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Pharmacy Verification in Nassau County

State: NY Type: Promising Practice Year: 2019

Located on Long Island, Nassau County is home to some 1,339,532 residents. It is bordered by New York City to the west and Suffolk County to the east. Nassau County's demographic profile is 72.98% white, 11.13% black, 7.63% Asian/Pacific Islanders and 14.58% Hispanic. It is home to many immigrants. Approximately 20% of Nassau County's population is foreign-born (2010 US Census).

Tuberculosis (TB) is a disease caused by the bacterium Mycobacterium tuberculosis. Although it most commonly affects the lungs, TB can attack any part of the body. Pulmonary TB is highly infectious and spreads through the air when an infected person coughs, sneezes, speaks or sings. If not treated properly, TB disease can be fatal. In 2017, the rate of TB in Nassau County was 2.99 per 100,000 population. 85% of cases were foreign born.

A person can be infected with the TB organism but not have active TB. This is called Latent Tuberculosis Infection (LTBI). A person with LTBI cannot transmit the disease; however, as per the CDC, ten percent will develop active TB in the future without proper prophylactic treatment. It is recommended that anyone diagnosed with LTBI be treated prophylactically. 

When a new case of active pulmonary TB is identified, the Nassau County Department of Health Bureau of Tuberculosis Control (TBC) conducts a contact investigation to identify individuals at risk for or who may already have TB infection. Contacts are tracked and monitored through a multistep evaluation process. Identifying exposed contacts and facilitating preventive LTBI treatment when necessary is imperative for proper TB prevention. As such, a monitoring tool for contacts on LTBI treatment is essential for any TB control program.

There is no standardized method for TBC to monitor adherence of LTBI treatment when the individual is not utilizing TBC contracted facilities. Active TB by contrast is monitored by directly observed therapy (DOT), a standard of practice whereby a healthcare worker witnesses the patient ingesting the prescribed TB medication. In the case of LTBI, DOT is not an option as it is too costly to administer in Nassau County due to its large disease burden. Nevertheless, monitoring of LTBI treatment is essential to verify treatment completion.

Prior to 2015, TBC did not have a structured mechanism for monitoring whether contacts being treated for LTBI by private physicians continued and/or completed their treatment. As time permitted, staff followed up with providers/patients to collect information regarding treatment. As a result, many contacts were lost to follow-up.

Thus, TBC sought to create an innovative tool for tracking and monitoring contacts being treated for LTBI who see private physicians. The goal was to monitor treatment adherence of contacts diagnosed with LTBI thereby mitigating TB transmission in the community. There were four primary objectives for the project:

  1. Develop a Pharmacy Verification process and collaborate with pharmacies in the community to obtain prescription data;
  2. Create a tool to monitor contacts adhering to LTBI treatment using Microsoft Excel;
  3. Implement the process and the tool;
  4. Improve monitoring process, increase TBC efficiency and reduce loss to follow-up.

Objective 1 was met by creating a process for pharmacy verification through collaboration. TBC recognized the need to address the issue of systematically following contacts managed by private physicians. TBC next engaged patients' pharmacies by explaining the information required. Furthermore, TBC addressed issues of confidentiality. In an effort to streamline communication between TBC and pharmacies, a script was created. It allows any TBC staff member to collect the information in a professional, consistent manner.

Objective 2 was met by creating an Excel spreadsheet to monitor treatment adherence. A formula calculates and flags the number of missed days of treatment to ascertain completion status. This alert system allows for timely case management and intervention to reduce loss to follow-up.

Objective 3 was met when TBC successfully implemented the Pharmacy Verification process. One designated TBC staff member was tasked with performing pharmacy verification. The data was collected and then entered in the Excel program. Any alerts were followed up on by TBC case manager.


Objective 4 was met by creating a standardized monitoring process therefore increasing program efficiency and reducing loss to follow-up. Monthly tracking allows for timely data collection and intervention. Tasking one staff person increases program efficiency and reduces miscommunication and redundancies.

The pharmacy verification tool impacts public health by facilitating LTBI treatment completion of contacts to active TB. If a contact completes proper LTBI based on CDC guidelines, they will not spread TB disease to others.

https://www.nassaucountyny.gov/1652/Health-Department

Essential components of a contact investigation include: 1) identifying persons exposed to a pulmonary case, 2) screening those contacts for infection, 3) ensuring that those with active or latent infection have access to treatment, 4) facilitating medical evaluation, treatment and follow-up of those contacts, and 5) reporting contact information on the NYS Health Commerce System (HCS). This is a very laborious process that requires careful documentation, consistent communication and timely follow-up. Because of Nassau County's high case rate, a large number of contacts are tracked each year. From 2015 to December 5, 2018, 1,441 contacts have been followed, of which 9.6% have LTBI, 76.8% started treatment and 49.1% have completed. With only two full-time field staff responsible for following contacts, timely follow-up of such large numbers of contacts is arduous.

