HIV: building relationships with patients

Grace McComsey, MD, FIDSA: Tavell, how do you support your patients? Obviously have HIV [human immunodeficiency virus] as a patient becomes more complicated. How can you support these people? Some of our patients come to see us and see the clinic as a great support in their lives. They may not have family or friends to support them. How do you support your patients in the clinic?

Tavell Kindall, PhD, DNP, APRN, FNP: When we first meet with them, it’s to build that rapport with them and let them know that we have a dedicated team of individuals who are there to help them whatever their problem is. Because we know that whatever the barriers, be it housing, transportation or lack thereof, lack of finances, lack of food, all of these things can have a significant impact on a person’s ability to become undetectable and remove the virus.

Our support team wraps a lot of resources around people when they first come to us. There is an initial assessment that is done. You are trying to find out some things that can be there. Sometimes patients are just shocked that they were diagnosed so we might not get all the information up front, and that’s okay. As they keep coming back to us, we can break it down so it’s not overwhelming and then try to meet the needs of those people. Over time we have to build that rapport and that relationship, and I’m all about relationships. My patients can text me whenever they need something. Some stop just to say hello, and that’s when you’ve reached a point where you’ve got a great relationship and broken through those stigmatizing things that patients go through.

When they come just to say hello and see how you are doing, you have made them come true as someone who is going to do well. Even if they are infected with HIV, they will live full, healthy lives. We take it on an individual basis. We have case managers, links to care coordinators, and HIV prevention coordinators. This role is interesting because not only do they educate people and make sure they know about PrEP [pre-exposure prophylaxis] and access to PrEP, but they also help patients understand that when they are undetectable, do whatever is right, and take their medications as they are supposed to, they will not transmit not HIV to others. Quality of life is a real issue. Often patients ask me, “Can I have children?” “” I am afraid of passing HIV to my fiancée, my partner or my wife. Or there is a woman living with HIV who is worried about passing HIV to her baby. We need to speak to patients strategically, making sure we deliver clear and correct messages, and making sure they understand that we are there for them throughout the journey as a tight-knit team and as a full team to give them everything they need to make sure they are successful.

Grace McComsey, MD, FIDSA: Do you use peer support groups?

Tavell Kindall, PhD, DNP, APRN, FNP: Yes, we do, and some people don’t want to participate in larger groups, so we have one-on-one support. I have several newly diagnosed and struggling women, and we have matched them with other women who have had an experience with HIV, and they are working very closely with them. We see a lot of improvement with them. Otherwise, for individuals who wish to participate in larger groups, they can. Some people, for example, a straight man who isn’t comfortable being in an all-male group with men who have sex with other men, you put that where you might have that group special support. We will find resources in the community. Fortunately, being in New Orleans, [Louisiana], there are a variety of service organizations that can be helpful. I am a big believer in customer service. People need good care and they deserve good care. I make sure my team recognizes that we are dealing with a population that historically has likely had poor customer service or been treated improperly or fairly. We need to find out and deal with it all, and make sure they understand that we are on their side, that they can trust us and that we are there to support whatever they need.

Grace McComsey, MD, FIDSA: John, did you have something different at Vanderbilt [University Medical Center]? Any comments on this?

John Koethe, MD: I would support what Tavell says, especially with regard to the importance of customer service in a community clinic. The patient experience begins at the door. One thing we are proud of is how long many clinic staff have been in our HIV clinic and the rapport patients have every step of the way.

The only other thing I would add is that we understand that HIV is something that exists both in a larger health context and in a larger health system context. It is necessary to navigate things like insurance. It is necessary to navigate in the access. You have to be able to call the clinic and say, “I don’t have transportation today” or “My child is sick, can I reschedule? And don’t turn people away 6 months before the next visit, but say, “That’s good, we’ll get you in next week.” One of the things we have is an entire office dedicated to the navigation of the Ryan White [HIV/AIDS] Program and commercial insurance. We also have in-house pharmacists, in-house mental health services, smoking cessation, nutrition and all of those things. As providers, we are increasingly dealing with cardiovascular, metabolic and other co-morbidities associated with aging. We know when to refer people out, but we also try to identify people to refer patients to people who appear to be aware of HIV in our other departments. At least they will see a specialist who may have interacted with our providers and understands that these people have received all of their care frequently in our HIV clinic, and are now being asked to leave the outpatient center, maybe, and get to the main campus where they will be in a different environment. Just to be aware of it.

Tavell Kindall, PhD, DNP, APRN, FNP: It’s a big deal. When I got to where I currently practice, I did my best to build relationships outside of where I currently work. I am fortunate to have a collective of colleagues who have a variety of other specialties — internal medicine, med peds [medicine pediatrics], family medicine, all of it — within organizational boundaries. But like you said, if you have to send them back, you want to send them where you know they’re going to be careful and no one is going to mistreat them. I made a point of going out into the community and meeting with these other vendors to make sure they understood, “Look, here’s who I’m sending you. I want to make sure we’re both on the same page and agree that this patient deserves to be treated with respect, dignity and that sort of thing. They can benefit from your expertise, but you need to deal with them properly. It is important.

Grace McComsey, MD, FIDSA: Confidence comes with time. I’ve been caring for some patients for over 15 years, and it’s amazing. They go to a different state. They keep coming every 6 months – trips and everything – just to see me because they don’t want to deal with a new doctor. This is partly why we attract identification [infectious diseases] fellows, because they go to our clinic and see how our patients treat us. A lot of them say, “Wow, I love this clinic”.

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About Bradley J. Bridges

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