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AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20

Interdisciplinary HIV care in a changing healthcare environment in the USA ab

a

a

a

a

Bisola Ojikutu , Jeremy Holman , Laureen Kunches , Stewart Landers , Dianne Perlmutter , a

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Melina Ward , Gregory Fant & Lisa Hirschhorn a

John Snow, Inc, Boston, MA, USA

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Harvard Medical School, Boston, MA, USA

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US Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA Published online: 06 Nov 2013.

Click for updates To cite this article: Bisola Ojikutu, Jeremy Holman, Laureen Kunches, Stewart Landers, Dianne Perlmutter, Melina Ward, Gregory Fant & Lisa Hirschhorn (2014) Interdisciplinary HIV care in a changing healthcare environment in the USA, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 26:6, 731-735, DOI: 10.1080/09540121.2013.855299 To link to this article: http://dx.doi.org/10.1080/09540121.2013.855299

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AIDS Care, 2014 Vol. 26, No. 6, 731–735, http://dx.doi.org/10.1080/09540121.2013.855299

RESEARCH ARTICLE Interdisciplinary HIV care in a changing healthcare environment in the USA Bisola Ojikutua,b*, Jeremy Holmana, Laureen Kunchesa, Stewart Landersa, Dianne Perlmuttera, Melina Warda, Gregory Fantc and Lisa Hirschhorna,b a

John Snow, Inc, Boston, MA, USA; bHarvard Medical School, Boston, MA, USA; cUS Department of Veterans Affairs, Veterans Health Administration, Washington, DC, USA

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(Received 6 May 2013; final version received 9 October 2013) HIV remains a complex disease that requires comprehensive, coordinated care to ensure optimal outcomes. In the USA, interdisciplinary models of care have developed over time to optimize treatment outcomes. These models may be increasingly important in an era of healthcare reform in the USA. A qualitative study of nine clinical sites funded by the Ryan White HIV/AIDS Program (RWHAP), the federally funded “safety net” program for uninsured and underinsured people living with HIV, was undertaken to identify components of successful models of interdisciplinary HIV care. Findings suggest that these include: (1) patient-centered, one-stop-shop approaches with integrated or co-located services; (2) diverse teams of clinical and nonclinical providers; (3) a site culture that promotes a stigma reducing environment for clients; (4) the availability of a comprehensive array of medical, behavioral health, and psychosocial services; (5) effective communication strategies, including electronic health records (EHRs); and (6) a focus on quality. The importance of RWHAP funding in sustaining these programs is highlighted. Keywords: HIV; AIDS; interdisciplinary care; multidisciplinary care; medical home

Introduction Improvements in antiretroviral therapy (ART) have transformed HIV into a chronic, manageable disease. Near-normal lifespans can be expected for most patients who are consistently engaged in care and are adherent to ART (Gallant et al., 2011). Yet, HIV remains a complex disease requiring expert care and coordinated services, especially for aging people living with HIV (PLWH) and for those with co-occurring substance use and mental health disorders. To manage these complexities, clinical sites in the USA have developed interdisciplinary models of HIV care that typically include a diverse team of healthcare providers from primary care physicians to behavioral health specialists. A recent literature review of services in the USA (Gallant et al., 2011) categorized these program models into three types: (1) coordinated, with parallel or sequential services delivered in different settings but facilitated by information sharing; (2) colocated, with a range of services delivered in one location with data sharing across disciplines; or (3) integrated, with services in one location enabling patients to move between services without administrative barriers. The development of interdisciplinary HIV care programs has been facilitated by the US federal policy. Since 1990, the Ryan White HIV/AIDS Program (RWHAP), funded by the US government, has provided *Corresponding author. Email: [email protected] © 2013 Taylor & Francis

HIV care and treatment and support services for PLWH and has served as a “safety net” for those who are underinsured or uninsured. Many RWHAP grantees have used these funds to build interdisciplinary HIV programs that provide comprehensive services including case management and psychosocial support. More recently, several policy changes have further encouraged the adoption of interdisciplinary approaches to HIV care. Released in 2010, the US National HIV/AIDS Strategy (NHAS) emphasizes the need for interdisciplinary care for PLWH (The White House Office of National AIDS Policy, 2010). In addition, healthcare reform in the USA, initiated by the Patient Protection and Affordable Care Act (ACA), has promoted the expansion of community health centers to provide comprehensive, interdisciplinary primary care for underserved populations, including PLWH (Health Resources and Services Administration, 2010). In order to better understand the facilitators and barriers to the provision of interdisciplinary care in a changing US healthcare environment, we conducted a qualitative study of selected RWHAP-funded programs.