The first step in a TB contact investigation involves careful interview of the index case. Establishing rapport and trust between the case and interviewer is critical in obtaining accurate exposure information and often requires investigative work over multiple visits. Cases are asked to retrace their steps over the three-month period prior to placement in isolation (called the infectious period). They are asked about the household, work, school, and social contacts and any history of travel. A prioritization category is assigned to each contact (high, medium, and low) depending on the type and duration of exposure, the age of the exposed, and the infectivity, symptomology, and resistance pattern of the index case. After contacts are identified and prioritized, field staff endeavor to track them down. This often requires extensive detective work, as the index case may not be able to provide specific information for each contact. Once contacts are located, each individual must be interviewed and educated on TB disease and transmission. For those with a known history of TB disease, or prior positive tuberculin skin test, a symptom review is performed, and a chest x-ray recommended. The chest x-ray may distinguish between active disease and latent disease. For those with no known prior exposure or a history of negative skin test, a symptom review is performed, and an initial skin test is planted as soon as possible. After two days the skin test is read. If negative, a repeat skin test is required at least 8 weeks after last known exposure, unless the initial skin test was planted eight weeks after the last date of exposure to the index case. For those with a positive skin test, a chest x-ray is recommended.  Those with active TB disease are often prescribed a 6 to 9 month treatment regimen consisting of four antibiotics, whereas those with latent disease are generally prescribed one antibiotic for nine months. Children five and under receive eight weeks of treatment regardless of tuberculin skin test result due to the potential for rapid progression of latent infection into active TB disease because of their immature immune system. The exact treatment regimens for contacts can vary depending on the index case's drug resistance pattern. For every step in the evaluation process, field staff facilitate the scheduling of medical follow-up and verify visit compliance, treatment initiation, and treatment completion.

Therefore, contacts with LTBI are followed for the duration of their treatment. While DOT is a service provided to active TB patients, as a mechanism to follow infectious, active cases, it is not provided to LTBI contacts due to the high cost and volume of individuals in this category.  Rather, field staff call patients and physicians to follow-up on medical appointments, as time permits. In addition, contacts include those who seek care at facilities not contracted with Nassau County and efforts to speak with these providers' offices and collect the information is challenging. It is often difficult to determine if these patients diagnosed with LTBI, as contacts to cases, are compliant with their medication and are completing treatment. Monitoring patients' adherence and ultimately completion of treatment after nine months is not efficient and is done when time allows. Follow-up typically occurred quarterly with an initial call to the contact and subsequent call to the provider to receive documentation verifying compliance. 

A better means to systematically follow LTBI contacts to cases would benefit the TBC staff, the program and most importantly, the contacts themselves. Improving the process would allow staff to better respond to contacts, help ensure adherence to medication and completion of treatment. Pharmacy Verification provides this needed tool; a mechanism to follow contacts' treatment in a structured and efficient manner. In addition, the community benefits as active TB is mitigated in the population. 

            The Pharmacy Verification process is a quick, standard method of tracking contact medication refills to collect information regarding the patient's treatment plan and ultimately treatment completion. The Pharmacy Verification process involves engaging the pharmacist, collecting information regarding contact medication pick-up time, confirmation of dose and medication, and any changes that have occurred. It is a means by using the pharmacist as a proxy for contact compliance. With this information gathered monthly, TBC can monitor contact medication, regularly and therefore respond to any inconsistencies either with the contact or his/her provider. The goal is to ultimately to track these contacts, monitor and respond to any issues throughout the treatment and follow the contact until completion. 

The concept of tracking pharmacy information is not new to public health. According to Mekuria et al, 2016 (https://onlinelibrary.wiley.com/doi/full/10.1111/tmi.12709), after comparing different proxies for measuring adherence, pharmacy refill non-adherence, among other methods, was a significant predictor of viremia in patients prescribed combination antiretroviral therapy. In a paper examining medication adherence among patients with Systemic Lupus Erythematosus, (https://onlinelibrary.wiley.com/doi/full/10.1002/art.22898), the researchers compare self-report method to the criterion standard” of pharmacy refill information. They discuss that the pharmacy refill method has less bias than physician opinion about patients' adherence, but it does require some time in phone calls. Research has also pointed to Continued Medication Monitoring to identify issues with mediations according to pharmacy records (https://www.ncbi.nlm.nih.gov/pubmed/28087207).  Goedken et al, in this paper, describes that pharmacy monitoring on a host of conditions identified issues with medications and opportunities to intervene. 

