1. August 2015 Quick Pharmacy pick-up (QPUP) for stable ART patients

2. Background Increasing numbers of stable patients Don’t need to collect folder/see clinician every visit Currently we have the club model Clubs don’t suit all our stable patients Our clinics can only manage certain number of clubs well Exploring alternatives….…..give our patients options & diversify our approaches

3. Combine +++ from club model & CDL pick-ups ClubsCDL pick-up Strict fixed appointment timeIndividual refill Negative consequence if patient doesn’t come on TCB + 5 days No clinical role at refill visits Club register to ensure good M&E (but simplified)! Use special pharmacy window Can send buddyClinicians script at 6m clinical review visit

4. Summary of QPUP Patient only collects folder & sees a clinician every 6 months Other 2 visits: – Given a specified appointment time (2.5 hour slot on specific date for max 50 patients) – Straight to special pharmacy window to collect 2 months CDU packed ART Can send a friend/family member if it is not a blood/clinical visit – only need green card!

5. Staff roles Facility manager: good oversight of QPUP Clinicians: routine assessment of stable patient/informed choice and 6m clinical visits/scripting Pharmacist: QPUP oversight management Pharmacy assistants: CDU management/Run QPUPs Registry/clerks: Capturing QPUP registers Counsellors: Explain QPUP when doing options counselling and also clarify if any questions Rest of clinic team: Good understanding & support

6. Patient eligibility and choice Clinicians will routinely assess whether patient is stable 12m on ART with 2 x LDL VL If stable: patient offered and counselled on options: Routine refill VS Facility or Community Club VS Quick PICK-UP (QPUP) Complete assessment form

7. Sister Linda 25/08/2015 Sister Linda

8. If QPUP chosen Clinician completes 2m clinic script (1m only if in October or November 2015) Clinician completes CDU script But does not insert 3 x TCB dates or QPUP number – these will be entered by pharmacy assistant (PA) Sends to pharmacy with folder (assessment form and 2 scripts)

9. On arrival at pharmacy Patient joins normal pharmacy queue but 1 window will be designated for QPUP enrolment (marked clearly above window). PA at this window will see next in the queue and all QPUPs in queue will go to this windo when they get to the front. Only 50 patients can be allocated to any QPUP – the intention is to reduce waiting times!

10. On arrival at pharmacy Patient is offered choice of Monday or Wednesday late afternoon (16h30-19h00) PA will have 2 QPUP registers (Mon and Wed) with them for particular week’s recruitment PA will look at QPUP schedule to determine which QPUP to allocate the patient too – see next slide.

11. How to allocate… Recruitment dates FromTo 05/10/201509/10/2015 25/01/201629/01/2016 22/03/201625/03/2016 QPUP 1QPUP 2 Pick-up date MondayWednesday 02/11/201504/11/2015 Pick-up date MondayWednesday 25/01/201627/01/2016 Pick-up date TuesdayWednesday 22/03/201623/03/2016 If patient is recruited in any of the weeks: In red, they will be allocated to QPUP 1 or 2. In blue, they will be allocated to QPUP 3 or 4 Recruitment dates FromTo 12/10/201516/10/2015 01/02/201605/02/2016 29/3/201601/04/2016 QPUP 3QPUP 4 Pick-up date MondayWednesday 09/11/201511/11/2015 Pick-up date MondayWednesday 01/02/201603/02/2016 Pick-up date TuesdayWednesday 29/03/201630/03/2016

12. Find QPUP 2 register Place patient sticker and complete QPUP registration date

13. After QPUP allocation Supply according to clinician script to cover until next QPUP collection date Place QPUP sticker with QPUP# on patient folder and green card Place pre-printed sticker on green card with next 6 visits and complete first 3 TCB dates: 1. Collect at pharmacy: 23/11/15 2. Collect at pharmacy: 18/1/16 3. Collect folder/see clinician/collect at pharmacy: 14/3/16 4. Collect at pharmacy: 5. Blood taken/collect at pharmacy: 6. Collect folder/see clinician/collect at pharmacy: Staple patient folder stickers into green card (for blood visit later on)

14. 1. Collect at pharmacy: 23/11/15 2. Collect at pharmacy: 18/1/16 3. Collect folder/see clinician/collect at pharmacy: 14/3/16 4. Collect at pharmacy: 5. Blood taken/collect at pharmacy: 6. Collect folder/see clinician/collect at pharmacy: QPUP 2

15. After QPUP allocation PA collects CDU script from patient Mark on script: – QPUP number (and place QPUP sticker) – 3 x TCB dates Script should look the same as club script Send/place: – Original submit to CDU – Copy in QPUP folder – Copy in patient folder

16. QPUP – 1 st refill date Patient/buddy straight to QPUP window to collect CDU pack btw 16h30-18h45 PA completes visit in QPUP register Check patient understands TCB date and to come straight to window next time

17. QPUP – 2nd refill date Patient/buddy straight to QPUP window to collect CDU pack PA completes visit in QPUP register Check patient understands TCB date and next time must first get folder, see clinician for script, then come to pharmacy window with folder

18. Patient comes to clinic during the day Collects folder at reception Sees clinician for quick check-up and new script Patient then queues in normal pharmacy queue and see PA at window designated for QPUP patients PA collects new script, enters QPUP number, 3 TCB dates, replaces copied in patient folder and QPUP file and submits original QPUP – 3rd refill date

19. 1. Collect at pharmacy: 23/11/15 2. Collect at pharmacy: 18/1/16 3. Collect folder/see clinician/collect at pharmacy: 14/3/16 4. Collect at pharmacy: 12/5/16 5. Blood taken/collect at pharmacy: 10/7/16 6. Collect folder/see clinician/collect at pharmacy: 8/9/16 QPUP 2

20. PA distributes ART, completes next 3 TCB dates on green card PA completes visit in QPUP register Check patient understands TCB date and to come straight to window next time QPUP – 3rd refill date

21. QPUP – 4 th refill date Patient/buddy straight to QPUP window to collect CDU pack PA completes visit in QPUP register Check patient understands TCB date and that the need to have blood drawn first at next visit and then to window.

