Done well, pharmacist-led care management programs attack multiple underlying causes that commonly hinder treatment and nonadherence among patients with HIV and other chronic conditions. Patients often suffer from depression, denial about their condition, and embarrassment and face logistical challenges that prevent them from accessing care, including critical, regular lab work.
Our colleagues at Chattanooga CARES are taking a hands-on, personalized approach to the way their pharmacy and partners use care management to improve access to care, medication adherence, and outcomes for patients with HIV. Below are the challenges the program addresses and the solutions implemented to date that have resulted in adherence levels of greater than 90% across the target program population, as measured by viral load in the early stages of the care management program.
Charlie was referred to Chattanooga CARES’ care management program in July 2017. He was an ideal fit for the program: He hadn’t been to the clinic or on HIV medication since November 2016. Despite repeated phone calls to the patient to come in for a checkup and to pick up his medication refill, the staff could not reach him and were unable to schedule an appointment.
DENIAL AND DEPRESSION
When the care management program staff finally reached him, Charlie admitted he was struggling with his HIV diagnosis and did not like taking his medication because it reminded him of the disease. That aside, he couldn’t even get a prescription for his medication without going to the clinic for a scheduled office visit.
The care management team was able to persuade Charlie to come in for a visit, his first in 6 months. The team enrolled him in the care management program (we’ll elaborate on its key elements and fixes below), and all was progressing nicely until the clinical pharmacist discovered Charlie had missed a week of medication therapy and needed a refill.
The same pharmacist discovered that Charlie had just started a new, third shift job. Scheduling appointments around 8 hours or more on the third shift became another barrier the team had to overcome.
BE ON THE LOOKOUT FOR DEPRESSION. Care managers cannot diagnose depression, but Charlie’s care manager suspected he was suffering from it. Antidepressants aren’t particularly expensive, but if patients aren’t adherent to those, they’re not likely to be adherent to other medications. Effectively addressing depression is often a required step toward successful management of patients’ other, more complicated chronic conditions, such as HIV. Charlie’s care manager notified the provider of the suspected depression, and the provider followed up with Charlie on his next visit to the clinic.
EDUCATE. Results from multiple studies indicate that doctors have time only to diagnose. Frequently, they don’t have time to provide the information on the importance of medication regimens, adverse effects (AEs), and AE mitigation.
Care management teams do have time for this. It starts with building a trusting relationship with patients such as Charlie, listening to and understanding their concerns, and convincing them that they have the power to take control of their treatment and improve the quality of their lives. Clinical pharmacists also have significantly more pharmacological expertise to draw on in communicating the importance of medication adherence and adverse effect mitigation with patients.
IMPROVE COORDINATION BETWEEN PROVIDER AND PHARMACY. The stronger the communication between providers and pharmacy teams, the greater the probability that obstacles to treatment and adherence will be identified and positively addressed. Without consistent, strong communication between the care manager and the provider, the larger team would not have identified Charlie’s new work responsibilities, his need for a new clinic visit schedule, and the teamwork needed to effect critical change and the resultant positive outcomes.
TAKE A CLOSER LOOK AT THE PATIENT POPULATION. How many patients with HIV suffer from denial, embarrassment, depression, and other comorbidities that obstruct effective treatment of their disease? Patients with HIV not retained in care commonly report expensive and unreliable transportation and the stigma of having the disease as barriers. Failure to address social and structural issues will almost always result in failure to achieve desired outcomes, such as adherence measures and viral suppression.
REAL-WORLD EARLY RESULTS. Taking a close look at an individual patient’s experi- ence with HIV and his treatment challenges provides insight into actions likely applicable across a much larger patient population. In Charlie’s case, his viral load went from 35,000 in October 2017 to 255 in November 2017. His Bactrim prescription was discontinued in December because his CD4 count had risen from 149 in October to 419 in November. And of equal, if not greater, importance, Charlie recently told his doctor he is now positive about his future and living with HIV. This is what care management and committed providers plus specialty pharmacy and specialty therapies should aspire to every single day.