Regarding pharmacy tracking of patients with tuberculosis, pharmacy information has been used in a limited way. Fallab-Stubi et al (https://www.ncbi.nlm.nih.gov/pubmed/9661817) detail the use of a Medication Event Monitoring System (MEMS) to track how often a patient is opening the medication container. This method, although effective, has limitations that include cost, patient access, and ineffective monitoring data when patients utilize pill organizers. The use of pharmacy data and tuberculosis was discussed by Yokoe et al (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320428) whose study was limited to individuals participating in a managed-care program and were utilizing their pharmacy benefit for obtaining their medications. The pharmacy data was collected through the health plan records. This method provided very reliable medication pick-up data but did not assist in the monitoring of patients not using a pharmacy benefit, whether by choice or due to lack of coverage. Therefore, while the practice of using pharmacy data is not new to public health, TBC has chosen to use simple refill data for the specific disease of latent tuberculosis, one which requires long-term, regular and dutiful compliance in order to ensure that activation of LTBI does not occur. TBC has created a novel tracking system to alert dosing and to address issues, all to reduce loss to follow-up. This use and its mechanism are an innovative practice to develop an effective and efficient means to monitor all contacts with LTBI.

Therefore, as established, Pharmacy Verification process is modeled after well-known evidence-based practices but is a creative use of the concept. Moreover, the contact investigation is itself a well-established method for stopping the transmission of tuberculosis (http://www.cdc.gov/tb/). A commissioned meta-analysis by the World Health Organization Expert Panel said that thorough investigation, evaluation and treatment of contacts was a priority in high income and resource limited settings, and that innovative strategies should be incorporated into investigation protocols (Eur Respir J. 2013 Jan;41(1):140-56. doi: 10.1183/09031936.00070812. Epub 2012 Aug 30.).  An additional report indicated that contact investigations were paramount to the success of TB control in high risk communities and low prevalence countries.” Furthermore, this report discussed that Further investigation should focus on questionnaire development and adaptation, electronic data management and infrastructure….” (Int J Tuberc Lung Dis. 2012;16(3):297-305. doi: 10.5588/ijtld.11.0350. Epub 2011 Dec 2). 

The Pharmacy Verification process extends the well-evidenced contact investigation practice into the domain of pharmacy data. While refill information has been used in other diseases, using it in the mitigation of tuberculosis is creative and particularly important. Diminishing the spread of TB in the community by long term medication adherence is difficult to put into practice. TBC has found an efficient method to track patients, address issues and decrease loss to follow-up.

TBC follows all contacts to active TB cases. These contacts are evaluated to determine if they have active disease or latent infection. Those with latent infection must be treated to avoid becoming infectious with active TB. Most of these individuals who agree to be treated are seen by physicians in Nassau County contracted hospital. At this facility, medication is dispensed directly to the contact requiring treatment. TBC receives documentation from the contracted facility. However, when contacts are treated by private physicians, follow-up becomes more difficult. TBC sought to create an innovative tool for tracking and monitoring contacts being treated for LTBI who see private physicians. The goal was to monitor treatment adherence of contacts diagnosed with LTBI thereby mitigating TB transmission in the community. There were four primary objectives for the project.

  1. Develop a Pharmacy Verification process and collaborate with pharmacies in the community to obtain prescription data;
  2. Create a tool to monitor contacts adhering to LTBI treatment using Microsoft Excel;
  3. Implement the process and the tool;
  4. Improve monitoring process, increase TBC efficiency and reduce loss to follow-up.

TBC recognized the need to address the issue of systematically following contacts managed by private physicians. TBC met over several weeks in early 2015 to discuss the steps necessary to accomplish this. At the time, TBC consisted of the administrator of the program, the clinical director, the epidemiologist, case management staff, field staff, and an intern. Pharmacists needed to be part of the process and therefore were engaged early on. The process needed to be regular and simple, so any staff could perform it. TBC created a script to use when speaking to pharmacies. The tool required specific fields necessary to follow patients satisfactorily, as well as a structure by which cells would be flagged depending upon refill pick-up timing. A color-coded alert system was embedded into the spreadsheet formulas Finally, periodic review of the contact monitoring identified issues requiring contacts and provider follow-up, completion of treatment, loss to follow-up and evaluation of the Pharmacy Verification process.

The process was piloted in 2015 with two contacts and implemented over time. In 2016, TBC had enrolled twelve contacts in the program. At that point, TBC had seen good results, but not enough to be considered evidence-based. To date, in 2018, 43 contacts have been tracked using the tool and the process has now been successfully running for nearly three years.

