Form 1 B1 Provder Interview Protocols

appendix b
PROVIDER interview protocols

This page has been left blank for double-sided copying.

CONTENTS

I. Scenario A Interview Protocol 1

I. RWHAP Provider: RWHAP Program Leadership (1 hour) 2

A. Introduction 2

B. Background 2

C. Access to Medical Care 3

D. Care Coordination and other Assistance 3

E. Outcomes 4

F. Opportunities for Improvement 5

II. RWHAP PROVIDER: SERVICE DELIVERY STAFF (1 HOUR) 6

A. Introduction 6

B. Background 6

C. Access to Medical Care 6

D. Care Coordination and other Assistance 7

E. Tracking Service Use and Outcomes 8

F. Opportunities for Improvement 8

III. NON-FUNDED OAHS PROVIDER: MEDICAL DIRECTOR (1 HOUR) 9

A. Introduction 9

B. Background 9

C. Medical Care 10

D. Working with Ryan White Providers 11

E. Outcomes 11

F. Opportunities for Improvement 12

ii. Scenario B Interview Protocol 13

I. RWHAP Provider: RWHAP Program Leadership (1 hour) 14

A. Introduction 14

B. Background 14

C. Medical Care 15

D. Care Coordination and Other Assistance 15

E. Tracking Service Use and Outcomes 16

F. Opportunities for Improvement 16

II. RWHAP PROVIDER: CASE MANAGER (1 HOUR) 18

A. Introduction 18

B. Background 18

C. Care Coordination and Other Assistance 18

D. Tracking Service Use 19

E. Opportunities for Improvement 19

III. RWHAP PROVIDER: MEDICAL PROVIDER (30 MIN) 20

A. Introduction 20

B. Medical Care and Service Utilization 20

C. Opportunities for Improvement 21

iii. Scenario C Interview Protocol 22

I. RWHAP PROVIDER: RWHAP PROGRAM LEADERSHIP (1 HOUR) 23

A. Introduction 23

B. Background 23

C. Medical Care and Service Utilization 24

D. Care Coordination and Other Assistance 25

E. Tracking Service Use and Outcomes 25

F. Opportunities for Improvement 26

II. RWHAP PROVIDER: CASE MANAGER (1 HOUR) 27

A. Introduction 27

B. Care Coordination and Other Assistance 27

C. Tracking Service Use and Outcomes 28

D. Opportunities for Improvement 29

III. RWHAP PROVIDER: MEDICAL PROVIDER (30 MIN) 30

A. Introduction 30

B. Medical Care and Service Utilization 30

C. Opportunities for Improvement 32

IV. NON-FUNDED OAHS PROVIDER (MEDICAL): MEDICAL DIRECTOR (1 HOUR) 33

A. Introduction 33

B. Background 33

C. Medical Care 34

D. Working with Ryan White Providers 35

E. Outcomes 35

F. Opportunities for Improvement 36

I. Scenario A Interview Protocol

Scenario A	Scenario B	Scenario C
RWHAP Provider (Non-Medical)	RWHAP Provider (Medical) Not funded for OAHS	RWHAP Provider (Medical) Funded for OAHS Some clients without OAHS
Non-funded OAHS Provider (Medical)		Non-funded OAHS Provider (Medical)

In Scenario A, a RWHAP provider does not deliver medical care; instead, medical care is delivered by a non-funded OAHS partner. The partner may be in the same health system as the RHWAP provider, may be linked through referral (e.g. the RWHAP provider renders case management services or mental health services), or may not have a formal relationship (e.g. the RWHAP provider renders only support services).

At the non-medical RWHAP provider, we will interview program management and service delivery staff. Service delivery staff are those who render direct client services, and will likely include case managers, social workers, patient navigators, mental health counselors, and other relevant support staff. Depending on the RWHAP-funded services, these non-medical providers may also have medical staff (e.g. psychologists) with knowledge of where clients receive medical care.

At the non-funded OAHS medical provider, we will interview the medical director and/or other staff who are familiar with care delivery to RWHAP eligible clients, and how referrals are coordinated with the RWHAP non-medical provider.

I. RWHAP Provider: RWHAP Program Leadership (1 hour)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care from providers who are not funded for RWHAP medical services. We’re interested in learning about your client population and how they’re being connected to HIV medical care and treatment.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

2. Can you provide a little background on your organization’s mission and activities?

   1. What are the primary services your organization delivers to your clients living with HIV? Who funds these services? If you know, which of these services are funded by Ryan White?

   2. How many clients do you serve overall? What share of your clients do you estimate are eligible for Ryan White?

   3. How do your new HIV clients come to you? Are they generally diagnosed here, or do you usually receive referrals from other organizations?

1. [If referrals]: Who refers them (for example, Ryan White providers, non-Ryan White providers, or a mix; emergency department, community health center)?

C. Access to Medical Care

Now that we have a good idea of what your organization is doing, we’d like to get a sense of if and how your Ryan White clients are accessing medical care.

1. What share of your Ryan White clients do you estimate are receiving regular HIV medical care (that is, seeing a provider who can prescribe HIV medications)? (Probe: How often are they seeing that provider?)

2. Where are your Ryan White clients going for their medical care? Do you know whether these medical providers are also funded by Ryan White?

3. Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship)?

1. Do you send referrals to them and/or do they send referrals to you?

2. Do these relationships vary by provider? If yes: How do they vary?

4. Why do you think some of your clients seek/access medical care from providers who are not funded for RWHAP medical services (for example, are there challenges with having enough Ryan White-funded providers, insurance network requirements)?

