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

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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.