The goal and objective of this practice is to increase adherence to HIV medication therapy and reduce the number of clients that fall out of care to improve health outcomes and reduce new HIV infections. According to the CDC, Improving the health of persons with HIV and reducing the number of new infections in the United States will depend on increasing access to HIV medical care and eliminating disparities in the quality of care received.” Steps taken to implement the program included a series of multidisciplinary staff meetings within DOH-Broward to create and deploy action plans. DOH-Broward endeavored to find a simple, easily deployable, and cost effective method to identify LHD clients who have not picked up their HIV medication, locate lost to care clients that are referred to the DOH-Broward PROACT Program, and either re-engage clients into care as appropriate and/or consult with the client's healthcare provider to provide timely feedback so as to provide optimal care and treatment.
DOH-Broward's pharmacy staff assure that HIV clients who are enrolled in ADAP and Ryan White Pharmacy Assistance program are receiving their HIV medications as prescribed. HIV medications are provided by DOH-Broward Pharmacy Department pursuant to prescriptions authorized from client's physicians/providers. Each workday, pharmacy staff generate a return to stock” report, which identifies all prescriptions that have not been picked up for 11 days (5 days early, plus a 6-day grace period) after the prescription's date filled”. Clients begin receiving automated prescription reminder refill calls before their prescription is due to ensure every opportunity is offered to pick up medications.
DOH-Broward pharmacy staff review the return to stock” report, retrieve the matching prescriptions from the medication pickup area and personally call each client by telephone. To ensure confidentiality, no messages are left on voicemail. Pharmacy staff document each call on a a shared Excel file and enter: the client's demographic information; the date called; an indication if the prescription was returned to stock; and a notation regarding the outcome of the personal call (ie: client contacted arriving today or another day, no answer, phone disconnected, wrong number, client in hospital, etc.).
DOH-Broward HIV Disease Intervention Specialists (DIS) review the Excel file to identify which clients have not been successfully contacted by the pharmacy staff of the two DOH-Broward Pharmacies, one in Ft. Lauderdale and the other in Pompano Beach. DOH-Broward HIV DIS staff then utilize a variety of methods to locate HIV clients such as database searches to obtain the most current contact information. Some client search databases include: Lexus Nexus, Driver and Vehicle Information database (DAVE), PRISM, Florida Department of Health STD Reporting database, Provide Enterprise, Broward County Ryan White HIV clinical database, Careware (HRSA database for HIV Clients), HMS, Florida DOH Health Management System, FMMIS, Florida Medicaid Management Information System, FLSHOTS, Florida Immunization database, WAGES, Wage database from Bureau of Labor eHARS, Enhanced HIV AIDS Reporting System, ADAP, AIDS Drug Assistance Program, FDLE type of database, Social Media and home visits as necessary. The HIV DIS staff ascertain/determine the reasons for which clients' have not picked up their HIV medications and clients that are lost to care. Every attempt to re-engage clients into care is made including calling case managers, clinicians, and/or other individuals connected with the client's care. The HIV DIS provide client contact outcome results to the Communicable Disease Director such as, returned to care, unable to locate, out of jurisdiction, incarcerated, refused services, in care, and has medical insurance,
Additionally, a separate but related activity is continually performed to help retain HIV clients in care: DOH-Broward's ADAP eligibility staff attempt to contact clients that have missed their ADAP re-enrollment appointment. An indicator of adherence to HIV medication treatment is compliance with re-enrollment in medication assistance programs. Thirty days before a client's ADAP eligibility is due to expire, ADAP staff call the client to advise/confirm their eligibility expiration date and make an appointment for re-enrollment. Appointment reminder calls are made two days prior to the appointment date. ADAP eligibility staff attempt to contact the client to reschedule as soon as possible after a missed appointment. If staff is unable to locate the client, the client is referred to a dedicated HIV DIS who attempt to locate the client to educate on the importance of adherence, address and remove barriers related to re-enrollment such as transportation issues by providing a bus pass.
To evaluate the outcomes of the DOH-Broward HIV DIS initiative, data is exported to an Excel report to determine the number and percentage of unique HIV pharmacy clients that had a prescription returned to stock (voided and/or not picked up) in a given month and whether that same client had a prescription filled during the following month. This indicates whether the client was lost to pharmacy care.
On a monthly basis, the Director of Pharmacy reports to the DOH-Broward Health Officer the total number of clients on the return to stock reports, the total number of clients successfully contacted by pharmacy staff, the number of clients referred” to HIV DIS, and the percentage of clients who did not pick-up their prescriptions that returned to the pharmacy (retained in care). Metrics were created in the department's performance management system, Active Strategy, to monitor this information monthly, to track trends and historical information. The criteria for those selected to receive the practice was any DOH-Broward pharmacy client that did not pick their HIV medication within 11 days of being filled and clients referred to PROACT as lost to care. The timeframe for the practice is implementation in July 2016 and is now a routine part of the DOH-Broward client care process. Other stakeholders involved with this program were the DOH-Broward HIV/AIDS program's ADAP staff and community HIV/AIDS providers with clients receiving medication(s) from the DOH-Broward Pharmacy. Their role in planning and implementation was nominal.
DOH-Broward has developed strong partnerships with our stakeholders that are involved in the system of care in Broward County. These include, but are not limited to the grantees for Ryan White Part A, Ryan White Part B, Ryan White Part C, Ryan White Part D, Community Based Organizations, Case Management agencies, Food Banks, and Substance Abuse Facilities. DOH-Broward Pharmacy and HIV DIS work closely with staff from these agencies to assure retention in care as well as appropriate care and treatment of HIV/AIDS clients.
Specific factors that led to the success of this practice included hiring and training of 5.0 FTE HIV DIS staff ($31,500 salary per employee), expanding to closely monitor prescription pickups and work closely with HIV DIS staff, education and training of Pharmacy and HIV DIS staff, development of a shared Excel spreadsheet, and the development of a specialized Excel report to process the pharmacy prescription information. Information Technology programming cost was approximately $1,000. All the information that is gathered about these clients are entered in a local database called HPPCC database. This database allows us to review the staff client load and discuss outcomes.