1. What are some of the benefits of getting care from clinics who are not funded for RWHAP medical services?

2. How about drawbacks?

5. Do you think you serve any Ryan White clients who aren’t receiving medical care at all (e.g., in last 2 years)? If so, what proportion would you estimate are not receiving any medical care?

6. Why do you think some of your Ryan White-supported clients aren’t going in for medical care? How do you think barriers to care differ between your Ryan White-supported clients versus those who are not supported by Ryan White?

D. Care Coordination and other Assistance

Next, let’s discuss how your organization is helping your clients stay in medical care.

1. Does your organization provide any financial support for medical care? (Probe: These financial supports may directly cover the cost of care, such as copay support, or help clients stay engaged in care, such as by helping them pay for a drivers’ license.)

2. Some Ryan White providers help clients access care through supporting insurance coverage. Do you offer Health Insurance Premium (HIP) support? Does your organization provide AIDS Drugs Assistance Program (ADAP) enrollment services?

1. If so, what share of your Ryan White clients do you estimate receive insurance assistance?

3. Does your organization provide any services to help your clients get linked to medical care? (Probe: Do you accompany them to their appointments, educate them on the purpose of the visit, provide them with insurance assistance etc.?) If so, please describe what you do.

4. Does your organization provide any services that help your clients get to their medical appointments or remain engaged in care? If so, please describe what you do.

5. Do you help clients with adhering to their HIV medications? If so, please describe what you do.

6. What challenges do you face in referring your Ryan White clients for medical services?

7. What strategies have been successful for supporting your Ryan White clients in accessing medical care?

E. Outcomes

Now we’d like to get a sense of the clinical outcomes of your Ryan White clients who receive medical care at a non-funded OAHS clinic. [Interviewer note: If also conducting a chart abstraction at provider site, indicate that their responses to the following questions will supplement the chart abstraction information.]

1. Do you know whether your Ryan White clients are prescribed ART? If so, what percent do you estimate are on ART?

2. What percent of your Ryan White clients would you estimate are virally suppressed?

1. From your perspective, do you think that viral suppression rates differ for clients who receive medical care from Ryan White clinics compared to those who receive services from clinics that are not funded for Ryan White medical services? If yes, why do you think so?

1. If yes, how do you think it differs? What is unique about clients who receive medical care from clinics that are funded for Ryan White medical services?

3. What, if any, barriers do you experience in obtaining the clinical information you need to monitor the outcomes of your Ryan White clients?

4. What changes would you make to better monitor how your Ryan White clients are doing clinically?

5. If you had clinical information for clients with OAHS/medical care that are not funded by RWHAP, how feasible would it be to report it to HRSA HAB? If not feasible, why not?

F. Opportunities for Improvement

Now that we know more about how your Ryan White clients access medical care and how you support them, let’s discuss your perceptions on opportunities for improving their access to medical care.

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met?

2. What, if anything, can non-funded OAHS providers who are providing care to eligible clients do to better engage and retain clients in medical care?

3. Do you have any suggestions for how HRSA HAB can better track health care utilization and outcomes for Ryan White clients getting medical care in a non-funded OAHS setting?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

II. RWHAP PROVIDER: SERVICE DELIVERY STAFF (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care from providers who are not funded for RWHAP medical services. We’re interested in learning about your client population and how they’re being connected to HIV care.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

• Can you please describe the general process flow for a client living with HIV from when they first arrive at the clinic to when they access services?

• What are the primary services you provide to a typical client, a high-needs client, and a low-needs client?

C. Access to Medical Care

Now that we have a good idea of what your organization is doing, we’d like to get a sense of if and how your clients are accessing medical care.

1. What share of your Ryan White clients would you estimate are receiving regular HIV medical care (that is, seeing a provider who can prescribe HIV medications)? (Probe: How often are they seeing that provider?)

2. Where are your Ryan White clients going for this care? Do you know whether these providers are also funded by Ryan White?

3. Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship)?

1. Do you send referrals to them and/or do they send referrals to you?

2. Do these relationships vary by provider? If yes: How do they vary?

4. What factors play into your decision about where to refer your clients? (Probe: Client choice, location, Ryan White versus non Ryan White)?

• What are the referral processes like and how do they differ by provider (Ryan White or non-Ryan White)? (Probes: standardized referral processes/forms, warm handoffs, communication mechanism)

5. Why are some of your clients receiving care from providers who are not funded for RWHAP medical services (for example, are there challenges with having enough Ryan White-funded providers, insurance network requirements)?

1. What are some of the benefits of getting care at a non-funded OAHS clinic?

2. How about drawbacks?

6. Do you think you serve any Ryan White clients who aren’t receiving medical care at all (e.g., in last 2 years)? If yes, what proportion would you estimate are not receiving any medical care?

1. Why do you think these clients aren’t going in for medical care?

D. Care Coordination and other Assistance

Next, let’s discuss what you do to help your clients stay in medical care.

1. Does your organization provide services that help your Ryan White clients get to their medical appointments (e.g., reminders, transportation)? Does your organization help your clients with maintaining adherence with their HIV medications? (Probe: Who specifically connects clients to these services?)

2. [ONLY FOR CARE MANAGER/NAVIGATOR]: What is your role in helping your Ryan White clients get access to, and remain engaged with, their medical care and treatment?

• What challenges do you face in referring Ryan White clients for medical services?

• What strategies have been successful for supporting Ryan White clients in accessing medical care?

E. Tracking Service Use and Outcomes

Now we’d like to get a sense of how you’re monitoring outcomes.

1. How do you track if Ryan White clients are receiving medical care?

• Do you follow up on whether Ryan White clients make it to their medical appointments? What do you do if a client misses a medical appointment? (Probe: Who is responsible for follow-up?)