TBC achieved the goals and the objectives of this innovative program by collaborating with partners and by streamlining operations within TBC. 

Objective 1 was met by creating a process for Pharmacy Verification through collaboration.  Overall, Pharmacy Verification's development was a collaboration among many stakeholders from a variety of backgrounds, including academia. It was originally envisioned as an improvement process used in TBC to aid in efficiency and to decrease loss to follow-up. In 2015, TBC interviewed and selected an intern from Creighton University. Nassau County Department of Health (NCDOH) is committed to working with universities and schools to create public health learning environments that stretch from the classroom to the health department and then the community at large. To this end, since 2011, NCDOH has created memoranda of understandings between the health department and academic institutions to create internships that are mutually beneficial. Bethany Abrahams, a doctoral student in pharmacology, spent a semester with TBC. Because of her expertise in pharmacology, TBC staff had the opportunity, and now the additional manpower, to develop what would become the Pharmacy Verification process to track contacts with LTBI. This idea and improvement process were initially conceived because TBC did not have a formalized, structured mechanism to track contacts with LTBI, beyond occasional phone calls and follow-up.  With the assistance of the intern, the realization of the idea was begun. She contributed work effort and pharmacological knowledge. TBC staff provided the expertise in regulatory requirements, TB pathology, and case management skills, and intimate understanding of the process of contact investigations in the office. 

A second key collaborating partner was the pharmacist. TBC has always appreciated the pharmacists' roles in disease prevention, as noncompliance remains the most significant barrier to treatment. With that understanding, TBC engaged the pharmacists within our community, in late Spring of 2015. It was an opportunity to remind fellow healthcare partners the role of TBC.  The conversations personalized the connection and importance of aligned efforts between pharmacies and TBC. The conversations established the details of the Pharmacy Verification process that TBC was about to launch. After learning about the program, the pharmacists had a greater involvement in disease prevention and provided additional feedback for the mechanism. Ultimately, the pharmacists understood that they would provide the information needed to collect the necessary data monthly on the prescriptions such as medication name and dose, date of pick-up and days supplied. The pharmacists became an essential collaborating entity, one that remains today, as TBC continues to speak with them monthly.

      During the planning stage, TBC also addressed issues of confidentiality. TBC provided information to pharmacy staff about the Health Information Portability and Accountability Act of 1996, (HIPAA) regulations. TBC staff discussed with pharmacies that the Act permits public health employees to gather information necessary for preventing and controlling communicable diseases. 

      Finally, in addition, to streamlining communication between TBC and pharmacies, a script was created. This script allows any TBC staff member to make calls and collect the information in a professional, consistent manner. The script introduces TBC, explains the verification process, provides contact information and requests medication information.

      Objective 2 was met by creating an Excel Workbook to monitor treatment adherence.  Patients who visit private doctors and receive their medication for LTBI from pharmacies are identified as eligible for tracking. The Pharmacy Verification tool used to monitor medication adherence is comprised of many fields. These include index case, contact demographics, physician information, treatment regimen, pharmacy, call log, treatment start date, expected completion date and monthly medication pick up log. Embedded formulas alert the user by flagging critical information. This alert system allows for timely case management and intervention to reduce loss to follow-up. This calculation is performed using the date the first prescription was picked up by the contact being treated for LTBI, the date the most recent prescription was picked up, the amount of days supplied from the last prescription, and the total amount of days supplied that was picked up from all the prescriptions. Completion of a six-month course of therapy within 9 months and completion of a nine-month course of therapy in 12 months' time are criteria for successful LTBI therapy regimen. A formula embedded in the spreadsheet calculates and flags the number of missed days of treatment to ascertain completion status. Therefore, the tool was designed to have monthly input and indicate a green, yellow, or red alert system. For example, a contact having missed less than 30 days of therapy displayed green indicating generally good adherence. If a contact missed at least 30 days but less than 90 days of therapy, a yellow indicator would alert the viewer that there may be a risk for unsuccessful treatment completion. Any contact cell having missed 90 days or more of therapy displayed red, indicating that the patient may not be able to successfully complete LTBI treatment. These cells in which indicators turned yellow or red provided important information for proper follow-up for case managers to confer with physicians or the patients themselves to discuss treatment.

        Objective 3 was met when TBC successfully implemented the Pharmacy Verification process. One designated TBC staff member was tasked with performing pharmacy verification.  Using the partnership approach with the pharmacist, the data were collected and then entered in the Pharmacy Verification tool. The staff member verified that the correct medication and dosage was picked up and that the appropriate number of refills remain. Furthermore, any alerts were followed up on by TBC case manager. For example, if the staff member learned that the wrong dosage was provided, the TBC case manager would subsequently confer with the physician for clarification. If the patient neglected to refill the prescriptions, then TBC staff reached out to both the patient and the provider. These issues are addressed the same day. The pharmacy calls occur monthly and a summary of activity is reported on at regular staff meetings.

