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Exploring implementation considerations for geriatric-HIV clinics: A secondary analysis from a scoping review on HIV models of geriatric care
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Oct 4 2023
CONCLUSION
To address the needs of the growing number of older adults living with HIV who require specialist geriatric support, geriatric-HIV models of care are emerging. Pragmatic and logistical factors to consider when implementing models of care in new settings are needed. Overall, the findings from this scoping review provide an initial understanding of the key factors to consider when implementing geriatric-HIV models of care across healthcare settings. We recommend that health system planners consider mechanisms of communication and collaboration, opportunities for provider buy-in, patient engagement and available resources. It is imperative that future research explore implementation in more diverse settings to understand the nuances that influence implementation and care delivery. Given the significant number of individuals living with HIV into older age, more research into how best to implement geriatric-HIV models of care across diverse care and geographical settings is warranted to improve provider experience, optimize the delivery of healthcare, and improve the quality of care provided to older adults living with HIV.
Characteristics of programmes
The models of care described varied in terms of their location and setting, the number and type of care providers involved, the mechanism of patient referral, the type of assessments and interventions performed and the methods of longitudinal patient follow-up. Models are described in greater detail in the original article [21]. In total, 14 unique programmes were described across the 11 articles. Two articles described the same ‘Golden Compass’ and two articles describe the same ‘Silver Clinic’. Ten of these models (n = 10/13, 77%) occurred in-person at outpatient settings. Most studies (n = 9/11, 82%) described an in-person geriatric consultation service located within an existing HIV clinic [14-16, 20, 43-47], although one (n = 1/11, 9%) detailed a community outreach service delivered in people's homes [48], and two (n = 2/11, 18%) included components delivered in an online or telemedicine format [15, 49]. Almost all models of care (n = 11/14, 79%) incorporated a multidisciplinary team [14-16, 20, 43-49] into the delivery of care.
The most common method of access to geriatric-HIV services described in the studies was via clinician referral when there was a perceived clinical need [14, 16, 20, 43-45] (n = 6/11, 55%); however, self-referral [49] (n = 1/11, 9%) and referral generation via screening processes [46, 47] (n = 2/11, 18%) were also described.
Assessments and care interventions commonly included geriatric screening tests [e.g. Montreal Cognitive Assessment (n = 1/11, 9%)], CGAs (n = 8/11, 73%), medication reviews (n = 2/11, 18%), mobility and functional assessments (n = 2/11, 18%) and patient education initiatives (n = 5/11, 45%). Some services provided a one-off geriatric-focused review and relied upon the primary care or HIV provider to implement any recommendations, while others offered longitudinal geriatric follow-up.
Implementation factors
When analysing the described geriatric-HIV models of care for factors that influenced their implementation, four key categories of barriers and facilitators emerged: care provider buy-in, patient engagement, mechanisms of communication and collaboration, and available resources. Each category presented in the following sections incorporates factors that can be considered as facilitating, as well as posing a barrier to, implementation.
Mechanisms of communication and collaboration (inner setting)
The mechanisms of communication and collaboration between primary and speciality care providers, multidisciplinary teams and older adults living with HIV were found to be significant factors in the implementation of geriatric-HIV care models in seven studies [14, 15, 20, 44, 45, 48, 49]. The co-location of geriatric and HIV services facilitated patient referrals and resulted in better communication, collaboration and coordination between clinicians in some programmes [44]. Timely access to specialist reviews and the ability to provide older adults living with HIV with assistance to navigate health systems had the potential to enhance their care [20]. Furthermore, good communication with older adults' primary care providers and well-kept medical records were important for the success of care programmes [45]. Having a case-manager to coordinate multidisciplinary teams [48] and means by which to provide linkages to community resources [48] also facilitated implementation. Finally, telemedicine was found to be an effective strategy to communicate with older adults living with HIV and to provide continuity of care during the COVID-19 pandemic [49].
Barriers to the implementation of coordinated geriatric-HIV care models from a communication and collaboration perspective were primarily related to referral and follow-up procedures. Confusion over referral workflow [14] and clinicians forgetting to refer older adults living with HIV to geriatric-HIV services [44] were detrimental to their operation. Similarly, the implementation of programmes was impeded when there was a lack of clarity regarding longitudinal follow-up plans [14] and when recommendations made by external providers were not feasible [15].
Intervention effectiveness
Most studies provided evidence that the addition of geriatric care providers to a patient's HIV care team improved access to holistic mental and physical health care. CGAs proved to be instrumental in guiding healthcare providers to consider the mental health of service users [47, 50]. Consequently, some models of care were effective in reducing depressive episodes [47, 50], particularly those that embedded mental health providers, such as psychotherapists, in their clinics [14, 45, 50]. The CGA also guided healthcare providers in considering the overall daily functioning and cognitive behaviour of older adults living with HIV, which helped to identify comorbidities [47] by recognizing and diagnosing any coexisting medical conditions that might have otherwise gone unnoticed [42, 51, 52]. By working within multidisciplinary care teams [44, 45, 48], healthcare providers were able to anticipate future patient needs and organize care and services to meet those needs [14, 15, 20, 44-46]. Moreover, healthcare providers were able to focus on the determinants of health of particular importance within the context of older adults living with HIV [45]. Focusing on the determinants of health and meeting older adults living with HIV's current and future needs were shown to improve patient's quality of life [14, 45, 48] and their satisfaction with care [14, 20]. Improving satisfaction in care increased trust between services users and providers [20]. Patient satisfaction was commonly measured through qualitative data collection methods, such as semi-structured interviews [14, 20]. No study explicitly examined healthcare providers’ outcomes, as the majority were focused on patient outcomes.
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