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Becker’s Healthcare Podcast
Optimizing Long Acting Injectable HIV Care with Dr. Jackie Kissel and Dr. Alvin Choy
00:14:25
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- [00:00]
A
Hi, everyone. This is Lucas Vaz with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare podcast series. Fantastic to have you. Today we're talking about how provider organizations are leveraging EHRs and EMRs to coordinate care and navigate insurance requirements for HIV PrEP patients prescribed long acting interjectionables, or LAIs as we might refer to them here. Joining me for today's discussion, very excited to have him, Dr. Jackie Koso, Director of clinical pharmacy at Equitas Health, and Dr. Elvin Choi, long acting interjectable antiretroviral therapy program manager and clinical pharmacist also at Equitas Health, Dr. Kissel. Dr. Choi, thanks so much for being here today. It's great to have you.
- [00:42]
B
Thanks for having us.
- [00:43]
C
Thank you.
- [00:44]
A
Absolutely. I want to start off with introductions for our audience that might not know you yet. Dr. Kissel, we'll start off with you.
- [00:52]
B
Yeah. So I'm Dr. Kissel. I'm a pharmacist. My pronouns are she, her, and I've been doing this type of work for a really long time. So I graduated from pharmacy school in 2013 and I did a residency at the Ohio State University and then I came over to Equitas Health, which at the time was AIDS Resource Center Ohio. And I started off in the community pharmacy over there and then kind of worked my way into building a clinical program and then eventually became a director over those clinical programs within Equitas Health. So really I landed at Equitas. Love the work that we do. And I've been here for over 11 years.
- [01:34]
A
It's so great to have you on. Excited to hear from you. Dr. Choi, over to you.
- [01:38]
C
Hey. Hi everybody. My name is Dr. Alvin Choi. My pronouns are he, him. I'm a clinical pharmacist and I also manage our HIV and prep injectables program here at Equitas Health. I've been in the space, the HIV and prep space, not as long as Jackie getting there soon, but I graduated from pharmacy school at the University of south Florida in 2021. I did a very similar residency to Jackie. I did the pharmacy residenc here at Equitas in 2021 and then have stayed on with Equitas ever since to really manage our injectables program.
- [02:12]
A
Yeah, it's great to have you both. I want to start off with sort of level setting everything. Give us a little bit of an introduction to what we're facing, what we're seeing here today and what we're going to hear about. We know that many clinics serving patients on long acting, injectable prep face a lot of complex operational challenges. There's scheduling, there's dose timing, and we haven't even touched on the insurance piece. Right. The insurance navig part is certainly, certainly important as well. Before optimizing EHR workflows, what were some of the biggest pain points you've seen your team encountered in coordinating care for the patients, for these patients that you were seeing? Dr. Kissel, we'll start with you.
- [02:56]
B
Yeah, so we really started trying to build this program back in 2021 and we were flying blind, like we did not know what we were doing, what we were getting ourselves into. Individuals think, oh, you're just, you know, you give the patient, you get it approved by the insurance, you give an injection. Well, it's way more complicated than that. There's way more steps. And we really, our first go at it. That program didn't even get off the ground. There was too many hands in the pot. Patients were being bounced from providers to nurses to clinical pharmacists, back to nurses, back to the provider. And then how were we tracking these patients? Who was following up with them if they no showed like what was going on? And it really came down to eventually realizing that that was just, we need a team. We need a team to really focus on these patients and watch them through the continuum of care to make sure that they're getting everything that they needed versus trying to do it within our normal workflows of medical centers, which I think a lot of us tried to do that without having a centralized. And we just realized that that was not possible. So in 2022, that's when we hired Alvin to kind of work with me to jumpstart a new process to really figure out how we can utilize a team to get these patients through the injectable process.
- [04:24]
A
Yeah. Dr. Troy, can you talk about that process a little bit?
- [04:27]
C
Yeah, absolutely. So before I kind of get into that, I want to really agree with Jackie. Having a method to track all of these patients is incre. There are just so many different steps in the process. And like Jackie had mentioned, it is difficult at first when you are kind of. You don't know what the steps are. It's a brand new medication and it was. Everybody was kind of just flying blind. But some of the biggest steps that we've kind of implemented moving forward has been instead of utilizing like our EHR per se, we utilize a customized tracker that integrates into a calendar. And in this calendar, this is where we operate all of our daily tasks from processing medications, following up on deliveries, following up on prior authorizations, whatever it is, and just making sure everything is done off of this calendar is how we operate and how we track all of our patients. I think there's definitely use of the hr. We use it mostly from a clinical standpoint. We obviously do all of our patients appointments, reschedule labs or take labs, reschedule appointments, do vaccines, all that stuff. Within the ehr, however, we utilize that tracker to track every touch point with our patients, and it's a lot easier just to do it on that tracker instead.
- [05:52]
A
So that's, that's tremendously improved the workflow piece in terms of being able to track things better, is that correct?
- [05:59]
C
Very much so, yeah.
- [06:00]
B
And I'll jump in to say that when we say a tracker, like we hired someone to code programs to make this so we can, you know, select our role, be able to see what we're assigned, see when patients miss appointments. Like we have it coded in a way that integrates with the calendar to give us all the dates. So anyone looking at a single date can really say, okay, today is November 13th. This is everything I need to do for the day. And as a director, I can look at that and see who's getting overwhelmed with too much work. What work is getting done, when's it getting done. I can ask people what's going on based on all of that so I can have oversight of the program as well by having that tracker and that calendar.
- [06:47]
A
Dr. Choi, you mentioned something important, which is the electronic prior authorization process, which is certainly important. We also talk about enhanced medication administration records, right? Those are certainly part of it as well. How did those tools change day to day operations for you?
