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Introduction

Most of these nations are attempting to revamp their methods for providing HIV services, from testing to treatment. Health systems are shifting away from the conventional models of treatment, which were more institution-based with frequent visits to the health facility, to models that employ a variety of places, such as the community, and strategies like a multi-month refill, for instance quarterly or biannually, and task shifting to expand the roles of the multidisciplinary team consisting of Nurses, Physicians, pharmacists, as well as lay healthcare workers (volunteers), and patients themselves such as models of hope in service delivery under the general term "differentiated care" (DC) or "differentiated service delivery" (DSD) [1].

DC reduces barriers to care and reduces clinical encounters, enabling the reallocation of resources and reaching more patients [2]. There is a growing call for moving away from a generic strategy to adopting a more patient-centered, individualized approach to care. More importantly, patients desire active involvement in their care, recognizing positive outcomes and involving themselves in solutions, ensuring tailored care [3,4].

Other phrases, such as individualized care, patient-centered care, and differentiated service, are used interchangeably with differentiated care, but their usage and meanings are not definite. Considering recent global initiatives and societal developments, the author made the decision to reexamine the concept of differentiated care and determine whether it can be employed as a catalyst for attain ing UNAIDS fast track agenda of 95-95-95 by 2030, i.e., 95% of HIV-positive individuals should be aware of their status, 95% of those with the virus should be connected to care, and 95% of those taking ART should achieve viral suppression [3]. In this regard, this study highlights the precedents, characteristics, and repercussion of differentiated care and how it can impact the management of HIV and other chronic infectious diseases and noncommunicable diseases such as Hypertension (HPT) and Diabetes Mellitus (DM). Walker and Avant’s process was used for the concept analysis to accomplish this goal because of its methodical nature and grounded viewpoint.

Background

Concept analysis examines the fundamental elements of a concept, enabling differentiation between similar and different concepts, identifying likeness and unlikeness, and determining its internal structure by breaking it down into simpler elements. It also examines a word or term's usage in language, comparing it to related words and examining their similarities and differences [5].

The speedy increase in the proportion of antiretroviral therapy (ART) in the face of financial and health system constraints has led to calls to make the most out of ART service delivery to skillfully avoid wasting resources. Embracing differentiated care for ART could potentially be more cost-effective and produce better outcomes [6].

To achieve these lots of African countries are scaling up differentiated care for HIV treatment, but there is not adequate explicit data to describe how care is differentiated. Differentiated care varies from one healthcare setting to the other and different modes of differentiated care are adopted based on an understanding of the concept and availability of resources [7].

A definite definition of “differentiated Care” can result in a better appreciation of the concept from the perspective of healthcare providers and patients alike. A vivid understanding of the concept can make bare the potential benefits of differentiated care to the healthcare system and patients, clarification of the concept, stating an operational definition as well as adding to existing knowledge on the concept to aid research and clinical practice.

Design

With the aid of Walker and Avant’s methodology, this study sought to define, examine, and explicate the concept of differentiated care. This systematic technique was used to examine the concept for a deeper comprehension, leading to the identification of its antecedents, attributes, and consequences. Three cases including a model case, borderline case, and contrary case was developed to define empirical referents and establish an operational definition of differentiated care [5].

Search Methods

Literature search was done online using the following Databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), SCOPUS, Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed and other sources. Keywords used for the search were “differentiated care” and “differentiated Service delivery” “differentiated instruction” “differentiated leadership” and “differentiated nursing practice” in the titles and abstracts of the articles from the origin of the databases to the 3rd of September, 2023. English dictionaries and textbooks that are germane to the subject of study were also searched. Concept analysis of differentiated care was not found in any of these literatures.

The initial search using the keywords yielded a total of eleven thousand five hundred and eighteen (11518) articles. The search was then restricted to keywords in Title/Abstract, English language, articles with full text published between 2019 and 2023 in academic journals, and the initial number was reduced to seven hundred and nineteen (719). After excluding duplicates, the titles, and abstracts of 185 articles were screened manually and 66 articles were included in the analysis after meeting the following inclusion criteria, articles containing the attributes, antecedents, consequences and empirical referents of differentiated care or differentiated service.

