DESCRIPTION (provided by applicant): VHA is currently transforming primary care through the implementation of Patient Aligned Care Teams (PACT), based on seven core principles: that care be patient-driven, team-based, efficient, comprehensive, continuous, coordinated and use good communication. Although VHA has made much progress transforming primary care delivery according to PACT principles, it is less clear how PACT can best be extended to specialty care. The Office of Specialty Care Services has prioritized the integration of specialty care and PACT, but how to do this remains unclear. VHA is the largest provider of HIV care in the United States. While historically Veterans with HIV have received the bulk of their care from HIV specialists in VHA medical centers, the setting of optimal HIV care is shifting. As the needs of veterans with HIV shifts more towards chronic illness and co-morbidity management, traditional models of care in specialty clinics may require new initiatives. Understanding how care for veterans with HIV varies across the VA is critical to the development and spread of such initiatives to integrate specialty HIV care with primary care in order to provide the best PACT-principled care to all of these veterans. The primary objective of this study is to better characterize the current structures, processes and patterns of care being provided for Veterans with HIV and to use this information to tailor ongoing initiatives to the needs of different care sites in order to provide the best care in line with PACT principles. Our study aims are:1) To characterize the patterns and structures of HIV care at low and high patient volume sites and examine the association between structures of care, adherence to PACT principles, and outcomes of care for HIV and comorbid conditions. 2) To characterize different types of sites with different structures of care with regards to the integration, coordination and team functioning at each site. This second, qualitative aim will generate a typology of sites of HIV care in VHA, including identifiable structures and processes of care coordination and how teams implement PACT principles for Veterans with HIV. We propose to conduct an observational, mixed methods study. We will first survey HIV clinicians across all VA facilities regarding the staffing, structure of care, and adherence to PACT principles in their current setting of care. The survey domains will evaluate the organization of HIV care for both HIV and primary care needs, how care is coordinated among providers and how care is PACT-principled. We will use secondary data to assess outcomes in HIV (virologic control), hypertension, diabetes, dyslipidemia, and depression. We will then conduct a qualitative study, conducting site visits at 12 facilities that vary on the structure of care and te quality of care delivered. We will conduct ethnographic observation of care, in-depth qualitative interviews of patients and in-depth qualitative interviews of staff and providers. This data will yield descriptions of how facilities provide coordinated, comprehensive care to Veterans with HIV.

VHA is currently transforming primary care into Patient Aligned Care Teams (PACTs), however it is less clear how PACT can best be extended to the specialty care such as caring for Veterans with HIV. Veterans with HIV require care focused not only on management of this stigmatized chronic disease, but also for comorbidities such as depression, substance abuse, hypertension and dyslipidemia. Understanding how care for veterans with HIV is organized across the VA is critical to the development and spread of initiatives to integrate specialty HIV care with primary care in order to provide the best PACT-principled care to all of these veterans. This study will describe how care is provided to Veterans with HIV across VHA, how this care is PACT-principled and the optimal ways of delivering coordinated, comprehensive care to this vulnerable population.