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      HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model

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          Abstract

          Background

          New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic).

          Methods

          We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders.

          Results

          Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8–5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5–5.2; engagement: aRRR, 1.3; 95% CI, 0.9–1.9).

          Conclusions

          The Max Clinic improved viral suppression among patients with complex medical and social needs.

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          Most cited references26

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          Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review.

          Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.
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            Predictors of Adult Retention in HIV Care: A Systematic Review.

            A systematic literature review was conducted to identify predictors of poor adult retention in HIV medical care in developed and developing countries. An electronic search was conducted with MEDLINE (OVID), PubMED, EBSCO, SCOPUS, and Cochrane databases, as well as manual searches. Original, quantitative, adult studies in English, published between 1995 and 2015 were included. Only those with a focus on predictors of retention in care were reported on. Of the 345 articles identified, thirty were included following an independent assessment by two raters. In developed countries, the most frequently cited predictors of poor retention were active substance use and demographic factors. In developing countries, physical health factors were most frequently associated with poor retention in care. The results from this review suggests primary concerns for poor retention include substance use and physical health factors. Other psychosocial factors, such as psychiatric illness and social/welfare factors, were also found to be relevant.
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              Interventions to reduce wait times for primary care appointments: a systematic review

              Background Accessibility and availability are important characteristics of efficient and effective primary healthcare systems. Currently, timely access to a family physician is a concern in Canada. Adverse outcomes are associated with longer wait times for primary care appointments and often leave individuals to rely on urgent care. When wait times for appointments are too long patients may experience worse health outcomes and are often left to use emergency department resources. The primary objective of our study was to systematically review the literature to identify interventions designed to reduce wait times for primary care appointments. Secondary objectives were to assess patient satisfaction and reduction of no-show rates. Methods We searched multiple databases, including: Medline via Ovid SP (1947 to present), Embase (from 1980 to present), PsychINFO (from 1806 to present), Cochrane Central Register of Controlled Trials (CENTRAL; all dates), Cumulative Index to Nursing and Allied Health (CINAHL; 1937 to present), and Pubmed (all dates) to identify studies that reported outcomes associated with interventions designed to reduce wait times for primary care appointments. Two independent reviewers assessed all identified studies for inclusion using pre-defined inclusion/exclusion criteria and a multi-level screening approach. Our study methods were guided by the Cochrane Handbook for Systematic Reviews of Interventions. Results Our search identified 3,960 articles that were eligible for inclusion, eleven of which satisfied all inclusion/exclusion criteria. Data abstraction of included studies revealed that open access scheduling is the most commonly used intervention to reduce wait times for primary care appointments. Additionally, included studies demonstrated that dedicated telephone calls for follow-up consultation, presence of nurse practitioners on staff, nurse and general practitioner triage, and email consultations were effective at reducing wait times. Conclusions To our knowledge, this is the first study to systematically review and identify interventions designed to reduce wait times for primary care appointments. Our findings suggest that open access scheduling and other patient-centred interventions may reduce wait times for primary care appointments. Our review may inform policy makers and family healthcare providers about interventions that are effective in offering timely access to primary healthcare. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2219-y) contains supplementary material, which is available to authorized users.
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                Author and article information

                Journal
                Open Forum Infect Dis
                Open Forum Infect Dis
                ofid
                Open Forum Infectious Diseases
                Oxford University Press (US )
                2328-8957
                July 2019
                26 June 2019
                26 June 2019
                : 6
                : 7
                : ofz294
                Affiliations
                [1 ]Department of Medicine, University of Washington, Seattle, Washington
                [2 ]Department of Epidemiology, University of Washington, Seattle, Washington
                [3 ]Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
                [4 ]Department of Global Health, University of Washington, Seattle, Washington
                [5 ]Social Work, Harborview Medical Center, Seattle, Washington
                Author notes
                Correspondence: J. C. Dombrowski, MD, MPH, 325 Ninth Ave, Box 359777, Seattle, WA 98104 ( jdombrow@ 123456uw.edu ).
                Article
                ofz294
                10.1093/ofid/ofz294
                6641789
                31341930
                71ef1dad-5577-4f91-884f-2fd989cbb75e
                © The Author(s) 2019. Published by Oxford University Press on behalf of Infectious Diseases Society of America.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence ( http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                : 19 April 2019
                : 21 June 2019
                Page count
                Pages: 8
                Funding
                Funded by: National Institute on Drug Abuse 10.13039/100000026
                Award ID: R03 DA 042668
                Funded by: University of Washington Center
                Funded by: National Institutes of Health 10.13039/100000002
                Award ID: P30AI027757
                Award ID: P30 AI 027757-28S1
                Categories
                Major Article

                care delivery,high-need patients,hiv care continuum,retention in care,substance use

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