Objectives: The primary objective of Link-Up Rx is to improve viral suppression amongst PLWH in Detroit by decreasing the length of time and instances of interruption in taking HIV medication. The secondary objective it to improve the partnership and coordination between the DHD, MDHHS and pharmacists.
Evaluation and data management have been central topics since the initial discussions for Link-Up Rx started in May 2017. Evaluation metrics were discussed at length with all partners. Primarily, outcome evaluation is used, but a full process evaluation will be done 12 months into the program to determine if any steps in the current data flow can be improved to minimize staff time and increase timeliness of data exchange. Short-term outcomes are monitored at the end of each month (minimum) and long-term outcomes will be evaluated at six and 12 months.
Short-term outcomes include:
- Number of individuals pharmacy shares with MDHHS/DHD
- Number of individuals successfully contacted by DHD
- Number of individuals successfully contacted by DHD that receive ART from referring pharmacy within 30 days of original fill date
- Number of individuals who are referred for other Ryan White-funded core or support services
Long-term outcomes include:
- Percent of successfully contacted individuals virally suppressed at six months
- Percent of successfully contacted individuals virally suppressed at one year
To date, Link-Up Rx has not looked at viral suppression before and after Link-Up Rx's intervention. However, from speaking with clients in Link-Up Rx and by working with the pharmacy on a daily basis, we know that we have been able to successfully locate (62%) and (re)engage a significant amount (54%) of people after the pharmacy has not been able to locate them. In theory, every time a person has less time off their HIV medication, that is less time their virus could be replicating, which results in improved health outcomes for them and limits the risk of HIV transmission in our community.
We have met and continue to build on our secondary objective to improve the partnership and coordination between the DHD, MDHHS and pharmacists. The DHD and MedCart Pharmacy are in contact on a weekly basis to discuss client cases. This communication has helped improve other systems in our HIV programs, including, but not limited to health insurance navigation, expedited medical appointments for individuals who need updated prescriptions, medication management (including discussions about adherence and side effects). In addition, the partnership that was created with MedCart for Link-Up Rx has already benefited other programs at MDHHS, including, but not limited; pre-exposure prophylaxis (PrEP) monitoring for HIV-negative individuals who are at high-risk for HIV infection and improving the quality of MDHHS Surveillance data for HIV. Each week that MedCart transfers data to MDHHS, MDHHS gets to ensure that they have the most updated information for each individual that they send. This data includes correct locating information (phone number, address), date of birth, gender and history of HIV medication treatment. All this information can help MDHHS have a more accurate image of what the HIV demographics are in Detroit so they are able to make informed programmatic and funding decisions. In addition, the DHD is an active member on MedCart's Quality Committee that meets quarterly to improve MedCart's pharmacy services.
Data: Link-Up Rx is dependent on data transfers from MedCart Pharmacy to MDHHS then MDHHS to the DHD on a weekly basis. Data is transferred in a password-protected Excel file through a MDHHS-sponsored secure file transfer system between each party. MedCart Specialty Pharmacy gets the primary data on individuals who do not fill their medications from their electronic medical records system, called CPR+. Each week, MedCart downloads data from CPR+ and sends it to MDHHS. MDHHS then uses SAS to pull additional data from the CDC-supported enhanced HIV/AIDS Reporting System (eHARS) and transfers the data to the DHD. All data systems have been setup in a time efficient manner, so it only takes individuals 10-15 minutes weekly to manage the data transfer.
Once the data arrives at the DHD, Link-Up Rx outreach and outcomes are captured in CAREWare (CW). CW is a free, HIPAA-compliant, electronic health and social support services information system for Ryan White HIV/AIDS Program grant recipients and their providers. CW was chosen to track Link-Up Rx data for several reasons. First, CW has been an effective way to track information for Link-Up Detroit. Secondly, CW is a secure data management system that allows for each contact attempt and referral to be easily tracked. It also records all services that an individual has received in the past from RW funded providers (medical and non-medical) and medication cost assistance from the Michigan AIDS Drug Assistance Programs (MIDAP). This allows for other RW providers to see what Link-Up Rx outreach has been done with their clients. It also helps the Link-Up Rx team locate individuals because they will be aware of what RW and MIDAP services an individual has accessed in the past. Lastly, it provides quick and easy access to de-identified data reports, so progress for Link-Up Rx can be easily tracked and evaluated on a weekly basis in a time-efficient manner. For example, it takes less than a minute to run data reports that determine Link-Up Rx outcomes for everyone investigated as well as outreach work (phone calls, text messages, voicemails, coordination with clinics, etc.) that went into (re)engaging them.
As of December 2018, Link-Up Rx has been running for over five months. As of December 1, 2018, 183 people have been initiated for outreach after they were three weeks past their prescription pick-up date. Out of these 183 people, 62% have been successfully contacted. Out of the 183 initiated, 166 (91%) cases have been completed. Of the 166 completed, 58 (35%) have been referred straight back to the pharmacy and 32 (19%) have been referred to external supports like case management or insurance navigation. In order to achieve these results, the Link-Up Rx team made 715 phone calls, left 332 voicemails, sent 117 text messages and coordinated care for 61 people with different Ryan White agencies, clinics, and MDHHS insurance programs (Medicaid and Drug Assistance).
Each month the Link-Up Rx team meets to discuss results and what could be done to improve processes and outcomes. One key barrier that has come from these discussion is that many clients fail to pick-up medications because of a lapse in health insurance coverage. This can happen when their yearly reappraisal is due for Medicaid, if their income changes, or every 6 months for their MDHHS premium assistance or drug assistance payments. As a result of Link-Up Rx, pharmacists, MDHHS, DHD, MIDAP and Ryan White providers are all collaborating more on how to simplify insurance programs and minimize frustrations for clients when they are unable to receive medications because of insurance issues.
In summary, 12 months into the program our key objective of improved VS will be analyzed. At five months in, we have had much success in re-engaging PLWH and have seen substantial improvement in coordination and collaboration with our pharmacy partners.