2. Do you get information back on how Ryan White clients are doing clinically? How is this information shared with you (e.g., EHR, fax, phone, care coordination services)? Do you collect the same types of clinical data for all your Ryan White clients or does data vary based on the services the client is receiving?

• Do you know whether your Ryan White clients are prescribed ART? If so, what percent would you estimate are on ART?

• Do you know if they are virally suppressed? What percent of your Ryan White clients would you estimate are virally suppressed?

1. From your perspective, do you think that viral suppression rates differ for your clients who receive medical care from Ryan White clinics compared to those who receive medical care from clinics that are not funded for Ryan White medical services?

1. If yes, how do you think it differs? What is unique about clients who receive medical care from clinics that are funded for Ryan White medical services?

• Do you experience any barriers in tracking this clinical information?

• What changes would you make to better monitor how your Ryan White clients are doing clinically?

F. Opportunities for Improvement

Now that we know more about how your clients access medical care and how you support them, let’s discuss your perceptions on opportunities for improving their access to medical care.

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? What, if anything, can non-Ryan White providers who are providing care to eligible clients do to better engage and retain clients in medical care?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion? Thank you so much for taking the time to speak with me about your experiences.

III. NON-FUNDED OAHS PROVIDER: MEDICAL DIRECTOR (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. This program funds care and treatment for approximately 500,000 people living with HIV who are low-income and uninsured or underinsured. HRSA HAB has been tracking improvements in Ryan White client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for people who receive medical care from providers who are not funded by RWHAP medical services. What we’re interested in learning from you is how your organization delivers care to people living with HIV, some of which may receive other services, such as case management or mental health counseling, from a Ryan White-funded provider, and how you interact with Ryan White providers.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White-funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White-funded clients from others, ask them to respond based on their overall HIV client population.]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

• Can you provide a little background on your organization’s mission and activities?

1. Please describe how your clinic is organized (e.g., university-based clinic, private practice, Federally Qualified Health Center (FQHC), hospital system, other)?

1. Are you a Patient-Centered Medical Home?

2. Are you in a Medicaid managed care plan network?

2. What services does your organization deliver?

3. What proportion of your patients would you estimate are uninsured? What about on Medicaid?

4. Approximately how many patients do you serve overall? What proportion of your patients would you estimate have HIV?

2. Are you familiar with the Ryan White program? [If no, describe the program and proceed with questions: The program funds care and treatment for people living with HIV who are low income and uninsured or underserved] Do you serve any patients that you think may be receiving services from a Ryan White provider? What share of your patients living with HIV would you estimate are eligible for and receiving Ryan White services?

C. Medical Care

Now, I’d like to learn more about your medical care model for people living with HIV.

1. How do your new HIV clients come to you? Are they generally diagnosed here, or do you usually receive referrals from other organizations or as part of an insurance network (or both)?

1. [If referrals]: Who refers them (for example, Ryan White providers, non-Ryan White providers, or a mix; emergency department, community health center)?

2. Is the medical care for your HIV patients provided by primary care providers (e.g., primary care physicians, nurse practitioners, or physician assistants) or infectious disease specialists?

• What is your treatment protocol for someone who has been newly diagnosed? Do you typically start them on ART right away? If not, what do you take into consideration when deciding when to start a client on ART?

• How frequently do you try to bring your HIV patients in for a medical visit (e.g., every three months, six months, annually)?

1. How do you determine the frequency of visits?

2. How long do these visits last and what do they typically entail?

• What primary and preventive care services do you provide onsite to your patients living with HIV?

• Does your clinic use a care team approach? If so, who participates in the care team and how often do they meet?

• What kind of services does your clinic provide to keep patients adherent with their HIV medications?

• Does your clinic offer any non-medical services to assist patients with getting to and keeping appointments, such as outreach, appointment reminders, or transportation?

3. If an HIV patient needs support, would you arrange it? Do you make a referral through your EHR, contact a case manager?

• Do you refer your patients living with HIV to other providers for services you don’t offer onsite? [If yes] For what services?

3. Who helps patients access these support services and referrals? Probe: Do you have a case manager to connect patients to these supports?

D. Working with Ryan White Providers

Now I’d like to ask questions about your referral relationships with any Ryan White providers. [If unfamiliar with Ryan White, explain: These would be providers that serve your HIV patients who are low-income and uninsured or underinsured, such as [name of site that connected us to medical director].]

1. Do you receive and/or send referrals to Ryan White providers? For what services? Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship, new versus long-standing relationship)?

• Can you describe how the referral occurs?

• Do you have a good understanding of what support services your HIV patients get from Ryan White providers? If so, how do you receive this information (e.g., referral specialist, case manager, formal referral process)?

• Do you share any patient data with Ryan White providers?

1. What data do you share (e.g., appointment attendance, medications, lab values, other)? How are those data shared? (e.g., EHR, fax, phone, care coordination services, other)?

• What are the barriers to coordinating with Ryan White providers about HIV care? How would you improve the relationship/process?

E. Outcomes

One of the most important goals of this project is understanding how Ryan White clients are doing clinically when they access medical care and treatment from providers who are not funded by RWHAP medical services. [Interviewer note: If also conducting a chart abstraction at provider site, indicate that their responses to the following questions will supplement the chart abstraction information.]

1. How does your clinic determine whether your HIV patients are receiving medical care for their HIV disease?

1. What would signal you to follow up with a patient you think might have fallen out of care?

2. What percent of your patients would you estimate are receiving HIV care?

3. Now, thinking specifically of patients eligible for Ryan White (that is, low income, uninsured or underinsured), what percent would you estimate are receiving HIV care?