      Objective 4 was met by creating a standardized monitoring process, therefore, increasing program efficiency and reducing contact loss to follow-up. Monthly tracking allows for timely data collection and intervention. Tasking one staff person with monitoring the process increases program efficiency and reduces miscommunication and redundancies. Prior to implementation, field staff made calls to contacts to inquire about on-going treatment. These calls were often a slow process, whereby field staff left messages, awaited call back and often were fruitless. Regardless if the contact called back, field staff had to call providers to inquire about treatment, enlist their assistance in reaching contacts or to verify the treatment status reported by the contact. This effort often occurred over the course of a week for one contact. In addition, field staff made these calls as time permitted, as they were often in the field providing DOT to active cases and were not available to receive and respond to callbacks. Miscommunications occurred when multiple staff received calls, took messages and attempted to resolve issues thus creating redundancies of effort. With this innovative Pharmacy Verification process, one designated staff person is responsible and accountable for gathering the information and conveying issues to the appropriate TBC staff. This individual also serves as the point person so that miscommunications and redundancies are avoided. In addition, this point person is solely responsible for maintaining the Excel workbook so that information is misentered or lost. This also allows for accurate documentation of process progress notes in the Excel workbook. The success of the Pharmacy Verification process is due in large part to the on-going collaboration between TBC, the pharmacist, and physician who all have a vested interest in effectively evaluating and treating exposed contacts.

      As is apparent by the collaboration process outlined in achieving the goal of this practice, success cannot be accomplished without the partnership. This partnership has allowed TBC to track patient compliance with a standardized, well-thought-out process. Characteristics of collaborative partner activities include the following principles as we have adapted from the CDC (https://www.cdcfoundation.org/guiding-principles-partner-collaboration)

  • Well-defined and substantial public health benefit based on sound science and the public good. This has been well established as pharmacy verification has been used before in other disease states, but not in TB. Proper adherence to medication by DOT for LTBI is not feasible for two field staff and the volume of patients. Pharmacy verification is used as a proxy for this observation. The collaborative partner, the pharmacist, now is actively participating in effectuating sound science.
  • Clear, identifiable, substantial leadership role for TBC and a designated lead and champion within the agency. TBC provides the leadership, with the Clinical Director at the helm. She conceived of the idea and with the team and additional collaboration from academia (the intern) provides the leadership necessary should the pharmacists have questions.
  • Ideas that have been reviewed and approved by TBC.
  • Activities with a manageable size and scope with specific timelines and milestones. The collaboration, while it began in 2015 has been on-going. Timelines are set as per the pathophysiology of TB as well as treatment guidelines for LTBI. As such, pharmacy verification must align to these treatment schedules. The pharmacists also fully understand the importance of adherence to these medications without interruptions.
  • Funding that is not revocable or contingent on any action by NCDOH. In the case of TBC's pharmacy verification, the cost of the process is in-kind from staff already working within TBC. The program was designed due to funding restrictions and the inability to hire additional field staff to individually engage the contacts directly. Therefore, this collaboration was created out of the necessity to find a low-cost mechanism to standardize this process.
  • Non-exclusivity in the proposed activity meaning other partners may join at any time.  By the nature of this project, additional pharmacists do continue to join the effort. 
  • Outcomes of the activity are not intended for direct monetary benefit for the partner; avoidance of conflicts of interest. This partnership with the pharmacist and the health department do not confer additional funding streams to either. There is no conflict as both entities' priorities are diminishing lost to follow-up.
  • Adherence to independence and objectivity of scientific judgment. This collaboration is based on the scientific judgment and the evidence that if LTBI is treated effectively, then active TB can be mitigated.
  • Equal access to results of findings for the public and partners. Monthly calls with the pharmacist allow for follow-up information exchanged, valuable to both the pharmacy and TBC.

   Additional costs were insignificant. This program requires general office equipment, computer, and telephone. Once the expertise has been used to create the Excel tool, very little modification is necessary as it can be used by multiple staff members. Any cost is in-kind, as it is dependent on health department staff already employed. This program was based on a restricted and limited budget already in place within the county. For that reason, Pharmacy Verification is cost saving, as it requires no field staff intervention and costly time.


