan White HIV/AIDS Program (RWHAP) provides persons infected with human immunodeficiency virus (HIV) with services not covered by other healthcare payer types. Limited data exist to inform policy decisions about the most appropriate role for RWHAP under the Patient Protection and Affordable Care Act (ACA).

METHODS

We assessed associations between RWHAP assistance and antiretroviral therapy (ART) prescription and viral suppression. We used data from the Medical Monitoring Project, a surveillance system assessing characteristics of HIV-infected adults receiving medical care in the United States. Interview and medical record data were collected in 2009-2013 from 18 095 patients.

RESULTS

Nearly 41% of patients had RWHAP assistance; 15% relied solely on RWHAP assistance for HIV care. Overall, 91% were prescribed ART, and 75% were virally suppressed. Uninsured patients receiving RWHAP assistance were significantly more likely to be prescribed ART (52% vs 94%; P < .01) and virally suppressed (39% vs 77%; P < .01) than uninsured patients without RWHAP assistance. Patients with private insurance and Medicaid were 6% and 7% less likely, respectively, to be prescribed ART than those with RWHAP only (P < .01). Those with private insurance and Medicaid were 5% and 12% less likely, respectively, to be virally suppressed (P ≤ .02) than those with RWHAP only. Patients whose private or Medicaid coverage was supplemented by RWHAP were more likely to be prescribed ART and virally suppressed than those without RWHAP supplementation (P ≤ .01).

CONCLUSIONS

Uninsured and underinsured HIV-infected persons receiving RWHAP assistance were more likely to be prescribed ART and virally suppressed than those with other types of healthcare coverage.

A review of how the quality of HIV clinical services has been evaluated or improved

To examine approaches being used to evaluate and improve quality of HIV clinical services we searched the MEDLINE, Cochrane Library collection, EMBASE, Global Health, and Web of Science databases for articles and abstracts focused on evaluating or improving quality of HIV clinical services. We extracted country income level, targeted clinical services, and quality evaluation approaches, data sources, and criteria. Fifty journal articles and 46 meeting abstracts were included. Of the 96 studies reviewed, 65% were programme evaluations, 71% focused on low- and middle-income countries, and 65% focused on antiretroviral therapy services. With regard to quality, 45% used a quality improvement model or programme, 13% set a quality threshold, and 51% examined patient records to evaluate quality. No studies provided a definition for quality HIV care. Quality assurance and improvement of HIV clinical services is increasingly important. This review highlights gaps in knowledge for future research, and may also help countries and programmes develop their HIV care quality improvement frameworks.

Delivering PACT-principled care: are specialty care patients being left behind?

BACKGROUND

With the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care.

OBJECTIVE

To examine the extent to which HIV specialty care in VA conforms to PCMH principles.

DESIGN

Qualitative study.

PARTICIPANTS

Forty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics.

APPROACH

We conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy.

KEY RESULTS

Patients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient's medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care.

CONCLUSIONS

Even in a large, integrated healthcare system, there is wide variation in patients' receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

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

PURPOSE

Rural-dwelling persons with HIV infection often have limited access to HIV specialty care, and they may instead use more nearby primary care. This study described use of infectious disease (ID) specialty and general primary care services among rural compared with urban veterans with HIV in the United States and determined associations between geographic access to ID and primary care and use of care.

METHODS

The sample included all veterans in the national Veterans Administration (VA) HIV clinical case registry in 2009 (N = 23,669, 10.2% rural). Geographic access was measured by calculating travel times to the nearest VA primary care and ID specialty clinic.

FINDINGS

Rural veterans were less likely than urban to use ID clinics (82% of rural vs 87% of urban, P < .01) and more likely to use primary care (82% vs 73%, P < .01). As travel time to ID care increased from less than 15 minutes to over 90 minutes, use of ID care decreased from 88% to 71% (P < .01), while use of primary care increased from 68% to 86% (P < .0001). In multivariable models, increased travel time to ID care-but not rural residence-was associated with decreased ID and increased primary care use.

CONCLUSIONS

Persons with HIV who live far from ID specialty clinics are less likely to use specialty care and more likely to use primary care. Specialty clinics should consider using telehealth to deliver care over distance and programs to coordinate "shared care" relationships with distant primary care providers.

[Increasing participation of primary care in the management of people with human immunodeficiency virus: hospital care professionals express their views]

AIM

To determine the opinions of infectious diseases professionals on the possibilities of monitoring patients with HIV in Primary Care.

DESIGN

Qualitative study using in-depth interviews.

LOCATION

Infectious Diseases Unit in the University Hospital "Virgen de la Victoria" in Málaga.

PARTICIPANTS

Health professionals with more than one year experience working in infectious diseases. A total of 25 respondents: 5 doctors, 15 nurses and 5 nursing assistants.

METHOD

Convenience sample. Semi-structured interviews were used that were later transcribed verbatim. Content analysis was performed according to the Taylor and Bogdan approach with computer support. Validation of information was made through additional analysis, expert participation, and feedback of part of the results to the participants.

RESULTS

Hospital care professionals considered the disease-related complexity of HIV, treatment and social aspects that may have an effect on the organizational level of care. Professionals highlighted the benefits of specialized care, although opinions differed between doctors and nurses as regards follow up in Primary Care. Some concerns emerged about the level of training, confidentiality and workload in Primary Care, although they mentioned potential advantages related to accessibility of patients.

CONCLUSIONS

Physicians perceive difficulties in following up HIV patients in Primary Care, even for those patients with a good control of their disease. Nurses and nursing assistants are more open to this possibility due to the proximity to home and health promotion in Primary Care.

Exploring the medical home in Ryan White HIV care settings: a pilot study

Amid increased attention to the cost of health care, health information technology, and specialization and fragmentation in medicine, the medical home has achieved recognition as a model for more effective and efficient health care. Little data are available on recently funded HIV medical home demonstration projects, and no research richly describes existing medical home characteristics, implementation challenges, and impact on outcomes in longstanding HIV outpatient settings. The Ryan White HIV/AIDS Program (RWP) provides federal funding for primary and specialty care for people living with HIV. Although RWP clinics developed independently of the medical home model, existing data indirectly support that, with emphasis on primary, comprehensive, and patient-centered care, RWP clinics operate as medical homes. This study explores the development, definition, and implementation of medical home characteristics by RWP-funded providers in order to better understand how it fits with broader debates about medical homes and health care reform.

Ryan White CARE Act Part D: matches and gaps in political commitment and local implementation

This article demonstrates the opportunities for and challenges of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Part D to implementing its mandate for comprehensive family-centered systems of care for women, infants, children, and youth with HIV/AIDS. Part D legislation should promote practices addressing families with models for basic security, judiciously embrace those universal public health policies aiming to improve children's overall welfare, and consistently repudiate those policies infringing on human rights of women infected with HIV, or ignoring their children's basic needs. The proposed revisions to Part D implementation may renew its political commitment to serving the needs of families who are HIV affected.