1 Marie Dorsey, Pharm.D., AAHIVPThe Telehealth and Collaborative Practice Pilot Project: Providing HIV Pharmacy Specialist Care to People Living with HIV in Rural Oregon The HIV Alliance Eugene, Oregon Marie Dorsey, Pharm.D., AAHIVP March 3, 2016 I will tell you a bit about our organization and then about an exciting new project we recently acquired funding for

2 The HIV Alliance Non-profit social service organization11 Counties, ~700 clients Services: Application assistance Housing, transportation, food cards Needle exchange, testing Dental care Nursing evaluations Pharmacist consultation Eugene, Oregon Non profit social services organization serving people living with HIV, the Human Immune Deficiency Virus, known to cause the Aquired Immunodeficiency Sydrome otherwise known as AIDS Case Management

3 Current Pharmacist ServicesMedication adherence counseling Patient and provider disease state and medication education Drug interaction analysis Side effect and symptom management HIV medication regimen review Refill alignment and pharmacy liaison HIV is a complex illness, but not a death sentance

4 The Benefit of Pharmacist Consultation ServicesA systematic review of 10 studies demonstrated that an HIV pharmacist’s care was associated with greater viral load suppression and statistically significant improvements in HIV medication regimen adherence. 1 Several pharmacist-implemented telehealth studies show benefit to chronic disease state patients and healthcare systems2,3 The benefit of pharmacist consultation services is shown in several studies There is a systematic review….. In comparison to the standard of care -ability to call a patient more frequently and follow up with new changes, medication adherence, and ask about symptoms -HIV clinical pharmacists that provide medication adherence counseling can usually provide medication adherence aids such as pillboxes, watches, calendars and can take the time for more extensive motivational interviewing. Chronic dz state: anticoagulation, diabetes, transplant, HIV -more time for follow up -clinical pharmacists will have specialized training for the chronic disease state they are working with 1.Saberi P, Dong BJ, Johnson MO, Greenblatt RM, Cocohoba JM. The impact of HIV clinical pharmacists on HIV treatment outcomes: A systematic review. Patient Prefer Adherence. 2012;6: 2.Jones C, Lacombe G. Enhancing patient care via a pharmacist-managed rural anticoagulation clinic. Healthcare Quarterly. 2009;13:69-74. 3.Singh LG, Accursi M, Black KK. Implementation and outcomes of a pharmacist managed clinical video telehealth anticoagulation clinic. Am J Health-Syst Pharm ;72:70-73.

5 The Need for Telehealth HIV Specialist Services in Rural OregonTotal HIV/AIDS cases (as of ):4 6,740 Urban: 5,615 Rural: 1,125 Yamhill county- 2hr round trip NorthEastern Oregon- 2.5 hr to Boise or to the TriCities Physicians available As of All counties-6,740 (M-5916, F-824) Multnomah-3348 Clackamas-446 Washington-819 Lane-395 Total HIV/AIDS cases (as of ): 6,740 Portland/Salem area: 74% Lane County: 5.8% Jackson County: 3.5% Rest of the state: 16.7% Data source:

6 Telehealth and Collaborative Practice Pilot ProjectDescription: HIV pharmacist consultation through secure videoconferencing software Collaborative practice agreement Efficient care Goals: HIV Patients-improve access to specialist care Providers-time and cost-savings *Establish ongoing reimbursement through insurance companies Outcomes: Improved laboratory values  improved overall health Increased number of HIV specialist consultations Patient and provider satisfaction Ongoing provider and patient relationships Funded through the Centers for Medicare and Medicaid Innovation and managed by the Oregon Office of Rural Health Ongoing maintenance care Multnomah Co with Portland-largest (~60%) HIV Alliance Clients (~30%) Rural (~10%) In addition to current services: A collaborative practice agreement(CPA) is a formal agreement in which a licensed provider makes a diagnosis and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specialized functions.19 Ordering and prescription of new medications Change or discontinuation of medications Ordering and interpretation of laboratory tests Referral of patients to other specialist providers as needed -CPA then gives pharmacist room to monitor and adjust treatment for chronic conditions as necessary and initiate therapies for side effects as needed --We recently began taking referrals at the Umpqua Community Health Center site. -Geoff is currently signed onto their EMR and our collaborative practice agreement has been signed. -We have also begun the process of getting our services paid for through insurance companies, in that we are discussing contracts right now. -Currently our pilot project services are not available to all physicians and only those who are associated with Umpqua Community Health Center or who have patients that receive services from the EOCIL. Dr. Clay Rosoe’s office, the Wellness Center, is the only center on ECHO that we know of that qualify. Please let us know if you are on ECHO and have patients associated with these two centers. The long term goal is to be able to continue and expand pharmacist clinical services through telehealth by obtaining funding through insurance companies. -I am seeing patients through the EOCIL and in the process of telling providers about our program. We have run into a bit of difficulty b/c of trying to collaborate across state lines where I am required to have a license in each state with each provider in those states that I am working with. This is one of the roadbumps that we will continue to see when working with telehealth and the ability to speak with patients and providers from anywhere on the map