Result

Any given concept's significance will fluctuate over time according to a variety of circumstances in the area and its boundaries. Therefore, a term that lacks a precise definition should be more thoroughly examined. When well accomplished, a concept analysis can be helpful and significant to nursing practice and research [5].

The concept of care is fundamental to nursing; Wolfe [8] hence the concept of “differentiated Care” was chosen for this analysis due to its pervasiveness and growing significance within the healthcare industry across nations. Although this concept is used occasionally in publications across several nations and has many applications among healthcare professionals, patients, and carers, there is no consensus on what it exactly means. In other fields such as education and leadership, terms such as “Differentiated Instruction” and “Differentiated Leadership” do exist respectively.

According to Avant and Walker, this completes the third stage of the concept analysis. It requires systematic exploration of all the uses of the concept using dictionaries, thesauruses, literature, and friends, without limiting oneself solely to nursing or medical literature, as this may lead to bias in understanding the concept. The uses must include both implicit and explicit applications of the concept [5].

Charalambous and Beadsmoore [9] highlight that the quality of nursing care is influenced by various factors, impacting both the nurse and patient's perception.

“Care is defined as responsibility for the safety and well-being of someone or something or attention accompanied by protectiveness and responsibility” [10]. The same dictionary defined differentiated as” to understand or point out the difference in” [11].

“Differentiated Care is a client-centred approach that simplifies and adapts HIV services across the cascade, in ways that both serve the needs of People Living With HIV(PLHIV) better and reduce unnecessary burdens on the health system”[1]

By providing differentiated care, the health system can refocus resources on those most in need because DC is a comprehensive approach that includes optimal, patient-- centered, needs-based, and tiered care, promoting simplicity, task shifting, and decentralization [12]

The term "differentiated nursing practice" refers to the grouping of registered nurses' roles, responsibilities, and tasks in accordance with certain predetermined criteria, most frequently education, clinical experience, and competence (Boston 1990) as cited by [13,14]

Lawrence and Lorsch (1967), as cited by, Baker, Lamm [13] states that, the assumption of differentiated practice is that it will enable healthcare organizations to make the most effective and efficient use of the limited resources required to cope with a fast-evolving healthcare environment, but integration of these efforts is required to guarantee goal achievement.

The key components of differentiated nursing include the division of labor necessary to satisfy client needs, the importance of appropriate educational preparation and practicums, the necessity of teamwork for optimal efficiency, and remuneration according to academic achievement [13-16].

In education, the term “Differentiated Instruction” (DI) incorporates adaptive methods of instruction, which help students with a range of traits and exceptionalities by using tailored types and levels of curriculum, instructional practices, materials, and assessment strategies [17,18].

Differentiation, at its most basic level, refers to teachers' efforts to handle student differences in the classroom. When a teacher engages with a student individually or in a small group to customize the educational process for that learner, this is known as differentiated instruction. The most important component of differentiation which assists students in achieving more and feeling more inspired in their educational pursuits is making sure that what teachers differentiate is of great quality.

DI is a comprehensive approach involving five key components: the learning environment, high-quality curriculum, valid assessment, flexible classroom structure, and individually tailored instruction [19,20].

In the field of leadership, the term "differentiated leadership" is used to describe the situation in which a leader shows differing degrees of individual-focused leadership behavior to various group members, such as giving certain members more attention or support than others based on their needs and relationship with the leader.

Individual-focused leadership tends to cause followers to form tight, direct relationships with their leaders that are marked by respect, comradery, fulfillment, and mutual interaction [21,22].

Defining Attributes

It focuses on identifying defining attributes of a concept, revealing clusters of frequently associated attributes for broad insight. Examining various instances of a concept helps identify its defining characteristics or attributes. These attributes help differentiate a specific concept from similar or related ones. Refinement of defining attributes is essential for identifying the concept of interest from surrounding concepts [5].

The literature review identifies Differentiated Care as an approach that involves evolving targeted interventions, collaborative decision-making, a holistic person-centered approach, multi-disciplinary collaboration, and resource optimization.