- [07:05]
C
Yeah, absolutely. So we use different databases to do our electric prior authorizations, and we just utilize those to keep track of all of our patients. But then we also tie that into our tracker to show, okay, this prior authorization is about to expire on this day. And making sure we're renewing that prior auth before the patient comes in, before it even expires. But utilizing electronic databases to track these prior auths has been really easy one to submit it, but also to tie it into our in house tracker to make sure that things are not kind of lost, I would say, from the enhanced medication administration records. We don't actually use as many of those mars per se within the outpatient space. Outpatient healthcare space, we don't have that many medications that we administer to the patient. It's mostly these long acting injectables vaccines and a few other injectables I would assume within the inpatient space. I don't work in the patient space, so definitely. Correct me if I'm wrong, but I would assume that they're giving more IVs, more medications, and more things you have to track on that actual administration record. So Enhanced Mars is not something that we actually utilize within our workflow as much.
- [08:22]
A
Yeah, that makes sense. Dr. Kissel, I wanted to come back on something that you mentioned earlier, which is again, the team aspect of this and the optimization part of it, which is really, really key. The too many hands in the pot.
- [08:35]
C
Right.
- [08:35]
A
Can certainly become an issue, as you've said. And coordinating prep Lai care really involves multi disciplinary teams. A lot of system touch points as we've just outlined throughout the conversations. Can you share how collaboration across those teams, the teams that you're working with, supported all of this optimization and what kind of impact you've seen there?
- [08:59]
B
Yeah, so really, every single day, this team for the Injectable program is interacting with billing, they're interacting with pharmacy, they're interacting with nurses, they're interacting with providers, they're interacting with insurance companies. And so what we've done is created communication channels for all of those different teams to make sure that they have access to Alvin, to his. We call them pharmacy care coordinators to answer any questions. They have to let us know if anything goes wrong and they can just send us a message. We get it, someone on that team will address it and then we will get back to them pretty much instantaneously, which is great to solve patient issues on the spot. The other thing that we implemented is monthly meetings with each of those teams to talk through workflow issues, to continue to enhance our workflow, make it better for the future, or find any gaps. If something happens, we always want to get to the root cause. So then we'll have meetings about, okay, why did that happen? How do we keep it from happening in the future? And even as you know, in this past year we learned a lot and we even changed the workflows probably sometime in February or March to help with some of those gaps.
- [10:12]
A
I'm assuming you had tremendous impact on your work as well.
- [10:15]
C
Yes, very much so. Something I do want to echo off of, Jackie, is one of the biggest takeaways is just having really strong communication, really strong coordination skills is vital for keeping track of all of these patients. Especially as different companies, different organizations start to ramp up and get into like hundreds of patients. It takes a lot, a lot of communication. Between different teams and different departments to make sure these are going smoothly. Like just for example, yesterday one of our providers was out sick. But they have patients that they're going to see. So just managing where those patients are going to go, are they still going to be seen? Are they still going to get their injection? Like all of that takes a tremendous amount of communication across departments. But I do want to echo also what Jackie said earlier too is just be careful with how many touch points because it does get very messy as more people start to come into the program. So having a small knit core team is vital for this program.
- [11:17]
B
Everything gets filtered back to me, Alvin or his team and that's really nice. So we know exactly what's happening at any point with any issues that arise.
- [11:27]
A
Yeah. And again, like it's so important because it trickles down to the, to the patient experience, right?
- [11:31]
C
Oh yeah.
- [11:32]
A
People 100% that enter, that come through the door and that's so such a critical component of it, which is so key. It's so great to have you both on. Thank you so much for sharing these insights with us. What a great conversation. I do want to turn the floor over to you. Anything else that you'd like to share with the audience? Anything else that comes to mind that folks might not know or that you'd like folks to know based on our conversation today that we haven't touched on. Dr. Kissel, we'll start off with you.
- [11:58]
B
So for those of you who aren't familiar with prep or might might not familiar with hiv, the reason it's so important to have these processes in place is because when they miss a patient misses an injection or an injection isn't given on time, it can be detrimental to their health in so many ways. And other injections in healthcare are like that as well. But, but I feel like this is a different level of how much it can impact a patient, especially for prep. If they aren't on time and they acquire hiv, then you just possibly don't have certain treatment options available to you. And so it's really important to not just not have these processes and think through how you're going to keep these patients in care and follow them. Because letting them, you know, not come to their appointments or they don't have an appointment set up just really can be detrimental overall.
- [12:55]
A
Yeah, Dr. Choi.
- [12:57]
C
Yeah, I do want to echo off that too. And having some of these medications that are cutting edge technology before any of these long acting injectables, we only had oral prep options and oral HIV treatment options. So having options for an injection that lasts months at a time. Many of my patients have told me that just without they struggle with taking a pill every day. So having an option for a long acting injector has just literally saved their lives. But outside of that, one other thing I did want to mention too is just the benefit of having a clinical pharmacist on the team. I know I'm biased because I am a clinical pharmacist, but medication access as a pharmacist is our absolute bread and butter. It's what we do every single day. Making sure that the patient is able to get their medication, making sure it's able to be affordable, and making sure that, you know, they're able to continue their care in the long term. So I would say, and there's multiple studies to back this up, but having a clinical pharmacist on the team, especially in a program such as this, where access is the name of the game, is so, so vital to the success of the program.
- [14:08]
A
Absolutely. Dr. Kissel, Dr. Choi, thanks so much for being here today, taking some time for us. It's great to have you.
- [14:14]
C
Thank you.
- [14:14]
B
Thanks for having us. Nice to meet you.
- [14:16]
A
Yes. And you can tune into more podcasts from Becker's Healthcare by visiting our podcast page@beckershospitalreview.com.