Online appendix 1: Patient navigation brochure
Iowa City VA Health Care System
Telehealth Team Care
To schedule appointments, call;
Toll Free: 1-800-XXX-XXXX
Local:
XXX-XXX-XXXX
Basic Information
To ensure patients receive the best care possible, the Iowa City VA Health Care System
has created telehealth care teams. This may include members of both the infectious
diseases specialty clinic team in Iowa City and the primary care team at your local clinic.
Both teams are available to assist you with your care needs. Working with two teams
may cause confusion. This sheet is designed to clarify what each team does and who
they are.
Infectious Diseases Specialty Clinic Team
The infectious diseases specialty clinic team is available to answer questions and help
you to manage HIV-related care. We look forward to working with you.
Infectious Diseases Specialty Clinic Team Members
Position
Team
Phone #
Function
Member
Infectious
Name
Phone #
Will arrange visits, lab tests or other
Diseases
tests you may need and guides you
Specialty Clinic
through the VA system
Care Manager
Scheduler
Name
Phone #
Helps arrange appointments in both
infectious diseases specialty clinic and
primary care clinics, as well as
appointments for labs
Pharmacist
Name
Phone #
Will assist with medication issues such
as: side effects, drug interactions, refills
for HIV medicines, ways to better take
your medicines
Physician
Name
Phone #
Works with you to make your HIV care
plan
The Infectious Diseases Specialty Clinic Team:
Online appendix 1: Patient navigation brochure



Monitors and treats your HIV infection by looking at how you are feeling and
your lab tests, such as CD4 counts and viral load.
Prescribes and manages your HIV-related medications. The infectious diseases
specialty clinic team will discuss the side effects the medications may cause and
ways to reduce them.
Assists with prevention of HIV-related infections.
If you have concerns related to these issues, call (HIV clinic nurse care manager name
here). If you are unsure of which team to contact, let (Name here) know and she will
make an appointment with the infectious diseases specialty clinic team or direct you to
primary care as needed.
Primary Care Team
Primary Care Team Members
Name
Contact Number
Community Based Outpatient
Clinic
Nurse Care Manager
Care Provider
Primary care is available to care for all of your general health care needs. The primary
care team will:
 Manage and monitor illnesses such as high blood pressure, diabetes, cholesterol,
heart disease and depression
 Manage pain
 Treat breathing problems such as asthma, emphysema, chronic bronchitis
 Provide preventive care services
o screening for smoking and alcohol use
o cancer screening
o vaccines (flu and pneumonia shots)
If you have concerns related to these issues, call (primary care nurse care manager name
here).
What if I’m not sure who to contact?
If you are not sure whether it is best to contact the Infectious Diseases or primary care
clinics, or if you’re just not feeling well and need someone to talk to, please call the
infectious diseases specialty clinic care manager, (name here).
Online appendix 2: Telehealth Collaborative Care (TCC) Process Map
HIV Clinic
Prior to TCC visit
HIV Provider
Pharmacist
Nurse Care
Manager
Primary Care Clinic
Clerical
Associate
Laboratory
Clerical
Associate
Nurse
Associate
Nurse Care
Manager
Registry reviewed
TCC tasks note*
created in chart
Laboratory
monitoring orders
placed
Patient visits
laboratory 1
week prior to
TCC visit
During TCC visit
Patient checks in,
vitals and
screenings
performed†
Patient visit with
primary care
provider (PCP)
Telehealth visit with HIV care team
TCC huddle
Follow-up plan formulated‡
After TCC visit
Primary Care
Provider
(Video telehealth link)
Next TCC visit
scheduled
(Telephone)
TCC huddle
Follow-up plan
formulated and
relayed to PCP‡
Next TCC visit
scheduled
Repeat
*Structured note detailing patient-specific care tasks and assigning responsibility to specific HIV or primary care team members, see text for description
† Screenings for tobacco use, alcohol use, and depression
‡Follow up plan is detailed in both the HIV provider and primary care provider visit notes, focusing on issues assigned to their team for follow up, notes are shared across sites
Online appendix 3: Semi-structured patient interview guide
Collaborative Care for Veterans with HIV Evaluation
Semi-structured Interview Guide: PATIENT
Semi-structured interviews are open-ended to allow participants to freely express their answers to the
questions. Additional questions may be asked by the interviewers to follow-up or to clarify participants’
responses.
Hi, my name is _____, and I’m part of the research team evaluating recent changes in how the
infectious disease/virology clinic at the Iowa City VA Health Care System (IC VA) provides health care to
veterans with HIV. You recently spoke with (consenter) about participating in this evaluation. I’d like
to talk with you today about the care you receive at your Community Based Outpatient Clinic, or CBOC
[alternate: local VA primary care clinic], including your telehealth HIV appointments. This phone
interview will take about 30 minutes. It’s completely voluntary, so if there is a question you prefer not
to answer, just say “skip question.” You also can stop at any time. I’ll be recording the interview to
ensure we accurately record what you say and so we can review your responses. The recording is encrypted
and secured to protect the confidentiality of this interview. A random number will also be assigned to
your study records so your interview cannot be linked back to you. And when we present results, we
do so in a way that protects your identity. Additional details about the interview can be found in the
informed consent document you discussed with (consenter) and signed. Before we begin, do you have
any questions?
