New Jersey pilot study brings community pharmacists to the adherence table
If successful, such a program could go national
Even as the HIV health care community continues to make progress in improving patients' adherence to antiretroviral medication regimens, there remain some growing and stubborn obstacles to individual patients achieving the 95-plus percent adherence rate deemed optimal.
Now a statewide pilot in New Jersey seeks to add a potent new step in adherence strategies. In this pilot, community pharmacists, who are the last health care professionals to see patients before they take their medications home, will provide adherence counseling to individual patients.
If the pilot is successful, it has the potential to become a national model for HIV adherence, funded by state and federal money through Ryan White and/or AIDS Drug Assistance Programs (ADAPs).
"If this works, it gets exciting," says David Schwed, RPh, FACA, APhA, president of Woodruff Drugs in Bridgeton, NJ. Schwed is an independent pharmacist and an investigator involved with the pilot.
There is some research showing positive results when pharmacists are involved in HIV medication adherence, but this large-scale adherence pilot might break new ground and open up some promising possibilities for HIV care and support services.
"ADAP is really sold on doing the pilot," Schwed says. "They see the merits of a well-run program, but they need results for verification internally in order to expand and continue the services."
Looking further ahead, if the study shows success and other state ADAPs climb on board, then state Medicaid programs might not be too far behind, Schwed predicts.
"Then we'll move to mainstreaming the program with a larger network of niche pharmacies providing HIV medication adherence services," Schwed says.
"The point of it is that these are community pharmacies where people are accessing care, and it's the last step before they take their medication," says John Faragon, PharmD, of Poestenkill, NY. Faragon is a pharmacy consultant with the New York/New Jersey AIDS Education and Training Center (AETC), and he's a co-investigator on the study of the pilot.
The community pharmacist adherence pilot will be studied as collaboration between New York/New Jersey and Pennsylvania/Mid-Atlantic AETCs and the AIDS Drug Assistance Program (ADAP) of New Jersey. Enrollment is expected to begin in the fall of 2008.
Some community pharmacists have been providing medication therapy management (MTM) services for diabetes and a few other chronic diseases for more than a decade, but this is likely the first time such a program has been extended on a large-scale basis to the HIV world, says David Rosen, MSW, LCSW, a co-investigator on the pilot. Rosen works in AIDS education at the University of Medicine and Dentistry of New Jersey, a local performance site of the New York/New Jersey AETC, located in Newark, NJ.
All pharmacy students now graduate with a PharmD degree, so there is a great potential for these well-trained individuals to provide medication management services, including meeting with patients to discuss medication side effects, interactions, and adherence strategies, Rosen says.
"The opportunity is greater now with the PharmD programs," Schwed says. "These [younger] pharmacists are trained to work with care teams, which we were lacking in my day," he adds. "We had to build those relationships one at a time."
So there is a pool of pharmacists who are open to the idea of providing medication management for HIV patients, provided they receive the necessary training in HIV/AIDS medication and provided they have the time available for such MTM, Schwed and Rosen say.
What makes researchers optimistic about the pilot's potential to show success in improving adherence among HIV patients is the way it utilizes a setting that is a common place to visit for this population.
"The idea for using the community practice setting is that a barrier to adherence, which has been documented in many studies, is accessibility," Rosen says. "Patients can't get into adherence counseling and receive an intervention if they don't show up for a doctor's appointment."
But these same patients often will show up to their regular pharmacy to pick up medications, and once they're there, they're a captive audience, he adds.
The biggest obstacle to having pharmacists involved in medication management and reinforcing a health care team's adherence messages is the lack of reimbursement for these services, they add.
"We have not been reimbursed for this type of service in an HIV population," Schwed says.
Since 1995, some Medicare programs and a select number of private insurers have paid for pharmacy adherence counseling for diabetes, chronic obstructive pulmonary disease (COPD), heart failure, hypertension, asthma, dyslipidemia, rheumatoid arthritis, osteoporosis, osteoarthritis, and depression.
But additional training and certification is needed for these programs to be successful, and this includes additional HIV/AIDS education for pharmacists.
Researchers found solutions through a collaborative pilot that uses AETC's training services to give motivated pharmacists the additional education they need and the New Jersey ADAP, which will pay for the study, including a $1.20 per minute for the pharmacists' adherence counseling time.
