Examining the Impact of the Golden Compass Clinical Care Program for Older People with HIV: A Qualitative Study

The combined burden of geriatric conditions, comorbidities, and HIV requires a model of HIV care that offers a comprehensive clinical approach with people 50 years or older with HIV. Golden Compass is an outpatient, multidisciplinary HIV-geriatrics program with an onsite HIV geriatrician, cardiologist, pharmacist, and social worker, offering specialist referrals, care navigation, and classes on improving functional status and cognition. Participants (13 patients and 11 primary care providers) were recruited using a non-probability sampling method to participate in semi-structured interviews on the perceived impact of Golden Compass on care delivered to older people with HIV. Interviews were transcribed verbatim and framework analysis used to analyze the transcripts. The perceived impacts of Golden Compass by patients and providers were organized by the Compass points (Northern: Heart and Mind, Eastern: Bones and Strength, Southern: Navigation and Network, Western: Dental, Hearing, and Vision). Overall, patients valued the focus on functional health and whole-person care, leading to greater trust in the ability of providers. Providers gained new skills through the geriatrics, cardiology and/or pharmacist consultations. The HIV-geriatrics specialty approach of Golden Compass improved functional ability and quality of life for older adults with HIV. Few integrated care programs for older people with HIV have been evaluated. This study adds to the limited literature demonstrating high patient and provider satisfaction with a HIV-care model that incorporated principles of geriatric medicine emphasizing a comprehensive approach to sustaining functional ability and improving quality of life.


Introduction
People with HIV are living longer. Worldwide, an estimated 7.5 million people with HIV are ages 50 years or older [1]. We use the age of 50 to characterize "older" for people with HIV due to the risk of age-related comorbidities and geriatric conditions at younger ages relative to the general population [2][3][4][5][6]. Managing comorbidities and geriatric conditions requires specialized treatments that in turn put older people with HIV at risk for other clinical complications, including drug-drug interactions [7][8][9]. Thus, the combined burden of geriatric conditions, comorbidities, and HIV requires a model of HIV care that offers a comprehensive clinical approach to complex clinical cases [10][11][12][13].
Golden Compass at Ward 86, a safety-net outpatient HIV clinic, was developed in response to the need for a broader care approach with older people with HIV ( Fig. 1) [14,15]. The Golden Compass multidisciplinary team includes a HIV geriatrician, a cardiologist, a pharmacist, and a social worker. Additional services include specialist referrals and navigation; classes on improving functional status and cognition [14,15].
While research has characterized the health care needs of older people with HIV, much less is known regarding the impact of care programs designed and implemented to specifically address these needs. The perspectives and preferences of patients and care providers are often missing even as they should guide the evaluation of care models [16,17]. The goal of this study was to explore the impact of Golden Compass from the perspectives of both patients and primary care providers at the Ward 86 HIV clinic using qualitative research methods.

Procedures
Participants (both patients and their primary care providers) were recruited for a one-time semi-structured interview at a metropolitan HIV clinic with 39 providers serving 2400 patients, most of whom are on public insurance or are uninsured. Interviews were conducted between October 2018 and May 2019 by authors JYT, CB, and JM. Non-probability sampling was used, resulting in a convenience sample of those who were easy to contact and engage. Patients were recruited via posted flyers and word of mouth; they were eligible for the study if they were living with HIV, 50 years of age or older, and had participated in at least one Golden Compass consultation or class. Individuals were screened by phone and, if eligible, were scheduled for an in-person or phone interview. Providers who referred at least one patient to the program were recruited via "Dear Provider" emails. Interviews were conducted in person or via phone or videoconference. Informed consent was obtained prior to the interview. Interviews were recorded for later transcription and each lasted 45-60 min. Participants received a $20 gift card. Study procedures were approved by the University's Institutional Review Board.
Separate interview guides were developed for patients and providers. Interviews among patients explored experiences with Golden Compass and impacts on health. Among providers, interviews focused on the referral experience and their perspectives on the usefulness of the geriatrics and cardiology consultations, including observed impacts on patient health and on the provider's care approach.

Heart and Mind
Onsite cardiologist, cogniƟve assessments by a geriatrician, and brain health classes for paƟents.

Bones and Strength
Onsite geriatric assessments for mobility, frailty, and falls, as well as exercise classes (Wellness Club) for sƟffness prevenƟon, balance, flexibility, coordinaƟon, and bone health.

NavigaƟon and Network
Service navigaƟon and classes to address social isolaƟon and loneliness.

Dental, Hearing, and Vision
Assessments for and referrals to specialized services.

Analysis Approach
Interviews were transcribed verbatim by a professional transcription service as they were completed. Transcripts were independently read by authors JYT, CB, JM, M. Greene as they became available, and interviews were conducted until thematic saturation was reached (i.e., no new information was gained from an additional interview) [18]. Themes were identified based on this preliminary reading of transcripts and were discussed and refined during regular team meetings. Data analysis was conducted separately by patients and providers via two approaches. First, analytic memos were developed independently by JYT, CB, JM who read and reread the same set of patient and provider transcripts and then met to discuss emergent themes and other observations [19,20]. Next, JYT conducted framework analysis by developing data matrices based on themes by patient and provider and by which to organize the raw data, allowing comparisons of quotes across themes and participants [21]. These analyses were presented and discussed during regular team meetings.