[Start Audio]
This is __________________, and I'm here with participant number _________;
Today is ______ / ______ / _____.
Are you aware that you're being tape-recorded?
_____Yes
_____No
Access and Convenience, Care Coordination and Role Clarity
[Description of change: In the past year or so there’s been a change in how your care is
delivered at the VA. You have been assigned a PCP at a CBOC [VA primary care clinic] closer
to your home. Your primary care team monitors common co-existing health conditions for
persons living with HIV, like high cholesterol, high blood pressure, and diabetes. They also
provide preventative care, like vaccinations and screening for changes in behavior or mood
that may affect your overall health. Instead of driving to the IC VA for your virology clinic
appointments, you now meet with the HIV team ((HIV clinic doctor name here) and his
pharmacist (Pharmacist name here) and nurse care manager (name here) at your PC clinic
via video conference.]
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Online appendix 3: Semi-structured patient interview guide
1. In the past year or so the VA has changed how it delivers your HIV care. How did you used to get
care before the change?
a. (Regarding HIV care)
i. When you came to the IC VA, who did you see for your HIV care? [Interested in
name(s) of HIV team members, and team members’ position]
ii. What types of things did you do during your appointments?
iii. What types of health concerns did you discuss with (your previous care team)?
iv. How did you get to these appointments?
v. If you had a concern or question, who did you contact?
b. Before the change, did you go to someone other than the infectious disease (ID) clinic
for your general health care needs? (If yes):
i. Who/where? [VA or non-VA, clinic or IC VA]
ii. What types of health issues did (your PC team) address?
iii. Do you know if (your PC team) talked with (the provider who monitored your
HIV infection)?
1. Did any issues come up because your providers didn’t talk with each
other about your care? [e.g., medication conflicts, management of comorbidities, missed diagnoses or inappropriate treatment plans]
iv. With more than one provider, how did you decide who to contact about
different health concerns or questions?
2. How do you get care now?
a. What CBOC/primary care clinic do you go to most often for your general health care
needs?
i. Who do you see during these visits? [Interested in name(s) of PC team members,
and team members’ position]
ii. What types of things do you do during these appointments?
iii. What types of concerns or health issues do you discuss with (your primary care
team)?
iv. Do you see a PCP outside of the VA?
b. How have your HIV care visits changed?
i. Where do your HIV appointments take place now?
ii. How have the types of things that you do during your appointments with (HIV
clinic doctor name here) changed now that they are telehealth visits?
iii. Have the concerns or health issues you talk about with (HIV clinic doctor name
here) changed? (If yes) What’s different? Why do you talk about different things
now than you used to?
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Online appendix 3: Semi-structured patient interview guide
Care Coordination and Role Clarity
3. Sometimes when a patient has more than one person providing their care there can be confusion
about who is taking care of specific health issues.
a. What do you see as needs related to your HIV infection?
i. What needs are related to your overall health, not specific to HIV?
ii. How do you distinguish between the two?
b. Are these the same needs (HIV clinic doctor name here) or (your PCP) address?
i. (If no) How do they differ? Can you provide an example?
c. Do you end up talking with (HIV clinic doctor name here) or (your PCP) about health
concerns that fall outside of what you think they are supposed to address?
i. Can you provide an example?
ii. Why did you talk with that team about this concern?
4. With more than one provider, how do you decide who to contact about different health concerns
or questions? [e.g., not feeling well now, chronic condition management]
5. Have you received the patient brochure that is designed to help you decide who to call for different
types of health concerns?
a. Have you used it to figure out who to contact?
b. Did you have any questions about who to contact, or how?
c. After you used it, did you feel you had contacted the right person?
d. Can you provide an example of a time you used the brochure?
e. Do you have any suggestions for how to improve the information provided on the
brochure?
6. When a person has multiple providers it’s important that care teams share information about
symptoms, diagnoses, labs, and medications. Think about (HIV clinic doctor name here)’s team
and (your PC team). In your opinion, how well do they coordinate your care?
a. Can you give me an example of a time where you thought that everyone seemed to be
knowledgeable and working together?
b. Is there an example of a time where it seems your care teams weren’t on the same
page?
c. Thinking about coordination between the two teams, what needs to be done better to
improve your care?
7. Are your HIV and primary care needs being met?
a. For example, is your HIV team reviewing your CD4 and viral loads and your antiretroviral
medications?
b. Are you getting your blood pressure and cholesterol monitored, receiving vaccinations
or screenings for changes in behavior or mood that may affect your overall health?
c. (If no) What needs are falling through the cracks?
