US Department of Veterans Affairs, Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford & VA Boston Healthcare System, Boston.
Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Worcester.
Med Care. 2021 Aug 1;59(8):727-735. doi: 10.1097/MLR.0000000000001563.
With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV.
Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality.
Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care.
Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.
随着人类免疫缺陷病毒 (HIV) 被作为慢性病进行管理，医疗保健必须改变和扩展，以包括其他严重合并症的管理。我们试图了解以患者为中心的医疗之家 (PCMH) 原则为基础的 HIV 和合并症护理的组织、结构和流程的变化与接受 HIV 治疗的退伍军人的护理质量之间的关系。
在退伍军人事务部医疗中心进行了 8 次有针对性的现场访问，这些医疗中心在 HIV 和常见合并症的护理质量和结果方面存在差异。现场访问包括对 60 名患者进行访谈；对 60 名 HIV 护理团队成员进行访谈；对 22 次诊所流程和团队互动进行直接观察；对 45 次患者与医生的临床接触进行直接观察。使用先验和新兴代码分析数据，构建站点综合报告，并比较具有不同质量水平的站点。
在 HIV 和合并症护理质量方面均处于最高和最低水平的站点在提供基于 PCMH 原则的护理方面存在明显差异。最高质量的站点提供了更多的以团队为基础、全面、以患者为中心和以数据为驱动的护理，并进行持续改进。注重心理社会需求的站点 HIV 护理质量更高。无论在 HIV 诊所还是初级保健诊所，都有一致的合并症护理流程的站点，其合并症护理质量更高。
提供高质量的 HIV 护理和高质量的合并症护理需要不同的护理结构和流程。提供这两者都需要专注于提供符合 PCMH 原则的护理，将心理社会需求纳入护理，并建立明确一致的合并症管理方法。
