Minnesota’s ADAP Medication Adherence Initiative

1. Minnesota’s ADAP Medication Adherence Initiative Dave Rompa ADAP/Part B Program Administrator

2. 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.

3. 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

4. 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

5. Why invest in medication adherence? • The paradigm of HIV treatment has changed • Anti-retroviral treatment is a life long commitment

6. Why invest continued… • Setting up clients for success makes good sense • Adherence helps identify other issues • Prevention benefit • Cost effective

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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 MDOT Pros and Cons

21. 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

22. 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

23. 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

24. 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.

25. 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?

26. Results from Site 1CD 4 Count

27. Results from Site 1Viral Load

28. 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

29. 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

30. 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

31. 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

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

33. 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

34. 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

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

36. Thank you! Dave Rompa Minnesota Department of Human Services HIV/AIDS Unit Program Administrator dave.rompa@state.mn.us 651.431.2378