TBC aspired to design a novel method for monitoring contacts of active TB cases who are being treated for LTBI, specifically those receiving care from private physicians. The goal was to monitor treatment adherence of contacts diagnosed with LTBI thereby mitigating TB transmission in the community. The four primary objectives for the project were the following:

1) Develop a Pharmacy Verification process and collaborate with pharmacies in the community to obtain prescription data;

2) Create a tool to monitor contacts adhering to LTBI treatment using Microsoft Excel;

3) Implement the process and the tool;

4) Improve monitoring process, increase TBC efficiency and reduce loss to follow-up.

In assessing the value of Pharmacy Verification process, it is important to consider each objective, its performance measures, the relevant data and evaluation results.

Objective 1 was to develop a Pharmacy Verification process and collaborate with pharmacies in the community to obtain prescription data. The outcome measures for this objective were the following: the final plan for creating Excel workbook identifying fields and desired alert flags, the script for pharmacy calls, participation by 22 pharmacies and all TBC staff (8 individuals) trained in the Pharmacy Verification program. The process to achieve these outcomes was evaluated by TBC staff tracking meeting minutes, email correspondence, training materials and the iterations of the script and Excel Workbook.

Through this evaluative process, TBC learned that pharmacy engagement was paramount to the success of the verification process. The collaboration between the pharmacy staff and TBC allowed for a more streamline implementation addressing potential roadblocks. Potential barriers included issues of confidentiality, establishing contact person at the pharmacy, best time to call and information TBC needed to provide to obtain desired data. In addition, TBC learned that greater familiarity with Excel programming capabilities would enhance the verification tool allowing us to create a flagging mechanism in the program. Finally, TBC realized that comfort with using Excel varies considerably between individuals; hands-on training, practice and demonstration of understanding is essential for successful staff use. Overall, all process and outcome measures were achieved, and the objective was met. 

Objective 2 was to create a tool to monitor contacts adhering to LTBI treatment using Microsoft Excel. The outcome performance measure for this objective was the successful creation of the Excel Workbook. This process was piloted in July 2015. Each year of follow-up has a separate spreadsheet, as does each subsequent year. The process measures were the various iterations in the spreadsheet design and the stages involving the flagging mechanism. Each iteration was tested, and modifications made until the final product was agreed upon by TBC staff.

The Pharmacy Verification tool used to monitor medication adherence is comprised of many fields. These include: index case, contact demographics, physician information, treatment regimen, pharmacy, call log, treatment start date, expected completion date and monthly medication pick up log. Embedded formulas alert the user by flagging information. This calculation is performed using the date the first prescription was picked up by the contact being treated for LTBI, the date the most recent prescription was picked up, the amount of days supplied from the last prescription, and the total amount of days supplied that was picked up from all the prescriptions. Completion of a six-month course of therapy within 9 months and completion of a nine-month course of therapy in 12 months' time are criteria for successful LTBI therapy regimen. Therefore, the tool was designed to have monthly input and indicate a green, yellow, or red alert system. For example, a contact having missed less than 30 days of therapy displayed green indicating generally good adherence. If a contact misses at least 30 days but less than 90 days of therapy, a yellow indicator would alert the viewer that there may be a risk for unsuccessful treatment completion. Any contact cell missing 90 days or more of therapy displayed red, indicating that the patient may not be able to successfully complete LTBI treatment. These cells which indicators turned yellow or red provide important information for proper follow-up. Data for objective two performance measures was collected by TBC staff. Primary data sources were agendas and meeting minutes and iterations of the Excel workbook.

 Objective 3 was to implement the process and the tool. The outcome measure was the successful implementation of the Pharmacy Verification process and tool. The program was evaluated by tracking performance using the Excel tool from 2015-2018. This data was collected by TBC. Data included, the number of contacts entered on the tool, the number of alerts and TBC response. The Pharmacy Verification process and tool were piloted in 2015. That year, TBC followed 372 contacts, 11.6% with LTBI, of those 79.1% started treatment, 73.5% completed LTBI treatment and 8.8% were lost to follow-up. Two contacts being treated for LTBI by private physicians were placed on the Pharmacy Verification tool. The Pharmacy Verification process was used to follow-up on these two contacts and both these contacts had alerts requiring follow-up by the case manager. After successful piloting, in 2016 the process was expanded to include all contacts prescribed LTBI treatment who were being followed by private physicians. Of the 232 contacts followed by TBC, 11.6% (32) had LTBI and all initiated treatment. Twelve (37.5%) of those contacts were placed on Pharmacy Verification tool as they were patients of private physicians. Sixty-seven percent (12) of those individuals were flagged either yellow or red. In 2017, TBC followed 497 contacts, 7.4% (37) had LTBI and 54% (20) began treatment. Of those 65% (13) were being seen by private physicians and were enrolled in the Pharmacy Verification process. 46% (6) of those in the program had alerts. Thus far for 2018, TBC is following 297 contacts, 8.8% (26) have LTBI and 76.9% (20) began treatment. Of those, 80% (16) are being followed by private physicians and are on the Pharmacy Verification tool. To date, 50% (8) have had alerts. All yellow and red alerts, for all years, were followed up by the TBC Clinical Director. In most cases physicians were notified and/or patients were contacted to discuss the treatment, mitigating potential loss to follow-up. No modifications have been made to the Pharmacy Verification process or tool since implementation as the data indicates success.