"I've been working for almost seven years specifically as a pharmacist-dedicated training coordinator for the New York/New Jersey AETC," Rosen says. "It's unusual for an AETC to dedicate significant training resources to develop, staff, and maintain a comprehensive training program for pharmacists, but the NY/NJ AETC saw the need in our region and made it possible for UMDNJ to do it."
As a result of these training activities, the New York/New Jersey AETC site at UMDNJ has been connected with Doug Krampel, RPh, who has conducted adherence research with the Health Federation of Pennsylvania, which is a local performance site for the PA/Mid-Atlantic AETC, and is one of the leaders of the adherence pilot, Rosen says.
The idea is to enroll pharmacists who are interested in HIV/AIDS training and providing patients with adherence counseling, he explains.
They'll receive about 36 hours of training through AETC. This will include didactic lectures and home-study training.
The pharmacies involved in the pilot also will need to set aside private space for the face-to-face counseling sessions.
Finding such space shouldn't be a problem, Schwed says.
"My pharmacy has 1,000 square feet including a storage area," Schwed says.
"I have 150 square feet that are walled off with a door for the pharmacist to go in and a door for the patient from the front," he explains. "It has no windows, and it's highly private for the patient to receive extensive counseling, and we've used this for counseling for many years."
Pharmacies also could use any suitable separate room or partitioned area in the pharmacy, Faragon says.
The study's protocol calls for pharmacists to spend 40 minutes in a first face-to-face counseling session with patients when they arrive to pick up their HIV medications, Rosen says.
During the first month, patients will be seen twice in face-to-face sessions, with the second meeting lasting about 20 minutes, Rosen adds.
The first encounter will focus on education and adherence counseling, including the importance of taking medications, understanding side effects, knowing when to call the provider, and other common issues, Faragon says.
"We're teaching pharmacists how to assess patients' adherence and how the patients are doing from a side effects standpoint," Faragon says.
The patient assessment might include a referral to a social worker if major barriers are found, such as if the patient has issues that might affect his or her adherence, including drug abuse, alcoholism, being homeless, etc., Schwed says.
Pharmacists and patients will develop an adherence plan and have the patient sign off on it, Rosen says.
"Each month there will be at least one face-to-face visit when the patient is picking up his medications," Rosen says. "There are two contacts with the patient each month, and the second one could be a telephone call or email or face-to-face, depending on the need of the patient."
For instance, patients who have co-morbidities might need more in-person counseling, but this is beyond the scope of the pilot, Schwed says.
Patients also might be called for brief adherence reinforcement.
One of the benefits pharmacists bring to adherence programs is that they can take a quick look at some measures of patients' adherence each time a patient comes into the pharmacy to fill a prescription, Schwed notes.
"We don't see the rate at which a patient is taking the medicine, but we do see the rate at which the patient is acquiring the medication, which is a surrogate marker," Schwed says. "Pharmacists can also scan for treatment of opportunistic infections and adherence to those therapies."
This is a dimension that nurses typically do not have at their fingertips, he adds.
A second benefit is that pharmacists have a basic knowledge of pharmacology and will receive a robust education about HIV drugs and care, Schwed says.
"That additional education is built up on a firm foundation of a good basis in pharmacology," he adds.
Since the program is designed to supplement any adherence messages patients receive from their HIV clinicians, one of its important components involves having pharmacists provide feedback to physicians, Rosen says.
"We want them to tell doctors what the patients' barriers are, what the patient is experiencing in terms of side effects, and what they're asking for in terms of over-the-counter drugs," Rosen says.
This type of pharmacist-doctor's office communications are common and will not add any additional burden on pharmacists, Schwed says.
Pharmacists, like Schwed, are eager for the pilot to start. And the pilot's researchers hope it will serve as an international model for improving HIV care and medication adherence.
"There are people living with HIV/AIDS in every state and every jurisdiction within the U.S., and that can serve as a model for the world," Schwed says.
"What we really want to do here is add a significant number of pharmacists to the care team in a significant role," he adds. "The pharmacist already is a member because of dispensing drugs, but we want pharmacists to have an interaction at the forefront of the adherence fight."
Even as the HIV health care community continues to make progress in improving patients' adherence to antiretroviral medication regimens, there remain some growing and stubborn obstacles to individual patients achieving the 95-plus percent adherence rate deemed optimal.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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