With the good news about the efficacy of long-acting injectable therapy, a question for clinicians is, how does a clinic accommodate every person who may want or need LA-ART? There are challenges for staffing (who will administer the injections, especially at peak times?), and administration (who handles the inevitable denials from payers?). And reminding people to come in for their injections takes resources, too.
A few possible solutions were offered at IDWeek 2023. Christen Kilcrease, PharmD, AAHIVP, a clinical pharmacist at the Johns Hopkins Hospital John G. Bartlett specialty practice, shared how Bartlett, a referral-based clinical service for HIV medication as well as for comorbidity management, has optimized workflow to make way for new injectable HIV treatments.
Bartlett serves 3,000 patients a year and has a wide array of specialists, as well as nurses and social workers who help manage and distribute the workload. The on-site pharmacy has four pharmacists, six pharmacy technicians and two clinic-based pharmacists, which include Kilcrease and another pharmacist. Still, management expected glitches in the rollout of LA-ART, so they prepared. In 2019, they had surveyed providers about possible barriers to serving patients with LA-ART, and an implementation team used those responses to develop a workflow. That workflow went live in August 2021.
The new workflow has two main components: a centralized referral process, and optimized documentation for providers to use when meeting patients; the documentation is integrated into a referral form.
Providers screen patients and educate them on LA-ART, then refer them to the pharmacy team. Pharmacists complete the secondary review, then nurses and pharmacists administer the medication and ensure that appropriate monitoring is taking place between appointments.
The benefits review process is a bit more complicated, Kilcrease said, due to eight Medicaid plans in Maryland having different formularies and different calculations for paying. For benefits, the Johns Hopkins team developed a workaround to explore pharmacy benefits first. If the medication is not covered under pharmacy benefits, the team will explore medical benefits.
“If CAB-LA [long-acting cabotegravir, which is given with a separate long-acting injectable, LA rilpivirine, for HIV treatment or by itself for PrEP] is covered under pharmacy benefits, the pharmacy
will administer the medication in the pharmacy,” Kilcrease said. “If it is covered under medical benefits, the nurse will administer the medication in the clinic.” At the on-site pharmacy, only one pharmacist administers and runs claims.
The workflow isn’t perfect, Kilcrease said. Because the pharmacy is not on the same system as the clinic for automated patient reminder notifications, it falls to the pharmacy—specifically, clinical pharmacy technicians—to do follow-ups, manually.
The team also developed a screening tool for each injectable antiretroviral to help providers with decision making when discussing CAB-LA. “[This tool] is the most commonly requested information from both payers as well as our pharmacists and nurses,” he said.
Operations are live in two adult clinics, one pediatric clinic and the site pharmacy, and the team is working to get long-acting PrEP at a third adult site. “We also have expansion in efforts for CAB-LA in other sites throughout the health system,” Kilcrease said.
The team also developed a screening tool for each injectable antiretroviral to help providers with decision making when discussing CAB-LA.
According to Johns Hopkins’ financial clearance department, in the six months before the new workflow, 22 individuals were started on LA-ART. After starting the new workflow, within three weeks, 20 new individuals started on LA-ART. And the wait list has drastically improved, Kilcrease said. “At one point there were over 100 patients on the wait list, and now we’re down to 23.”
Kilcrease shared several lessons in workflow change that other clinics could consider. First, aim for a centralized referral process and hub, and use existing staff to evaluate their scope of practice. “If the scope of practice does not allow them to administer these medications, work with state boards and advocate for those disciplines to practice at the top of their license,” she said.
For better benefits workflow, Kilcrease recommended creating a process for evaluating payer authorizations and reauthorizations, including an appeal template and a pill letter template for providers to help them respond to denials. Because there are always denials, she added.
Finally, clinics could consider using the manufacturer hub for benefits determination for the patient. “If you do go
that route, I would recommend creating a tracking system for patient appointments as well as authorization dates,” she said.
Responding to a question about how Hopkins keeps people engaged in care, Kilcrease said that having the advantage of many resources such as dedicated outreach specialists helps. She added that most of the people who expressed interest in CAB-LA do a good job of self-regulating and coming to their appointments.
“We do have the systems in place for automated reminders on the clinic side,” she said. “We are utilizing our clinical pharmacy technicians to help with reminders on the pharmacy side, and we have the automated system on the clinic side. But what I would say is that, mostly, the patients come back because they are treated the way they want to be treated.”
Larry Buhl is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, the New York Times and others.