Innovative Use of Incentives to Improve Treatment Adherence

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Innovative Use of Incentives to Improve
Treatment Adherence

• Ryan White Care Act Training and Technical
• Assistance Grantee Meeting
• August 31, 2006
• Washington, DC
• Presented by Gail Gramarossa, MPH, CHES and
• Norm Deschaine, RN, ACRN
• Holyoke Health Center
• Holyoke, MA

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Holyoke Health Center (HHC)

• Holyoke, Massachusetts
• Located 90 miles west of Boston
• Poor, urban community of almost 40,000 41.4 of
  population is Latino
• 2nd Highest rate of HIV/AIDS in the state 77 of
  HIV/AIDS cases occur among Latinos
• HHC is currently medically managing almost 200
  persons living with HIV/AIDS

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Reconnecting Patients to Care

• Holyoke Health Center (HHC), a federally-qualified
  community health center, is the Lead Agency for
  a regional Ryan White Title III EIS grant and is
  also supported by an Enhanced Medical Management
  Services (EMMS) contract with the Massachusetts
  Department of Public Health (MDPH)
• 9 sites in Holyoke and Springfield serving over
  1,200 registered HIV consumers
• IVDU / Substance Abuse is documented as the
  highest mode of HIV transmission for the
  population served

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HIV Care in a Primary Care Setting

• Holyoke Health Center is fortunate to have
  specialty Infectious Disease (ID) consultant
  providers holding on-site clinics within our
  Primary Care facility MDs are paid through the
  RW III grant
• 3 sessions are held weekly, allowing for regular
  consultations between Infectious Disease and
  Primary Care Medical Providers

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Reconnecting to Care through Direct Observed
Therapy (DOT)

• Initially, the local hospital Rounding Internists
  identified increasing numbers of Emergency Room
  visits and Hospitalizations related to
  Opportunistic Infections (OI) among our HIV
  patients
• HIV Chronic Care Team suggested the possibility
  of more actively outreaching to and reconnecting
  these individuals to care
• HIV Chronic Care Team identified Direct Observed
  Therapy (DOT) as an option for prophylaxis of the
  most common Opportunistic Infections (OI) as well
  as an opportunity for intensive educational
  sessions on treatment adherence and the need for
  regular primary care

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Reconnecting to Care
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Setting up a Consumer-friendly Incentive Program

• Initially submitted a proposal and obtained funds
  from pharmaceutical companies to provide low-cost
  incentives for patient adherence
• Secured working relationship with a local Latino
  market/deli to accept meal vouchers from HHC
  consumers no mention of HIV
• Developed program around consumers needs, i.e.,
  methadone dosing times

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Elements of DOT Program

• Program coordinated with Primary Care MDs and
  referrals are sent to the Nurse Medical Manager
• Initial outreach and connection with consumers to
  explain program goals
• 12-week therapy set up for 3x week dosing of
  Bactrim and weekly Azithromycin administration as
  well

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Nutrition is Important, too!

• HHC secured unrestricted grant money from
  pharmaceutical companies to buy snacks and juices
  to offer consumers during their one-on-one DOT
  /educational visit with the RN Medical Manager
• When a consumer complied with the 3 times a week
  DOT/educational visits, they were given a 5.00
  lunch voucher for the local market/deli

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Lunch Vouchers

• Sample

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Reconnecting to Care

• Data to Date
• 9 men and 4 women have participated
• All completed DOT for 12 weeks 1 relapsed with
  substance use, but continued to connect with
  staff and continued with AB therapy during the 12
  weeks
• All consumers are now on ARVs
• All consumers had substantial increase in PCP and
  ID visits during this time consumers verbalized
  improved knowledge of disease process, meds and
  adherence

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Positive Outcomes

• Staff identified consumers disconnected from care
  and took active steps to reconnect them
• Consumers were educated on their disease process,
  harm reduction/positive prevention and how to use
  their primary health care providers appropriately
• Noted increased in consumers connection with
  Primary/ID physicians and RN Medical Manager
  more adherence to scheduled visits more walk-in
  traffic from participating patients
• Noted decrease in Emergency Room Visits
• Costs 10/week/patient X 12 weeks 120 HHC
  expects the annual cost will be no more than
  2,400

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Annual TB Screening Program

• Patients due dates for annual TB screening are
  identified through existing patient registry
• Patients are mailed reminder cards, given a
  reminder phone call appointments are set up with
  RN Medical Manager to have PPD planted and read
  in office
• When patients return 3 days later for PPD
  reading, they are given the same 5.00 voucher
  for lunch at local market/deli and their test
  results are documented in chart

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Outcomes

• In the last 8 months, we have seen a 30 increase
  in rate of PPD tests read
• We expect the rate to continue to increase as
  patients are informed of incentive
• We expect to make this incentive a permanent part
  of operations to insure annual TB screening as
  recommended by DHHS guidelines
• Annual maximum cost 975

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Contact Information

• Gail Gramarossa, MPH, CHES
• Holyoke Health Center
• 230 Maple Street P.O. Box 6260
• Holyoke, MA 01041-6260
• [phone]
• Gail.Gramarossa_at_hhcinc.org
• Norm Deschaine, RN, ACRN
• [phone]
• Norman.Deschaine_at_hhcinc.org