Florida Department of Health in Broward County
Use of Inter Program Collaboration to Improve HIV Retention in Care
Brief description of LHD
Broward County's 2016 population estimate of 1,809,604, represents 10% of Florida's population (US Census). Its residents represent over 200 different countries speaking more than 130 languages with 31.5% of residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2016 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%). Broward County has received federal designations of both a Health Professional Shortage Area and Medically Underserved Area and Population in multiple geographic areas and populations within the county.
The Florida Department of Health in Broward County (DOH-Broward) is the official lead Public Health Agency in Broward County and is part of the Integrated Florida Department of Health (DOH) which provides core public health functions and essential services as part of a complex public health system that includes hospitals, clinics, planning agencies, and community-based organizations.
In 2013, the Fort Lauderdale metropolitan statistical area ranked 10th in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. In 2014, Broward County had the 2nd highest number of new HIV cases of all 67 Florida counties. The public health issue is the care and treatment of HIV AIDS clients. The goal and objective of this practice is to increase HIV medication adherence and reduce the number of clients that fall out of care. The practice began in May 2016 and has been effective in engaging HIV DIS staff to identify pharmacy clients whose medications had not been picked up in a timely manner and were therefore returned to pharmacy stock.
The specific factors that led to the success of this practice were the re-tasking of HIV DIS workers to focus on medication adherence as evidenced by the non-pickup of prescription HIV medications. The Public Health impact of this practice was a reduction of the number of HIV clients lost to care.
Web Address (if applicable) www.broward.floridahealth.gov
Statement of the problem/public health issue
The public health issue addressed is the enhancement of quality of care and treatment of HIV clients such that the community viral load is minimized to the greatest extent possible.
What target population is affected by problem (please include relevant demographics)
o What is target population size?
The average number of HIV clients served per month by the DOH-Broward pharmacy is 2,113, with an average of 230 clients that did not pick-up their prescriptions in a timely manner each month.
o What percentage did you reach?
The average percentage of the target population reached was 79%. Of the average number of clients (230), 41% were reached by pharmacy, the remainder (59%) were referred to HIV DIS staff.
Of the HIV DIS referred clients (59%), 64% returned to pharmacy on the subsequent month. 59% x 64% = 38%.
The net result was 38% + 41% = 79%.
What has been done in the past to address the problem?
Prior to implementing this proactive integrated program, DOH-Broward's HIV clients received automatic calls from the pharmacy IVR system to alert them when their prescriptions were ready for pickup and ADAP program staff monitored clients' enrollment status.
Why is current/proposed practice better?
The DOH-Broward practice is better because it engages pharmacy and HIV DIS staff to collaborate and identify and locate potentially non-adherent HIV clients so as to retain them in care to improve retention in care and potentially reduce new HIV rates.
Is current practice innovative? How so/explain?
The practice is innovative. To our knowledge, DOH-Broward is the only Health Department that utilizes this practice model. The process of utilizing pharmacy and HIV DIS staff to take a proactive approach to locate potentially non-adherent HIV clients is innovative and new to the field of public health by ensuring no opportunity is missed to identify a non-adherent, or potentially â€˜lost to careâ€ HIV client. What tool or practice did you use in an original way to create your practice?
DOH-Broward utilized the Program Collaboration System Integration Model (PCSI). For this practice to be successful, internal stakeholders must be willing to collaborate on a daily basis
Is current practice evidence-based?
The practice is evidence based in that is follows the CDC, AIDS.gov, and the National HIV/AIDS Strategy (NHAS).
HIV in the U.S.
Goal(s) and objectives of practice
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 in order to improve health outcomes and reduce new HIV infections.
What did you do to achieve the goals and objectives?
Steps taken to implement the program included a series of multidisciplinary staff meetings within DOH-Broward. 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, assess their adherence to their drug regimen, and either re-engage them 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.
The process is provided by DOH-Broward's existing pharmacy network whereupon pharmacy staff assure that HIV clients who are enrolled in the Aids Drug Assistance Program (ADAP) and the local 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.
Newâ€ prescriptions are packaged with a medication education sheet and every client, at every pharmacy visit, is offered counseling by the pharmacist. Clients are asked, at every pharmacy visit, to verify their telephone number which pharmacy staff maintain in the pharmacy computer software system. DOH-Pharmacy staff automatically refills clients' prescriptions five days in advance of their refill dueâ€ date.
The pharmacy's commercial off-the-shelf software (QS/1), which includes an Interactive Voice Response (IVR) feature, is programmed to call each client and advise that their prescription(s) are ready for pickup.
Four automated phone calls are made over 8 days: notification/reminder calls are made on day 0, 3, 7; and a final call on the 8th day advising that the medication will be returned to stock unless picked up.
Each workday, pharmacy staff generate a return to stockâ€ 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 filledâ€. Note that that clients begin receiving calls before their prescription is actually due.
A grace period is needed due to a limitation of the software which is such that the programming for the return to stockâ€ report utilizes the date filledâ€ instead of the date receivedâ€.
Each workday, pharmacy staff generates a return to stockâ€ report and personally call each client (no message is left if a voicemail is reached). Using an EXCEL file on a secure network drive, Pharmacy staff enter: the client's demographic information; date called; indication if the prescription was returned to stock; 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.).
