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Strengths and Challenges of Various Models of Geriatric Consultation for Older Adults Living with HIV
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Clinical Infectious Diseases 06 August 2021 - Amelia J Davis, Meredith Greene, Eugenia Siegler, Kathleen V Fitch, Sarah A Schmalzle, Alysa Krain, Jaime H Vera, Marta Boffito, Julian Falutz, Kristine M Erlandson
from Jules: Selecting & implementing the best model is critical. This article discusses and briefly reviews & provides an overview of several different models of "HIV Geriatric Care Models" that have been implemented or are pending. In my opinion we need a model that incorporates elements of such a Geriatric-HIV Care Model. It is crucial to imbed & colocate all elements of this Geriatric-HIV Care Model within the HIV clinic itself. Accessibility & convenience is the paramount issue for elderly PLWH. as son as it becomes to inconvenient & burdensome they will find it too much & may not feel satisfied & may not use the program as well. All HIV care, geriatric consultation & advice & there support services should be colocated & imbedded within the HIV clinic. The PLWH's personal HIV clinician/doctor must be in close proximity to the Geriatriician & the PLWH must feel both these 2 clinicians are physically close to each other & working in tandem with the PLWH on all aspects of their care. For example. a PLWH has a visit with their HIV doctor & then they can walk immediately into the Geriatrician's office for their evaluation or visit & there MUST be a joint followup between the 3 in person immediately following where all 3 are together or perhaps preferrably by telehealth. Another problem is access & communication with specialists. I suggest again due to convenience all specialists be colocated & imbedded into the HIV clinic: cardiologists, renal, diabetes-bone, neurology, and of course all supportive services: social workers, housing, mental health, etc. We are in the early stages of evaluating & planning care models & systems for the aging & elderly PLWH. They must be paid for & sustainable. Apparently at this point in time all the models discussed below are forced to seek outside independent funding. A system must be set up within the confines of reimbursement & financial support yet fulfill all the needed elements necessary to provide the care elderly & aging need. Already many PLWH are over 65, I estimate 250,000 at least and many of these suffer mental & physical impairment & disability & multimorbidity. There are certain particularly vulnerable populations including Women with HIV and African-Americans & Latinos, who need attention for special needs. Its not only the population served by the RWCA that must be addressed but much HIV care takes place outside the RW clinic system. This is a large problem but clearly with an expected 75% of PLWH in the USA to be over 50 by 2030 & increasing numbers who will become frail & suffer serious affects of comorbidities - we need swift action. TheMACS cohoe has reported 25% of PLWH over 65 are frail, and we expect that percent to increase. This will place great burden on our healthcare system for which we are not prepared. Lastly, the concern around housing. With good interventional programs including exercise & diet we can delay & perhaps prevent further decline but many will decline & need nursing home care & assisted living facilities, we have not discussed this. We need HIV dedicated care & facilities for elderly & disabled PLWH who need this type of care. We must discuss this & plan. But there are potential alternative approached such as "aging in place" villages & concepts that may provide solutions, we must begin to discuss & explore these, but we have not yet begin these processes.
Jules Levin
"Patient involvement is essential to ensure that these models of care reflect what PWH seek in their care"
Summary: For persons living with HIV age 50 and over, there is an increasing need to address concerns associated with aging. Thus, three models of geriatric consultation are described: outpatient referral/consultation, combined HIV/geriatric multidisciplinary clinic, and dually-trained providers within one setting.
Abstract
As care of persons living with HIV (PWH) has transitioned from management of opportunistic infections to management of conditions associated with older age, new models of geriatric consultation are needed. The authors, who represent nine different clinics across North America and the United Kingdom, provided their insights on models of geriatric consultation for older individuals living with HIV. Three models of geriatric consultation are delineated: outpatient referral/consultation, combined HIV/geriatric multidisciplinary clinic, and dually-trained providers within one clinical setting. A patient-centered approach and the utilization of expertise across disciplines were universally identified as strengths. Logistical barriers and the reluctance of older PWH to see a geriatric care provider were identified as barriers to implementing these models. Although the optimal model of geriatric consultation depends on a region's resources, there is value in augmenting the training of infectious disease providers to include principles of geriatric care.
