Program Collaboration to Improve HIV Retention in Care

State: FL Type: Promising Practice Year: 2019

Broward County is the second most populous county in Florida, 17th most populous in the United States with almost 1.9 million people and 10% of Florida's residents. Broward County is home to an international airport that is ranked 19th in the U.S. in total passenger traffic and a sea port which is the cruise ship capital of the world. 15.4 million tourists visit our beautiful beaches each year. However, there is more to Broward County. We are a majority/minority community with a population of 37% White, 30% Black, and 30% Hispanic of any race (U.S. Census) with one-third residents being foreign born. Nearly 15% of the residents are living below the poverty level and 20 % of children under age 18 are living in poverty. South Florida continues to be the most cost-burdened metro region in the nation with over half of Broward residents spending more than 30% of their monthly income on housing expenses. The county-seat, Fort Lauderdale, ranks 10th nationwide as one of the most cost-burden communities. Broward County Public Schools (BCPS) is the sixth largest public-school system in the United States. Students are from 204 different countries and speak 191 different languages. There are many innovative, strategic, systems-oriented and data-informed ways that Broward is working towards sustaining a vibrant culture of health in our diverse county. In 1995, a United Way of Broward County Needs Assessment revealed that a coordinated community effort was needed to solve persistent problems in the effective delivery of services to residents and visitors. These findings convinced Broward leadership and policymakers that a formal, long-term and intensive collaboration would provide significant and sustainable solutions. This led to the establishment of the Coordinating Council of Broward (CCB), with accomplishments related to affordable housing and long term disaster recovery discussed later in this proposal. Broward County is widely known as collaboration county” due to the multitude of coalitions and task forces that work together in a non-competitive way to improve the health and quality of life of residents. These coalitions are mobilized in strategic ways that address key health challenges based on community needs assessments. In 2018, the Florida Department of Health in Broward County (DOH-Broward) Community Health Assessment (CHA), priorities identified for the Community Health Improvement Plan (CHIP) include: 1) Increase Access to Health Services, 2) Reduce the Incidence of Communicable and Infectious Diseases, 3) Improve Maternal, Infant and Child Health, and 4) Enhance Preventive Care Activities. Significant challenges for Broward County include access to primary care, health equity, safe and affordable housing and a large senior population. Cultural diversity is both a strength and a challenge. To address these issues, we partner across the public and private sector to improve our community and view challenges and solutions through a health equity lens.

Understanding the role of Social Determinants of Health from the HHS Healthy People 2020 initiative and the role of institutional racism in creating and perpetuating health disparities has allowed DOH-Broward to develop a more comprehensive approach to building a culture of health. DOH-Broward implements, evaluates and refines our actions to address the social determinants of health through a more inclusive health equity approach with the goal to ultimately eliminate health disparities in Broward County.  In 2017, Broward County had 20,661 PLHIV of which 715 were newly diagnosed HIV cases and 262 diagnosed with AIDS. In 2017, Broward County had the 2nd highest number of new HIV cases of 67 Florida counties.  In 2016, Broward County had 20,499 PLHIV. The public health issue is ensuring the continued care and treatment of HIV/AIDS clients.  The goal and objective of this practice is to ensure HIV positive clients remain on antiretroviral medication to increase HIV medication adherence and reduce the number of clients that fall out of care. By increasing the number of client's in care, DOH-Broward's goal is to decrease community viral load and new HIV cases in Broward County. Dedicated HIV Disease Intervention (DIS) staff, who are trained in HIV linkage and retention, to identify pharmacy clients whose medications had not been picked up in a timely manner and locate clients lost to care and re-link them back to care and treatment. The specific factors that led to the success of this practice were the re-tasking of DOH-Broward HIV DIS workers to focus on medication adherence and re-linking clients lost to care.  The Public Health impact of this practice was a reduction of the number of HIV clients lost to care and decreasing the number of new infections.

