PEMs have to be miracle workers with new meds
PEMs have to be miracle workers with new meds
Individual teaching improves adherence
Although the newest bumper crop of medications for HIV are touted as "miracle" drugs, the hype hasn’t improve compliance. Health care workers at the Erie County Medical Center in Buffalo, NY, for example, still were seeing a 50% failure rate for adherence to the complex medication regimens after patients were given these new medications.
Therefore, the University of Buffalo School of Pharmacy developed an HIV medication adherence clinic. The clinic is designed to give patients — who might take as many as 40 pills a day — intensive education and support.
"A big part of this program focuses on educating the patient about the disease, the drugs, how they work together, and how the patient’s role dictates whether they work or don’t work," explains Lori Esch, PharmD, clinic and HIV pharmaceutical care specialist at the medication adherence clinic.
An initial assessment of patients with HIV and their caregivers revealed a lot of misconceptions about HIV and the medications used to treat it. One of the biggest barriers to adherence is the fact that many people do not understand the importance of following the medication regimen.
Yet adherence is crucial to the success of anti-HIV drugs because if therapy is interrupted for any reason, the second-line drugs will never work as well as the first-line drugs, says Esch.
"We realized we needed to have more contact with the patient at the beginning, before we changed their medication or sent them off and expected them to be 100% compliant with their new medication," says Esch.
To improve compliance, patients referred to the clinic by their physicians attend three one-on-one educational sessions that last one hour each. Topics covered include:
• The disease.
The first session focuses on the disease and how it multiplies and takes over a person’s body. Patients also learn how health care professionals determine if the disease is progressing. The lab tests the patients are currently undergoing to determine the best course of treatment are discussed as well.
• The medications.
At the second visit to the clinic, patients learn which HIV medications are available, how they work, and what type of regimen they require. Then patients are asked about their lifestyle in an effort to determine which drugs fit best. For example, if a drug could cause diarrhea, it might not be suitable for a person who works as a bus driver. "There really are optimal medications to use in certain situations, but they aren’t optimal if the person is not going to take them, so we try to match the best drugs to the patient and then make recommendations to the physician," says Esch.
If staff determine that the patient has other medical problems, such as depression, they recommend treatment before the patient is placed on the complex medication regimen.
• The regimen.
The third visit takes place after the physician has prescribed the medication. At this time, patients bring their medications into the clinic, and each pill is discussed so patients know what it looks like and how to take it. Patients receive a written schedule that indicates which pills to take at what time, whether to take them with or without food, which pills should never be taken together, and what non-prescription drugs should be avoided.
Boxes, beepers, and syringes
The clinic has a variety of tools to help patients keep track of their medications, know when to take them, and know the dosages. Patients can carry a week’s worth of medication in a pill box with the daily dosages separated. Beepers also are available that are programmed at the clinic to beep when it is time to take medication. Most patients carry the beeper on their key chains.
When liquid medications are prescribed, patients are given oral syringes so they can carry the proper dose with them without having to take the entire bottle. (For more information on tools to aid patients in medication compliance, see article below.)
• Follow-up.
Patients receive a phone call three to four days after they start their medication regimen to see if they are compliant. They are asked to return to the clinic one week after their third educational session and to bring the pill box with them. Staff check to see if they are taking all their medications and then have them refill the pill box under supervision.
"Usually, the side effects are worse the first week, so we will know what side effects they are having and if they are having trouble adjusting to the drug schedules," says Esch. Armed with this knowledge, staff are able to offer targeted support.
Patients are given as much help and support as they want. For example, Esch called one patient twice a day the first week because she needed a pep talk to help her stick to the medication regimen.
Patients come to the clinic two weeks later for lab work and support and then again four weeks later. "Usually, by that time, the medication regimen is part of their daily schedule," says Esch. Patients then are released to their physicians. (For information on providing intensive teaching in an outpatient setting, see article, p. 35.)
HIV patients who already are on a complex medication regimen and who are having compliance problems also can be referred to the program for intense education and support.
Sources
For more information on the HIV medication adherence clinic, contact:
• Lori Esch, PharmD, Clinic and HIV Pharmaceutical Care Specialist, Erie County Medical Center, Department of Immunodeficiency Services, 462 Grider St., Buffalo, NY 14215. Telephone: (716) 898-4484. Fax: (716) 898-3187. E-mail: [email protected].
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