Minnesota’s ADAP Minnesota’s ADAP Medication Adherence Medication Adherence InitiativeInitiative

Dave Rompa

ADAP/Part B Program Administrator

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.

Basic HIV Adherence: What do you know?

What percentage of adherence does a client need to achieve to eliminate the development of resistance? >95%

If a client is on a once a day regimen how many doses can be missed to maintain >95% 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

Who’s responsible for a client’s adherence to treatment? Client Prescribing physician Dispensing pharmacist Nurse Case manager Support services ADAP Program Everyone can play a part in

a patient’s adherence to treatment

Why invest in medication adherence? The paradigm of HIV

treatment has changed

Anti-retroviral treatment is a life long commitment

Why invest continued… Setting up clients for success makes good sense

Adherence helps identify other issues

Prevention benefit

Cost effective

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

Minnesota ADAP’s 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

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

Getting started Looked at what was currently

being provided

Convened focus groups

Involved community stake holders

Engaged MATEC

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

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

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

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

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

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

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

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

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

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

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

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

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

Outcomes continued A patient’s 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/AdultandAdolescentGL.pdf.

What we collected Unique ID

Demographics (race/ethnicity, gender)

CD4, VL at initial contact and follow up

Visit date

Visit length (short <15, long >15)

Any self reported problems with adherence

Did patient receive MDOT?

Results from Site 1CD 4 Count

Comparison of CD4 Count at Baseline and Follow-Up

0.00

100.00

200.00

300.00

400.00

500.00

600.00

700.00

800.00

900.00

1000.00

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61

Patient

CD

4 C

ou

nt

BaselineFollow-Up

Results from Site 1Viral Load

Viral Load at Baseline

29%

71%

0-75 (Undetectable)76+ (Detectable)

Viral Load at Follow-Up

68%

32%

0-75 (Undetectable)76+ (Detectable)

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

Medication Therapy Management (MTM)Covered services include: Performing or obtaining necessary

assessments of the patient’s health status Face-to-face encounters done in:

Clinics Pharmacies Recipient’s home setting if the provider-directed

care coordination team orders service Formulating a medication treatment plan

Medication Therapy Management (MTM)Covered services continued Monitoring and evaluating the patient’s

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 patient’s primary care providers

Medication Therapy Management (MTM)Covered services continued Providing verbal education and training

designed to enhance patient understanding and appropriate use of the patient’s medications

Providing information, support services, and resources designed to enhance adherence with the patient’s therapeutic regimens

Coordinating and integrating MTM services within the broader health care management services being provided to the patient

MTM EligibilityEligible recipients

Medical Assistance (MA)General Assistance Medical Care

(GAMC)MinnesotaCare (fee-for-service and

managed care)

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 DTaking four or more prescriptions to treat or

prevent two or more chronic conditions

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

Conversation At what point does patient responsibility come

into play?

How far is too far with interventions?

Should adherence be used punitively?

Thank you!

Dave Rompa

Minnesota Department of Human Services

HIV/AIDS Unit

Program Administrator

dave.rompa@state.mn.us

651.431.2378