The target population is the 20,661 people living with HIV and AIDS in Broward County. The average number of HIV clients served per month by the DOH-Broward pharmacy for 2017 is 2,192.  Of these, an average of 280 clients had a voided/cancelled/non-received prescription each month.  There have been 1834 referrals to the HIV DIS to locate clients lost to care. 95.03% of HIV clients served by our DOH-Broward Pharmacy were retained in care. Of the average number of all pharmacy clients (280) with a voided/cancelled/non-received prescription, 39% were contacted by pharmacy and 61% were subsequently referred to HIV DIS staff.  Of the HIV DIS referred clients 71% were successfully contacted.

In 2017, of the 1834 referrals (90%) to the DOH-Broward PROACT Program HIV DIS the outcomes are; 681 In care (37%), 303 unable to locate (17%), 148 moved out of jurisdiction (8%), 30 are deceased (1%), 178 linked back to care (10%), 27 refused DOH services (1%), 127 have insurance (7%) and 340 closed cases (19%). This is an increase from 70% in 2016 and 81% in 2017 for a 20% increase in referrals.

Prior to implementing this proactive integrated program, DOH-Broward's HIV clients received automatic calls from the pharmacy system to alert their prescriptions were ready for pickup. In a  separate related process, the HIV eligibility program staff monitored clients' enrollment status.  PROACT program staff were contacted by pharmacy and HIV eligibility staff as needed to evaluate, intervene and assist clients. In the past we did not have a lost to care program that outside agencies could refer clients.

The DOH-Broward practice is better because it facilitates pharmacy and HIV Disease Intervention Specialist (DIS) staff to collaborate, identify and locate potentially non-adherent HIV clients to improve retention in care and potentially reduce new HIV rates. DOH-Broward PROACT Program has evolved from prescription focused” to a client focused” and is able to accurately monitor HIV clients' pharmacy participation on a monthly basis by calculating and evaluating the percentage of clients not returning to pharmacy due to a voided/cancelled/non-received prescription.  Prior to this new approach, the number of AIDS Drug Assistance Program (ADAP) prescriptions filled each month was monitored and evaluated to determine the percentage that were picked up.

The practice is innovative. To our knowledge, DOH-Broward is the only health department that utilizes this practice model. The process of jointly utilizing pharmacy and HIV DIS staff to take a proactive approach to contact and/or locate potentially non-adherent HIV clients is innovative and new to the field of public health by ensuring no opportunity is missed to identify a non-adherent, or potentially lost to care” HIV client.

 DOH-Broward utilized the Program Collaboration System Integration Model (PCSI). For this practice to be successful, internal stakeholders must be willing to collaborate daily.  To measure the impact of the initiative, pharmacy prescription data is imported to an Excel spreadsheet to identify and calculate the total number of ADAP clients served, the total number of ADAP clients with a voided or non-received prescription, and the total number of clients with a voided or non-received prescription that picked up a prescription the following month.  This information is utilized to determine the percentage of pharmacy clients that are retained in care each month. The HIV DIS use a DOH program called HIV Prevention Care Coordination (HPCC) that monitors the number of referrals and outcomes monthly. The practice is evidence based in that is follows the CDC,, and the National HIV/AIDS Strategy (NHAS) and utilizes actual DOH-Broward pharmacy data.

The goal and objective of this practice is to increase adherence to HIV medication therapy and reduce the number of clients that fall out of care to improve health outcomes and reduce new HIV infections. According to the CDC, Improving the health of persons with HIV and reducing the number of new infections in the United States will depend on increasing access to HIV medical care and eliminating disparities in the quality of care received.” Steps taken to implement the program included a series of multidisciplinary staff meetings within DOH-Broward to create and deploy action plans. DOH-Broward endeavored to find a simple, easily deployable, and cost effective method to identify LHD clients who have not picked up their HIV medication, locate lost to care clients that are referred to the DOH-Broward PROACT Program, and either re-engage clients into care as appropriate and/or consult with the client's healthcare provider to provide timely feedback so as to provide optimal care and treatment.