An interesting observation in these results is that the percent of patients starting LTBI treatment has increased over the last few years.  It is difficult to explain the potential reasons for this, as the numbers may likely be driven by social determinants of health.  Nevertheless, should the percent continue to climb, the necessity for this tracking system will be even greater. TBC likes to stay ahead of the curve in anticipating additional challenges with innovation.

Objective 4 was to improve monitoring process, increase TBC efficiency and reduce loss to follow-up. Prior to the Pharmacy Verification process, as a conservative average, field staff spent 3 days per contact to follow-up. With the program, the designated administrative assistant must enter each contact in the tool, make monthly calls to the pharmacies and log results. The TBC Clinical Director spends time responding to alerts. Together, a conservative estimate would be one day of staff time spent collectively on all contacts in the program. From 2015 to 2018, 43 individuals were enrolled in the program. At three days per contact, it is reasonable to estimate 129 days of staff time would have been spent following up on 43 contacts. Compare this value to where one day per month is spent over three and a half years, equaling 42 days of staff time spent with the Pharmacy Verification process.  

Without a standardized method for follow-up on contacts receiving LTBI treatment who see private physicians, many contacts were lost to follow-up. This is defined as the inability to verify if a contact completed or stopped taking LTBI medication for a reason (chose to stop, adverse reaction, etc.). In 2011, 45.7% of contacts with LTBI were lost to follow-up, in 2012 this number decreased to 11.5%, in 2013 it was 13.8% and in 2014, 14.3%. Pharmacy Verification process was piloted in 2015, 8.8% of contacts who initiated LTBI treatment were lost to follow-up. However, the two individuals followed by the Pharmacy Verification process both completed treatment and were not lost to follow-up. Upon full implementation in 2016, 12 individuals were enrolled in the program and 0% were lost to follow-up. The overall loss to follow-up for all contacts on LTBI treatment was 6.3% for that year. In 2017, 13 individuals were followed using the Pharmacy Verification process and 0% were lost to follow-up which was also true for all contacts on LTBI regardless of provider type. Thus far, in 2018 16 individuals have been followed by the Pharmacy Verification process and no one has been lost to follow-up. This success is largely due to the alerts displayed in the Pharmacy Verification tool.

In summary, TBC successfully met all four of the project objectives described above, developing a Pharmacy Verification process and collaborating with pharmacies in the community to obtain prescription data; creating a tool to monitor contacts adhering to LTBI treatment using Microsoft Excel; implementing the process and the tool and improving monitoring process, increase TBC efficiency and reduce loss to follow-up.

One of the advantages of employing the Pharmacy Verification process is the ease of which it can be sustained. Its sustainability is derived from the simplicity of the way it is conducted, the willingness and ability to collaborate among stakeholders (pharmacies and TBC staff), its low-tech and cost-free mechanisms, and the resulting efficiency. The Pharmacy Verification process supports TBC staff in their goal to mitigate the spread of active TB throughout Nassau County. The Pharmacy Verification process is an effective way to confirm that contacts being treated for LTBI are following their treatment regimen.

The Pharmacy Verification process benefits from various resources which contribute to its sustainability. Microsoft Excel is the program through which the Pharmacy Verification tool is managed. Microsoft Office, which includes Excel, is available to all Nassau County employees on their personal computers. By using Excel, TBC staff did not have to request to purchase additional software, thus saving the County money. County Information Technology (IT) can provide support for Excel glitches, should the need arise, at no additional cost. Another resource is the expertise in Excel programming provided by inhouse TBC staff. While complicated formulas are necessary to make appropriate calculations, the Pharmacy Verification tool is simple to execute. TBC staff piloted the Pharmacy Verification tool and created a spreadsheet in Microsoft Excel which is clear and concise and is still in use today. Since no advanced knowledge of Microsoft Excel is required to use the tool, this allows for any TBC staff member with basic computer and Microsoft Excel knowledge to be able to enter data. An additional resource for the Pharmacy Verification process is a standardized script to be used when conducting the pharmacy calls, which also allows any TBC staff member to make the calls.