Findings
A total of 13 patients with HIV and 11 primary care providers were included in the study. Patients with HIV selfidentified as the following: 11 (84.6%) as male, two (15.4%) as female, six (46.2%) as Black/African American, three (23.1%) as "Other", three (23.1%) as White, two (15.4%) as Latinx, and one (7.7%) as Native Hawaiian/Other Pacific Islander. Demographics of primary care providers are not presented in order to protect the confidentiality of the small group of providers. Below, we first present findings on the overall experience of Golden Compass by patients and then providers. Next, we discuss respective patient and provider experiences (Table 1) organized by the Compass points ( Fig. 1).

Overall Impact of Golden Compass
Patients felt that Golden Compass resulted in them having greater confidence in the quality of care received. Narratives centered on having greater confidence and, as a result, more engagement in their care as a result of participating in Golden Compass. Patients appreciated that their care was focused not around disease alone, but around functional health and a full spectrum of needs above and beyond HIV: Providers also observed that the positive impacts of Golden Compass on patients' health bolstered patients' confidence in their care. A provider explained how improvements from the medication reconciliation from Golden Compass promoted care engagement by the patient: I have one patient who is pretty frail and has a whole bunch of medical problems. Having Golden Compass say, "No, not that medicine, too risky, and please focus on these things and do this and come back in a month and check-in with me"…has been really good for his health actually, that I think he has a lot more confidence in his medical care and that he's being listened to and seen and paid attention to and therefore has been a little more willing to change some of the ways he's been doing his healthcare...

Heart
The cardiology consultations increased patients' awareness of cardiovascular health risks as a result of aging and living with HIV. In the following passage, a patient attributed his recovery from myocardial infarction to the care he received from the on-site cardiologist:

Mind
Cognition and memory classes offered by Golden Compass were highlights for many patients. Patients noted improvements in memory and concentration as a result of participating in classes such as "Brain Health." One patient learned specific skills not only for recall, but also for managing feelings of frustration around not remembering: For providers, the detailed advice given by the geriatrician and additional cognitive assessments were crucial in delineating specific next steps to address multimorbidity, as illustrated in the following: As a medical provider, when you get all the comorbidities, how to address each of those but then how to bring those things all together in the aging person. There's been a couple of very complex patients with comorbidities that I just kind of wasn't sure where to go with and Dr. [HIV geriatrician] was able to kind of give some good direction on what kind of referrals might be needed.
[F]or me big issues are cognition so her assessment, being able to spend more time and doing a more detailed assessment and then her recommendations on next steps is super helpful.

Eastern Point: Bones and Strength
On-site geriatric assessments for mobility, frailty, and falls often uncovered underlying health issues. A patient related how a neurological exam initiated by the HIV geriatrician led in a diagnosis and subsequent treatment to slow the progression of an underlying condition: Patients described improvements in mobility, posture, agility, daily functional status, and pain as a result of participation in the Wellness Club exercise classes: I have noticed changes in my physical wellbeing.
[B]efore, I wasn't really as active. Now, when I do that, my body's not as stiff, it's not as sore, I'm more limber, and that helps me in my life. If I didn't have that, then I would probably be in a worse situation than I am.

Navigation
Patients described the benefits of accessing co-located services at a familiar location through the Program: There is an advantage…because it's communication between the [primary] doctor, the pharmacist, the HIV-geriatrician, and then myself. So, it's kind of like teamwork, and that teamwork is all there to help us. They're centrally located, I think that's a great benefit.
Patients appreciated that the pharmacist reviews their medications and obtains input from the patient's care team in modifying their medication regimen, which reduced pill burden. Collaboration between providers and the pharmacist helps to ensure that patient medication regimens are streamlined.

Network
While classes did not focus specifically on addressing social isolation, they naturally provided a forum for building new relationships and social connections. Classes not only improved individual outcomes such as memory and concentration ("Brain Health") or physical strength ("Wellness Club"), but also provided opportunities to socialize with others who share similar experiences, as in the narratve storytelling class called Telling Your Story. Engaging in personal storytelling with other older people with HIV helped one patient feel less stigmatized and isolated as illustrated by the statement below: As we get older, we lose a lot of our friends, and we're just left alone with our minds thinking about the past, and that becomes a big issue for people like me. The class has helped me a lot because I get to meet other people that are just like me, and that, I think, is very healthy-to connect to other individuals that are going through the same things.

