Interventions to build capacity of the HIV healthcare workforce: Lessons learned from practice transformation projects in California

Despite significant advances in medicine, shortages in the US healthcare workforce threaten to undermine these gains. Providers are a critical piece of a robust health system. Yet workforce shortages in the US are growing, and are particularly prominent in the primary care workforce [Petterson, 2013]. The HIV care workforce faces similar challenges. Treatment advances have shifted HIV into a model of chronic care management, and as more patients are living longer with HIV, the provider workforce is not growing at a rate to meet the growing population of patients in need of care [AAHIVM 2016, Weiser 2016].

California has one of the highest numbers of cases of HIV in the country [CDC 2018], and prior study found some difficulty in access to HIV care after Medicaid expansion and implementation of the Affordable Care Act [Hazelton 2014, Arnold 2018]. When patients who had been seen under the Ryan White Program (the payer of last resort) became eligible to receive care in mainstream clinics, many struggled to find providers who were competent in providing HIV care and were accepting new patients.

This guide provides an overview of two safety-net clinics in California that expanded their HIV care workforce as part of a national Health Resources and Services Administration (HRSA) demonstration project. The demonstration project, funded from 2014-2018, aimed to address shortages in the HIV workforce through clinical practice transformations such as training new providers and improving care coordination [HRSA 2016]. This guide describes how the two demonstration sites aimed to improve workforce capacity and patient access to care, and what they learned throughout the course of the project. Descriptions of each site’s projects and the lessons learned were adapted from the materials they produced for the initiative-wide monograph [TargetHIV 2019].

Background:

• Family Health Centers of San Diego (FHCSD) is a non-profit, Federally Qualified Health Center (FQHC) with over 20 health centers located throughout San Diego County.
• The center provides comprehensive, affordable healthcare to low-income individuals and families. As a Ryan White Part C-funded provider of HIV medical care and support services, the center provides HIV care to over 1,200 patients per year.

Practice Transformation Overview:

As part of the HRSA initiative, the health center’s goal was to increase the capacity of its primary healthcare workforce to provide more HIV medical care. Specifically, the model included the expansion of HIV-related training in non-HIV clinical sites throughout their clinic network, and to enhance linkage and retention across the clinical sites through patient navigation. See the following page for specific components of the model.

[Family Health Centers of San Diego logo]. (n.d.). Retrieved July 29, 2019, from https://www.fhcsd.org

[Medical residents log patient information during a training session at a Family Health Centers of San Diego clinic in City Heights, Jan. 4, 2019.]. (2019, January 24). Retrieved August 3, 2019, from https://www.fhcsd.org/health-center-trains-recruits-doctors-to-serve-poor-amid-growing-shortage/

San Diego

At the end of the initiative, demonstration site representatives shared the following lessons learned:

Support for practice transformation is needed from all levels at the clinic

• In addition to upper-management support, support was needed from middle-management such as staff supervisors, clinic directors, and associate directors.

Allow time to gain buy-in and train project champions

• The project team worked closely with each health center, ensuring that at least one staff member from each section of the health center had extra training so they could mentor others.

Providers drive the expansion of the project to new clinical sites

• Having providers who are already experts in HIV care is crucial, as these individuals can help to train other staff and providers and provide ongoing support and mentorship.

Provide trainings through a variety of modalities

• Provide training for medical providers through HIV didactic curriculum as well as independent studies and clinical shadowing. Leverage existing training programs and mechanisms, internal or external to the organization.

Transitioning care for patients can be challenging

• The health center observed that some patients preferred to stay with their existing provider rather than switch to a new one who may be unfamiliar.

Background:

• San Ysidro Health (SYHealth) is a Federally Qualified Health Center (FQHC) in San Diego County and Ryan White Part C provider.
• The health center is a regional clinic system that provides comprehensive primary care services and family support programs for predominantly low-income Latino populations.
• The clinic serves nearly over 90,000 patients across an integrated network of 34 clinic sites, including 1,200 patients who receive care for HIV.