Evolving Targeted Interventions

Interventions aimed at increasing access to life-saving interventions, reducing new HIV infections, increasing linkage to care and retention and adherence to ART, and subsequent viral load suppression. Moving between facility-based models of care to community-based models of care based on their specific characteristics and needs. It entails using a balanced combination of health- and non-health based therapies, aimed at solving a particular problem, moving patients from one care model to the other based on their current state, and possibly identifying a cure or developing a vaccine that can catalyze the current gains in prevention including targeted interventions for key populations [23-27].

Collaborative Decision-Making

Nurses rely on family caregivers for care planning and decision-making; collaboration between clients, family caregivers, and nurses is crucial for effective care, promoting control over health, well-being, and better treatment compliance. Collaborative decision-making also prevents medical error [4,28,29]. Nurses and physicians should only guide patients in making decisions that affect their health [8,30-32].

HIV is associated with a variety of medical and psychosocial needs that affect individuals during their lifetime. Systemic problems of access, increasing costs of care, and varied quality of HIV care as well as individual roadblocks to care such as stigma, perceived discrimination, competing needs, and comorbid conditions have emphasized the necessity of adopting holistic approaches to care delivery [33].

Patient-centredness is a holistic concept in which all the components interact and give the patient a unique experience with the health system. Generally, patients desire a patient-centred approach to care when they encounter the health system, nurses must be willing to provide this within all the domains listed by Little, Everitt [31]. The three domains are communication, partnership, and health promotion, which are assessed from the patient’s perspective.

Being patient-centered truly entails considering the patient's need for information, participation in decision-making, and appropriate responses. Patients value all aspects of patient-centeredness, and all patients want to be treated uniquely and holistically. A holistic approach to care complements conventional methods and advances functionality and mental and physical well-being to ever-higher levels [34-37].

Multi-disciplinary collaboration and sharing of information is critical in rendering appropriate care. It requires managing the patient as a whole and in a continuum; it demands collaboration with other healthcare professionals for improved quality of life, increased satisfaction, and low mortality rates. Multi-disciplinary collaboration helps the patient navigate complex healthcare systems with ease and has the potential to improve the quality of care [8,38-40]. For example, a patient who becomes depressed because of being diagnosed with HIV would need a clinical psychologist to be part of his management for improved outcomes.

Resource optimization involves timely and cost-effective ways of planning and utilizing resources available for patients and the health system [39].

Patients who received greater patient-centered care used fewer medical resources overall, including fewer hospital stays, visits to specialty care clinics, fewer referrals, and laboratory testing [41-44]. This leads to efficiency and optimization of both human and material resources.

A model case is an ideal, paradigmatic, or complete illustration of a concept, showing all of its distinguishing features. [5] The model case below demonstrates clearly all the attributes of differentiated care listed above (Evolving Targeted Interventions, Collaborative Decision-making, Holistic Person-Centered Approach, Multi-disciplinary Collaboration, and Resource Optimization).

Miss S.A. a 55-year-old woman, was recently diagnosed with HIV type 1. She has a history of hypertension (HPT) and type 2 diabetes mellitus (DM). Miss S.A. is a primary caregiver for her elderly mother and works full time as a teacher. She faces challenges in managing her health due to her busy schedule and caregiving responsibilities.

Upon diagnosis, miss S.A.’s healthcare provider conducted a comprehensive assessment considering her medical history, lifestyle, and social determinants of health.

A customized care plan was developed based on her unique needs and preferences considering her busy schedule and caregiving role. Regular follow-ups and adjustments to her treatment plan were scheduled within the first six months to ensure her care evolved as her health status and needs changed.

She was actively engaged in the decision-making process. Her healthcare team provided her with adequate information about her treatment options, lifestyle changes and potential risks and benefits. Miss S.A and her healthcare providers worked together to set achievable goals and make informed decisions about her Anti-Retroviral Therapy (ART), DM and HPT management.

Recognizing the psychosocial challenges that came with her new diagnosis, and the caregiving role, the healthcare team incorporated mental health support in the form of counselling sessions into her care plan. They also addressed her dietary and exercise preferences, aligning her care with her values and lifestyle. She felt treated with dignity, heard, respected, and understood (non-judgmental approach), fostering trust in her healthcare team.

