Minnesotas ADAP Medication Adherence Initiative

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Minnesotas ADAP Medication Adherence Initiative

• Dave Rompa
• ADAP/Part B Program Administrator

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What is medication adherence counseling?

• HRSA defines medication adherence counseling as
  the provision of treatment adherence counseling
  to ensure readiness for, and adherence to,
  complex HIV treatments.
• Taking 100 of prescribed medication doses each
  day as directed.
• Taking all doses at the scheduled time.
• Taking medications as they pertain to with or
  without food or other medications.

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Basic HIV Adherence What do you know?

• What percentage of adherence does a client need
  to achieve to eliminate the development of
  resistance?
• gt95
• If a client is on a once a day regimen how many
  doses can be missed to maintain gt95 adherence
  during a one month period?
• One dose
• If a client is on a once a day regimen what
  should they do if they remember they have missed
  taking their meds?
• Adhere to the 12 hour rule

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Whos responsible for a clients adherence to
treatment?

• Client
• Prescribing physician
• Dispensing pharmacist
• Nurse
• Case manager
• Support services
• ADAP Program
• Everyone can play a part in a patients adherence
  to treatment

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Why invest in medication adherence?

• The paradigm of HIV treatment has changed
• Anti-retroviral treatment is a life long
  commitment

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Why invest continued

• Setting up clients for success makes good sense
• Adherence helps identify other issues
• Prevention benefit
• Cost effective

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HIV in Minnesota

• Medium incidence state
• 6,220 people living with HIV/AIDS
• 326 newly diagnosed infections in 2008
• 3,441 live in the Twin Cities
• 1,887 live in the suburbs
• 870 live in greater Minnesota
• ADAP Program serves approximately 1,500 people

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Minnesota ADAPs history with medication adherence

• Invested until fiscal short fall in 2003
• Fiscal short fall forced scaling back
• Formulary Advisory Committee kept commitment
  alive
• Received significant increase in FY07 Ryan White
  Funding
• In Spring 2007 Minnesota ADAP made business
  decision to re-invest in adherence

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Goals of the Minnesota ADAP Adherence Initiative

• Create a statewide, comprehensive network of
  medication adherence services
• Every client starting HIV medications for the
  first time or restarting due to adherence issues
  receives some level of comprehensive counseling
• Clients successfully integrate HIV medications
  into their daily life

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Getting started

• Looked at what was currently being provided
• Convened focus groups
• Involved community stake holders
• Engaged MATEC

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Strategy development

• Funded programs with program income dollars for
  flexibility
• Decided on a two-year time frame
• Funded three new programs based on geography and
  clinic size
• Additional funding for one existing program
• Gave programs latitude to create and implement
  interventions based on experience and expertise
• Program development meetings with newly funded
  programs

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The Role of MATEC

• Helped coordinate technical assistance to
  programs
• Coordinated provider meetings for the purpose of
  developing outcome measures and best practices
• Conducted one-year program implementation
  evaluation
• Created on-line adherence tool ordering system

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Program specifics

• Programs were directed to think outside the box
• Created programs that served through brief and
  comprehensive visits
• Employed on-site counseling, phone, email and
  home visits
• Created linkages to case management and social
  services

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Strategies to Improve Adherence to Antiretroviral
Therapy

• Establish readiness to start therapy
• Provide education on medication dosing
• Review potential side effects
• Identify possible contraindicating medications
• Anticipate and treat side effects
• Utilize educational aids including pictures,
  pillboxes, and calendars
• Engage family, friends
• Simplify regimens, dosing, and food requirements
• Utilize team approach with nurses, pharmacists,
  and peer counselors
• Provide accessible, trusting health care team

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Program Elements

• Pharmacist or nurse is lead adherence provider
• Integrated into the care team
• Patient sees provider whenever they visit clinic
• Provider receives training and has access to
  tools
• Provider has flexibility to see patient on or
  off-site

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Adherence tool on-line program

• Began by conducting a tool fair
• Ease of use www.apothecaryproducts.com
• Providers can get specific tools on an as needed
  basis
• Easily track utilization and expenditures
• Offered to any program needing tools

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Metro Sites

• Pharmacist delivered service
• Adherence service delivered during HIV clinic
• Integrated on-site pharmacy
• Electronic medical record tailored to program
• Modified Directly Observed Therapy (MDOT) used
  for treatment naïve and restarts due to adherence
  issues

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Dedicated Pharmacy Services

• Dispense HIV medications
• Track dispensing
• Communicates with health care team
• Specialized in HIV medications
• Documented in patient record
• Familiar with ADAP and other MHCP
• Can fill using pill boxes and adherence tools

