Objective: Oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV-1 acquisition, yet it is underutilized among at-risk populations. In this pilot quality improvement (QI) initiative, we sought to identify barriers to PrEP implementation and create interventions to improve access to PrEP in a primary care clinic for homeless veterans. Methods: The setting was a large homeless primary care clinic at the Veterans Affairs in an urban area with high HIV prevalence. A root cause analysis was performed to identify barriers to PrEP expansion in the primary care clinic. Targeted interventions to improve provider knowledge and patient access to PrEP were implemented by the QI team. Results: Root cause analysis revealed 3 primary barriers to PrEP expansion in the primary care clinic: institutional limitations for prescribing PrEP, inconsistent screening and recognition of eligible patients by clinic staff, and lack of clinic workflow processes to support PrEP prescription. A multidisciplinary focus group found low levels of PrEP awareness and knowledge, with only 22% of providers reporting comfort discussing PrEP with patients. This improved to 40% of providers following targeted clinic educational interventions. The QI team also developed a pathway for primary care providers to obtain institutional PrEP prescribing privileges and used work groups to develop clinic workflows and protocols for PrEP. At the end of the intervention, at least 50% of primary care providers in the clinic had initiated PrEP in a new patient. Conclusions: We describe a multidisciplinary QI model to implement PrEP within a primary care setting serving Veterans and persons experiencing homelessness. Our program successfully addressed provider knowledge deficits and improved primary care capacity to prescribe PrEP. The primary care clinic can be a viable and important clinical setting to improve access to PrEP for HIV prevention, especially for vulnerable populations.
Influenza A viruses cause respiratory disease in several species, including humans and pigs. The bidirectional transmission of FLUAV between humans and pigs plays a significant role in the generation of novel viral strains, greatly impacting viral epidemiology.
PURPOSE
High-quality, comprehensive care of vulnerable populations requires interprofessional ambulatory care teams skilled in addressing complex social, medical, and psychological needs. Training health professionals in interprofessional settings is crucial for building a competent future workforce. The impacts on care utilization of adding continuity trainees to ambulatory teams serving vulnerable populations have not been described. We aim to understand how the addition of interprofessional trainees to an ambulatory clinic caring for Veterans experiencing homelessness impacts medical and mental health services utilization.
METHODS
Trainees from five professions were incorporated into an interprofessional ambulatory clinic for Veterans experiencing homelessness starting in July 2016. We performed clinic-level interrupted time series (ITS) analyses of pre- and post-intervention utilization measures among patients enrolled in this training continuity clinic, compared to three similar VA homeless clinics without training programs from October 2015 to September 2018.
RESULTS
Our sample consisted of 37,671 patient- months. There was no significant difference between the intervention and comparison groups’ post-intervention slopes for numbers of primary care visits (difference in slopes =−0.16 visits/100 patients/month; 95% CI −0.40, 0.08; p=0.19), emergency department visits (difference in slopes = 0.08 visits/100 patients/month; 95% CI −0.16, 0.32; p=0.50), mental health visits (difference in slopes = −1.37 visits/month; 95% CI −2.95, 0.20; p= 0.09), and psychiatric hospitalizations (−0.005 admissions/100 patients/month; 95% CI −0.02, 0.01; p= 0.62). We found a clinically insignificant change in medical hospitalizations.
CONCLUSIONS
Adding continuity trainees from five health professions to an interprofessional ambulatory clinic caring for Veterans experiencing homelessness did not adversely impact inpatient and outpatient care utilization. An organized team-based care approach is beneficial for vulnerable patients and provides a meaningful educational experience for interprofessional trainees by building health professionals’ capabilities to care for vulnerable populations.
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