Methodology Sample and data collection Based upon a literature review and consultation with key informants, 12 RWHAP-funded sites were proposed for

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this study. Nine were selected using stratified purposeful sampling to reflect geographic (location in the USA), site type (e.g., community clinic), size (patient volume), and demographic (e.g., gender) diversity. Qualitative methodology was chosen to provide an understanding of factors essential to the development of interdisciplinary models of HIV care. Two members of the research team facilitated focus groups during site visits held from May through July 2012. Separate groups were conducted with leadership, staff, and patients; each group was comprised of 4–11 participants. Semi-structured interview guides including questions about the model of care, services, staffing, financing, and quality of care, were developed for each focus group. Verbal consent was obtained, and all focus group sessions were recorded. Study procedures were reviewed by an independent Research Protections Specialist and were deemed exempt from full institutional review board review.

Data analysis Thematic analysis and text coding were used to analyze the interview transcripts and identify emerging themes. The two members of the research team who facilitated the focus groups at assigned sites reviewed the transcripts and generated a list of thematic codes. An iterative process was used to analyze and further develop the list. The team discussed and modified the themes through a facilitated, inductive approach until consensus was obtained. The transcripts were reviewed again using the agreed-upon thematic codes. NVivo® (version 9.0, QRS International; Cambridge, MA) was used to confirm the preliminary themes and to highlight those not previously identified. Results were organized according to key themes which emerged from the data.

Results

Model of care Respondents uniformly indicated that interdisciplinary care is ideally delivered using a “one-stop shopping” model wherein services are co-located within one building with one administrative access point and crossdisciplinary data sharing. In addition to co-location, successful interdisciplinary sites were described as patient-centered and responsive to the unique needs of PLWH Staffing and team structure Interdisciplinary clinics are staffed by diverse cadres of healthcare professionals, including nutritionists, dentists, and pharmacists. However, at the majority of sites, the “core” team for each patient consists of a primary care provider, a nurse, and a case manager. The centrality of case management was emphasized. Site culture Respondents emphasized that staff at successful interdisciplinary sites embody intangible characteristics such as compassion and a passion for addressing the HIV epidemic. A clinic culture where patients do not feel judged or stigmatized was noted as essential to satisfaction and retention. Cultural competency regarding race, ethnicity, gender, and sexuality was identified as important by all respondents. Spectrum of services Ideally, interdisciplinary HIV care includes a comprehensive array of services. Given the high prevalence of behavioral health issues among patients, there was a consensus among respondents that mental health and substance abuse treatment should be co-located at sites. The overwhelming need for ongoing psychosocial (including case management and peer counseling) and adherence support was emphasized by all respondents. Treatment for hepatitis C co-infection, dental care, and specialty services were also identified as important to the provision of interdisciplinary care.

Interdisciplinary site characteristics Of nine selected sites, four were associated with AIDS service organizations (ASOs), two with universities, one with a health department, one with a federally qualified health center, and the ninth with a free clinic. Additional site characteristics are detailed in Table 1.

Factors influencing successful interdisciplinary service provision Seven themes critical to the success of interdisciplinary sites are described below. Themes, subthemes, and examples are provided in Table 2.

Communication Communication across the interdisciplinary care team is essential to care coordination. Regular team meetings to discuss patient issues and electronic health records (EHR) were identified as essential communication and care coordination tools. The most highly functional EHRs can easily be accessed by a range of staff and capture notes from all providers. Quality of care Leadership and staff respondents highlighted the need for interdisciplinary sites to measure quality of care.

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Table 1. Characteristics of study sites. Patient insurance type Uninsured/ RWHAPc (%)

Public insurance (%)

Private/ other (%)

Female (%)

Nonwhite (%) 79

18

Not available 39

77

58

22

50

77

9

64

27

43

99

Large

21

18

61

18

45

Free Clinic

Small

56

21

32

18

55

ASO→CHC ASO→CHC

Medium Medium

80 15

4 44

16 41

17 26

61 65

University Affiliated

Large

35

12

53

22

55

Location

Site typea

APICHA Community Health Center Chatham CARE Center

New York, NY Savannah, GA

ASO→CHC

Small

38

36

26

Medium

53

29

Community Health Center Family and Medical Counseling Services Harborview Madison Clinic (University of Washington) Kansas City Free Clinic d Peabody Clinic Philadelphia Fight