• Are retention rates different for your patients who receive Ryan White services (for example, those going to [name of site]) compared to those who do not?

1. What factors help Ryan White patients remain engaged in care?

2. What challenges are there in serving Ryan White patients?

• What percent of your HIV patients would you estimate are virally suppressed?

3. Do you think there are differences in viral suppression rates between Ryan White patients and non-Ryan White patients? If yes, how and do you think the rates differ?

4. What factors contribute to the difference?

5. Do you think there are differences in rates across sub-populations (e.g., privately insured, publicly insured, or uninsured; age; race; HIV risk factor)? If yes, how do you think the rates differ?

F. Opportunities for Improvement

Now that we have a sense of the medical services you provide and your relationship with Ryan White providers, let’s get your perspective on opportunities for improving access to medical care for people living with HIV.

1. Why do you think that some clients are eligible for Ryan White medical care, but go to providers who are not funded for RWHAP medical services?

1. What are some of the benefits your patients get from receiving HIV medical care at a non-funded OAHS clinic?

2. How about drawbacks?

• What if anything could HRSA HAB and/or Ryan White providers do to help you deliver care to your patients living with HIV more effectively?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

ii. Scenario B Interview Protocol

Scenario A	Scenario B	Scenario C
RWHAP Provider (Non-Medical)	RWHAP Provider (Medical) Not funded for OAHS	RWHAP Provider (Medical) Funded for OAHS Some clients without OAHS
Non-funded OAHS Provider (Medical)		Non-funded OAHS Provider (Medical)

In Scenario B, a RWHAP provider delivers medical care but is not funded for outpatient ambulatory health services (OAHS). We assume that clients are primarily receiving medical care onsite and health utilization and outcomes data are available even though they are not reported to HRSA HAB.

Interviews will be conducted with program management, case management and medical staff at the RWHAP provider. However, if the RWHAP provider refers out a significant portion of their clients for medical care, then we will use the Scenario C protocols.

I. RWHAP Provider: RWHAP Program Leadership (1 hour)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care at organizations that aren’t funded by RWHAP for outpatient ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population, and how they’re doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

2. Can you provide a little background on your organization’s mission and activities?

1. What medical and support services does your organization deliver to your clients living with HIV? Which of these services are funded by Ryan White?

2. How many clients do you serve overall? What share of your clients would you estimate are eligible for Ryan White?

3. Has your organization ever considered using its Ryan White funding to pay for OAHS? Why or why not?

1. What are your sources of funding for OAHS?

C. Medical Care

Now, I’d like to learn more about how your clients living with HIV are accessing medical care.

1. How do your new HIV clients come to you? Are they generally diagnosed here, or do you usually receive referrals from other organizations or as part of an insurance network (or both)?

1. [If referrals]: Who refers them (for example, Ryan White providers, non-Ryan White providers, or a mix; emergency department, community health center)?

2. If not here, where are your clients going for their medical care? What proportion of your clients would you estimate are going elsewhere for medical care?

1. Do you know whether these medical providers are also funded by Ryan White?

3. Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship)?

1. Do you send referrals to them and/or do they send referrals to you?

2. Do these relationships vary by provider? If yes: How do they vary?

4. Do you think you serve any clients who aren’t receiving medical care at all (e.g., in last 2 years)? If yes, what proportion would you estimate are not receiving any medical care?

5. Why do you think some of your clients aren’t coming in for medical care?

D. Care Coordination and Other Assistance

Next, let’s discuss how your organization is supporting your clients in staying in medical care.

1. Does your organization provide any financial support for medical care? (Probe: These financial supports may directly cover the cost of care, such as copay support, or help clients stay engaged in care, such as by helping them pay for a drivers’ license.)

• Some Ryan White providers help clients access care through supporting insurance coverage. Do you offer Health Insurance Premium (HIP) support? Does your organization provide AIDS Drugs Assistance Program (ADAP) enrollment services?

1. If so, what share of your clients receive insurance assistance?

• Does your organization provide any other services that help your clients get to their medical appointments? Does your organization help clients with maintaining adherence with their HIV medications? (Probe: Who specifically connects clients to these services?)

• What are the biggest challenges your clients face in staying engaged in care?

2. How do you think these barriers differ for your Ryan White eligible population versus those that are not eligible?

3. How do you think these barriers differ by other sub-population (e.g., privately insured, publicly insured, or uninsured; age; race)?

• What strategies have been successful in supporting your Ryan White clients in accessing and staying engaged in medical care?

E. Tracking Service Use and Outcomes

Now we would like to get a sense of how you’re monitoring outcomes for Ryan White clients.

1. How do you track whether Ryan White clients are receiving HIV care?

1. What percent of your clients would you estimate are receiving HIV care?

2. What percent of your Ryan White clients would you estimate are prescribed ART?

• What percent of your Ryan White clients would you estimate are virally suppressed?

1. Do you think viral suppression rates differ by sub-population (e.g., privately insured, publicly insured, or uninsured; age; race)? If yes, how do they differ?

2. From your perspective, do you think that viral suppression rates differ for clients who are eligible for Ryan White compared to those who are not? If yes, how do they differ? What is unique about clients who are eligible for Ryan White?

3. What are the biggest challenges to improving viral suppression rates?

4. What, if any, barriers do you experience in tracking this information?

• What changes would you make to better monitor how clients are doing clinically?

• If you had clinical information for clients with OAHS/medical care that are not funded by RWHAP, how feasible would it be to report it to HRSA HAB? If not feasible, why not?

F. Opportunities for Improvement

Now that we know more about how your clients access medical care and how you support them in accessing care, let’s discuss your perceptions on opportunities for improving access to medical care.

