Effectiveness and Implementation of Geriatrics Resources for Assessment and Care of Elders With HIV (GRACE-HIV) (GRACE-HIV)

Each participant randomized to the intervention will undergo an initial visit at their home or preferred location, where the RN will conduct a comprehensive geriatric assessment including physical, cognitive, functional, psychosocial and community needs assessment, and a medication review including prescribed and over the counter medications. After the initial visit, the RN attends the weekly multidisciplinary team meeting to discuss the findings which trigger evidence-based geriatric HIV care protocols for inclusion in the personalized care plan. After multidisciplinary review, the RN will coordinate with the participant's HIV care team, and when relevant, with primary care, specialists, pharmacists, social workers, and community service organizations to refine and implement the care plan.

Medical Outcomes Short Form Survey36 (SF-36) to measure health related quality of life. The SF-36 includes eight scales measuring domains of physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Our primary outcome measure is the Component Summary Scores

This outcome is a 24-month participant level Geriatric Syndrome Identification and Management Process Score, derived from EHR, medication, and referral data in both study arms. The composite will be defined as the number of eligible care processes completed divided by the number of eligible care processes during 24 months of follow-up. Components will include:

(1) identification of key geriatric syndromes in the EHR, including falls/fall risk, depression, cognitive impairment or dementia, urinary incontinence, and polypharmacy and (2) management of identified syndromes, including medication reconciliation, syndrome-specific treatment or referral, prescribing of indicated medications such as antidepressants or dementia medications when clinically appropriate, and deprescribing of potentially inappropriate medications. Higher scores will indicate better delivery of recommended geriatric care processes.

We will collect emergency department visits and hospitalization data from the Indiana Network for Patient Care, the health information exchange for the State of Indiana.