Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes.

BACKGROUND: Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics (consolidated care) or combining HIV care with comorbidity management in primary care clinics (shared care). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS: We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS: Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS: Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes

The moral discourse of HIV providers within their organizational context: An ethnographic case study.

OBJECTIVE: Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS: Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS: We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as good, behaving, or socio-paths, and flakes. Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS: When self-management is viewed as an individuals responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients behaviors as socially embedded

Lessons Learned From VHA\u27s Rapid Implementation of Virtual Whole Health Peer-Led Groups During the COVID-19 Pandemic: Staff Perspectives

Background: Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session Taking Charge of My Life and Health (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups. Objective: We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually. Methods: We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts. Results: Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans\u27 reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group\u27s role as an antidote to isolation during the COVID-19 pandemic. Conclusion: Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems

Leaning Into Whole Health: Sustaining System Transformation While Supporting Patients and Employees During COVID-19

Background: The US Veterans Health Administration (VA) is transforming its healthcare system to create a Whole Health System (WHS) of care. Akin to such reorganization efforts as creating patient-centered medical homes and primary care behavioral health integration, the WHS goes beyond by transforming the entire system to one that takes a proactive approach to support patient and employee health and wellness. The SARS-CoV-2 pandemic disrupted the VA\u27s healthcare system and added stress for staff and patients, creating an exogenous shock for this transformation towards a WHS. Objective: We examined the relationship between VA\u27s WHS transformation and the pandemic to understand if transformation was sustained during crisis and contributed to VA\u27s response. Methods: Qualitative interviews were conducted as part of a multi-year study of WHS transformation. A single multi-person interview was conducted with 61 WHS leaders at 18 VA Medical Centers, examining WH transformation and use during the pandemic. Data were analyzed using rapid directed content analysis. Results: While the pandemic initially slowed transformation efforts, sites intentionally embraced a WH approach to support patients and employees during this crisis. Efforts included conducting patient wellness calls, and, for patients and employees, promoting complementary and integrative health therapies, self-care, and WH concepts to combat stress and support wellbeing. A surge in virtual technology use facilitated innovative delivery of complementary and integrative therapies and promoted continued use of WH activities. Conclusion: The pandemic called attention to the need for healthcare systems to address the wellbeing of both patients and providers to sustain high quality care delivery. At a time of crisis, VA sites sustained WH transformation efforts, recognizing WH as one strategy to support patients and employees. This response indicates cultural transformation is taking hold, with WH serving as a promising approach for promoting wellbeing among patients and employees alike