1. What are some of the challenges of providing medical care to clients without receiving Ryan White funding for OAHS?

1. Do you think these challenges affect viral suppression and retention in care? If yes, how?

2. Do you have any clients who aren’t receiving medical care at all (e.g., in last 2 years)? Why do you think some of your clients aren’t coming in for medical care?

3. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? Do you have any suggestions for how HRSA HAB can better track health care utilization and outcomes for clients who aren’t funded by Ryan White for their medical care?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion? Thank you so much for taking the time to speak with me about your experiences.

II. RWHAP PROVIDER: CASE MANAGER (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care at agencies that aren’t funded by RWHAP for outpatient ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population, and how they’re doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

First, I’d like to get a sense of your role within your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

C. Care Coordination and Other Assistance

Let’s discuss how your organization is supporting your clients in staying in medical care.

1. What role do you play in connecting Ryan White clients to insurance assistance?

• Do you provide services that help clients get to their medical appointments (e.g., reminders, transportation)? If yes: Please describe.

• Do you follow up on whether clients make it to their medical appointments? What do you do if a client misses a medical appointment?

• Do you re-engage clients who have been lost to care? If so, how?

• Do you help clients take their HIV medications as prescribed? If so, how?

• What are the biggest challenges your clients face in staying engaged in care?

1. How do you think these barriers differ for your Ryan White eligible population versus those who are not eligible?

2. How do these barriers differ by other sub-populations (e.g., privately insured, publicly insured, or uninsured; age; race)?

• What strategies have been successful for supporting your Ryan White clients in accessing and staying engaged in medical care?

D. Tracking Service Use

Now we’d like to get a sense of how you’re monitoring outcomes for your Ryan White clients.

1. How do you track whether Ryan White clients are receiving continuous HIV care?

• Do you and/or members of the care team providing support services have access to Ryan White clients’ clinical data like viral load and CD4 tests? How is information shared? How is it used?

• Does the medical team have access to your case notes? How is information shared? How is it used?

• What barriers, if any, do you experience in tracking this information?

• What changes would you make to better monitor how clients are doing clinically?

E. Opportunities for Improvement

Now that we know more about how your clients access medical care and how you support them, let’s discuss your perceptions on opportunities for improving access to medical care.

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

III. RWHAP PROVIDER: MEDICAL PROVIDER (30 MIN)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral load and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care at agencies that aren’t funded by Ryan White for outpatient-ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population and how they’re doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Medical Care and Service Utilization

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White-funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White-funded clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

Today, we’d like to get a sense of your care delivery model and what services are available to people living with HIV. We’ll end with a couple broader questions about health outcomes and how Ryan White can best support you in serving people living with HIV.

1. Who provides medical care to people living with HIV – primary care providers (e.g., primary care physicians, nurse practitioners, or physician assistants) or infectious disease doctors?

2. What is your treatment protocol for someone who has been newly diagnosed? Do you typically start them on ART right away? If not, what do you take into consideration when deciding when to start a client on ART?

• How often do you try to bring people living with HIV in for a visit (e.g., every three months, six months, annually)?

1. How do you determine the frequency of visits?

2. How long do these visits last and what do they typically entail?

• What primary and preventive care services do you provide onsite to people living with HIV?

• Does your clinic use a care team approach? If so, who participates in the care team and how often do they meet?

• What kind of services does your organization provide to help clients take their HIV medications as prescribed?

• Does your clinic offer any non-medical services to assist clients with getting to and keeping appointments, such as outreach, appointment reminders, or transportation?

3. If a Ryan White eligible client needs support, how would you arrange it?

• Do you refer your clients living with HIV to other providers for services you don’t offer onsite? [If yes] For what services?

4. Who helps patients access these support services and referrals? Probe: Do you have a case manager to connect patients to these supports?

3. What would you estimate is the viral suppression rate among your Ryan white eligible client population?

4. How do you think viral suppression rates differ by sub-population (e.g., privately insured, publicly insured, or uninsured; age; race)?

5. What are the biggest challenges to improving viral suppression rates? How do you think these challenges differ for Ryan White eligible clients compared to those who aren’t eligible?

C. Opportunities for Improvement

If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

iii. Scenario C Interview Protocol

Scenario A	Scenario B	Scenario C
RWHAP Provider (Non-Medical)	RWHAP Provider (Medical) Not funded for OAHS	RWHAP Provider (Medical) Funded for OAHS Some clients without OAHS
Non-funded OAHS Provider (Medical)		Non-funded OAHS Provider (Medical)

In Scenario C, a RWHAP provider is funded for outpatient ambulatory health services (OAHS), but reports that only some clients are receiving OAHS onsite. We assume that clients are receiving medical care at another non-funded OAHS provider (e.g. at a private doctor’s office) and support services through the RWHAP provider, or that clients are not engaged in medical care during the reporting period.

Interviews will be conducted with program management, case management and medical staff at the RWHAP provider.

If the provider has established connections with non-funded OAHS provider(s) to whom they refer, we will interview the medical director and/or other staff who are familiar with care delivery to RWHAP eligible clients, and how referrals are coordinated from the RWHAP.

I. RWHAP PROVIDER: RWHAP PROGRAM LEADERSHIP (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who do not have clinical data reported in the Ryan White Services Report (RSR). Your organization reports some clients with outpatient ambulatory health services and some clients without. We assume the clients without clinical data are receiving their medical care at organizations that aren’t funded by Ryan White for outpatient ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population, referral partnerships you have with non-funded OAHS providers, and how clients are doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

• Can you provide a little background on your organization’s mission and activities?

1. What medical and support services does your organization deliver to your clients living with HIV? Which of these services are funded by Ryan White?