Miss S.A.’s healthcare team consisted of her primary care physician, a registered dietitian, a clinical psychologist, and a nurse practitioner, a biomedical scientist, and a community health worker. Regular team meetings allowed for a holistic view of her health, enabling them to coordinate interventions effectively. This collaborative approach ensured that all aspects of her healthcare including laboratory investigations, dietary and psychological counselling, consultation and medication refills, were addressed comprehensively and simultaneously.

Miss S.A.’s healthcare team leveraged telemedicine and Community Drug Distribution Points (CDDP) for some appointments, reducing the need for her to take time off work to attend clinic for consultations and medication refills. Community resources such as treatment support groups for ART and Noncommunicable diseases (NCDs) and support groups for caregivers, were identified and recommended to her, enhancing her social support and psychological well-being. Her health provider used evidenced - based guidelines and cost-effective interventions to manage her comorbidities, optimizing the allocation of resources and overall health outcomes

Over the course of a year, miss S.A. was virally suppressed and clinically stable. Her DM and HPT management improved significantly as evident by a well- controlled blood sugar and blood pressure levels. Miss S.A.’s acceptance of her HIV status and adherence to treatment is an indication of improved psychological wellbeing. She reported feeling more confident in her ability to manage her health while juggling her caregiving responsibilities and work. The model case above typifies differentiated care.

Mr. J. D., a 45-year-old man with HIV, received a referral from his primary healthcare practitioner to a community-based differentiated care program. The example of Mr. J.D. demonstrates the distinctive qualities of D.C.

At the time of enrolment, a thorough evaluation was carried out, considering his socioeconomic condition, physical and mental health, and personal objectives.

Together, the team created a treatment plan that addressed all of Mr. J.D.'s unique requirements. These included how to replenish his antiretroviral therapy (ART), when and where to get his viral load tested, how to manage the adverse effects of ART, how to deal with worries about stigma, and how to enhance his general well-being

A pharmacist and a community health worker (Model of Hope) were members of a healthcare team under the direction of a nurse.

The nurse changed Mr. J.D.’s prescription as needed and performed routine examinations and adherence counselling.

In addition to leading support groups and providing emotional support, the community health worker assisted him in navigating healthcare services, it was up to Mr. J.D. to decide between community-based and facility-based treatment. Owing to his work schedule, he chose - community-based care, which consisted of follow-up - phone appointments in addition to the nurse's monthly visits.

After initial stability, he was given a multi month supply of ART, which allowed him to visit the clinic just once every three months. He found this to be economical and effective, therefore he was satisfied with the care he received. To improve medication adherence, a pill organizer and refill reminders were sent to his cell phone. Through group counselling sessions, Mr. J.D.'s self-stigma decreased, and his comprehension of HIV management increased.

He was urged to take an active role in his care, and the medical staff assisted him in setting personal health objectives including beginning an exercise regimen. Mr. J.D.'s viral load disappeared because of the differentiated care, and he experienced a notable improvement in the quality of life. This model case demonstrates how differentiated care for HIV in a community setting effectively combines the defining attributes to provide holistic, patient-centered care while improving the overall well-being of individuals living with HIV. The personalized, flexible, and empowered care approach contributed to better health outcomes, fewer clinic visits, and increased patient satisfaction.

The sixth step in the concept analysis, is identifying additional cases. Examining other cases can help identify the defining attributes of a concept of interest, as they may overlap with related concepts. Several types of cases, such as borderline, related, invented, and contrary ones, can be used to determine what counts as a defining attribute [5]. For this analysis, borderline and contrary cases will be looked at.

Borderline cases are instances with most defining attributes of a concept but differ substantially in one aspect, such as time or intensity. They help clarify the model case's consistency and help understand the defining attributes of the concept.

Mr. J.K. a 58-year-old man, presented with a complicated medical history. He has been managing multiple chronic conditions including diabetes mellitus (DM), hypertension and chronic obstructive pulmonary disease (COPD) for several years. Recently, his health has taken a turn for the worse. His conditions are worsening, and traditional treatments are proving to be less effective.

Mr. J.K’s healthcare team regularly reviews his condition, conducts new assessments, and adapts his treatment plan accordingly. The team introduced advanced therapies such as precision medicine tailored to his genetic profile, to better manage his conditions.