22. QPUP – 5th refill date Patient had choice for blood draw: – Either on 5 th ART refill date goes with green card to blood room btw 15h00-16h15 for blood draw, no folder. – Comes to clinic any other day between 08h00-15h30 4-8 weeks before 6 th refill date for blood draw, no folder Nurse uses patient id stickers from green card for lab form and blood tube Sticks bar code from lab form on green card as proof blood drawn Patient then goes straight to QPUP window to collect CDU pack Check patient understands TCB date and next time must first get folder, see clinician for script, then come to pharmacy window with folder

23. QPUP – 5th refill date PA completes visit in QPUP register Check patient understands TCB date and next time must first get folder, see clinician for script + clinical visit, then come to pharmacy window with folder If patient sends buddy on blood visit, provide CDU pack - ask buddy to tell patient to come for blood taking in next 2 weeks otherwise will be removed from QPUP at next visit

24. Patient attends clinic during the day Collects folder at reception Sees clinician for annual clinical visit (check VL) and only rescript with CDU script if VL is LDL Patient joins normal pharmacy queue but when gets to the front goes to QPUP designated PA window to collect last CDU pack PA collects new script, enters QPUP number, 3 TCB dates, replaces copied in patient folder and QPUP file and submits original QPUP – 6 th refill date

25. PA distributes last CDU pack, completes next 3 TCB dates on green card PA completes visit in QPUP register Check patient understands TCB date and to come straight to window next time QPUP – 6 th refill date

26. 1. Collect at pharmacy: 23/11/15 2. Collect at pharmacy: 18/1/16 3. Collect folder/see clinician/collect at pharmacy: 14/3/16 4. Collect at pharmacy: 12/5/16 5. Blood taken/collect at pharmacy: 10/7/16 6. Collect folder/see clinician/collect at pharmacy: 8/9/16 1. Collect at pharmacy: 2/11/16 2. Collect at pharmacy: 18/1/17 3. Collect folder/see clinician/collect at pharmacy: 10/3/17 4. Collect at pharmacy: 5. Blood taken/collect at pharmacy: 6. Collect folder/see clinician/collect at pharmacy:

27. If high VL or clinically unwell inform patient require more regular clinical/adherence support, first need to regain wellness/resuppress before back into QPUP Complete patient assessment form to note exit form QPUP and cross out QPUP label on patient folder and patient green card If high VL, patient first goes to ROTF/enhanced adherence Then to pharmacy queue and designated QPUP PA for last collection PA will confirm that patient understands will no longer come to the QPUP window next time QPUP – 6 th refill date If high VL or unwell

28. Sister Linda 25/08/2015 Sister Linda Dr Hewittson 20/02/2016

29. Enters collection and exit in QPUP register PA checks QPUP number cancelled on green card, patient folder and removes CDU script from QPUP folder QPUP – 6 th refill date

30. Late/missed appointments Arrive after 2.5hrs or within 5 days PA informs that patient has to come within time slot or if they cannot come - send a buddy to collect. If late again, will be removed from QPUP Complete collection + LATE in QPUP On clinical visit (3 & 6) can come anytime on day as joins normal pharmacy queue

31. Late/missed appointments After 5 days or 2 nd late visit PA informs patient nicely that unfortunately patient cannot use the QPUP going forward and needs to collect their folder, see clinician and them come to pharmacy. PA cancels QPUP on green card, patient folder and marks exit on assessment form. Removes CDU script from QPUP folder Come to usual pharmacy queue – can provide CDU pack or pre-pack

32. Festive season cover Different approach to clubs as difficult to manage within scripting cycle Clinic pharmacy provides 1m additional supply to CDU pack if TCB btw 16/12-13/1 (clinic scripts will need to be written for entire QPUP and place in QPUP folder) Provide TCB date – 3 months later and then continue as usual CDU pack will arrive 1m early but will be corrected at next script date

33. RECAP

34. 6 individual visits a year: 4 very quick (30min-1hr) 1 slightly longer to take blood (1hr) (or keep short and add 1 visit for blood draw) 2 normal clinic visits – folder/clinician and pharmacy (3-4 hours) 2 x year (visit 3&6) 3 x year (visit 1,2&4) 1 year (visit 5)

35. Pharmacy planning MSF to provide QPUP files for CDU scripts QPUP registers QPUP stickers and TCB stickers QPUP boxes where CDU packs unpacked in preparation, QPUP files and registers kept MSF will support set up if pharmacy – need to sit with pharmacy team to determine what they need.

36. LETS GET RID OF OUR QUEUES AND KEEP OUR PATIENTS ON ART BY MAKING IT EASIER!