Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study


Autoři: Wayne T. Steward aff001;  Kimberly A. Koester aff001;  Mary A. Guzé aff001;  Valerie B. Kirby aff001;  Shannon M. Fuller aff001;  Mary E. Moran aff001;  Emma Wilde Botta aff001;  Stuart Gaffney aff001;  Corliss D. Heath aff002;  Steven Bromer aff003;  Starley B. Shade aff001
Působiště autorů: Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America aff001;  U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Rockville, Maryland, United States of America aff002;  Department of Family and Community Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America aff003;  Institute for Global Health Sciences, University of California San Francisco (UCSF), San Francisco, California, United States of America aff004
Vyšlo v časopise: Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003079
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003079

Souhrn

Background

The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).

Methods and findings

Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014–2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37–54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02–1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00–1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02–1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.

Conclusions

In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

Klíčová slova:

Antiretroviral therapy – Health services administration and management – HIV – HIV diagnosis and management – HIV epidemiology – Insurance – New York – Primary care


Zdroje

1. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505. doi: 10.1056/NEJMoa1105243 21767103

2. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li C, Wabwire-Magnen F, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. N Engl J Med. 2000;342:921–9. doi: 10.1056/NEJM200003303421303 10738050

3. 90-90-90: An Ambitious Treatment Target to Help End the AIDS epidemic. Geneva, Switzerland: UNAIDS; 2014.

4. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;365:493–505.

5. White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States: Updated to 2020. 2015 July [Cited 2019 February 1]. Available from: https://files.hiv.gov/s3fs-public/nhas-update.pdf.

6. Centers for Disease Control and Prevention. HIV Surveillance Report, 2017. 2018;29 [Cited 2019 March 4]. Available from: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2017-vol-29.pdf

7. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2016. HIV Surveillance Supplemental Report 2018;24 [Cited 2019 February 1]. Available from: https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-24-4.pdf

8. Committee on Public Financing and Delivery of HIV Care & Board on Health Promotion and Disease Prevention. Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White. Washington, DC: Institute of Medicine; 2005.

9. Health Resources and Services Administration. Ryan White HIV/AIDS Program. Annual Client-Level Data Report. Ryan White HIV/AIDS Program Services Report. 2017 [Cited 2019 April 23]. Available from: https://hab.hrsa.gov/sites/default/files/hab/data/datareports/RWHAP-annual-client-level-data-report-2017.pdf

10. Petterson SM, Liaw WR, Phillips RL, Rabin DL, Meyers DS, Bazemore AW. Projecting U.S. primary care physician workforce needs: 2010–2025. Ann Fam Med. 2013;10:503–9.

11. Chandrsekar P, Havlicheck D, Johnson LB. Infectious disease subspecialty: Declining demand challenges and opportunities. Clin Infect Dis. 2014;59:1593–8. doi: 10.1093/cid/ciu656 25148890

12. Weiser J, Beer L, West BT, Duke CC, Gremel GW, Skarbinski J. Qualifications, demographics, satisfaction, and future capacity of the HIV care provider workforce in the United States, 2013–2014. Clin Infect Dis. 2016;63:966–75. doi: 10.1093/cid/ciw442 27358352

13. HRSA-SPNS Workforce Capacity Building Initiative. Expanding HIV Care for People Living with HIV: A Stepwise Approach for Health Care Organizations Seeking to Add HIV Care or to Increase Services for PLWH [Cited 2020 January 28]. In: TargetHIV [Internet]. Available from: https://targethiv.org/library/expanding-care-people-living-hiv-toolkit-practice-transformation

14. HRSA-SPNS Workforce Capacity Building Initiative. Optimizing the Care Team: Lessons Learned, Best Practices, Critical Issues, and Site Examples [Cited 2020 January 28]. In: TargetHIV [Internet]. Available from: https://targethiv.org/library/optimizing-care-team-lessons-learned-best-practices-critical-issues-and-site-examples

15. HRSA-SPNS Workforce Capacity Building Initiative. The PEACCH Tool: Patient Engagement and Care Coordination in HIV Health [Cited 2020 January 28]. In: TargetHIV [Internet]. Available from: https://targethiv.org/library/patient-engagement-and-care-coordination-hiv-health-peacch-tool

16. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)–A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81. doi: 10.1016/j.jbi.2008.08.010 18929686

17. Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Annals of Family Medicine. 2014;12:166–71. doi: 10.1370/afm.1616 24615313

18. Health Resources & Services Administration HIV/AIDS Bureau. HIV/AIDS Bureau Performance Measures. 2017 [Cited 2019 March 4]. Available from: https://hab.hrsa.gov/sites/default/files/hab/clinical-quality-management/coremeasures.pdf

19. Department of Health and Human Services. Ending the HIV Epidemic: A Plan for America. 2019 [Cited 2019 February 15]. Available from: https://files.hiv.gov/s3fs-public/ending-the-hiv-epidemic-flyer.pdf

20. Shade SB, Sackett N, Khamarko K, Koester KA, Bie J, Newberry J, et al. Quality of comprehensive HIV care in underserved communities: does clinical training lead to improvement. Am J Med Qual. 2013;28:143–50. doi: 10.1177/1062860612453756 22892826

21. Spach DH, Wood BR, Karpenko A, Unruh KT, Kinney RG, Roscoe C, et al. Creating a National HIV Curriculum. J Assoc Nurses AIDS Care. 2016;27:261–73. doi: 10.1016/j.jana.2016.02.002 27086188

22. Selke HM, Kimaiyo S, Sidle JE, Vedanthan R, Tierney WM, Shen C, et al. Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. J Acquir Immune Defic Syndr. 2010;55:483–90. doi: 10.1097/QAI.0b013e3181eb5edb 20683336

23. Rabkin M, de Pinho H, Michaels-Strasser S, Naitore D, Rawat A, Topp SM. Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa. AIDS. 2018;32(Suppl 1):S47–S54.

24. Cunningham WE, Weiss RE, Nakazono T, Malek MA, Shoptaw SJ, Ettner SL, et al. Effectiveness of a Peer Navigation Intervention to Sustain Viral Suppression Among HIV-Positive Men and Transgender Women Released From Jail: The LINK LA Randomized Clinical Trial. JAMA Intern Med. 2018;178:542–53. doi: 10.1001/jamainternmed.2018.0150 29532059

25. Broaddus MR, Hanna CR, Schumann C, Meier A. "She makes me feel that I'm not alone": linkage to Care Specialists provide social support to people living with HIV. AIDS Care. 2015;27:1104–7. doi: 10.1080/09540121.2015.1028882 25854534

26. Saag MS. Ryan White: an unintentional home builder. AIDS Read. 2009:19:166–8. 19554735

Štítky
Interní lékařství

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PLOS Medicine


2020 Číslo 3

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