His healthcare team consisting of a nurse, physician, dietitian, respiratory therapist, and a social worker all involved him in the decision process concerning his conditions. They respect his opinions and values, and his input is crucial in determining the direction of his care, fostering a sense of autonomy and trust in the healthcare process.

Even though the team involves Mr. J.K in his care, the team does not meet to discuss his health and draw a single comprehensive plan of care for him. Last week he came to see the physician, but the dietitian and respiratory therapist were unavailable. He had to return the third day to see them also. The multiple visits drained his pocket and got him excessively worried. He sometimes spent money taking the same laboratory investigations multiple times due to the lack of coordination within the team. He sometimes fails to honor his clinic appointments due to lack of funds.

The good thing is that Mr. J.K.’s healthcare was not limited to managing his chronic conditions only, but also addressed his overall well-being. His team considers his mental health, social circumstances, and lifestyle factors aiming for a holistic person-centered approach. He was connected to support groups and mental health professionals to manage the emotional toll of his conditions knowing that these aspects are interconnected with his physical health.

In this borderline case, two of the attributes were missing; multidisciplinary team collaboration and resource optimization and so does not qualify to be called differentiated care.

The concept's main attributes are not included in this statement, indicating that it is not an example of the intended concept. This disparity is so glaring that most individuals can confidently assert that this scenario is not an example of the proposed concept. With reference to the model case, Miss S.A., the healthcare provider did not conduct a comprehensive assessment of her medical history, lifestyle, and social determinants of health.

A one-size-fits all approach was adopted not paying attention to her unique needs and preferences. Her plan was not regularly reviewed to address any changing health need. Miss S.A. was not involved in the decision-making process concerning her plan of care. She received very scanty or no information about her treatment plan.

She got depressed over her HIV status as the team was judgmental and paid little attention to her mental health. There was no plan for lifestyle changes, leaving her dietary needs and exercise preferences unattended to. She doesn’t feel heard, respected, or understood by her healthcare team hence has no trust in them.

The multi-disciplinary team never meets to discuss her health needs, so there was poor collaboration, and her interventions were fragmented poorly coordinated. Her psychosocial health needs were totally ignored making the care atomistic

Miss S.A. visits the clinic on monthly basis for her follow-ups and medication refills and sometimes earlier due to unstable clinical conditions. She was frequently admitted on account of opportunistic infections and hyperglycemia or hypertensive urgency. This was challenging for her as she regularly asks permission from work to be at the hospital and also impacted her finances negatively. Her providers did not adopt evidence- based cost-effective interventions to address her health needs. She had challenges combining her job, care of her mother and frequent appointments and admissions at the hospital for various reasons and so does not honor her appointment religiously making her conditions worse. Over the years her condition deteriorated, she failed to achieve viral suppression, her blood sugar and blood pressure were poorly controlled, her depression symptoms augmented. To make matters worse she also been diagnosed of tuberculosis (TB) because of her nonadherence to ART, making her prognosis and health outcomes very poor. She is currently on another admission in the hospital and feels apprehensive about her ability to manage her health, work, and caregiving responsibilities. This is a typical contrary case as it has no attribute of differentiated care.

The next step in the analysis process is identifying antecedents and consequences. Antecedents are events or incidents that must occur prior to the occurrence of differentiated care and cannot be a defining attribute for the same concept [5].

Patient population and characteristics determine how care is differentiated. Certain preferences of the patient may not be ideal due to the patient’s specific characteristics. Sub-populations, epidemic type, varying needs of women, men, adolescents, children, and key populations are potential influencers of DC, just as specific clinical characteristics of patients are also determinants of DC.

Professionally competent healthcare providers: such as nurses, physicians, pharmacists, and lay health workers are needed for effective differentiated care to take place. Hence these professional must be trained to provide differentiated care to different patient populations based on their varying characteristics.

Organizational support; in the form of rostering, adequate education and training and promotion of differentiated care services policies and standard operating procedures, resource allocation, provision of equipment, and machinery necessary for effective differentiation of care.