Practice Transformation Overview:

As part of its practice transformation project, SYHealth focused on expanding access to a wider array of services for its HIV population. Although the clinic network offered comprehensive services, those departments had been historically siloed from the HIV clinic. The project also trained providers (family medicine residents and non-HIV primary care providers) in HIV clinical care in order to expand the center’s capacity to provide HIV care and to provide primary care and other services to patients living with HIV.

[San Ysidro Health logo]. (n.d.). Retrieved July 29, 2019, from http://www.syhc.org/about-us/

[Provider training]. (n.d.). Photo used with consent from San Ysidro Health team

San Ysidro

At the end of the initiative, demonstration site representatives shared the following lessons learned:

Making Time for Staff and Provider Training

• The main issue that the SYHealth Practice Transformation team encountered was related to making time for practice transformation. Scheduling times for staff training was difficult given the many competing priorities with clinical care. However, scheduling became easier over time as it became clear that making time provided tangible improvements in clinical procedures and patient experience.
• A similar issue was related to clinical teaching time for providers, as there was a limited amount of protected time for teaching.

Prioritization and Role Clarification

• The patient referral system was complex and difficult for a single Patient Navigator to manage since there were a lot of outside factors (e.g., lack of knowledge about HIV and other services available, the stigma around HIV, and the complexities of the healthcare system) that impacted patient engagement and uptake of services. It also took time to build connections between the staff and providers across the different departments. To address this problem, the Patient Navigators focused on facilitating referrals to high priority areas such as women’s health, behavioral health, and health education, while medical assistants could support patients with other referrals.

This document highlighted two practice transformations located in California that were part of a national demonstration project to address capacity issues in the HIV healthcare workforce. Both projects were successful in training new providers and expanding access to HIV services for their patient populations.

Collaborating between family medicine residency programs and HIV specialty care is one way to address shortages in the HIV care workforce. Echoing preliminary findings from the demonstration sites, a qualitative study conducted in New Haven, Connecticut, found that trainees who provided care under the supervision of an HIV specialty provider delivered care of comparable quality and level of patient satisfaction [Sherbuk 2019]. Also, FQHCs provide ripe opportunity for integrated care and training models because of the comprehensive services that are already available within their network. Although, as our demonstration sites illustrate, even when comprehensive services are available within network, they may not necessarily be easy for patients to access. Thus, it is critical to build systems that foster collaboration between departments and seamless referrals for patients.

Not only does such a system make care more coordinated for providers, but other studies have underscored the value that patients place on being able to receive services in one location [Norberg 2019].

Most infectious disease providers also function as primary care providers for patients with HIV [Lakshmi, 2018], so being able to delegate primary care responsibilities to non-HIV providers is one way of making the HIV care workforce more efficient for a growing patient population. Overall, project leaders reported that demonstration projects were well accepted at the clinical sites, though they did take time to launch, and securing buy-in was an ongoing process. One of the most common and difficult challenges the sites encountered had to do with allocating sufficient time for training. However, once the sites made time, they found the efforts to be valuable. Another challenge had to do with staff attrition. Incentivizing providers to stay for a certain number of years after their training, and committing to retraining staff at regular intervals can address issues of attrition.

Although both projects were similar in terms of their goals and overall approach (i.e., by training non-HIV providers and trainees and coordinating care in FQHCs), they each tailored their programs to address the structures of their organizations and their specific needs. For example, since finding time for training staff was challenging, sites used different strategies to carve out time for trainings and tried to leverage existing resources as much as possible. And as another example, one of the sites focused its patient navigation efforts in the departments with highest need.

Taken together, these brief vignettes illustrate that practice transformations are feasible and may be possible to implement with existing resources, particularly in FQHC settings with residency training programs or collaborations in place.

For more information about each demonstration site’s project, please see their project narratives, which will be available soon through TargetHIV.  Also, stay tuned for more reports from the larger initiative.