Journal of General Internal Medicine

, Volume 28, Issue 9, pp 1165–1173 | Cite as

Mixed-Methods Evaluation of a Telehealth Collaborative Care Program for Persons with HIV Infection in a Rural Setting

  • Michael Ohl
  • Dena Dillon
  • Jane Moeckli
  • Sarah Ono
  • Nancee Waterbury
  • Jo Sissel
  • Jun Yin
  • Brian Neil
  • Bonnie Wakefield
  • Peter Kaboli
Original Research

Abstract

BACKGROUND

Delivery of comprehensive care for persons with human immunodeficiency virus (HIV) infection in rural and low prevalence settings presents many challenges. We developed and evaluated a telehealth collaborative care (TCC) program for persons with HIV in a rural area.

OBJECTIVE

To determine the feasibility of TCC, and identify factors influencing implementation in rural settings.

DESIGN

Mixed methods evaluation of a quality improvement program with pre-measures and post-measures.

PATIENTS

Veterans with HIV infection in Iowa and Illinois.

INTERVENTION

TCC integrated HIV specialty care delivered by clinical video telehealth, with primary care delivered by generalist providers, in seven Community Based Outpatient Clinics (CBOCs) serving rural areas. Principles guiding TCC design were: 1) clear delineation of specialty and primary care clinic roles in co-managed care; 2) creation of processes to improve care coordination between specialty and primary care teams; and 3) use of a patient registry for population management across sites.

MEASURES

Veterans Affairs (VA) healthcare system performance measures for care for HIV infection and common comorbidities, patient travel time to obtain care, and patient satisfaction. Qualitative evaluation involved semi-structured telephone interviews with patients.

KEY RESULTS

Thirty of 32 eligible patients chose TCC over traveling to the HIV clinic for all care. Among 24 patients in TCC during the June 2011–May 2012 evaluation period, median age was 54 (range, 40–79), most (96 %) were men, and median CD4 count was 707 cells/cm3 (range, 233–1307). VA performance measures were met for > 90 % of TCC patients. Median yearly travel time decreased from 320 min per patient prior to TCC to 170 min during TCC (p < 0.001). Interview themes included: 1) overcoming privacy concerns during care in local primary care clinics; 2) tradeoffs between access, continuity, and care coordination; and 3) the role of specialist involvement in collaborative care.

DISCUSSION

Telehealth Collaborative Care is a feasible approach to providing accessible and comprehensive care for persons with HIV in rural settings.

KEY WORDS

HIV rural health telehealth veterans 

Notes

Acknowledgments

The work reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, Veterans Rural Health Resource Center—Central Region. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States government.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2013_2385_MOESM1_ESM.docx (410 kb)
ESM 1(DOCX 410 kb)

REFERENCES

  1. 1.
    Handford CD, Tynan AM, Rackal JM, Glazier RH. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database Syst Rev. 2006;3:CD004348.PubMedGoogle Scholar
  2. 2.
    McInnes K, Landon BE, Malitz FE, et al. Differences in patient and clinic characteristics at CARE Act funded versus non-CARE Act funded HIV clinics. AIDS Care. 2004;16:851–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Schur CL, Berk ML, Dunbar JR, Shapiro MF, Cohn SE, Bozzette SA. Where to seek care: An examination of people in rural areas with HIV/AIDS. J Rural Health. 2002;18:337–47.PubMedCrossRefGoogle Scholar
  4. 4.
    Ogrinc G, Mooney SE, Estrada C, et al. The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: Explanation and elaboration. Qual Saf Health Care. 2008;17(Suppl 1):i13–32.PubMedCrossRefGoogle Scholar
  5. 5.
    Reinert DF, Allen JP. The alcohol use disorders identification test: An update of research findings. Alcohol Clin Exp Res. 2007;31:185–99.PubMedCrossRefGoogle Scholar
  6. 6.
    Meader N, Mitchell AJ, Chew-Graham C, et al. Case identification of depression in patients with chronic physical health problems: A diagnostic accuracy meta-analysis of 113 studies. Br J Gen Pract. 2011;61:e808–20.PubMedCrossRefGoogle Scholar
  7. 7.
    Backus LI, Boothroyd DB, Phillips BR, et al. National quality forum performance measures for HIV/AIDS care: The Department of Veterans Affairs’ experience. Arch Intern Med. 2010;170:1239–46.PubMedCrossRefGoogle Scholar
  8. 8.
    Triant VA. HIV infection and coronary heart disease: an intersection of epidemics. J Infect Dis. 2012;205(Suppl 3):S355–61.PubMedCrossRefGoogle Scholar
  9. 9.
    Asch SM, Kilbourne AM, Gifford AL, et al. Underdiagnosis of depression in HIV: Who are we missing? J Gen Intern Med. 2003;18:450–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Justice AC, Lasky E, McGinnis KA, et al. Medical disease and alcohol use among veterans with human immunodeficiency infection: A comparison of disease measurement strategies. Med Care. 2006;44:S52–60.PubMedCrossRefGoogle Scholar
  11. 11.
    Bernard H, Ryan G. Analyzing qualitative data: Systematic approaches. Thousand Oaks: Sage Publications; 2010.Google Scholar
  12. 12.
    Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364:2199–207.PubMedCrossRefGoogle Scholar
  13. 13.
    Katz MH. Human immunodeficiency virus is (once again) a primary care disease. Arch Intern Med. 2011;171:719–20.PubMedCrossRefGoogle Scholar
  14. 14.
    McKinnell JA, Willig JH, Westfall AO, et al. Antiretroviral prescribing patterns in treatment-naive patients in the United States. AIDS Patient Care STDS. 2010;24:79–85.PubMedCrossRefGoogle Scholar
  15. 15.
    Emanuel EJ. Why accountable care organizations are not 1990s managed care redux. JAMA. 2012;307:2263–4.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Michael Ohl
    • 1
    • 2
    • 3
  • Dena Dillon
    • 1
    • 2
    • 3
  • Jane Moeckli
    • 1
    • 2
  • Sarah Ono
    • 1
    • 2
  • Nancee Waterbury
    • 4
  • Jo Sissel
    • 4
  • Jun Yin
    • 5
  • Brian Neil
    • 6
  • Bonnie Wakefield
    • 1
    • 2
    • 7
  • Peter Kaboli
    • 1
    • 2
    • 3
  1. 1.VA Office of Rural Health (ORH)Veterans Rural Health Resource Center—Central Region, Iowa City VAMCIowa CityUSA
  2. 2.Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Medical CenterIowa CityUSA
  3. 3.Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityUSA
  4. 4.Iowa City VA Healthcare SystemIowa CityUSA
  5. 5.Department of BiostatisticsUniversity of Iowa Carver College of MedicineIowa CityUSA
  6. 6.Chief of Clinical Informatics, Veterans Integrated Service Network (VISN) 23Veterans Affairs Healthcare SystemMinneapolisUSA
  7. 7.University of Missouri College of NursingColumbiaUSA

Personalised recommendations