Adaption of the Transition of Care Model for Post-Discharge HIV-NCD care in Malawi

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PROJECT SUMMARY Most hospitals in Low Middle-Income countries (LMICS) do not practice the discharge planning models shown in high-income settings (HICS) to avert adverse outcomes posthospitalization. In the absence of such integrated programs and an increment in the double burden of disease of HIV and NCDs, the mortality in people living with HIV(PWH) continues to be high post-hospitalization. The long-term goal is to improve discharge practices and linkage to care for PWH and NCDS and achieve dual control of both conditions. The objective of this R21 application is to adapt the Transitional care Mode based in HICS (TCM) for targeted use as a post-discharge intervention for adults hospitalized with comorbid HIV and NCDs in Malawi and evaluate the feasibility and acceptability of the adapted intervention in preparation for a larger implementation science evaluation. The rationale for the project, is that there is a high mortality post-hospitalization for PWH and NCDS, in part because of the lack of integrated discharge- related interventions to support care post-hospitalization. TCM is an evidence-based model in the U.S. adopted into clinical practice for diverse patient populations and demonstrated effectiveness in improving patient outcomes after discharge. This model can be useful if adapted to the context and resources available in LMICS, and feasibility tested for long-term adoption in the care of PWH and NCDs. This research study will explore three specific aims: 1. Adapt the TCM for PWH hospitalized with NCDs in Malawi. 2. Pilot test the adapted TCM with PWH admitted with NCDs. 3. Evaluate the feasibility, effectiveness and acceptability of the adapted intervention. For the first aim, through in-depth interviews (IDI) and focus groups discussions (FGDs) with HIV/NCD stakeholders, hospital staff, patients, and caregivers, we will develop the SOPs for an adapted TCM. For the second aim, we will enroll 62 consecutive adults hospitalized with HIV and known with at least one common HIV- cardiometabolic comorbidity (hypertensive urgency, heart failure, or diabetes,) and provide the adapted TCM. For the third aim, using mixed methods, FGDs and IDI to hospital staff and patient/caregivers who participated in TCM, we will evaluate the feasibility of providing TCM for a larger study. We will describe 3-month post-discharge outcomes including re-admission, linkages and retention in care, mortality, and dual control of HIV and NCDs. Comparison with a historical control group recruited just prior to the pilot phase will provide preliminary data in regard to potential effects on readmission and death. This project is innovative in that it will adapt a known model of transitional care from HICS to LMICS for PWH/NCDS using existing resources to avert adverse outcomes. It will reinforce integrated linkages to care for both HIV/NCDs. The proposed research is significant because it represents a new effort to bridge the gap between inpatient and community-based care and integrate the care of HIV/NCDs posthospitalization.