Hennepin Healthcare System

Targeted Meds to Beds Program for HIV Care

Submitted by Mark Holtan, PharmD, BCACP, AAHIVP

Site Description

The program has been implemented at the Hennepin Healthcare System (HHS) community pharmacy. Which is connected to an ambulatory care clinic.

Med to Beds Service Description

HHS has a modified meds to beds program associated with HIV care in our pharmacy. We have a pharmacy specific to our HIV patient population that serves our positive care clinic. This pharmacy provides robust services that includes direct dispensing to patients, mail services, as well as high-touch adherence support dispensing for patients determined to be in need.

Patients who start new HIV medications, have trouble with adherence to medications, or interested in a comprehensive review, will receive a referral for MTM pharmacy services in clinic, where we have 4 clinical pharmacists. These patients are seen and assessed for their ability to adhere to their medication regimens. Patients who are doing well and interested in navigating pharmacy services by themselves will be triaged to use our HIV-specific pharmacy for mail service or pick up of medications. Patients who are struggling with medication use will often elect to continue to meet with the clinical pharmacist for ongoing adherence support in clinic.

The pharmacy technicians have a process where they review the upcoming clinical pharmacist schedule for the following day. The technicians will prepare those medications, obtain refills and prior authorizations, so they are ready for dispensing to the patient as part of a clinic visit. The pharmacist also has adjusted their documentation template in order to identify the medications needed for the following visit.

The medication dispensing in clinic may include evaluating each bottle and providing re-education on the medications, or may result in assisting the patient with pillbox filling of medications for ease of organization and administration. Adherence tools are provided through grant funding.

Policies and Procedures

The pharmacy staff for this particular pharmacy are all aware of these processes and one specific technician is assigned to this task. Nursing staff and providers are aware of this service but are not involved in the operationalization of them. Medications are stored in the double-locked medication room until the patient arrives for the visit and they are dispensed. Meds that are not dispensed (if a patient cancels or no-shows) are returned to the pharmacy.

The interaction between the patient and clinic pharmacist are documented within the context of their CMM (Comprehensive Medication Management) documentation.

Additional Tools

We are able to target the patients who will receive direct medication dispensing in clinic by reviewing the PharmD schedule for that day. 

Patient Population Target

The scope of this service is limited to patients seeing the clinical pharmacist in our HIV clinic.

Financial Considerations

For this service, the clinical pharmacists are funded through our ambulatory pharmacy department. Interestingly, this dispensing model, in addition to benefiting patients tremendously, allows these pharmacists to see more patients in a day than a clinic without access to these pharmacy services. Less time is spent navigating getting a patient a PA approval, refill approval, or calling a pharmacy to clarify as this has been done in advance. Also, all medications are coordinated to a single date with also streamlines the patient’s pharmacy experience.

HIV medications, if not taken properly, can be harmful to the patient. With this semi-automated process, the community pharmacy staff can safely and accurately fill more medications than they would with a standard process that is more reactive to the patient requesting medication fills. The pharmacy self-funds the process through claims process and 340b when applicable. This meds to beds program contributes to the positive care of HIV patients and supports the financial stability of the organization.

Patient Assistance

We have a centralized PA and PA team owned by the pharmacy department. This particular clinic is Ryan White grant funded, so we are able to lean on social workers, alcohol and drug use counselors, and benefits coordinators that keep patients insured.

Key Stakeholders and Operational Considerations

This process was started on a small scale 17 years ago and has grown by leaps and bounds. The clinic and pharmacy recently were approved for a strategic initiative with a plan for future growth through pharmacy and clinic renovation that would be tied to patient and prescription growth. Statistics on clinic visits, prescriptions filled, unique patients serviced, and capture percentage are shared in a team meeting monthly and evaluated more critically quarterly.

Outcomes & Measures

Patients receiving medications (both through the pharmacy directly and meds to beds) were shown to have a 96% viral suppression rate several years ago when we looked at this data. Many of the patients that see our pharmacists are disproportionately more complex than the general population in the clinic, so it is difficult to determine “success” when comparing to the entire clinic population. 

Key Elements of Success

Grant funding from Ryan white pays for clinic resources to meet the patient’s needs, and we are able to triage issues quickly and effectively. The ROI on these medications is high, which has allowed us to place precision resources toward this area. The continued growth of the program has allowed it be successful, especially as the pharmacy also looks productive on paper when comparing prescriptions filled vs staffing, as the process is very efficient for processing meds.

Lessons Learned

I would ensure that there are adequate processes in place to “automate” processes. At one point our team used EMR inbaskets to request medications to be filled for clinic. These messages were missed often and patients would have to wait to have their medications filled so they could be provided in the clinic visit.

Future Goals

We are adding a pouch packaging robot to support this work further and provide adherence packaging for patients who normally have to come in for a clinic visit. This will allow us to mail these medications to the patient directly and create space for patients who have additional needs to have access to clinic visits. We are also relocating our space to be adjoined with the clinic so that we can be better connected physically to the clinic. Currently the pharmacy is a few hundred feet away and is inconvenient for patients to access directly. This will also allow us to improve efficiency of the meds to beds as the medications will be filled closer to where they will be dispensed to the patient in clinic.