Each workday, DOH-Broward HIV Disease Intervention Specialists (DIS) review the EXCEL file to identify which clients have not been successfully contacted by the pharmacy staff. DOH-Broward HIV DIS staff then utilize a variety of methods to locate HIV clients such including database searches (ie: client search databases include Lexus Nexus, DAVE, PRISM, Provide Enterprise, Careware, HMS, FMMIS, FLSHOTS, WAGES, MEVSNET, eHARS, ADAP, 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 make every attempt to re-engage them into care by calling case managers, clinicians, and/or other individuals connected with their care.
HIV and pharmacy staff work closely together to communicate information, needs, and activities.
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. In advance (30 days) of each client's ADAP eligibility, ADAP staff call the client to advise of their eligibility expiration date and make an appointment for re-enrollment. Reminder calls is made 2 days prior to their appointment date.
Regarding missed appointments: ADAP eligibility staff attempt to contact the client to reschedule as soon as possible, same day whenever possible. If staff is unable to locate the client, then the information is referred to HIV DIS who endeavor to locate the client (by phone or possibly a home/field visit) to address and remove barriers related to their re-enrollment.
To evaluate the results of this DOH-Broward HIV DIS initiative, an EXCEL report was programmed to determine the number (and percentage) of unique HIV pharmacy clients that had a prescription returned to stock (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 care.
The Director of Pharmacy provides a monthly report to the DOH-Broward Public Health Director as to 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 referredâ€ to HIV DIS, and the percentage of clients who did not pick-up their prescriptions that returned to the pharmacy (retained in care).
Any criteria for who was selected to receive the practice (if applicable)?
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.
What was the timeframe for the practice
The timeframe for the practice is implementation in July 2016 and is now a routine part of the DOH-Broward client care process.
Were other stakeholders involved? What was their role in the planning and implementation 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.
o What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
We have 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 in order to assure retention in care as well as appropriate care and treatment of HIV/AIDS clients.
Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown.
Specific factors that led to the success of this practice included hiring and training of 2.0 FTE HIV DIS staff ($31,500 salary per employee), expanding the role of pharmacy staff to closely monitor prescription pickups and work closely with HIV DIS staff, education and training of Pharmacy and HIV DIS staff, and development of specialized EXCEL reports. Information Technology programming cost was approximately $1,000.
What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section.
The goal and objective is the increase of medication adherence and retention in care for HIVAIDS clients in order to reduce new HIV infections and improve health outcomes.
DOH-Broward found out that over the past seven months, the average number of pharmacy clients that did not pick-up their prescriptions that responded to pharmacy staff's phone calls was 41%. The remaining 59% of clients were evaluated by HIV DIS staff.
DOH-Broward learned that, of the clients evaluated by HIV DIS staff, an average of 64% of clients returned to the pharmacy the following month to pick up their prescriptions.
From May-November 2016, the DOH-Broward Pharmacy served an average of 2113 HIV + clients per month. An average of 229 clients per month did not pick up their medications. 41% of phone calls to clients were successful in reaching the client and have the medication picked up. The remaining 59% of clients were referred to a HIV-DIS to locate the client and retain them in care.
% OF PATIENTS WITH NOT PICKED UP RX THAT RETURNED TO PICK UP THE FOLLOWING MONTH:
# of clients that did not pickup
DOH-Broward's objective was achieved. We continue to see a decline in the number of HIV clients not picking up their HIV medication in a timely manner which is a measure of increased adherence and increased retention in careâ€.
o Primary data sources include: internal secure database, electronic HIV/AIDS reporting system (eHARS), Patient Reporting Investigating Surveillance Manager (PRISM), electronic lab reporting. Data was collected by the Pharmacy, ADAP, and perinatal staff.
o List any secondary data sources used (if applicable)
o Performance measures were created and tracked in the DOH-Broward performance management system, Active Strategy. These include prescriptions picked up, number of medications returned to stock, number of clients who did not pick up medications, number of client's reached, pick up rates, and treatment adherence.
o Describe how results were analyzed. Our objective of preventing transmission of HIV has been achieved. Due to this objectives success, the process will continue and is supported by DOH-Broward's Director. Every LHD that interacts and/or serves HIV clients may have potential benefit this program by reducing HIV transmission through medication adherence. DOH-Broward analyzed the process and determines there is an improvement in knowledge and awareness by DOH-Broward Pharmacy and ADAP staff regarding the importance of clients understanding the importance of medication adherence to reduce or eliminate the risk of transmission of HIV thus improving health outcomes.
o Were any modifications made to the practice as a result of the data findings? No
Lessons learned in relation to practice
Lessons learned were such that there was an improvement in knowledge and awareness by DOH-Broward Pharmacy and ADAP staff regarding the importance of retaining HIV clients in care.
Lessons learned in relation to partner collaboration (if applicable)
As a result of this practice, DOH-Broward's relations with its community partners improved through interagency collaboration. DOH-Broward is able to refer and link clients into care very effectively. Community partners are extremely appreciative of the efforts by DOH-Broward to retain HIV clients in care and alert clinicians to clients with possible adherence issues.
Did you do a cost/benefit analysis? No
Is there sufficient stakeholder commitment to sustain the practice? Yes, there is sufficient stakeholder commitment from clients, pharmacy staff, and HIV DIS staff to sustain this practice.
o Describe sustainability plans
DOH-Broward is attempting to develop documentation and billing activities such that payors/providers could fund the major portion of this endeavor.
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