DOH-Broward's pharmacy staff assure that HIV clients who are enrolled in ADAP and Ryan White Pharmacy Assistance program are receiving their HIV medications as prescribed.  HIV medications are provided by DOH-Broward Pharmacy Department pursuant to prescriptions authorized from client's physicians/providers. Each workday, pharmacy staff generate a return to stock” report, which identifies all prescriptions that have not been picked up for 11 days (5 days early, plus a 6-day grace period) after the prescription's date filled”.   Clients begin receiving automated prescription reminder refill calls before their prescription is due to ensure every opportunity is offered to pick up medications. 

DOH-Broward pharmacy staff review the return to stock” report, retrieve the matching prescriptions from the medication pickup area and personally call each client by telephone. To ensure confidentiality, no messages are left on voicemail. Pharmacy staff document each call on a a shared Excel file and enter: the client's demographic information; the date called; an indication if the prescription was returned to stock; and a notation regarding the outcome of the personal call (ie: client contacted arriving today or another day, no answer, phone disconnected, wrong number, client in hospital, etc.).

DOH-Broward HIV Disease Intervention Specialists (DIS) review the Excel file to identify which clients have not been successfully contacted by the pharmacy staff of the two DOH-Broward Pharmacies, one in Ft. Lauderdale and the other in Pompano Beach. DOH-Broward HIV DIS staff then utilize a variety of methods to locate HIV clients such as database searches to obtain the most current contact information. Some client search databases include: Lexus Nexus, Driver and Vehicle Information database (DAVE), PRISM,  Florida Department of Health STD Reporting database, Provide Enterprise,   Broward County Ryan White HIV clinical database, Careware (HRSA database for HIV Clients), HMS, Florida DOH Health Management System, FMMIS, Florida Medicaid Management Information System, FLSHOTS, Florida Immunization database, WAGES, Wage database from Bureau of Labor eHARS,  Enhanced HIV AIDS Reporting System, ADAP, AIDS Drug Assistance Program, FDLE type of database, Social Media and home visits as necessary. The HIV DIS staff ascertain/determine the reasons for which clients' have not picked up their HIV medications and clients that are lost to care. Every attempt to re-engage clients into care is made including calling case managers, clinicians, and/or other individuals connected with the client's care.  The HIV DIS provide client contact outcome results to the Communicable Disease Director such as, returned to care, unable to locate, out of jurisdiction, incarcerated, refused services, in care, and has medical insurance,

Additionally, a separate but related activity is continually performed to help retain HIV clients in care:  DOH-Broward's ADAP eligibility staff attempt to contact clients that have missed their ADAP re-enrollment appointment.  An indicator of adherence to HIV medication treatment is compliance with re-enrollment in medication assistance programs.   Thirty days before a client's ADAP eligibility is due to expire, ADAP staff call the client to advise/confirm their eligibility expiration date and make an appointment for re-enrollment.  Appointment reminder calls are made two days prior to the appointment date. ADAP eligibility staff attempt to contact the client to reschedule as soon as possible after a missed appointment.  If staff is unable to locate the client, the client is referred to a dedicated HIV DIS who attempt to locate the client to educate on the importance of adherence, address and remove barriers related to re-enrollment such as transportation issues by providing a bus pass. 

To evaluate the outcomes of the DOH-Broward HIV DIS initiative, data is exported to an Excel report to determine the number and percentage of unique HIV pharmacy clients that had a prescription returned to stock (voided and/or not picked up) in a given month and whether that same client had a prescription filled during the following month.  This indicates whether the client was lost to pharmacy care.

On a monthly basis, the Director of Pharmacy reports to the DOH-Broward Health Officer the total number of clients on the return to stock reports, the total number of clients successfully contacted by pharmacy staff, the number of clients referred” to HIV DIS, and the percentage of clients who did not pick-up their prescriptions that returned to the pharmacy (retained in care).  Metrics were created in the department's performance management system, Active Strategy, to monitor this information monthly, to track trends and historical information. The criteria for those selected to receive the practice was any DOH-Broward pharmacy client that did not pick their HIV medication within 11 days of being filled and clients referred to PROACT as lost to care. The timeframe for the practice is implementation in July 2016 and is now a routine part of the DOH-Broward client care process. Other stakeholders involved with this program were the DOH-Broward HIV/AIDS program's ADAP staff and community HIV/AIDS providers with clients receiving medication(s) from the DOH-Broward Pharmacy.  Their role in planning and implementation was nominal.

