Canadian HIV Care Settings as Patient-Centered Medical Homes (PCMHs)

Claire E. Kendall, MD, PhD; Esther S. Shoemaker, PhD; Janessa E. Porter, MA; Lisa M. Boucher, MA; Lois Crowe, BA; Ron Rosenes, MA, LLD (hon), CM; Christine Bibeau; Philip Lundrigan; Marissa L. Becker, MD, MSc; Shabnam Asghari, MD, PhD; Sean B. Rourke, PhD; Clare Liddy, MD, MSc

Disclosures

J Am Board Fam Med. 2019;32(2):158-167. 

In This Article

Abstract and Introduction

Abstract

Purpose: For people living with HIV (PLWH) using continuous antiretroviral therapy, HIV is now a complex chronic condition often managed in primary care settings. The patient-centered medical home (PCMH) is a model to deliver comprehensive, coordinated, and integrated primary care that promotes collaboration between primary and specialist care and allied services. The study assessed how both Canadian primary and specialist HIV care settings align with the PCMH.

Methods: Mixed-methods surveys and interviews with providers in Canadian HIV care settings.

Results: Twenty-two settings completed the survey, 12 of which participated in follow-up interviews. Settings had a mean PCMH score of 8.06/12 (SD = 1.53), indicating the basic elements of each PCMH domain have been implemented. We found no significant differences between HIV primary care and specialist care settings. Continuous team-based healing relationships had the highest score (mean = 9.2; SD = 2.15), and quality improvement strategy had the lowest score (mean = 7.19; SD = 2.26). The themes that arose from the interviews were 1) endorsement of the domains of the PCMH by all settings, 2) organizational structures of settings located in hospitals facilitating the implementation of the PCMH through existing technology, patient advisory boards, and accessible services, and 3) dissonance between complex care needs and existing organizational structures in some settings, including limited clinic hours, lack of electronic medical records, and limited mental health services.

Conclusions: HIV care in Canada is reasonably well aligned with the PCMH, irrespective of structure of settings. We propose the need for improvements in the use of electronic medical records, quality improvement strategies, and integration of mental health services to achieve better care delivery and health outcomes among PLWH in Canada.

Introduction

Due to increased quantity and quality of life arising from combination antiretroviral therapy, HIV has evolved into a complex chronic health condition.[1–3] In turn, there is a requirement to shift from a focus on treatment of opportunistic infections toward the prevention and management of multimorbidity[4] among people living with HIV (PLWH). This shift reinforces the importance of meeting the comprehensive, continuous care needs of PLWH while promoting the integration of primary care with other medical specialties.[5] Physicians specialized in HIV or infectious diseases predominately manage the care of PLWH in Canada,[6] and while they are best equipped to deliver disease-specific care,[7] primary care providers have the expertise to deliver chronic disease care.[8] Canadian HIV primary care settings are more likely to offer preventative health services than specialist care settings.[9] Currently, we know little about how the evolving needs of PLWH are met within the settings where they receive care.

The patient-centered medical home (PCMH) is an approach to transforming primary care delivery through improving its quality, effectiveness, and efficiency, thereby facilitating its role as the foundation of a high-performing health system.[10] The joint domains of the PCMH (Table 1) have the potential to address existing care gaps through integration and collaboration between primary and specialist care, community health and social services.[11] The Ryan White–funded HIV clinics became early adopters of the PCMH model[12] that has since become the standard for primary care delivery.[13–15] A recent study of HIV clinics within the Veterans Affairs Health System found variation in the alignment of HIV specialty clinics to PCMH principles.[16] Our objective was to determine the alignment of Canadian HIV care settings, which vary considerably in structure, function, and team composition,[9] to the PCMH. As all Canadian provinces have a single-payer system with universal access to physician services, our findings can inform recommendations to ensure PLWH receive patient-centered care in a setting and with providers appropriate to their evolving physical, mental, cognitive, and social needs.

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