C. Medical Care and Service Utilization

Now, I’d like to learn more about your medical care model for Ryan White clients.

1. How do your new HIV clients come to you? Are they generally diagnosed here, or do you usually receive referrals from other organizations or as part of an insurance network (or both)?

1. [If referrals]: Who refers them (for example, Ryan White providers, non-Ryan White providers, or a mix; emergency department, community health center)?

• Some of your Ryan White clients don’t receive their medical care at this clinic. Do you think they are not receiving medical care at all (e.g., in last 2 years) or are receiving care from another medical provider?

2. What proportion of your clients would you estimate are not receiving medical care at all?

3. What proportion of your clients would you estimate are receiving medical care elsewhere?

1. Do you know whether these medical providers are also funded by Ryan White?

• For those clients who are out of care, why do you think they aren’t going in for medical care? How do you think barriers to care differ for Ryan White clients compared to non-Ryan White clients?

• For those clients who are receiving care at a non-funded OAHS clinic, why do you think they receive care there? (For example, are there challenges with having enough Ryan White-funded providers, with insurance networks)?

4. What are some of the benefits of getting care outside of your clinic or from providers who are not funded by RWHAP medical services?

5. How about drawbacks?

• What aspects of your organization’s medical care model do you think are beneficial to keeping your Ryan White clients in medical care and treatment, but may not be as common in non-funded OAHS clinical settings in your area? For example, team-based care, multidisciplinary care teams, patient-provider continuity.

D. Care Coordination and Other Assistance

Next, let’s discuss how your organization is supporting your clients in retention in medical care and how processes differ for Ryan White clients getting their medical care here versus elsewhere.

1. Some Ryan White providers help clients access care through supporting insurance coverage. Do you offer Health Insurance Premium (HIP) support? Does your organization provide AIDS Drugs Assistance Program (ADAP) enrollment services?

1. If so, what share of your Ryan White clients would you estimate receive insurance assistance?

• Does your organization provide any services that help clients get to their medical appointments or take their HIV medications as prescribed?

2. If yes: Who specifically connects clients to these services?

3. Do these services differ by Ryan White clients who receive their medical care here versus those who receive their medical care elsewhere? If yes, please explain.

What are the biggest challenges your clients face in staying engaged in care?

4. How do you think the challenges differ for your Ryan White eligible population that receives care here versus those that go somewhere else? How do you think these barriers differ by other sub-populations (e.g., privately insured, publicly insured, or uninsured; age; race)?

• What strategies have been successful for supporting your Ryan White clients in accessing medical care?

• What are the challenges you face in supporting Ryan White clients who receive their care elsewhere?

E. Tracking Service Use and Outcomes

Now we’d like to get a sense of how you’re monitoring outcomes for Ryan White clients who don’t receive their care here.

1. If a Ryan White client goes to a different provider for medical care, do you know where they go? How do you know?

1. Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship)? Do these relationships vary by provider? If yes: How do they vary?

2. Do you think that outcomes like retention in care, ART prescription, and viral suppression are different for your Ryan White eligible population that receives medical care here versus those that go somewhere else (that is, a clinic that is not funded by RWHAP medical services)? If so, how and why are they different?

3. Do you track clinical information for Ryan White clients receiving medical care elsewhere?

1. If you had clinical information for clients with OAHS/medical care that are not funded by RWHAP, how feasible would it be to report it to HRSA HAB? If not feasible, why not?

What changes would you make to better monitor how clients are doing clinically?

F. Opportunities for Improvement

Let’s wrap up by discussing your perceptions on opportunities for improving access to medical care.

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? What, if anything, can non-funded OAHS providers who are providing care to eligible clients do to better engage and retain clients in medical care?

2. Do you have any suggestions for how HRSA HAB can better track health care utilization and outcomes for clients who aren’t funded by Ryan White for their medical care?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

II. RWHAP PROVIDER: CASE MANAGER (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who receive medical care at organizations that aren’t funded by RWHAP for outpatient-ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population and how they’re doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

• First, I’d like to get a sense of your role within your organization.

• How long have you been at your current position, and what are your roles and responsibilities?

B. Care Coordination and Other Assistance

Next, let’s discuss how you support your clients in retention in medical care and how processes differ for Ryan White clients getting their medical care here versus elsewhere.

1. What role do you play a role in connecting Ryan White clients to insurance assistance?

2. Do you provide services that help clients get to their medical appointments (e.g., reminders, transportation)? If yes: Please describe.

3. Do you follow up on whether clients make it to their medical appointments? What do you do if your client misses a medical appointment?

• Do you re-engage clients who have been lost to care? If so, how?

• Do you help clients take their HIV medications as prescribed? If so, how?

• Do the services you provide to support retention in care and medication adherence differ for Ryan White clients who receive their medical care here compared to those who receive their medical care elsewhere? If yes: How so?

• What are the biggest challenges your clients face in staying engaged in care?

1. How do barriers differ for your Ryan White eligible clients who receive care here versus those who go somewhere else (that is, a clinic that does not receive funding for RWHAP medical services)?

2. How do these barriers differ by other sub-populations (e.g., privately insured, publicly insured, or uninsured; age; race)?

• What strategies have been successful for supporting your Ryan White clients in accessing and staying engaged in medical care?

• What are the challenges you face in supporting Ryan White clients who receive their medical care elsewhere (that is, a clinic that does not receive funding for RWHAP medical services)?

• Do you have any clients who aren’t receiving medical care at all (e.g., in last 2 years)?

3. Why do you think these clients aren’t going in for medical care?

1. How do you think barriers to care differ for Ryan White clients served here versus those who go somewhere else (that is, a clinic that does not receive funding for RWHAP medical services)?

