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HIV clinic gets ART to toughest cases
Patients with 10-plus meds targeted
For HIV providers who continually see a certain cohort of patients return to the hospital and fail on their antiretroviral therapy (ART) regimens, there's a new model for medication support that might prove helpful.
The outpatient Comprehensive Care Center HIV clinic in Nashville, TN, launched a program in January, 2009, that identifies HIV patients most at risk for health and medication-related problems and provides them with medication therapy support.
The program includes a full-time nurse case manager, a nurse practitioner, and a part-time pharmacist who handle all referrals for medication adherence and other issues.
More than 2,200 HIV patients visit the clinic, and about 450 of them have prescriptions for 10 or more medications, says Kimberly S. Lippard, RN, MSN, case manager of clinical pharmacy services at Comprehensive Care Center.
ART adherence is a huge issue at the clinic, but it's particularly problematic for the people who have comorbidities and high numbers of medications, she notes.
The clinic formed the interdisciplinary team to improve outcomes and to give physicians assistance in achieving optimal medication therapy adherence.
"Our chief medical officer was astute to admit that when it came to medication reconciliation and screening for drug events and interactions, he and the other providers didn't have time to do all that needed to be done," Lippard says.
The team is dynamic with different backgrounds and strengths, she says.
"I look at a patient's issue and see if it's something I can handle or if the nurse practitioner or pharmacist needs to handle it," she says.
For instance, some patients have ongoing substance abuse problems, and the nurse practitioner has a great deal of experience in working with these patients, Lippard explains.
"And some patients are on 20-plus medications, and our pharmacist can quickly and easily look at their medication list, screen for drug-drug interactions, and see which medications they might not need to be taking," she says.
The team members' clinical pharmacy services time is covered by Ryan White funding, which gives them flexibility in how they pursue solutions.
For instance, Lippard or the nurse practitioner might go to great lengths to track down a patient who, perhaps for substance abuse reasons, has stopped coming to the clinic.
"We will go out looking for the patient, calling family members, or checking certain drug hotspots," Lippard says.
The team's pharmacist also provides smoking cessation sessions, which is a big issue for some patients, she adds.
The team also has collected some useful data about the clinic's patients. For instance, they found that only 6% of the HIV patients brought their medications with them to the clinic on a regular basis, Lippard says.
"There was this huge gap in being able to accurately assess these patients and provide medication reconciliation, and so that's where we've tried to target our efforts," she says. "We've had some improvement in this."
Team members also track their total number of patient contacts and drug events, finding that from January, 2009, to October, 2009, they had 651 patient contacts and discovered 220 adverse drug events and 446 potential adverse drug events, she adds.
"Our ultimate goal is for every patient who comes to the clinic to have a medication reconciliation done, but that's not a reality right now," Lippard says.
The team initially tackled all 456 cases of patients taking 10 or more medications, meeting with these patients when they visited the clinic to conduct medication reconciliation.
"In some cases we'd have to call the patient's pharmacy to do the medication reconciliation," Lippard says. "So we slowly tackled the list."
Also, soon after the program began, the clinic's medical and psychiatric providers and social workers began to refer patients with actual or anticipated adherence problems and other issues.
"We'd receive notes from providers stating that patients had issues going on in their lives that could cause problems with medication adherence, and so we'd target those patients first," Lippard says.
Other referrals arrive from outside organizations that work closely with the clinic's patients.
The team approach to medication reconciliation might have begun as a way to take some of the burden off of providers' shoulders, but it has also been a boon to patients.
Team members develop trust with patients and take a long view, with follow-up care.
"I handle a lot of issues with patients being unable to afford their medications or co-pays," Lippard says.
She looks for programs that could assist them with obtaining medications, and she also might help patients receive home health services or hospice care when these are needed.
"I work with the inpatient case manager, ensuring our patients have had a medication reconciliation to see if any of their drugs have changed," Lippard says.
The medication reconciliation team also is involved in the clinic's twice-weekly ART conferences.
Providers attend one of these Tuesday or Friday morning conferences to discuss all patients starting new therapy or changing their medication regimen because of side effects or treatment failure.
"The conferences give everyone a chance to discuss patients and what's going in their lives, including whether a patient is homeless or is being turned down for coverage by a medical insurer," Lippard says. "There might be a psychiatric issue or other things going on."
Through the conference, new patients are automatically referred to the team, which meets with new patients for 40 minutes to an hour to discuss HIV, its pathology, how HIV affects the body, general medication information, and the patient's specific medication.
"We screen patients' backgrounds to find out what support systems they have and where they live," Lippard says.
The program is too new to show concrete outcomes, but anecdotal evidence suggests that it is making a big difference in patients' lives.
For example, Lippard had one 51-year-old female patient who had been admitted to Vanderbilt Medical Center repeatedly for hospitalizations due to her poor medication adherence and renal disease.
"She came to our clinic to see one of our providers, and he referred her to our team, saying, 'She has a huge bag of medications, and I don't have time to go through all of them,'" Lippard recalls.
"I sat down with the woman and found out she was taking old HIV medications that had been discontinued months ago, along with new HIV medications," she adds. "So she was double-dosing with medication."
Med woes, substance abuse
Plus the woman was taking multiple doses of Lactulose, a diarrhea medication. She had a prescription under one generic name and a second prescription under a different generic name, and she didn't know they were the same thing.
"And she was taking old hypertension medications that had been discontinued months ago," Lippard says.
Since the woman had most recently been admitted to the hospital for hypotension and acute renal failure, her continuing the old medication was particularly alarming.
And despite her double-dosing of ART, her HIV disease was not well controlled because of her inconsistent medication habits when she was home, Lippard says.
On top of everything else, the woman had long-standing substance abuse issues.
The team addressed all of her problems by eliminating the duplicate and unnecessary medications and helped her become adherent to her ART.
"I met with her several times, and I am still following-up with her today," Lippard says. "She has been managing her HIV disease very well, but because of her substance abuse issues, her renal disease and the decline of her mental status, she's now in hospice care."
When team members meet with patients like this woman, they go over all of the patients medications, discussing why the patient needs to take certain drugs and why others should be discontinued.
'We talk about what the side effects are and help them understand their medications better," Lippard says.
"We work with setting up weekly pill boxes that are delivered in bubble packets once a month," she adds.
These show patients which pills to take at which times.
"We provide an education sheet that shows a picture of the pill, its brand name and generic name, and it provides information on how to take the medication, when to take it and what the side effects are," Lippard says. "They can hang this information from their refrigerator and it serves as a guide.