The above are the antecedents to differentiated care [12,45-48]

These are events that occur because of the concept, strictly speaking, consequences are the outcomes or products of a concept [5]. A review of literature identified three consequences of differentiated care as discussed below

Differentiation of care results in high quality of care and increased satisfaction among patients and their families. Providers who adopted differentiated practices had more time to attend to patients as well as evaluate their care. Individualization of care makes room for an enhanced knowledge about the patient’s condition and build their trust in the healthcare team which in turn improves patient outcomes and satisfaction. Patient-centered practice enhance health, reduce discomfort, and improve mental health, leading to increased care efficiency and fewer diagnostic tests and referrals. Reduced clinic visits and waiting times are also determinants of patient satisfaction and these are associated with DC [13,41,43,49,50].

Health care is an intermediate product, aiming to improve health through efficiency in resource inputs and intermediate outputs or final health outcomes. The application of efficiency concepts in healthcare systems presents both theoretical and practical challenges due to the complex relationship between inputs and outcomes.

Efficiency can be assessed from three angles, thus technical efficiency, productive efficiency, and allocative efficiency.

Technical efficiency is the optimal balance between resources (capital and labor) and health outcomes, aiming for maximum improvement from a set of resource inputs while productive efficiency is the goal of maximizing health outcomes at a specific cost, or minimizing costs for a specific outcome. Allocative efficiency on the other hand is a strategy that aims to maximize the health of society by combining the right mix of healthcare programs. Efficiency and high quality of care is attained by employing appropriate differentiated practices such as Patient centeredness which is an attribute of differentiated care, associated with decreased utilization of health care services and low cost of healthcare improving efficiency in the long run [41,44,49,51,52].

Spector [53], Lu, Barriball [54] identified various aspects of job satisfaction, including appreciation, communication, coworkers, fringe benefits, job conditions, work nature, organization, policies, pay, personal growth, promotion opportunities, recognition, security, and supervision. Differentiated care results in increased job satisfaction [47] and this might be related to organizational support towards DC, multidisciplinary team collaboration and collaborative decision making processes associated with DC as well as appreciation and recognition from satisfied patients.

The last stage in the analysis process is identifying empirical referents. Empirical referents are crucial in concept analysis as they help identify or measure defining characteristics or attributes. They are not tools to measure the concept itself, but directly relate to these attributes. Identifying these referents is essential for instrument development, content, and construct validity, and practice [5].

For DC systems to operate as efficiently as possible without sacrificing service quality, quality improvement measures are essential. It is crucial to close service provision gaps in facilities and expand the employment of community healthcare workers, as well as to use local data iteratively for development [45].

Patient-reported outcome measures (PROMs) are essential for comprehending health outcomes and directing quality and safety improvement in healthcare. The value of PROMs in the health system depends on sincere participation, proper instrument selection, sufficient funding, and a compelling justification for data usage. PROMs can direct clinician consultation, monitor patient progress, and incorporate patient viewpoints into actions aimed at enhancing the quality of care. They can also be applied for macro computations of relative healthcare intervention values and performance measurement [55].

It’s usage in the evaluation of differentiated care would be appropriate, to understand the participation of patients in the advancement of healthcare service delivery [56].

Another tool for the assessment of DC could be health care policies and guidelines such as those provided for the management of HIV [46,57,58].

Patient satisfaction surveys can also be carried out using appropriate instruments to assess patient satisfaction with differentiated care and cost-effectiveness analyses to as sess efficiency and optimization of resources. A patient satisfaction scale with five items covering health worker confidentiality, psychosocial support received, time for other priorities, health costs, and time spent traveling and waiting to receive services was used to assess patient satisfaction with DC in HIV management [50,59].

Differentiated care could be defined as a dynamic approach to healthcare for a specific patient population, that requires professionally competent healthcare providers, and organisational support, to tailor evolving targeted interventions to individual needs, promote collaborative decision-making, adopt a holistic person-centred approach, encourage multi-disciplinary collaboration, and optimize use of resources leading to improved patient outcomes, mutual satisfaction of patient and staff and efficiency of the health system.

Discussion

This paper analyzed differentiated care, in the context of infectious and non-communicable chronic diseases that demands long term therapy, slightly skewing towards HIV management.