C. Tracking Service Use and Outcomes

Now we’d like to get a sense of how you’re monitoring outcomes for Ryan White clients that don’t receive their care here.

1. If a Ryan White client goes to a different provider for medical care, do you know where they go? How do you know?

1. Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship)? Do these relationships vary by provider? If yes: How do they vary?

• Do you get information back from these providers on how your Ryan White clients are doing clinically? For example, do you know whether your clients are virally suppressed?

• Do you think that outcomes like retention in care, ART prescription, and viral suppression are different for your RWHAP clients who receive care here versus those who go somewhere else (that is, a clinic that does not receive funding for RWHAP medical services)? If yes, how and why are they different?

• What barriers do you experience with tracking clinical information for your Ryan White clients who receive care outside of your clinic?

• What changes would you make to better monitor how clients are doing clinically?

D. Opportunities for Improvement

Let’s wrap up by discussing your perceptions on opportunities for improving access to medical care.

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? What, if anything, can non-funded OAHS providers who are providing care to eligible clients do to better engage and retain clients in medical care?

• Do you have any suggestions for how HRSA HAB can better track health care utilization and outcomes for clients who aren’t funded by Ryan White for their medical care?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

III. RWHAP PROVIDER: MEDICAL PROVIDER (30 MIN)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. HRSA HAB has been tracking improvements in client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for clients who do not have clinical data reported in the Ryan White Services Report (RSR). Your organization reports some clients with outpatient ambulatory health services and some clients without. We assume the clients without clinical data are receiving their medical care at organizations that aren’t funded by Ryan White for outpatient ambulatory health services. What we’re interested in learning from you is how you are delivering medical care and support services to your client population, referral partnerships you have with non-funded OAHS providers, and how clients are doing in terms of health outcomes.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Medical Care and Service Utilization

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population. If the respondent is unfamiliar with the term OAHS, use “medical care.”]

Today, we’d like to get a sense of your care delivery model and what services are available to people living with HIV. We’ll end with a couple broader questions about health outcomes and how Ryan White can best support you in serving people living with HIV.

1. Who in your clinic provides medical care to your clients living with HIV – primary care providers (e.g., primary care physicians, nurse practitioners, or physician assistants) or infectious disease doctors?

2. What is your treatment protocol for someone who has been newly diagnosed? Do you always start them on ART right away? If not, what do you take into consideration when deciding when to start a client on ART?

• How often do you try to bring your clients living with HIV in for a visit (e.g., every three months, six months, annually)?

1. How do you determine the frequency of visits?

2. How long do these visits last and what do they typically entail?

• What primary and preventive care services do you provide onsite to your clients living with HIV?

• Does your clinic use a care team approach? If so, who participates in the care team and how often do they meet?

• What kind of services does your organization provide to help clients take their HIV medications as prescribed?

• Does your clinic offer any non-medical services to assist clients with getting to and keeping appointments, such as outreach, appointment reminders, or transportation?

3. If a Ryan White eligible client needs support, how would you arrange it?

• Do you refer your clients living with HIV to other providers for services you don’t offer onsite? [If yes] For what services?

4. Who helps patients access these support services and referrals? Probe: Do you have a case manager to connect patients to these supports?

5. What are the referral processes like and how do they differ by provider (Ryan White or non-Ryan White)? (Probes: standardized referral processes/forms, warm handoffs, communication mechanism)

1. How successful are different referral processes at connecting clients to services?

• What aspects of your organization’s medical care model do you think are beneficial to keeping your Ryan White clients in medical care and treatment, but may not be as common in non-funded OAHS clinical settings in your area? For example, team-based care, multidisciplinary care teams, patient-provider continuity.

• Why are some clients at this location receiving care outside of your clinic?

6. What are some of the benefits of getting care at a clinic that is not funded by RWHAP medical services?

7. How about drawbacks?

• Do you think that outcomes like retention in care, ART prescription, and viral suppression are different for your Ryan White eligible population that receives medical care here versus those that go to a non-funded OAHS clinic? If so, how and why are they different?

C. Opportunities for Improvement

1. If you had more Ryan White funding, what else would you do to make sure clients are getting their medical care and treatment needs met? What, if anything, can non-funded OAHS providers who are providing care to eligible clients do to better engage and retain clients in medical care?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.

IV. NON-FUNDED OAHS PROVIDER (MEDICAL): MEDICAL DIRECTOR (1 HOUR)

A. Introduction

Thank you for agreeing to speak with me today. My name is [name] and I am with [company]. Our team is working with the HIV/AIDS Bureau (HAB) in the Health Resources and Services Administration, which administers the Ryan White HIV/AIDS Program. This program funds care and treatment for approximately 500,000 people living with HIV who are low-income and uninsured or underinsured. HRSA HAB has been tracking improvements in Ryan White client outcomes, especially viral suppression and retention in care, for years. However, we don’t know what these outcomes look like for people who receive medical care from providers who are not funded by RWHAP medical services. What we’re interested in learning from you is how your organization delivers care to people living with HIV, some of which may receive other services, such as case management or mental health counseling, from a Ryan White-funded provider, and how you interact with Ryan White providers.

I want to make sure you know that your responses will be confidential, and we won’t be attributing any comments directly to you or your clinic. What you say is important to the study, so in addition to taking notes, I’m going to record the interview unless you object. That will help me accurately record what you tell me. [Interviewer: Get verbal consent, turn recorder on]. Also, if there are any questions you feel you cannot or do not want to answer, just let me know and we can skip them. Do you have any questions for me before we begin?

