The patient-centered medical home: a reality for HIV care in Nigeria

Abstract

Objective: HIV care delivery in resource-limited settings (RLS) may serve as a paradigm for chronic disease care, but comprehensive measurement frameworks are lacking. Our objective was to adapt the patient-centered medical home (PCMH) framework for use in RLS, and evaluate the performance of HIV treatment programs within this framework.

Design and setting: Cross-sectional survey administered within the AIDS Prevention Initiative in Nigeria (APIN) network.

Participants: Medical directors at APIN clinics.

Main outcome measures: We adapted the 2011 US National Committee on Quality Assurance's PCMH standard to develop a survey measuring five domains of HIV care: (i) enhancing access and continuity, (ii) identifying and managing patient populations, (iii) planning and managing care, (iv) promoting self-care and support and (v) measuring and improving performance.

Results: Thirty-three of 36 clinics completed the survey. Most were public (73%) and urban/semi-urban (64%); 52% had >500 patients in care. On a 0-100 scale, clinics scored highest in self-care and support, 91% (63-100%); managing patient populations, 80% (72-81%) and improving performance, 72% (44-78%). Clinics scored lowest with the most variability in planning/managing care, 65% (22-89%), and access and continuity, 61% (33-80%). Average score across all domains was 72% (58-81%).

Conclusions: Our findings suggest that the modified PCMH tool is feasible, and likely has sufficient performance variation to discriminate among clinics. Consistent with extant literature, clinics showed greatest room for improvement on access and continuity, supporting the tool's face validity. The modified PCMH tool may provide a powerful framework for evaluating chronic HIV care in RLS.

Keywords: HIV; patient-centered medical home; resource-limited settings.

Figure 1

Schematic of study design.

Figure 2

Average scores across five PCMH domains within the APIN network. This figure shows the average and range of individual clinic scores within the APIN network. Each colored bar represents one of five measured PCMH domains. Clinics scored highest on self-care and support activities. Clinics scored lowest in enhancing access and continuity, and had the most variability in scores in planning and managing evidence-based care. Average composite score across the five domains was 72%.

Figure 3

Dashboard of highest and lowest performing clinic sites. This figure is a dashboard summarizing APIN's highest and lowest performing sites within each PCMH domain. Thirty-two of 33 clinics scored higher than APIN's average domain score (colored rectangles) in at least 1 PCMH domain. Five of 33 (15%) clinics were performance leaders (scoring above average in all 5 domains. Four of 33 clinics (12%) were performance trailers; only 1 clinic scored below average in all 5 domains, other 3 clinics scored below average in 4 out of 5 domains. Performance leader.