DOH-Broward has developed strong partnerships with our stakeholders that are involved in the system of care in Broward County.  These include, but are not limited to the grantees for Ryan White Part A, Ryan White Part B, Ryan White Part C, Ryan White Part D, Community Based Organizations, Case Management agencies, Food Banks, and Substance Abuse Facilities.  DOH-Broward Pharmacy and HIV DIS work closely with staff from these agencies to assure retention in care as well as appropriate care and treatment of HIV/AIDS clients.

Specific factors that led to the success of this practice included hiring and training of 5.0 FTE HIV DIS staff ($31,500 salary per employee), expanding to closely monitor prescription pickups and work closely with HIV DIS staff, education and training of Pharmacy and HIV DIS staff, development of a shared Excel spreadsheet, and the development of a specialized Excel report to process the pharmacy prescription information. Information Technology programming cost was approximately $1,000.  All the information that is gathered about these clients are entered in a local database called HPPCC database. This database allows us to review the staff client load and discuss outcomes.

The goal and objective is the increase of medication adherence and retention in care for HIVAIDS clients in order to reduce new HIV infections and improve health outcomes.  In 2017, the average number of DOH-Broward pharmacy clients who did not pick-up their prescriptions that responded to pharmacy staff's phone calls, was 39%.  The remaining 61% of clients were evaluated by HIV DIS staff.  As of November 2018, services have been provided to 5400 clients which 1659 clients were referred to the Pharmacy HIV DIS. The outcomes are:  981 picked up meds, 52%, 30% unable to locate, 10% moved out of this jurisdiction, 8% had insurance and about 411 field visits were performed. In 2017, of the 1834 referrals (90%) to the DOH-Broward PROACT Program HIV DIS the outcomes are; 681 In care (37%), 303 unable to locate (17%), 148 moved out of jurisdiction (8%), 30 are deceased (1%), 178 linked back to care (10%), 27 refused DOH services (1%), 127 have insurance (7%) and 340 closed cases (19%). This is an increase from 70% in 2016 and 81% in 2017 for a 20% increase in referrals. By increasing the percentage of PLHIV on antiretroviral and in care, community viral load will decrease and new HIV infections. DOH-Broward learned that, of the clients evaluated by HIV DIS staff, an average of 61% of clients returned to the pharmacy the following month to pick up their prescriptions.

DOH-Broward's objective was achieved. We continue to see a high percentage of clients retained in pharmacy care and a low percentage of HIV clients that did not pick up their HIV medication which is a measure of increased overall adherence and retention in medical care”. Primary data sources include: internal secure database, electronic HIV/AIDS reporting system (eHARS), Patient Reporting Investigating Surveillance Manager (PRISM), electronic lab reporting. Data was collected by the Pharmacy, ADAP, and perinatal staff.

Performance measures were created and tracked in the DOH-Broward performance management system, Active Strategy. These include prescriptions picked up, number of medications returned to stock, number of clients who did not pick up medications, number of client's reached, pick up rates, and treatment adherence.  A pharmacy metric includes the pick up rate of ARV's from DOH pharmacies”. Due to the success of this objective, the process will continue and is supported by DOH-Broward's Director.  Every LHD that interacts and/or serves HIV clients may have the potential benefit of this program by reducing HIV transmission through ensuring the highest possible rate of medication adherence.  DOH-Broward analyzed the process and determined there is an improvement in knowledge and awareness by DOH-Broward Pharmacy and ADAP staff regarding the importance of clients understanding the importance of medication adherence to reduce or eliminate the risk of transmission of HIV thus improving health outcomes. 

As a result of this practice, DOH-Broward's relations with its community partners improved through interagency collaboration. DOH-Broward is able to refer and link clients into care very effectively. Community partners are extremely appreciative of the efforts by DOH-Broward to retain HIV clients in care and alert clinicians to clients with possible adherence issues.

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