VA Video Connect to Improve Access to Multi-disciplinary Specialty Care

背景：改善人类免疫缺陷病毒(HIV)护理的保留率并提高比例 持续抑制艾滋病毒的退伍军人是VHA艾滋病毒，肝炎中概述的4个国家优先事项之一 和相关条件计划的2016年度报告。治疗像HIV这样的复杂疾病需要 在与多个提供者的定期诊所就诊时进行多学科护理和监测。在VHA，护理位于 主要在退伍军人医疗中心提供，给退伍军人进入造成了后勤和耻辱方面的障碍 多学科的艾滋病毒护理。VA Video Connect(VVC)，一种支持VA的移动健康视频技术 允许退伍军人和提供者从任何远程位置完成临床访问，包括家中，具有 通过增加对艾滋病毒和其他慢性疾病的多学科护理提供转变的潜力 获得护理的途径。退伍军人管理局领导层希望在2018财年通过VVC接受护理的退伍军人比例为5%，但不到0.1% 携带艾滋病毒的退伍军人使用过VVC。VVC可以帮助填补医疗保健方面的这些空白。 具体目标：目标是：目标1-临床有效性：确定VVC交付的有效性， 多学科艾滋病毒护理与常规护理在保留护理方面的比较。目标2--执行：开展 混合方法形成性评估，以细化和评估我们的实施促进(IF)战略，以 扩大VVC提供的艾滋病毒护理的覆盖范围，增加提供商和退伍军人的采用率，并确定潜力 为了可持续发展。探索性目标：评估VVC提供的艾滋病毒护理在6个国家的实施潜力 不同的VHA设置，并根据具体情况确定采用障碍和促进者。 对退伍军人健康的意义：退伍军人管理局是美国最大的艾滋病毒护理提供者之一，而且还在不断改进 保留护理和抑制艾滋病毒与提高艾滋病毒的存活率有关。 优先领域：改善获得护理的机会、退伍军人管理局现代化、医疗保健公平和健康差距。 创新：虽然VVC在精神卫生保健领域站稳了脚跟，但它还没有被广泛应用于专科 医疗护理。我们将确定VVC提供的多学科护理是否可以提高护理和 需要特殊医疗护理的脆弱退伍军人的临床结果。这项研究将提供模型 和证据表明，有一个变革性的解决方案，可以增加退伍军人获得多学科护理的机会。 方法：目标1将通过务实的混合第二类有效性--执行研究来实现 在迈克尔·E·德巴基VA医疗中心传染病诊所内，该诊所为近1000人提供服务 携带艾滋病毒的退伍军人。我们将部署IF战略，以促进VVC的吸收，并将退伍军人随机分配到 被提供或不被提供VVC。这项研究将招募360名退伍军人，并有权检测到12%的绝对 改善护理保留率，这是主要结果。次要结果包括坚持 抗逆转录病毒治疗、艾滋病毒抑制和安全措施。在RE-AIM Quest框架的指导下，目标2 在有效性试验的基础上进行混合方法评估，招募了40名经验丰富的参与者 许多工作人员在审判的所有阶段都进行了深入访谈。探索性目标将在工作中进行 与6个不同的退伍军人管理局艾滋病毒诊所合作，包括评估组织准备情况，部署IF战略， 进行深入访谈，并评估VVC在这些诊所的覆盖范围和采用情况。 预期结果：我们假设VVC将改善参与度和临床结果，并 患者和提供者都可以接受。我们将在以下方面产生极其宝贵的数据和经验 在精神卫生保健之外实施VVC，而不考虑对艾滋病毒护理的影响，并确定IF策略 这可以在以后的VVC实现中使用。 下一步：如果成功，我们将与合作伙伴合作，为多学科传播和实施VVC 在整个退伍军人事务部提供艾滋病毒护理。我们还将促进其他慢性病患者的工作。我们的结果可能会导致 加速了VVC的使用，改善了获得护理的机会，并改善了许多退伍军人的健康状况。

Background: Improving retention in human immunodeficiency virus (HIV) care and increasing the proportion of Veterans with persistent HIV suppression is one of the 4 national priorities outlined in the VHA HIV, Hepatitis and Related Conditions Program’s 2016 Annual Report. Treatment of complex conditions like HIV requires multidisciplinary care and monitoring at regular clinic visits with multiple providers. In VHA that care is located and delivered primarily in VA medical centers, posing logistic and stigma related barriers to Veterans’ access to multidisciplinary HIV care. VA Video Connect (VVC), a VA-supported mobile health video technology that allows Veterans and providers to complete clinical visits from any remote location including the home, has the potential to transform delivery of multidisciplinary care for HIV and other chronic conditions by increasing access to care. VA leadership wants 5% of Veterans to receive care via VVC in FY2018, but less than 0.1% of Veterans with HIV have used VVC. VVC could help fill these gaps in care. Specific Aims: The aims are: Aim 1-Clinical Effectiveness: To determine the effectiveness of VVC-delivered, multidisciplinary HIV care compared to routine care on retention in care. Aim 2-Implementation: To conduct a mixed-methods formative evaluation to refine and evaluate our implementation facilitation (IF) strategy to improve the reach of VVC-delivered HIV care, increase provider and Veteran adoption, and determine potential for sustainability. Exploratory Aim: To assess the implementation potential of VVC- delivered HIV care across 6 diverse VHA settings and identify contextually specific barriers and facilitators to adoption. Significance to Veterans’ Health: The VA is one of the largest providers of HIV care in the US, and improving retention in care and HIV suppression is associated with improved survival with HIV. Priority areas: Improving access to care, modernization of VA, healthcare equity and health disparities. Innovation: While VVC is gaining a foothold in mental health care, it has not been widely used in specialty medical care. We will determine if multidisciplinary care delivered by VVC can improve retention in care and clinical outcomes for vulnerable Veterans in need of specialty medical care. The research will provide models and evidence for a transformative solution to increase Veterans' access to multidisciplinary care. Methodology: Aim 1 will be achieved with a pragmatic, Hybrid Type II effectiveness-implementation study within the Michael E. DeBakey VA Medical Center infectious diseases clinic, which cares for nearly 1000 Veterans with HIV. We will deploy an IF strategy to facilitate uptake of VVC and randomize Veterans to either be offered or not offered VVC. The study will enroll 360 Veterans and is powered to detect a 12% absolute improvement in retention in care, the primary outcome. Secondary outcomes include adherence to antiretroviral therapy, HIV suppression, and safety measures. Guided by the RE-AIM QuEST framework, Aim 2 layers a mixed-method evaluation on top of the effectiveness trial, enrolling 40 Veteran participants and numerous staff in in-depth interviews at all phases of the trial. The Exploratory Aim will be conducted working with 6 diverse VA HIV clinics and includes assessing organizational readiness, deploying the IF strategy, conducting in-depth interviews, and assessing reach and adoption of VVC in these clinics. Expected Results: We hypothesize that VVC will improve engagement and clinical outcomes and be acceptable to patients and providers. We will generate extremely valuable data and experience on implementation of VVC outside mental health care, regardless of impact on HIV care, and identify IF strategies that could be used in later implementation of VVC. Next Steps: If successful, we will work with partners to disseminate and implement VVC for multi-disciplinary HIV care throughout VA. We will also foster work in other chronic medical conditions. Our results could lead to accelerated uptake of VVC, improved access to care, and improved health for many Veterans.