Western Point: Dental, Hearing, Vision
The Western point of Dental, Hearing, Vision refers to care navigation and referrals made to specialists outside of our clinic that are essential to the health of older individuals. Consultations led to timely access to a wide range of services and referrals: [The HIV geriatrician] was a type of doctor that teaches you how to get to a specialist. She hooked me up with the eye doctor, the ear doctor, a back doctor and a pharmacist all at the same time. It's like within a month I had seen them all. And where previously that would take nine months to see all four doctors; all four of the same doctors at once that would've taken nine months.
Providers appreciated the referrals and navigation to specialty services that help guide them in accessing specific resources and services, which can be challenging: You know, dental, I'm not sure how much they do and as primary care, this is one of the hugest things that's an obstacle is that you have to print all this stuff, you have to have it faxed to the dental school, you have to call the patient and the systems aren't real good.

Discussion
The broad and different care approaches of Golden Compass at Ward 86 were credited by both patients and providers for improvements across health domains, including daily functioning and quality of life. Patients perceived improvements in memory, social isolation, falls, physical pain, walk/ gait, navigation, polypharmacy, and skills for co-managing other chronic conditions. Geriatric, cardiology, and pharmacy consultations improved patient-reported outcomes and raised provider knowledge and confidence in caring for older patients. Navigation to dental, hearing, and vision services off site enhanced the whole-person care approach. Patients' improved functional status and quality of life also contributed to greater trust in their care overall and in their willingness to participate in shared decision making. Few integrated care programs for older people with HIV have been evaluated. The findings in this and in previous assessments of Golden Compass [15] are consistent with the limited literature demonstrating high patient and provider satisfaction with care models that incorporated geriatric medicine in HIV care [22,23]. Principles of geriatric medicine emphasize a comprehensive problem-solving approach to sustaining functional ability and improving quality of life [22,23]. Our findings illustrate that the Golden Compass multidisciplinary team embedded within an HIV clinic contributed to self-reported improved knowledge and confidence among providers in caring for patients, which aligns with other models of HIV care for older adults involving both a general practitioner and specialists [22].
Participant narratives commonly related to two aspects of Golden Compass-co-location of services and a positive patient-provider relationship-that facilitated their care experience. Co-location of services improved timely access to a wide range of services and supported coordination of holistic care across providers, whereas positive patient-provider relationships fostered trust and empowered patients to advocate for their care. These findings are consistent with prior research demonstrating that patients with HIV value care coordination, inter-service communication, ease of access to services, a good health care professional-patient relationship, and involvement in decisions about care [16,17]. Research has also emphasized the importance of onestop, co-located services with diverse teams of clinical and nonclinical providers to provide successful interdisciplinary HIV care [24].
The co-location of services and enhanced patient-provider relationships described by participants may help explain their perceived improvements in health outcomes. A systematic review of 36 studies in which HIV services were co-located with other services showed some evidence for the association between co-location and improved HIV outcomes [25]. Among 10 studies in which non-HIV specific services were paired with HIV primary care, eight (80%) of studies reported positive associations across an HIV-related outcome and two (20%) reported no effect [25]. With respect to patient-provider relationships, high-quality relationships, where a provider knows a patient "as a person," are associated with higher odds of HIV treatment adherence and viral suppression [26]. Explanatory modeling suggests that patient-provider interactions directly and positively impact patient satisfaction, medication adherence, and quality of life [27]. Furthermore, conceptual models highlighted the important of dyadic trust between patients and providers in facilitating adherence to non-HIV specific medications among people with HIV [28]. While research on patientprovider relationships among older adults with HIV is lacking, studies of older adults enrolled in Medicare have demonstrated that higher quality patient-provider relationships are associated with patients being more active in healthcare decisions [29]. Higher engagement in health care decision making-engagement that is enhanced by Golden Compass-has been associated with better quality of life indicators, including mental, physical, cognitive, and behavioral outcomes, among people with HIV [30].

Limitations
A convenience sample was recruited and may not be representative of the entire patient population 50 years or older at Ward 86. However, the study was designed to offer insights to inform future research directions, an inductive research approach for which a purposive sampling method was appropriate.

Conclusions
The population of people ages 50 years or older with HIV is growing and requires unique models of care to address specific health challenges currently further exacerbated by the COVID-19 pandemic. While such models are emerging, little is known regarding their impact on patient outcomes and the way that primary care providers manage older patients' care. This study explored the perspectives of patients and their providers regarding their experiences with Golden Compass, a multidisciplinary program serving people with HIV 50 years or older at a safety-net HIV clinic. Findings highlighted the positive impacts of co-location and that Golden Compass improved patient trust, which in turn enhanced patient-provider relationships. Future research should evaluate this and other HIV and aging programs for improving patient outcomes over time. Data Availability Data associated with this manuscript will not be deposited.
Code Availability There were no software applications or custom codes associated with this study/manuscript.

Conflict of interest
The authors declared no potential conflicts of interest.
Ethical Approval This research was reviewed and approved by the UCSF Committee for Human Subjects Research (study # 15-17859) and determined to fall under program evaluation, quality improvement, or other research activities which did not require further IRB oversight per federal regulations summarized in 45 CFR 46.102(d). All participants gave informed consent prior to participation.
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