Differentiated care is advantageous in comparison to the standard care because it has the potential to cater for the needs of the clients and improve service and client outcomes [60].

The HIV care model provides a prime example of differentiated care. Differentiated models of care for HIV include task-shifting, where lower-level healthcare workers provide routine care, allowing physicians to focus on complex cases. This approach has been shown to improve retention in care and viral suppression rates [61-63].

Differentiated care has been proved to address challenges in HIV care across the entire cascade. It has the possibility of addressing all patient populations form children to the aged, stable and unstable patients as well as key populations like female sex workers, men who have sex with men (MSM) and injection drug users (IDU) [57,64].

Differentiated care encourages service users to take an active role in their care, which, among other things, increases treatment compliance and attendance rates. The delight of seeing their clients' outcomes improve as well as more productive and efficient working practices are both advantages for service providers. Differentiated care planning requires validated data for monitoring progress, identifying strengths, and implementing quality-improvement activities, thereby improving understanding and enhancing of specific situations [48].

Implementing differentiated care often requires additional training and support for healthcare workers to effectively deliver patient-centered care [65].

Healthcare policies and funding models may need to be adapted to support differentiated care approaches. Robust health information systems are needed to track and manage the diverse care plans associated with differentiated care [66].

In maternal and child health, differentiated care can involve home visits, community health worker programs, and customized prenatal care plans that consider the specific needs of pregnant women and newborns [67].

Differentiated care affords patients with comorbidities to access all their health care needs in a single visit or at a single point either in the community or on facility basis thereby reducing fragmentation and duplication of care and improved efficiency in the use of resources, even though the data backing this is limited.

For instance, a PLHIV who develops any of the Non-Communicable Diseases like Diabetes or Hypertension would have the opportunity to receive care for all his comorbidities during a single clinic visit [68,69].

Also, a multidisciplinary approach to care is important to rendering differentiated care and reducing workload on health staff as well as reducing cost of service delivery. As such task shifting, work culture, health work policies and capacity building for health care workers should be geared towards providing differentiated care [59,63,70].

It is noted that patients who received care ,provided in a differentiated manner are more likely to be satisfied due to reduced cost of transportations (less frequent visits to the clinics) and waiting time at clinic [50].

Although DC is an exciting and potential "next step" in the delivery of HIV health care, it has already become apparent that it is not a cure-all and has its own unique set of difficulties [45].

Availability of resources (human and material) for the implementation of DC could be a potential barrier to its adoption [60]. If DC is not holistic in nature it will result in clash between patient appointments with other members of the multidisciplinary team, resulting in failure to honor some of the appointments. Inadequate staffing, lack of provider expertise on the concept as well as low literacy and lack of understanding on the part of patients can impact DC negatively. Finally, cost of training and supervision, needed for the implementation of differentiated care may countervail the traditional models of care [71,72].

Conclusion

Walker and Avants eight steps were employed in the concept analysis of DC. It has been established that DC is widely used and is of great importance to healthcare organizations worldwide especially third world countries due to its ability to address issues of scarcity of resources and quality of care especially in the care of people living with chronic infections like HIV and TB. Evolving targeted interventions, collaborative decision-making, a holistic person-- centered approach, multi-disciplinary collaboration, and resource optimization were identified in literature as the defining attributes of DC. It has been observed in the antecedents of Patient Population, Professionally Competent Healthcare Providers, and Organizational Support. DC would eventually result in improved patient outcomes and satisfaction, Efficiency, and Staff Satisfaction. By developing healthcare policies and guidelines and institution of quality improvement measures the effectiveness of DC could be assessed using PROM and patient satisfaction. Model, borderline, and contrary cases were developed to demonstrate what the concept is what it is not.

DC was defined as “a dynamic approach to healthcare for a specific patient population, that requires professionally competent healthcare providers, and organisational support, to tailor evolving targeted interventions to individ-ual needs, promote collaborative decision-making, adopt a holistic person-centred approach, encourage multi-disciplinary collaboration, and optimize use of resources leading to improved patient outcomes, mutual satisfaction of patient and staff and efficiency of the health system”.

Healthcare organizations willing to deliver top notch care to their patients can leverage on DC to achieve that.