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Medication Adherenc
Samantha Thompson
The Impact of Pharmacist Implemented HIV Medication Adherence in Minority Communities
samantha.thompson@famu.edu
7082204425
Jacksonville
FL
32206
Your summary must address all the questions below:
The FAMU-DOH Medication Adherence Program is designed as a practice that has been a positive staple in the Duval community for over five years. Located in Jacksonville, Florida, the Florida Department of Health-Duval (FDOHD, http://duval.floridahealth.gov/index.html) is the largest provider of HIV specialty care in Jacksonville. Serving over >1,500 HIV patients, FDOHD is dedicated to the comprehensive care of this population and also determined to foster pathways for all patients to be virally suppressed. This dedication and service is the design of the pharmacist-initiated and engineered medication adherence program. Funded by Ryan White Part C and clinically applied by the Senior Clinical Pharmacist and Assistant Professor of Advanced Pharmacy Practice at Florida A&M College of Pharmacy, the medication adherence program is supervised by the Senior Clinical Pharmacist. The Medication Adherence Program is composed of FAMU College of Pharmacy and Institute of Public Health clinical pharmacists as well as Pharm.D. Candidates. Pharm.D. Candidates are monitored by registered pharmacists at all times. Progress of medical interventions and adherence are monitored and submitted monthly to the Florida Department of Health.
FDOH also incorporates a central pharmacy on campus to continue the comprehensive care of these patients allowing both clinical outreach in the practice area and dispensing and medication adherence follow up expeditiously in the pharmacy.
Medication adherence, being the quintessential challenge of most therapies and huge public health issue, is key to achieving viral suppression. Therapeutic success has been achieved with anti-retroviral therapy, decreasing morbidity and mortality. First line therapy has resulted in adequately treating patients, blocking resistance, lowering adverse side effects, and contributing to increased CD4(+) counts and lowering viral load. With emerging and pharmacokinetically stable advances in HIV medication regimens, there has been an alarming incidence in HIV in Duval as well as a rising level of viral load. Viral suppression, usually measured by a viral copy of <200 copies/mL or less, is the goal of HIV therapy. Viral suppression, as well as high CD4(+) count, not only ensures the patient's successful immune response but also severely decreased the ability to spread the virus to another person. In 2015, Dr. LeMorris Prier, former Sr. Clinical Pharmacist, was touched by the amount of minority men not reaching undetectable status. He implemented the FAMU-FDOH Medication Adherence Program to ensure that all patients, especially minority male HIV patients, were able to access their medication and an outlet to hold themselves accountable for their therapy. Weekly to monthly appointments and daily adherence calls were scheduled and success was measured by decrease in viral load, increase in CD4(+) count, and quality of life surveys. This practice still continues today with a compendium of data that furthers research and positively impacts public health.
Goals of the Medication Adherence Program
Deliverables of the Medication Adherence Program
Impactful outcomes have been both objective and subjective. Feedback from the community has been immensely positive, non-compliance lowering from 88% in 2016 to >40% in 2019. Huge milestones include positive feedback from the state capital, success in large audits and reviews by Ryan White, and submission for publication of adherence research. Medication adherence is one of the largest public health issues however it is the honor of this program to address the behavioral aspect of HIV therapy.
Monthly reports to the State of Florida are required to be submitted by the Sr. Clinical Pharmacist describing what obstacles occurred recently that may have impacted any success in the program. Objectives that are met monthly include the contact of at least 60 non virally suppressed patients. Reaching goals of viral suppression on a larger scale can be much more challenging. Outpatient adherence is, once again, a behavioral public health issue. However, providing constant verbal and medical support is extremely helpful for our patients. Success we have found with patients in this program usually centers around monthly pick- ups that were preluded by phone calls from the adherence team to pick up medication. These pick-ups are then followed by a brief medication adherence interview by the pharmacist or Pharm.D. Candidate.