B. Background

[Interviewer note: If a question asks specifically about Ryan White clients, we are interested in Ryan-White funded clients, not Ryan White-eligible clients. However, if the respondent cannot distinguish their Ryan White clients from others, ask them to respond based on their overall HIV client population.]

First, I’d like to understand your role and responsibilities here, and then learn a little more about your organization.

1. How long have you been at your current position, and what are your roles and responsibilities?

• Can you provide a little background on your organization’s mission and activities?

1. Please describe how your clinic is organized (e.g., university-based clinic, private practice, Federally Qualified Health Center (FQHC), hospital system, other)?

1. Are you a Patient-Centered Medical Home?

2. Are you in a Medicaid managed care plan network?

2. What services does your organization deliver?

3. What proportion of your patients would you estimate are uninsured? What about on Medicaid?

4. Approximately how many patients do you serve overall? What proportion of your patients would you estimate have HIV?

• Are you familiar with the Ryan White program? [If no, describe the program and proceed with questions: The program funds care and treatment for people living with HIV who are low income and uninsured or underserved] Do you serve any patients that you think may be receiving services from a Ryan White provider? What share of your patients living with HIV would you estimate are eligible for and receiving Ryan White services?

C. Medical Care

Now, I’d like to learn more about your medical care model for people living with HIV.

1. How do your new HIV clients come to you? Are they generally diagnosed here, or do you usually receive referrals from other organizations or as part of an insurance network (or both)?

1. [If referrals]: Who refers them (for example, Ryan White providers, non-Ryan White providers, or a mix; emergency department, community health center)?

2. Is the medical care for your HIV patients provided by primary care providers (e.g., primary care physicians, nurse practitioners, or physician assistants) or infectious disease specialists?

• What is your treatment protocol for someone who has been newly diagnosed? Do you typically start them on ART right away? If not, what do you take into consideration when deciding when to start a client on ART?

• How frequently do you try to bring your HIV patients in for a medical visit (e.g., every three months, six months, annually)?

1. How do you determine the frequency of visits?

2. How long do these visits last and what do they typically entail?

• What primary and preventive care services do you provide onsite to your patients living with HIV?

• Does your clinic use a care team approach? If so, who participates in the care team and how often do they meet?

• What kind of services does your clinic provide to keep patients adherent with their HIV medications?

• Does your clinic offer any non-medical services to assist patients with getting to and keeping appointments, such as outreach, appointment reminders, or transportation?

3. If an HIV patient needs support, would you arrange it? Do you make a referral through your EHR, contact a case manager?

• Do you refer your patients living with HIV to other providers for services you don’t offer onsite? [If yes] For what services?

3. Who helps patients access these support services and referrals? Probe: Do you have a case manager to connect patients to these supports?

D. Working with Ryan White Providers

Now I’d like to ask questions about your referral relationships with any Ryan White providers. [If unfamiliar with Ryan White, explain: These would be providers that serve your HIV patients who are low-income and uninsured, such as [name of site that connected us to medical director].]

1. Do you receive and/or send referrals to Ryan White providers? For what services? Please describe the relationships you have with these providers (e.g., within the same healthcare system, formal versus informal referral partnership, no referral relationship, new versus long-standing relationship)?

• Can you describe how the referral occurs?

• Do you have a good understanding of what support services your HIV patients get from Ryan White providers?

1. If yes, how do you receive this information (e.g., referral specialist, case manager, formal referral process)?

2. If no, what is needed in order for you to get a holistic view of care and support for each client?

• Do you share any patient data with Ryan White providers?

3. What data do you share (e.g., appointment attendance, medications, lab values, other)? How are those data shared? (e.g., EHR, fax, phone, care coordination services, other)?

• What are the barriers to coordinating with Ryan White providers about HIV care? How would you improve the relationship/process?

E. Outcomes

One of the most important goals of this project is understanding how Ryan White clients are doing clinically when they access medical care and treatment from providers who are not funded by RWHAP medical services. [Interviewer note: If also conducting a chart abstraction at provider site, indicate that their responses to the following questions will supplement the chart abstraction information.]

1. How does your clinic determine whether your HIV patients are receiving medical care for their HIV disease?

1. What would signal you to follow up with a patient you think might have fallen out of care?

2. What percent of your patients would you estimate are receiving HIV care?

3. Now, thinking specifically of patients eligible for Ryan White (that is, low income, uninsured or underinsured), what percent would you estimate are receiving continuous HIV care?

• Are retention rates different for your patients who receive Ryan White services (for example, those going to [name of site]) compared to those who do not?

4. What factors help Ryan White patients remain engaged in care?

5. What challenges are there in serving Ryan White patients?

• What percent of your HIV patients would you estimate are virally suppressed?

6. Do you think there are differences in viral-suppression rates between Ryan White patients and non-Ryan White patients? If yes, how do you think the rates differ?

7. What factors contribute to the difference?

8. Do you think there are differences in rates across sub-populations (e.g., privately insured, publicly insured, or uninsured; age; race; HIV risk factor)? If yes, how do you think the rates differ?

F. Opportunities for Improvement

Now that we have a sense of the medical services you provide and your relationship with Ryan White providers, let’s get your perspective on opportunities for improving access to medical care for people living with HIV.

1. Why do you think that some clients are eligible for Ryan White medical care, but go to providers who are not funded by RWHAP medical services?

1. What are some of the benefits your patients get from receiving HIV medical care at a non-funded OAHS clinic?

2. How about drawbacks?

• What if anything could HRSA HAB and/or Ryan White providers do to help you deliver care to your patients living with HIV more effectively?

Those are all the questions I have, but is there anything else you would like to add before we end our discussion?

Thank you so much for taking the time to speak with me about your experiences.