As a leader in healthcare, the Department of Veteran Affairs (VA) is transforming to a patient-centered model where care is personalized, proactive and patient-driven; health and wellbeing are situated within patients' context; patients are at the center of care. Complex patients, such as those with HIV, may benefit in particular from a transformation to patient-centered, contextually sensitive model of care. HIV has been transformed into a chronic condition. Veterans with HIV are living longer. Consequently, comorbidities are often of greater importance to their overall health than HIV status alone and a major concern of providers. Further complicating disease management, patients with HIV have less education, high unemployment, and are more likely to live in poverty or experience homelessness. Yet, HIV providers may not be attuned to patient contexts and, as specialists, may not be comfortable managing other comorbidities. Patient-centered management of HIV requires patient-provider communication that entails providers asking about patient context, engaging them about daily activities, priorities, and then tailoring recommendations accordingly. OBJECTIVES 1) Understand how Veterans with HIV engage in health behaviors in the context of their daily lives. 2) Explore how HIV providers consider the role of patient context and comorbidities when providing care. 3) Examine communication between HIV providers and their aging patients to understand how they attend to context and comorbidities. METHODS The objectives will be accomplished through three projects. Project 1 will be an ethnographic exploration of patients' illnesses experiences situated in their daily-lives and contexts. Patients with HIV will be interviewed and observed as they go about daily activities. Project 2 will examine how HIV providers attend to and incorporate patient contexts and comorbidities when providing care. General HIV clinic functioning will be observed and providers will be interviewed. Project 3 will examine how providers attend to and incorporate context in clinical interactions with patients with HIV. Patient-provider clinical encounters will be recorded and analyzed, to identify elements of comorbidity management, attention to context and shared-decision making. ANTICIPATED IMPACT This study will identify key ways to incorporate patient context into care planning and decision making. Further, most patient-centered care effort has been in primary care, with little attention paid to specialty care, a population arguably in great need of personalized, patient-driven care. Understanding the needs of patients with HIV is particularly needed in light of their increasing age and comorbidities. By bringing patient-context into the clinical encounter, providers may be able to untangle complex, socially situated reasons behind patients' poor adherence and have more meaningful conversations with patients about barriers to successful management of their health. Patient-centered communication has the potential to improve quality of care, patient-satisfaction, and facilitate a personalized, patient-driven approach to care. As the VA moves towards transforming the culture of care, health services research approaches can bring great insight into this transformation. This proposed work will provide evidence and methods for incorporating patient context into clinical care, patient-provider communication and shared decision making.
The Department of Veteran Affairs is transforming to a patient-centered model, where care is personalized, proactive and patient-driven, and health is situated within patients' contexts. Complex patients, such as those with HIV, may benefit in particular from a transformation to a patient-centered, contextually sensitive model of care. HIV has been transformed into a chronic condition where comorbidities may be of greater importance to patients' overall health than HIV status alone. By bringing patient-context into the clinical encounter, providers may be able to untangle complex, socially situated reasons behind patients' poor adherence and have more meaningful conversations with patients about barriers to successful management of their health. This study will identify the contexts in which aging Veterans with HIV and comorbidities engage in health behaviors, explore how their providers understand patient context and comorbidities, and then examine communication between these providers and their aging patients to understand how they attend to comorbidities and context.
