Background: Veterans Health Administration (VHA) is the largest provider of HIV care in the United States, with over 26,000 Veterans in care for HIV infection in 2013. Since the early 1990s, VHA has concentrated care for Veterans with HIV in infectious disease and dedicated HIV specialty clinics, usually located in large, urban medical centers. As Veterans with HIV have grown older (median age 57) and accumulated comorbidities that increasingly dominate their care needs, most HIV specialty clinics have by necessity taken on primary care for common comorbid chronic conditions, such as hypertension and diabetes. This specialty-centered, co-located model delivers convenient primary care for Veterans who live near HIV clinics in urban areas. However, it does not adapt to the needs of the ~25% of Veterans with HIV who live in rural and outlying urban areas, where access to HIV specialty clinics is limited. As a consequence, there is need for delivery models that provide accessible and comprehensive care for aging Veterans with HIV in rural and outlying areas. Intervention: We have pilot-tested a telehealth collaborative care (TCC) model for Veterans with HIV in rural and outlying areas. In overview, TCC is a shared-care model that integrates HIV specialty care delivered by clinical video telehealth (CVT) with primary care by Patient Aligned Care Teams (PACTs) in VHA clinics serving rural and outlying areas. Our pilot study of TCC found that - when given a choice over how to obtain care - 41 (95%) of 43 Veterans with HIV who lived nearer to a primary care clinic than to the HIV clinic chose to use TCC instead of usual care (i.e. traveling to HIV clinic for all care). This highlights Veteran preference for TCC. Importantly, TCC maintained high-quality HIV care, as evidenced by high rates of HIV viremia suppression (viral control), while improving quality measures for selected comorbid conditions. As part of its Promising Practices initiative, the VHA Office of Rural Health (ORH) is currently funding expansion of the TCC model to 3 Texas facilities that serve large, geographically-dispersed populations of Veterans with HIV (Dallas, Houston, and San Antonio VAMCs). The goal of this proposal is to seize this time- sensitive opportunity for operationally-partnered research to complete a cluster-randomized trial to determine TCC effectiveness, in order to inform VHA policy about wider TCC dissemination. Research plan: Twenty-eight primary care clinics will be cluster-randomized to immediate vs. delayed TCC implementation, creating a one-year trial of TCC vs. usual care. Veteran-level outcomes will be determined using Corporate Data Warehouse (CDW) elements routinely gathered during care encounters.
Aim 1 will determine TCC effectiveness compared to usual care, and test three hypotheses: 1) TCC will lead to non- inferior HIV viral control; 2) TCC will improve retention in HIV care, and 3) TCC will reduce mean blood pressure among Veterans with HIV and hypertension.
Aim 2 will determine the influence of TCC on VHA and fee basis non-VHA health care utilization. Implications: Our operational partners in ORH and the Office of Public Health (OPH) intend to support national roll out of the TCC model, contingent on findings from this study. If Veterans prefer TCC, as was found in the pilot, and viral control is at least non-inferior to usual care, this will justify wider dissemination. Understanding changes in utilization associated with TCC will inform need for additional studies to measure costs. This will set the stage for future efforts to advance TCC implementation for HIV, and potentially other chronic conditions that may benefit from generalist-specialist co-management in rural and outlying urban settings
In the modern era of effective therapy, Veterans living with HIV infection can anticipate an essentially normal lifespan, and are likely to acquire common conditions associated with aging, such as hypertension and diabetes. Historically, aging Veterans with HIV have received all of their care in HIV specialty clinics, usually located in large urban areas. This specialty-centered model provides accessible care for Veterans with HIV in large cities, but does not serve the needs of Veterans in rural areas far from HIV clinics. We have developed a telehealth collaborative care (TCC) model that combines HIV specialty care delivered using telehealth with primary care by local care teams in clinics serving rural and outlying areas (i.e. ?shared care?). As part of its Promising Practices program, the Office of Rural Health is currently supporting expansion of the TCC model in three VHA facilities. This proposal will seize this opportunity to complete a trial to rigorously determine TCC effectiveness, in order to inform decisions about wider TCC dissemination.