Middletown, CT Washington, DC Seattle, WA

County Health Department Clinic FQHC

Small

20

ASO→CHC

Medium

University Affiliated

Site name

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Number of PLWH seen in 2011b

1917 Clinic (University of Alabama)

Kansas City, MO Dallas, TX Philadelphia, PA Birmingham, AL

Notes: aASO, AIDS Service Organization; FQHC, Federally Qualified Health Center; CHC, Community Health Center. b Small (1500 patients). c While RWHAP is essential for care of uninsured patients, a substantial portion of RWHAP enrollees also have public or private insurance. d Kansas City Free Clinic changed its model in 2013 and is now known as the Kansas City Care Clinic.

Most sites reported that they collect quality measures, including viral load suppression, retention in care, and receipt of Papanicolaou smear to assess the quality of care provided by their site. Patient satisfaction is also routinely measured at a number of sites. Financing The current availability of RWHAP funding was deemed essential to the success of interdisciplinary care. RWHAP has covered the cost of case management and other support services that are not covered by other funders. In addition, many patients at the sites visited are uninsured and require RWHAP-funded services.

increase the availability of co-located services, they are costly to incorporate. Across all sites, leadership respondents indicated that RWHAP is essential for optimal, interdisciplinary care for PLWH. Concerns regarding the potential loss of or decrease in RWHAP funding were emphasized. Referrals The majority of sites are unable to provide all services onsite and depended upon referrals for specialty care. Referring patients off-site is challenging because of the limited number of specialty care providers who are willing to care for uninsured patients and the lack of frequent communication from these specialists back to the clinic.

Barriers to the provision of interdisciplinary services Four themes were identified as barriers to the provision of interdisciplinary services. These are described as follows. Financing Funding constraints have limited sites’ ability to offer comprehensive services. Though sites would like to

Increasing number of patients Sites are challenged by the growing number of patients requiring HIV care and treatment services. Test and treat initiatives, “treatment as prevention,” and enhanced efforts to link and retain patients in care have stretched sites to capacity. Several respondents noted a lack of adequate space and limited staff as barriers to interdisciplinary care.

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Table 2. Factors influencing successful interdisciplinary service provision. Themes Model of care

Subthemes “One stop shop”

Patient-centeredness

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Team structure

Diverse cadres of healthcare providers

Description/examples . . . . . . .

Patient’s core team

. .

Culture

Centrality of case management Dedication to mission Creation of “safe” space Cultural competency

Spectrum of services

Integration of “ancillary services”

. . . . . .

Communication

Quality of care (QoC) Financing

.

Onsite availability of nonclinical services Comprehensiveness of clinical services Team meetings

.

Electronic health records (EHRs)

. .

Use of common quality measures Patient satisfaction Importance of RWHAPa

.

.

. . .

Services provided in one clinic or building Streamlined entry with one administrative access point Integrated and coordinated services with cross-disciplinary data sharing Responsiveness to the unique and changing needs of PLWH Mechanism to solicit and act upon regular input from patients Staff willing to serve as an ongoing support system for patients Staffing includes clinicians, case managers, behavioral health specialists, dentists, pharmacists, nutritionists, medical assistants, outreach workers, and others Primary care provider (physician, nurse practitioner, or physician’s assistant), a nurse and a case manager Case management charged with providing critical services including access to social services and ensuring medication access Staff are passionate and committed to addressing the HIV epidemic De-stigmatizing, nonjudgmental, familiar environment Race, ethnicity, gender, sexual diversity acknowledged and respected Cultural competency valued Case management, peer support, adherence support, and individual psychosocial support are provided Staff leading these nonclinical efforts should be integrated into the interdisciplinary care team to facilitate care coordination Behavioral, mental health and substance abuse counseling and treatment available onsite Specialty clinical services should include hepatitis C treatment as well as other care to meet the needs of the population served Regular team meetings (daily, weekly, biweekly) essential to care coordination EHRs are used to integrate services across all service providers Clinical and nonclinical records are included and all providers utilize the EHR for documentation Commonly used measures to assess QoC include viral load suppression, retention in care, and receipt of Pap smear Measured at several sites on a regular basis to assess QoC Essential for case management and other nonclinical services Funds provide extra resources to manage complex medical issues

Note: aRyan White HIV/AIDS Program.