There were many valuable lessons learned in utilizing the Pharmacy Verification process. Prior to the onset of this project, the pharmacy used by the contact with LTBI was not readily collected by TBC. Therefore, it was necessary for TBC staff to contact physician offices to find out which pharmacies the contacts used. TBC has since begun to document that information in the Pharmacy Verification tool, decreasing the need to contact the physician. In addition, in 2016 electronic prescriptions were mandated. As a result, providers know which pharmacy the contact patrons, TBC can communicate with either the contact or physician's office for the information. TBC also learned that with proper education and outreach, pharmacies are generally willing and able to provide the requested information. TBC staff engaged with the pharmacies to ascertain how to best obtain the information needed to verify patient pickup of medications. In most cases, this was done with ease, verbally over the phone, but there was the occasional hesitancy on part of a few pharmacies due to HIPPA regulations. However, once it was explained to them that health departments are exempt from HIPPA and that it is permissible to release such information without patient authorization for the purpose of preventing and controlling communicable disease, the pharmacies were compliant in providing the requested information.

            In conducting Pharmacy Verification calls, TBC learned many helpful lessons. It was discovered that over the course that the Pharmacy Verification process had been in place that it is most effective to make the calls at the end of the month. The reason is this timing captures the entire month of information. By calling at the end of the month it saves time for the TBC staff. If they were to call earlier in the month, they would most likely have to call again at a later date to collect information of those who pick up their prescriptions at the end of the month. A second lesson learned is that it is important is to always ask the pharmacist for the medication days supplied. In so doing, the TBC staff member will know approximately when the LTBI patient should be picking up the next refill. Also, if the supply is for over 30 days, e.g. 90 days, the staff will know to call the pharmacy back in 3 months, and not have to waste time calling the pharmacy in the ensuing months. A third lesson identified was that staff should always ask for the number of refills remaining. This will inform TBC if the contact has enough refills to complete treatment and if their physician needs to be contacted for a new prescription. Finally, since the implementation of the Pharmacy Verification process, the pharmacies have come to expect the monthly verification call from TBC. As a result, there is little to no push back. The call is simple and quick and moves even faster if the staff has the contact's information readily available when calling.

      There is a stakeholder commitment to sustain the Pharmacy Verification process. A key collaborating partner is the pharmacist. TBC has always appreciated the pharmacists' roles in disease prevention, as noncompliance remains the most significant barrier to treatment. The conversations continue to provide a personal connection and highlight the importance of aligned efforts between pharmacies and TBC. The pharmacists, to date, have an even a greater stake in disease prevention and provide additional feedback, when necessary. The pharmacists have become an essential collaborating entity, one that remains today, as we continue to speak with them monthly. Furthermore, within the health department, this program has the complete support of all TBC staff employees, including the Division Director and the Clinical Director of TBC, as well as the Nassau County Board of Health, due to its effective and efficient manner of monitoring LTBI contacts adherence to treatment. For this very reason the Pharmacy Verification process is utilized by all TBC staff and is an integral aspect of case management and contact follow-up.

TBC continues to support the sustainability of the Pharmacy Verification process by regularly assessing the activities and acting to ensure that the program is utilized in the correct manner. TBC staff meets monthly to review TB cases and contacts to TB cases. At the monthly meetings, staff discuss LTBI contacts, including their treatment regimen. Questions or comments may arise, and it is often useful to have the Pharmacy Verification tool available at hand to view LTBI contacts adherence to treatment. Since the Pharmacy Verification tool is used frequently, there is enough opportunity for any potential issues to be identified and resolved in a timely manner.

The Pharmacy Verification process will also be sustained through its adaptability. TBC is considering expanding the process to include active TB patients refusing DOT and immigrants participating in the Class B program who require LTBI treatment, all who see private physicians for follow-up. The Pharmacy Verification process can be expanded to accommodate data for these individuals. As previously discussed, the Pharmacy Verification process uses Microsoft Excel to manage the collected data. There are several TB staff members, namely the epidemiologist, who are well-versed in Microsoft Excel who could easily revise the Pharmacy Verification tool to include all individuals.

Accountability is essential for sustainability. The full-time administrative assistant working in TBC was assigned the task of routinely performing Pharmacy Verification calls. These calls are made at the end of every month. Prior to this, the calls were not conducted with any form of regularity. Now that this has been assigned to a specific staff member, the administrative assistant, there is accountability for the work getting done. The administrative assistant is diligent and reliable in performing this duty. Any and all issues or questions about the LTBI contacts and their treatment are immediately brought to the attention of the Clinical Director of TBC and are addressed forthwith.

The Pharmacy Verification process is sustainable because it is simple, low-tech, cost-free, and an effective and efficient tool for monitoring contacts' adherence to treatment. This innovative tool could be used in other areas of health, to mitigate the spread of other communicable diseases other than TB.

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