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
This practice is not new to the field of public health although is does address a huge public health issue with a creative way of modifying an existing tool: medication adherence outreach. Primarily providing care for the minority HIV population in Duval, the FAMU-FDOH Medication Adherence Program possessed pharmacist initated and engineered adherence initiative that was designed by minority pharmacists to connect with minority patients. The program is not specifically implemented for minority patients however it was initially designed to meet with specific needs of minority HIV patients (particularly minority male patients). In 2016, over 85% of the minority male patients were reported as either non adherent to their medication regimens, lab appointments, and/or doctor's appointments. Research prior to the initation of this program demonstrated the lowest adherence in HIV therapy was from minority males. The Department of Health recognized this need and fostered a relationship with a FAMU College of Pharmacy, a historically black college, that would help address this specific need. Pharmacists, who are now seen as invaluable members of the healthcare team, have the training to foster a full clinical acumen and lifelong learning, possess the skill of bridging the clinical portion and medication maintenanace. The Senior Clinical Pharmacist funded for this program is not only required to have an extensive research and clinical background but also demonstrates competency in the clinic and lab on campus and verfication, ordering, and dispesning of all medications prescribed in the clinic. Innovation was expressed with a simple question: Would minority populations feel compelled to be more adherent if they had access to an adherence counselor to help them navigate through their care and advocate for their health? Inventive tools involving extensive empathy and cultural competency were applied extensively. While not always able to positively reach and maintain every patient, positive feedback was enormous.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
The FAMU-DOH Medication Adherence Program is designed as a practice that has been successfully granted a plethora of resources that have maintained this practice for several years. The medication adherence program is funded by Ryan White Part C and is clinically applied by the Senior Clinical Pharmacist and Assistant Professor of Advanced Pharmacy Practice for a yearly contract. Maintenance and sustainability are reviewed by the State of Florida and Ryan White every month with Medication Adherence and Viral Suppression reports which are completed by the Sr. Clinical Pharmacist. In 2015, Dr. LeMorris Prier, former Sr. Clinical Pharmacist, was touched by the amount of minority men not reaching undetectable status. He implemented the FAMU-FDOH Medication Adherence Program to ensure that all patients, especially minority male HIV patients, were able to access their medication and an outlet to hold themselves accountable for their therapy. Weekly to monthly appointments and daily adherence calls were scheduled and success was measured by decrease in viral load, increase in CD4(+) count, and quality of life surveys. This practice still continues today with a compendium of data that furthers research and positively impacts public health. While the implementation and planning process was simple in theory, challenges that occur between any two entities presented themselves, mostly financially. These challenges were addressed with the involvement and positive participation between FAMU and DOH. Consistent and effective reporting has been a measurable outlet to remain compliant with not only all standards set forth by Ryan White but also standards of HIV medication adherence and care. What was an invaluable lesson learned about the partnership between an academic entity and a local health department is maintaining and fostering the professional bridge between the two organizations. Complete transparency, even in the midst of lack of funding, disappointing results, low adherence, and distorted communication, is always required for the best outcome between two entities. Both organizations, FAMU and the Department of Health-Duval, have made a commitment to remain transparent about the deliverables of this practice. Measuring clear deliverables and communicating effectively to the team regarding follow up, obstacles, and triumphs is essential for success. This success isn't limited to the success of continuing the grant. In my opinion, it is primarily measured by the subjective and objective response of the patients in our program. Since adherence is measured by objective data, it is collected by subjective data. This includes phone calls, office visits, and medication adherence appointments. These visits are not long, usually 15-20 minutes, including a full evaluation of medication regimen, possible adverse side effects, access to care, and most importantly the accomplishing viral suppression. Of course, objective data such as quarterly lab results are necessary for measuring the effectiveness of this practice as well. Cost/benefit analysis are completed by the Executive Leadership Team yearly at the Department of Health, evaluating the results of the viral suppression and medication adherence programs, as well as the impact the pharmacy medication adherence team and clinical pharmacy interns have made on the population.