Concern that quality of care could be compromised as volume increases was expressed. Growing patient diversity As the number of patients has increased so has patient diversity (e.g., transgender, youth, black men who have sex with men, and immigrants). Respondents expressed concern about the capacity to meet their unique needs without additional funding. Discussion Over the past decade, advances in HIV care in the USA include more effective and better-tolerated treatment (Panel on Antiretroviral Guidelines for Adults and

Adolescents, 2012), incorporation of HIV testing into routine healthcare (Centers for Disease Control and Prevention, 2012), increased focus on the needs of aging PLWH (Gebo & Justice, 2009), treatment of noncommunicable chronic diseases (Monroe, Chander, & Moore, 2011), and treatment as prevention (Cohen, Chen, & McCauley, 2011). Interdisciplinary care has also evolved to meet the complex needs of PLWH. While the literature describing interdisciplinary HIV care has grown, guidance regarding requisite program components and characteristics is sparse (Hirschhorn et al., 2012). This study helps fill this gap in the literature. Respondents highlighted the importance of co-location of services, the integration of psychosocial and adherence support services, and a de-stigmatizing clinic culture. The

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AIDS Care critical importance of comprehensive service provision, including case management, psychosocial support, and behavioral health, was also noted. Collaboration and communication between diverse healthcare providers were deemed necessary to coordination of services among providers. Effective EHRs have been essential at these clinics for seamless exchange of information to achieve the goal of “meaningful use” – use by providers achieves significant improvements in care (Blumenthal & Tavenner, 2010). Study respondents indicated that the most effective EHRs were those that enabled access by both clinical and nonclinical service providers and included patients’ mental health and substance use treatment histories. The most significant challenge that interdisciplinary programs face now and in the near future is maintaining model components essential to effective HIV care. As healthcare reform is implemented, many more PLWH will become insured. However, funding for case management, psychosocial support, adherence counseling, and behavioral health is uncertain. Obtaining supplemental funding (e.g., RWHAP, private funding, state or local public sector support) will be essential. If interdisciplinary programs do not secure additional funds, they will need to make tough choices to adapt to the changing national healthcare funding and policy environment. These choices may include limiting the availability of services that are essential to optimizing patient outcomes. Acknowledgments The authors would like to acknowledge the staff of the nine sites who participated in this study. This research was supported by Health Resources and Services Administration (HRSA), HIV/ AIDS Bureau (HAB) (HHSH250200646026I).

References Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health records. The New England

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Journal of Medicine, 363, 501–504. doi:10.1056/NEJMp 1006114 Centers for Disease Control and Prevention. (2012). Initiation of and adherence to treatment as prevention: Antiretroviral treatment for prevention of HIV transmission. Retrieved from http://www.cdc.gov/hiv/pwp/antiretroviraltreatment.html Cohen, M., Chen, Y., & McCauley, M. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine, 365, 493–505. doi:10.1056/ NEJMoa1105243 Gallant, J., Adimora, A., Carmichael, J., Horberg, M., Kitahata, M., Quinlivan, E., … Williams, S. (2011). Essential components of effective HIV care: A policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition. Clinical Infectious Diseases, 53, 1043–1050. doi:10.1093/cid/cir689 Gebo, K. A., & Justice, A. (2009). HIV infection in the elderly. Current Infectious Disease Reports, 11, 246–254. doi:10.1007/s11908-009-0036-0 Health Resources and Services Administration. (2010). The Affordable Care Act and health centers. Retrieved from http://www.bphc.hrsa.gov/about/healthcenterfactsheet.pdf Hirschhorn, L., Kunches, L., Ojikutu, B., Holman, J., Landers, S., Perlmutter, D., … Fant, G. (2012, November). Interdisciplinary models of HIV care: Findings from a literature review and expert consultations. Poster session presented at the Ryan White Grantee Meeting, Washington, DC. Monroe, A., Chander, G., & Moore, R. (2011). Control of medical comorbidities in individuals with HIV. Journal of Acquired Immune Deficiency Syndrome, 58, 458–462. doi:10.1097/QAI.0b013e31823801c4 Panel on Antiretroviral Guidelines for Adults and Adolescents. (2012). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents (Department of Health and Human Services). Retrieved from http://www. aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolesc entgl.pdf The White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States. Retrieved from http://www.whitehouse.gov/sites/default/ files/uploads/NHAS.pdf

Interdisciplinary HIV care in a changing healthcare environment in the USA.

HIV remains a complex disease that requires comprehensive, coordinated care to ensure optimal outcomes. In the USA, interdisciplinary models of care h...
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