March 30, 2011
Thirty years ago, when AIDS was first discovered, the medical model of care was the primary way we provided services to the sick and dying. The HIV/AIDS community asked the question, "Is this the best way to take care of People with AIDS (PWAs)?" especially since many hospitals and doctors refused to take in our friends.
As a result, the Robert Wood Johnson Foundation* funded pilot projects to look for alternatives. Using the "San Francisco Model" as a case study, the HIV/AIDS community transformed the medical model of care into the Continuum of Care Model that is still utilized for treating HIV.
The difference between these two models is profound and deserves a re-examination as we implement healthcare reform. In general, the medical model of care is doctor-focused. Health information and services are coordinated and informed by doctors and hospitals. The Continuum of Care Model is client-focused. It is a partnership between consumers, doctors, and community based organizations. It looks at the whole person, not just their healthcare. The Continuum of Care Model understands that housing, food, transportation and other services are essential to staying healthy.
Last week the Health Resources and Services Administration (HRSA) put out a request for proposals (RFP), including support for technical assistance for HIV/AIDS Medical Homes. This model of care was new to me, but HRSA explained it as follows:
In 2007,the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association, in considering the idea that every individual should have a personal medical home, developed joint principles to describe the core elements of a medical home. These include:
See the Joint Principles of Patient-Centered Medical Homes here.
Medical homes have been defined by the American Academy of Pediatrics as primary care that is "accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective."
Ryan White funded medical care providers have a history of providing multidisciplinary, comprehensive, consumer focused and culturally competent HIV primary care. These providers are therefore readily identifiable and characterized as the future medical homes for Ryan White consumers. These characteristics of Ryan White programs are marked by the provision of sound clinical care and adaptation of different models of care by gender and ethnic or racial background of target populations.
The Ryan White HIV/AIDS Program complements the Affordable Care Act which supports the adoption of medical home programs. As the National Committee on Quality Assurance is developing standards and accreditation criteria for medical homes and Accountable Care Organizations, Ryan White providers must be primed to respond to these emerging treatment and care continuum efforts.
I am concerned that HIV/AIDS Medical Homes may just be a rebranding of the medical model of care, a system that did not work for the HIV/AIDS community. It's the range of services provided under the Ryan White Care Act and HOPWA (Housing Opportunities for People with AIDS) that are central to a person's wellbeing.
The descriptions of Medical Homes from these medical associations talks about a "personal physician to provide continuous comprehensive care." This assumes you have a personal physician. If you don't have a personal physician, it assumes that you can go to your local community clinic. HIV medicine is a specialty care, many community clinics do not have the skills, desire or ability to take care of people with AIDS.
For all the problems and challenges with our current systems of HIV/AIDS care, we've learned that in order to keep consumers healthy, we need to provide more than medical care. In some ways, HIV/AIDS Medical Homes make the best case for the reauthorization of the Ryan White Care Act.
As healthcare reform is implemented -- and I am very hopeful it will be implemented -- we still need the Continuum of Care Model to ensure PWAs remain healthy. Our consumers who are managed via HIV/AIDS Medical Homes are going to need additional services. We can use a reauthorized Ryan White Care Act and HOPWA to support case management, housing, transportation, and other community needs that are beyond the scope of this reform.
Nobody ever said the Affordable Care Act was a panacea for HIV/AIDS. It will expand medical services and provide access to HIV/AIDS medications, but we will still need the Ryan White Care Act and Housing Opportunities for People with AIDS to keep PWAs alive.
* The Robert Wood Johnson Foundation was one of the first major foundation to support HIV/AIDS care. Giving millions of dollars at a time when most foundations did not even say the word AIDS, their support of this new model of care paved the way for how services are provided today. The HIV/AIDS community owes them a huge debt.
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