Table 1
Evolution of the integrated chronic care model during scale-up in routine clinical services in Uganda (n = 4 facilities).
| FEATURE | PRACTICE BEFORE PILOT STUDY (STANDARD CARE) | PILOT INTERVENTION (STUDY CONDITIONS) | PRACTICE AFTER THE PILOT STUDY (UP TO ONE YEAR AFTER STUDY ENDED) |
|---|---|---|---|
| Reception, triage and waiting areas | Reception, triage and waiting areas were separate for patients with HIV and NCDs across the sites. In 2/4 facilities, patients with NCDs did not have a designated NCD clinic but were seen alongside acute care in outpatient clinics. | Reception and triage areas for HIV and NCD clinics were combined, so that all patients were seen at a single reception and triage point. Patients with any condition also waited together. | Kiswa, Wakiso and Ndeje facilities maintained joint reception, triaging, and waiting areas at a single point for all patients regardless of medical condition. Kisugu shared reception and triage areas but separated waiting areas for patients with HIV and NCDs |
| Medical records | All sites had robust systems for capture and storage of HIV records, whereas systems for capture and storage of medical records for NCDs were informal or did not exist. For example, prescriptions for NCDs were documented in hand-held government medical forms or in patients’ books, which often got lost or they forgot to bring them when seeking care | HIV clinics used an HIV clinic card for documenting clinical information. An NCD clinic card similar to that for HIV was created for patients with NCDs. The same filing system used for HIV was used for NCDs and records for both conditions were stored together | Record capture and storage was maintained for HIV as part of standard care. For NCDs, all facilities continued with NCD record capture and filing system. However, NCD records were stored in separate rooms from HIV records. In Kisugu, the NCD care card was inserted into the HIV file for patients with HIV and other comorbidities |
| Consultation | Patients with HIV or NCDs were seen by different clinicians, either on different days or at different health facilities. Patients with HIV with concurrent conditions were referred to other health facilities to seek care for their conditions, resulting in multiple visits to the clinic for each condition In two facilities, without designated NCD clinics, patients with NCDs were managed alongside acute care | All patients regardless of condition were seen by the same clinicians. If a patient had more than one condition, management of both conditions occurred within the single consultation | Patients with HIV or NCDs continued to be managed by the same clinical staff. All conditions were managed during a single consultation across the facilities |
| Patient tracking and follow up | HIV clinics had robust structures for patient follow up and tracking, with clear appointment record books and/or electronic registers to track patient visits. Patients with NCDs were not followed up, patients presented for care when they wished, alongside episodic care | Follow up of patients with NCDs was aligned with systems for tracking and follow up of patients with HIV | Kiswa, Kisugu and Wakiso facilities continued tracking and following up patients with HIV or NCDs the same way. When patients missed scheduled visits, phone calls were made to remind them of clinic visits. Home visits were made but for patients with HIV only. At Ndejje, patients with NCDs were not followed up. The prerogative to honour scheduled clinic visits was left to the patient. Only patients with HIV and other comorbidities were followed up |
| Pharmacy and dispensing | Separate pharmacies were used for patients with HIV or NCDs. Where patients shared a pharmacy, separate dispensing points were used for HIV and NCDs. For example, NCD drugs were dispensed at the front window and the HIV drugs were dispensed at the back window. Drugs were also dispensed by different pharmacists | The same pharmacy with same dispensing point (or adjacent dispensing points) for HIV and NCD drugs was used. Staff received training to be able to dispense drugs for either condition so that patients only had to go to a single window to receive their drugs | Both patients with HIV and NCDs continued getting their drugs from the same pharmacy, sharing dispensing staff. Kiswa, Ndejje and Wakiso facilities dispensed both HIV and NCD drugs from the same area while in Kisugu separate dispensing areas were used for either condition |
| Counselling and patient education | Patients with HIV received adherence counselling while counselling services were not available for patients with NCDs | Counselling services were aligned so that all patients were receiving the same care package | Counselling services were maintained for both groups of patients at Ndejje and Kiswa health facilities. In Wakiso and Kisugu, patients with NCDs and those with HIV were counselled by different clinical staff |
| Laboratory | Patients with HIV and NCDs received the same centralized laboratory services | Patients with HIV and NCDs received the same laboratory services, however during the study fasting diabetic patients were prioritised. The study also provided free glucose strips for monitoring blood glucose among patients with diabetes | Blood sugar measurements for patients with diabetes, regardless of HIV status were taken at the NCD triage across the facilities. All other samples were sent to centralized laboratory services for clinical investigations |