Background
Antiretroviral therapy (ART) regimens have led to improved rates of HIV-1 viral suppression and subsequent increases in life expectancy of people living with HIV (PWH). PWH aged 50 and older now comprise over 50% of adults living with HIV in the U.S. and Europe.1 Worldwide, an estimated 6.7 million people aged 50 years and older are living with HIV, and rates are expected to increase over the next decade.2
For those aging with durable HIV viral suppression, comorbidities and syndromes associated with aging are more common than conditions related to AIDS, such as opportunistic infections. Many PWH have expressed concerns relating to cognition, access to community services, daily function and gait, management of complex comorbidities, and healthy aging.3 Compounding the complex care of older adults living with HIV is a shortage of infectious disease providers, especially HIV specialists, and geriatricians.4 National Resident Matching Program (NRMP) data from 2021 shows that only 52.0% positions were filled across all geriatric medicine fellowship programs in the United States.5 In 2019, 20.7% of infectious disease positions were unfilled in the U.S.6 With limited resources and a growing population of older adults living with HIV, new models of care may be needed.
Such models may include referrals to geriatricians outside of the HIV clinic, geriatricians embedded within HIV clinics, and referral to internists or family medicine providers for co-management, though many other care model types may exist, and this summary is not an exhaustive list of all existing clinics. Relatively little is known regarding patient and provider acceptability and outcomes with any of these models, and nor do we know how best to integrate care of older PWH across health systems.7
Based on the experiences and perspectives of nine diverse clinics across North America and the United Kingdom, this piece highlights lessons learned from three models of geriatric consultation: outpatient referral/consultation, combined HIV/Geriatric multidisciplinary clinics, and dually-trained providers. The co-authors are representatives of all three aforementioned models and have provided their insights regarding initial strengths and challenges of these three models, patient or provider feedback, and areas for improvement.
Discussion
In these three models of geriatric consultation for older PWH, there is a demonstrated commitment to enhance patient goals and outcomes by focusing on the geriatric 5Ms: what matters most to patients, mobility, mind, medications, and multicomplexity.21 A patient-centered approach was a strength across all these models, as was the utilization of expertise across disciplines. Similar challenges arose, regardless of geographic location or institution type. They included: 1) Logistical barriers: The ideal location for PWH to access geriatric care services (within or outside of the facility) is variable. 2) Referral criteria and role clarity of the geriatric specialist: If a patient was younger than 65 years, some providers were prevented from referring patients to a geriatric care provider. PWH aged 50 and older were often reluctant to see a geriatric care provider, as they did not consider themselves "geriatric." Providers must acknowledge the intersectional identities that may impact patient experiences and stigmatization, including older age.22 3) Financial barriers: Providers noted the challenges of navigating billing processes, such as those within an embedded multidisciplinary clinic. These issues could be better mitigated within the single-payer system, as limitations related to licencing, remuneration, and other logistic considerations common to multi-payer systems are minimized. Obtaining sufficient and sustainable funding sources is a challenge for many clinics.
The COVID-19 pandemic's economic impact cannot be understated, as it has resulted in reallocation of personnel and significant loss in revenue due to a decline in outpatient visits over several months.23 This ongoing decline resulted in a reconfiguration of HIV practices and geriatric consultation models. The loss of support and attention by governmental agencies as personnel have been reassigned to COVID-related matters has tabled government resources and grant opportunities. Many of these geriatric consultation programs incorporated socialization activities for participants, but without maintenance of these programs during the pandemic, there has been an exacerbation of isolation and other mental health concerns. With these considerations in mind, video and phone visits have been proposed as a temporizing solution.24 However, it must be noted that telehealth visits may not engender the same level of trust or understanding that in-person visits can provide, and patients have expressed concerns that telehealth will replace in-person visits when in-person visits may be preferred.
Conclusion
This summary of models of geriatric consultation for individuals aging with HIV is not exhaustive, and it is important to acknowledge the variation in resources that a clinic within a given healthcare system can utilize in pursuit of the most effective and efficient model. Geriatricians have been recruited in the models outlined due to their expertise in aging syndromes, management of complex multi-morbidities, and much more, but some regions may have limited number of geriatricians. Over the short term, it may be beneficial for HIV providers seeking geriatric consultation to utilize telehealth. Over the long term, given the shortage of geriatricians and infectious disease providers, in addition to more aggressive recruitment of providers into these specialties, there may be some benefit in enhancing and modifying both the geriatrics and HIV competencies included in family medicine and internal medicine residency programs across the United States. It may also be beneficial to integrate principles of geriatric medicine into training requirements for infectious disease physicians. Patient involvement is essential to ensure that these models of care reflect what PWH seek in their care. Evaluation of these models with regards to patient outcomes (e.g. quality of life, mortality outcomes, healthcare utilization, and frailty outcomes), improvement in geriatric syndromes, and cost-effectiveness compared to standard of care is essential in informing the development of new programs and creating sustainable funding from policymakers.
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