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Care Coordination for Older Patients With HIV

Jonathan Appelbaum, MD, FACP, AAHIVS

Laurie L. Dozier Jr, MD, Education Director
Professor of Internal Medicine
Department of Clinical Sciences
Florida State University College of Medicine
Tallahassee, Florida

Jonathan Appelbaum, MD, FACP, AAHIVS, has disclosed that he has received consulting fees from Merck and ViiV Healthcare.

View ClinicalThoughts from this Author

Released: August 15, 2019

I recently saw a 70-year-old woman who presented with newly diagnosed HIV, but she also had several comorbidities, including hypertension, diabetes, and elevated cholesterol. She was receiving multiple medications and was in the care of several different specialists. With so many concomitant conditions, I needed to carefully review her history, evaluate her current medications, and contact her specialists to devise an appropriate HIV treatment plan, as well as outline a feasible strategy for managing her other conditions and appointments. This patient provides a prime example of one of the biggest challenges we face when treating older patients with HIV: care coordination.

If you are providing care for older patients living with HIV, it is likely that they have other medical conditions and social challenges that must be considered, a very different scenario from caring for younger patients who are generally healthy. As patients get older and the number of their comorbidities increases, the health consequences are compounded and the overall impact is essentially “greater than the sum of each condition,” reflecting the geriatric concept of multimorbidity. In addition, HIV itself can exacerbate some of these diseases and studies have shown that many age-related comorbidities occur earlier in people living with HIV. As a result, an essential component of providing comprehensive healthcare for these patients is the need for solid communication and a high level of coordination among all members of the healthcare team. Unfortunately, in my experience, that communication and coordination does not happen easily, even in the era of electronic health records.

Who Is Steering the Ship?
As noted above, advancing age typically brings with it an increasing number of diseases/conditions that require medical management. With more diseases come more specialists. For example, the patient I mentioned above was also receiving care from an endocrinologist and a cardiologist. A common challenge with this scenario is a lack of clear leadership across the clinical team. Who should ultimately sign off on clinical decisions for her? Is it the HIV specialist? Is it the primary care provider? If the patient has heart disease, is it the cardiologist? Sometimes that role delineation is not clear, which ultimately can be harmful to the patient. Without a designated decision maker, challenges can arise with prescribing too many drugs, opening the door for drug–drug interactions. In my opinion, the primary care provider is often well positioned to take over more of the patient’s overall management to help avoid some of these problems. However, the primary care provider for an older patient with HIV should have a solid working knowledge of HIV management and gerontology. In many settings, older patients with HIV are receiving care from providers who lack broad enough expertise to cover the intersection of primary care, geriatric care, and HIV care needs. This will become increasingly important as our patients with HIV continue living longer. There are several resources available to inform clinical decisions for this population, including the DHHS guidelines and HIV-age.org.

Of importance, the patient must be at the center of the care team and should be involved in decision-making, including decisions regarding who should manage different aspects of their care. For example, a patient who has stable heart disease may be comfortable having the primary care physician manage the disease vs keeping separate appointments with a cardiologist. Alternatively, the patient may feel strongly about wanting to keep the cardiologist on board and have the extra appointments; it really depends on the individual patient.

Models of Successful Care Coordination
There are several good models of successful care coordination where communication works well. Patient-centered medical homes, a concept based on the Ryan White HIV/AIDS Program, provide comprehensive care under one roof. These centers generally have a larger, more highly coordinated care team that includes physicians, advance practice providers, nurses, nutritionists, and social workers and/or case managers, who work together to provide a more full range of services (eg, arranging transportation if needed for appointment attendance). Although this model of extensive care is not available or feasible in all clinics and generally does not include other specialists, physicians providing care for older patients with HIV must recognize the importance of coordinating care for their patients. This requires active management on our part to ensure that someone is ultimately responsible for making and coordinating the important decisions necessary for effectively comanaging  HIV and comorbidities associated with aging.

Your Thoughts?
What are your experiences with coordinating care for older patients living with HIV? Answer the polling question and share your thoughts in the discussion section.

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