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Online appendix 3: Semi-structured patient interview guide
Access and Convenience
8. How have the telehealth appointments affected your ability to access care, or get the care you
need? [e.g., Distance travelled? Improved ability to keep appointments?]
9. How has your use of care outside of the ID clinic changed? [e.g., Change in number and frequency
of primary care appointments? New diagnoses, treatment plans?]
10. Since you began your telehealth appointments, what face-to-face interactions have you had with
the team members from the ID Clinic?
a. What gets in the way of seeing them in these instances? [want to capture possible
reimbursement issues, but maybe there are other things that are barriers as well]
11. When would you prefer to see the (HIV clinic doctor name here) or his team in person rather than
by video conference?
a. Would you prefer to have more, less, or about the same number of face-to-face
interactions? Why?
12. Now that you’ve experienced HIV telehealth visits, does the location where you receive HIV care matter to
you? Why/why not?
Telehealth for HIV care
13. Do you like using the telehealth system? Why/why not?
14. How comfortable are you with the telehealth technology?
15. Have you had any technical failures, or problems with the equipment (e.g., hardware, bandwidth)? If so,
how did it affect your appointment?
16. How useful is the video conferencing for your appointment, compared with the option of talking
over the phone, for example?
17. The telehealth visits generally involve talking about how you’re feeling and reviewing your
medications. Equipment is being purchased to listen to your heart, and a camera is being installed
so that (HIV clinic doctor name here) can do some physical exams, like looking at rashes. How
important is this for you? Why/why not?
18. How well does it work for talking about medications? How about other things you discuss with
(HIV clinic doctor name here) and the HIV team?
19. Are there things you feel you are giving up by not coming to the IC VA for your HIV care?
a. What, if anything, do you gain? [may or may not be related directly to care]
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Online appendix 3: Semi-structured patient interview guide
Stigma and Privacy Concerns
20. Think about (your primary care team at your CBOC).
a. Do you think they are comfortable participating in and contributing to your overall
health care needs? Can you provide an example? [discomfort could be social (prejudice)
or medical (fear of exposure, but also worry about competency)]
b. (If no) What are they not comfortable with? Why do you think they aren’t comfortable?
c. Do you have any concerns about privacy at (your CBOC)? Can you provide an example?
[prompt: being seen for HIV care at a primary care clinic, the clinic being closer to home,
issues with discretion/confidentiality, people finding out]
d. Do these concerns differ from those you have about seeing your HIV team in the Iowa
City ID clinic? [privacy and level of perceived acceptance by and competency of care
teams]
Shifting Perceptions of Specialty Care
21. In the last 15-20 years+, HIV has shifted from a fatal to a condition that people live with for many
years. Now your health care within the VA has shifted from getting all your care from the ID clinic
to shared care between the ID clinic and (your local clinic).
a. Have these shifts changed how you think about your HIV status? Or how you go about
your daily life? Can you provide an example?
b. Do you think it’s changed how your health care providers interact with you? Can you
provide an example?
22. Is your specialty care more or less “special” now that it takes place at your local CBOC?
a. (If yes) Can you provide an example of how you treat this appointment differently than
you did your ID clinic appointments at the IC VA?
Problems and Suggested Solutions
23. I am going to ask you your opinions about specific aspects of these telehealth visits. Please tell me
what, if any, problems occurred in each of these areas and what might be done to resolve these
issues.
a. Scheduling telehealth visit?
b. Checking in at the CBOC for the telehealth visit?
c. Using the videoconferencing equipment?
d. Talking and interacting with the ID/virology team?
e. Discussing problems with or changes in your HIV medications?
f. Getting the care you needed for problems that were bothering you (e.g., pain, stomach
problems, skin rash)?
g. Coordination between ID/virology clinic in IC and the primary care clinic?
h. Scheduling your routine labs, such as CD4 and HIV viral loads? [supposed to happen a
week before visit; used to travel to IC, now at CBOC]
i. Getting your blood drawn or other needed laboratory testing during or before the visit?
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Online appendix 3: Semi-structured patient interview guide
24. Returning to our first set of questions, think about how you used to get care. What worked and
didn’t work?
a. What works and doesn’t work about your telehealth HIV appointments, and the shared
care between the ID and (your local) clinics?
b. Which do you prefer? Why?
25. In your opinion, would this new way of getting care work throughout the VA?
a. From your experience getting care through the VA, what might be issues that make it
difficult for this type of care to work?
b. What about the VA might make this type of care work well?
26. I’m curious, if you knew that your PC provider could talk to an ID specialist, like (HIV clinic doctor
name here), when they had questions about HIV-related health needs, would you be comfortable
getting all of your care - general and HIV care - from your PCP? I want to emphasize that this isn’t
the plan. I’m just curious about your response to getting all of your care from one provider who
could talk with specialists when they needed to, instead of you seeing multiple providers who
specialize in different things.
27. Is there anything else you would like to tell us about your VA care that might help us improve care
for veterans with HIV infection?
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