7 Patient Benefit of Telehealth Pharmacist ConsultationGreater access to specialist care Decrease travel time and cost5 More comfortable, at-home setting Greater opportunity for presence of family and friend support6 Encourage connectedness to providers6 Improved ability to work5 Geoff and I both certified though the American Academy of HIV Medicine as HIV specialist pharmacists. We look forward to providing consultation to providers that don’t work with a lot of HIV and don’t have the time to keep up with our ever changing HIV guidelines and information Decreased travel time and cost. In one study, 300,000 miles, which is equivalent to almost 20,000 travel hours were averted from patients using telehealth for their visits. The no show rate was also much improved (4% versus 10%) Study: 236 Florida VA patients use pharmacy telehealth services 5.Coakley C, Hough A, Dwyer D, Parra D. Clinical video telehealth in a cardiology pharmacotherapy clinic. Am J Health Syst Pharm. 2013;70: no-show rate for clinical pharmacy telehealth visits was 4% as opposed to 10% for traditional face-to-face appointments. averted 300,904 miles, equivalent to 19,928 travel hours in the 2012 fiscal year. Study: Telehealth in rural Canada 6.Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Patients and families experiences with video telehealth in rural/remote communities in northern Canada. J Clin Nurs ;18: *Also improved no-show rates for visits (ref 1)

8 Provider Benefit of Telehealth Pharmacist ConsultationHigher-value clinical services to a greater number of patients Allow physicians to spend more time with new and more complex patients Time savings Cost savings Increased revenue Time is money Higher value= greater comprehensive care -Monitoring of chronic disease states is not cost-efficient for physicians -pharmacists goal is to supplement, not replace the care given by physicians -Pharmacists can help monitor complex disease states such as HIV -pharmacists can follow up more frequently and ask more detailed questions for medication adherence -Detailed drug interaction check Different providers will have various comfort levels with collaborative practice agreements that are written and pharmacists are willing to write the protocol and work with the providers to meet their comfort level 7.Alkhateeb FM, Unni E, Latif D, et al. Physician attitudes toward collaborative agreements with pharmacists and their expectations of community pharmacists responsibilities in West Virginia. J Am Pharm Assoc. 2009;49: 8.Hlubocky JM, Stuckey LJ, Schuman AD, et al. Evaluation of a transplantation specialty pharmacy program. Am J Health Syst Pharm. 2012;69: *Providers’ perceptions of specialty pharmacy services in numerous acute care and ambulatory settings have been positive7,8

9 Telehealth and Collaborative Practice Pilot ProjectTotal enrollment Goal: 30 patients Geoff L’Heureux, Pharm.D., AAHIVP 1 patient enrolled 11 patients enrolled Geoff- Provider trust Centralized care Current plans: -Patient party in Roseburg -Target Deschutes Co -Dr. Yeakey -Dr. Perez Marie Dorsey, Pharm.D., AAHIVP

10 Electronic Medical Record AccessWhy Geoff’s was successful -Improve medication adherence -Improve patient and provider satisfaction -Order medications, labs -Obtain Washington pharmacist’s license -Ask patients to enroll -Convince individual physicians to sign CPA -Each targeted physician to have at least 7-15 patients -Obtain data: Components: Provider trust Electronic medical records access Licensing Patient need Non-liability Pilot team collaboration HIV specialist pharmacists HIPAA compliant software Patient interest Provider trust Established patients Centralized location In state providers Electronic Medical Record Access

11 Entering the Unknown Lack of provider connections and trustOut of state providers Provider licensing Dispersed providers Large geographical distances Entering the unknown

12 Looking Forward Increase enrollment in RoseburgWashington physician to obtain Oregon medical license Collaborative practice agreements with primary care providers Deschutes County Coastal providers Increase patient enrollment in Roseburg section: party One Washington provider may be willing to walk the rocky road with me to obtain Oregon Medical License May invite Deschutes county to participate Have contacted a Eugene and ________provider to help patients living on the coast Trying to find rural physicians that take care of at least 5 patients living with HIV Electronic medical records system

13 Patient Example 1 Patient Example 2 References1.Saberi P, Dong BJ, Johnson MO, Greenblatt RM, Cocohoba JM. The impact of HIV clinical pharmacists on HIV treatment outcomes: A systematic review. Patient Prefer Adherence. 2012;6: 2.Jones C, Lacombe G. Enhancing patient care via a pharmacist-managed rural anticoagulation clinic. Healthcare Quarterly. 2009;13:69-74. 3.Singh LG, Accursi M, Black KK. Implementation and outcomes of a pharmacist managed clinical video telehealth anticoagulation clinic. Am J Health-Syst Pharm ;72:70-73. 4. Oregon Disease Surveillance Data. Accessed 5.Coakley C, Hough A, Dwyer D, Parra D. Clinical video telehealth in a cardiology pharmacotherapy clinic. Am J Health Syst Pharm. 2013;70: 6.Sevean P, Dampier S, Spadoni M, Strickland S, Pilatzke S. Patients and families experiences with video telehealth in rural/remote communities in northern Canada. J Clin Nurs ;18: 7.Alkhateeb FM, Unni E, Latif D, et al. Physician attitudes toward collaborative agreements with pharmacists and their expectations of community pharmacists responsibilities in West Virginia. J Am Pharm Assoc. 2009;49: 8.Hlubocky JM, Stuckey LJ, Schuman AD, et al. Evaluation of a transplantation specialty pharmacy program. Am J Health Syst Pharm. 2012;69: Patient Example 1 Newly diagnosed HIV patient was given two drug regimen options by provider Pharmacist found drug interaction Treatment failure prevented Patient Example 2 Pharmacist found medication misunderstanding Patient lives 3 hours from specialist and does not qualify for federally funded rides