Goals of the Medication Adherence Program
Deliverables of the Medication Adherence Program
Steps that are consistently completed to continue the success and growth of the medication adherence program include monthly follow up with the State of Florida (Ryan White) as well as with the contract manager, medical director, and director of pharmacy. These reports and follow up describe the statistical analysis of the adherence program, particularly patients who are not virally suppressed.
No start up costs were needed with implementation of this practice.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
It is honorable to say, as a researcher, that long term health goals are clearly being reached. This is seen with both objective and subjective patient data. What was discovered was that HIV medication adherence, although primarily target for minority patients and implemented by minority pharmacists, is still completely behavioral. Access to care at FDOH may be extremely manageable for some patients but for others, no matter what background they may be from, is impossible. We have seen this primary data in patient surveys throughout the past 4 years both at the pharmacy as well as in research settings for IRB approval and publication. Additional data is compiled by the Pharm.D. Candidates and Sr. Clinical pharmacist and is compressed by a statistician from Florida A&M University. With over a 40% increase in medication, lab, and clinical appointment compliance, short term success has been reached with more undetectable virus statuses. However, long term goals, some reaching over 10 years, include completely eradicating HIV from the population entirely. Another includes achieving viral suppression for >95% of patients in Duval. Results, whether monthly or quarterly, are analyzed by the Senior Clinical Pharmacist, Director of Pharmacy, Chief Medical Director, and contract manager. Perfomance measures, outside of subjective and objective information from patients and team members include laboratory levels, appointment adherence, and sucessful medication pick ups every 30 days. Modifications made included incorporating a "ready fill" program for patients in compliance with their Ryan White and AIDS Drug Assistance Program (ADAP). This additional program has allowed patients to faithfully pick up their medication every thirty days without calling for a refill request. The Medication Adherence program is able to access this system to quickly to find patients who have missed their pick up times. A phone call is made to the patient to discuss the importance of adherence and picking up their medication. A further medication interview is completed over the phone as a follow up and discussion of obstacles are covered with the patient. The provider is always immediately informed of encounter. Further developments include modifying to delivering medications to patients without transportation.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
The FAMU-DOH Medication Adherence Program is designed as a practice that has been successfully granted a plethora of resources that have maintained this practice for several years. The medication adherence program is funded by Ryan White Part C and is clinically applied by the Senior Clinical Pharmacist and Assistant Professor of Advanced Pharmacy Practice. Maintenance and sustainability are reviewed by the State of Florida and Ryan White every month with Medication Adherence and Viral Suppression reports which are completed by the Sr. Clinical Pharmacist. This reporting has been an effective and measurable outlet to remain compliant with not only all healthcare standards but also standards of HIV medication adherence and care. What was an invaluable lesson learned about the partnership between an academic entity and a local health department is maintaining and fostering the professional bridge between the two organizations. Complete transparency, even in the midst of lack of funding, disappointing results, low adherence, and distorted communication, is always required for the best outcome between two entities. Lessons learned in relation to practice sustainability have been involved with the research and success of lowering viral load in our patient population. This, I found, requires an exceptional team. Both organizations, FAMU and the Department of Health-Duval, have made a commitment to remain transparent about the deliverables of this practice. Measuring clear deliverables and communicating effectively to the team regarding follow up, obstacles, and triumphs is essential for success. This success isn't limited to the success of continuing the grant. In my opinion, it is primarily measured by the subjective and objective response of the patients in our program. Since adherence is measured by objective data, it is collected by subjective data. This includes phone calls, office visits, and medication adherence appointments. These visits are not long, usually 15-20 minutes, including a full evaluation of medication regimen, possible adverse side effects, access to care, and most importantly the accomplishing viral suppression. Of course, objective data such as quarterly lab results are necessary for measuring the effectiveness of this practice as well. Cost/benefit analysis are completed by the Executive Leadership Team yearly at the Department of Health, evaluating the results of the viral suppression and medication adherence programs, as well as the impact the pharmacy medication adherence team and clinical pharmacy interns have made on the population.
