Adoption of the chronic care model to improve HIV care: in a marginalized, largely aboriginal population.

OBJECTIVE: To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes. DESIGN: Multisite, prospective, interventional cohort study. SETTING: Two urban community health centres in Vancouver and Prince George, BC. PARTICIPANTS: Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites. INTERVENTION: Systematic implementation of the CCM during an 18-month period. MAIN OUTCOME MEASURES: Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period. RESULTS: Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up. CONCLUSION: Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an "infectious disease" approach to a "chronic disease management" approach to HIV care for marginalized populations is strongly recommended.

Closing the health equity gap: evidence-based strategies for primary health care organizations.

INTRODUCTION: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. METHODS: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. RESULTS: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. CONCLUSIONS: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.

Enhancing measurement of primary health care indicators using an equity lens: An ethnographic study.

INTRODUCTION: One important goal of strengthening and renewal in primary healthcare (PHC) is achieving health equity, particularly for vulnerable populations. There has been a flurry of international activity toward the establishment of indicators relevant to measuring and monitoring PHC. Yet, little attention has been paid to whether current indicators: 1) are sensitive enough to detect inequities in processes or outcomes of care, particularly in relation to the health needs of vulnerable groups or 2) adequately capture the complexity of delivering PHC services across diverse groups. The purpose of this paper is to contribute to the discourse regarding what ought to be considered a PHC indicator and to provide some concrete examples illustrating the need for modification and development of new indicators given the goal of PHC achieving health equity. METHODS: Within the context of a larger study of PHC delivery at two Health Centers serving people facing multiple disadvantages, a mixed methods ethnographic design was used. Three sets of data collected included: (a) participant observation data focused on the processes of PHC delivery, (b) interviews with Health Center staff, and (c) interviews with patients. RESULTS: Thematic analysis suggests there is a disjuncture between clinical work addressing the complex needs of patients facing multiple vulnerabilities such as extreme levels of poverty, multiple chronic conditions, and lack of housing and extant indicators and how they are measured. Items could better measure and monitor performance at the management level including, what is delivered (e.g., focus on social determinants of health) and how services are delivered to socially disadvantaged populations (e.g., effective use of space, expectation for all staff to have welcoming and mutually respectful interactions). New indicators must be developed to capture inputs (e.g., stability of funding sources) and outputs (e.g., whole person care) in ways that better align with care provided to marginalized populations. CONCLUSIONS: The current emphasis on achieving greater equity through PHC, the continued calls for the renewal and strengthening of PHC, and the use of monitoring and performance indicators highlight the relevance of ensuring that there are more accurate methods to capture the complex work of PHC organizations.