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MDOT

• Two to four week intensive intervention at the
  beginning of new regimen or a re-start due to
  failed regimen
• Improve patient medication self-administration
  during a limited period
• Pharmacist administered at the designated
  pharmacy utilizing dedicated clinic pharmacy
• First regimen is the best chance for long-term
  success (cost-effective)
• M stands for Modified not mandatory, patients can
  opt out if not suitable or practical for
  intervention

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MDOT Pros and Cons

• Pros
• Direct observation of medication usage, side
  effects and barriers
• Successful in TB management
• Successful with non-adherent patients in other
  disease states

• Cons
• Labor Intensive
• Expensive
• Intrusive
• Complex to initiate and complete
• HIV has a life long period of therapy

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Greater MinnesotaSite

• Program delivered by clinic nurse
• Program integrated in team approach with
  physicians and case managers
• Focuses heavily on in-reach activities
• Relies on ability to reach people via telephone
• Works closely with new starts and re-starts in
  conjunction with doctor

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Building Bridges to Case Management and Consumers

• All programs expected to do training for case
  managers and consumers
• All programs available for referral from case
  management programs

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Outcomes Work

• Outcome development challenging
• Labor intensive for providers
• Viral load and t-cell count great indicators but
  not perfect
• Self-reporting of complete adherence is unreliable

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Outcomes continued

• A patients estimate of suboptimal adherence is a
  strong predictor and should be taken seriously
• Clinicians estimate of the likelihood of patient
  adherence has proven to be an unreliable
  predictor
• Panel on Antiretroviral Guidelines for Adult
  and Adolescents. Guidelines for the use of
  antiretroviral agents in HIV-1-infected adults
  and adolescents. Department of Health and Human
  Services. January 29, 2008 pp 1-128. Available
  at http//www.aidsinfo.nih.gov/ContentFiles/Adulta
  ndAdolescentGL.pdf.

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What we collected

• Unique ID
• Demographics (race/ethnicity, gender)
• CD4, VL at initial contact and follow up
• Visit date
• Visit length (short lt15, long gt15)
• Any self reported problems with adherence
• Did patient receive MDOT?

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Results from Site 1CD 4 Count
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Results from Site 1Viral Load
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Next Steps

• Continue to gather outcome data
• Refine program elements in year two
• Strengthen connection to case management
• Coordinated marketing plan
• ADAP utilization data project

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Medication Therapy Management (MTM)

• Covered services include
• Performing or obtaining necessary assessments of
  the patients health status
• Face-to-face encounters done in
• Clinics
• Pharmacies
• Recipients home setting if the provider-directed
  care coordination team orders service
• Formulating a medication treatment plan

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Medication Therapy Management (MTM)

• Covered services continued
• Monitoring and evaluating the patients response
  to therapy, including safety and effectiveness
• Performing a comprehensive medication review to
  identify, resolve, and prevent medication-related
  problems, including adverse drug events
• Documenting the care delivered and communicating
  essential information to the patients primary
  care providers

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Medication Therapy Management (MTM)

• Covered services continued
• Providing verbal education and training designed
  to enhance patient understanding and appropriate
  use of the patients medications
• Providing information, support services, and
  resources designed to enhance adherence with the
  patients therapeutic regimens
• Coordinating and integrating MTM services within
  the broader health care management services being
  provided to the patient

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MTM Eligibility

• Eligible recipients
• Medical Assistance (MA)
• General Assistance Medical Care (GAMC)
• MinnesotaCare (fee-for-service and managed care)

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MTM Eligibility

• Eligible recipients continued
• Except MinnesotaCare Limited recipients they
  are eligible if they are
• An outpatient (not inpatient or in an
  institutional setting)
• Not eligible for Medicare Part D
• Taking four or more prescriptions to treat or
  prevent two or more chronic conditions

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MTM Rates for Reimbursement

• A first encounter service performed face-to-face
  with a patient in a time increment of up to 15
  minutes 52
• Follow-up encounter use with the same patient in
  a time increment of up to 15 minutes for a
  subsequent or follow-up encounter 34
• Additional increments of 15 minutes of time for
  99605 or 99606 24

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Conversation

• At what point does patient responsibility come
  into play?
• How far is too far with interventions?
• Should adherence be used punitively?

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Thank you!

• Dave Rompa
• Minnesota Department of Human Services
• HIV/AIDS Unit
• Program Administrator
• dave.rompa_at_state.mn.us
• 651.431.2378