1. Utilizing Medication Refill Criteria to Expand Access and Address Hypertension in a Homeless Population
VANDERBILT PROGRAM
IN INTERPROFESSIONAL LEARNING
Hannah Johnson, Conor McWade, Morgan McDonald MD, Jule West MD, Katherine Nola PharmD Neighborhood Health Downtown Clinic
Introduction & Background
Intervention 1: Program Enrollment
Intervention 2: Patient Education
Discussion
Hypertension among homeless individuals has been shown to be more prevalent1 and more poorly controlled2 than in the general population. Proposed approaches for improved chronic disease management among vulnerable populations have included increasing frequency of visits3 and expanding the role of pharmacists4. Medication adherence for general primary care patient populations has been linked to medication cost and frequency of follow up5.
The Neighborhood Health Downtown Clinic (DTC) is a Federally Qualified Health Center providing healthcare to people experiencing homelessness in Nashville, TN. Patients are seen at DTC regardless of their ability to pay or insurance status. DTC had 16,000 patient visits in 2013.
Prior to the implementation of a medication refill program, a 30-day supply of medications was given at each visit due to the high risk for lost or stolen medications within this patient population as well as the intent to closely monitor the medical condition of patients. The large volume of patients and high frequency of visits outnumbered the available appointments at DTC. Many patients ran out of their medicines while waiting for an appointment. Blood pressure (BP) control (<140/90) averaged approximately 50% prior to this study.
Most patients with controlled BP maintained BP control with less intensive follow up during the study period.
The project was successful in expanding access to appointments for providers participating in the medication refill initiative. There was initially slow uptake among providers to utilize the refill program, but initial successes have resulted in more provider participation.
This program did not have a negative impact on clinic-wide BP control despite less frequent follow-up for controlled patients and an increase in new patients seen at the clinic.
The percentage of controlled unenrolled patients increased during implementation. The program may allow for more provider time with unenrolled patients leading to improved BP control.
After nine months, only 15% of unenrolled/uncontrolled patients returned to clinic within 30 days for a follow up appointment. This suggests that the incentive of refills does not adequately address factors contributing to non-adherence and poor disease control in this sub-population. Poor disease control and poor adherence to follow up appear to be markers of overall patient risk. Therefore, greater access to care may be less of a determinant for BP control in this sub-population and efforts may need to be focused in other areas.
Medication refill program patient flowchart
Flyer posted in waiting areas, exam rooms, and the pharmacy
Aim
Results
By establishing medication refill criteria, Neighborhood Health DTC aimed to double the number of new patient visits to participating providers in six months without decreasing clinic-wide hypertension control.
Conclusions
Establishing refill criteria based on control of disease states may be an effective approach to prioritize patient access for those with uncontrolled chronic disease.
Hypertension control can be maintained with less intensive follow up in patients enrolled in a medication refill program.
Clinic-wide BP control was not negatively impacted by expanded access to new patients.
Offering a refill incentive did not result in adequate follow-up for patients with uncontrolled blood pressure.
Future research is needed to better understand and address factors contributing to blood pressure control in homeless populations.
Methods
The medication refill program was designed by an interprofessional team of physicians, nurse practitioners, pharmacists, social work practitioners, and students in these various healthcare fields. The clinic initiated discussion of refill criteria in response to access concerns raised by patients, clinicians, and staff. The project team developed the following goals:
Expand access to provider appointments
Maintain BP control in patients who are already controlled
Maintain average clinic-wide BP control
Improve BP control among unenrolled patients with a refill incentive
First, the team developed easily understandable refill criteria for hypertensive patients. Beginning in November 2013, if a hypertensive patient had a BP of <140/90 at a clinic visit, the provider could enroll them in the program. The patient could then pick up refills of all medications for 3 months at the on-site pharmacy and schedule a 3 month provider follow-up appointment. Patients who were not enrolled in the refill program were instructed to keep a follow-up appointment within 30 days to address uncontrolled BP. Providers could elect not to enroll controlled patients if other conditions necessitated follow-up within the next 30 days.
The second intervention the team made was to post flyers advertising the refill program in waiting areas, exam rooms, and the pharmacy in June The intent of the flyers was to prompt patients to request enrollment if their BP was controlled.
The number of new patients seen by two participating providers (totaling 0.8 FTE) was recorded on a monthly basis from November 2013 through August The percentage of all hypertensive patients with a controlled BP (<140/90) was recorded on a monthly basis for all patients visiting the clinic. Chart review was conducted one and eight months after implementation of the first intervention to determine (1) the percentage of patients enrolled in the program who continued to have controlled BP; (2) the percentage of unenrolled patients with controlled BP; and (3) the percentage of unenrolled patients who followed up with a provider within 30 days as recommended to address uncontrolled BP.
Data was maintained in a de-identified database. As this was a quality improvement initiative, exemption was granted by the Vanderbilt IRB (#141473).
Chart review results one and eight months after the first intervention are shown. Left: the percentage of enrolled patients who continued to have controlled BP; Middle: the percentage of unenrolled patients with controlled BP; Right: the percentage of unenrolled patients who followed up with a provider within 30 days as recommended to address uncontrolled BP.
Acknowledgements and References
The contributions of John Thurman, MSW and Kaia Howard, PharmD candidate helped make this project possible. The Vanderbilt Program in Interprofessional Learning provided mentorship and guidance. We would also like to acknowledge the remarkable resilience of our patients and the dedication of our colleagues at Neighborhood Health Downtown Clinic under the leadership of Bill Friskics-Warren, Janet Fowler, and Mary Bufwack.
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Tamlyn et al. The incidence and determinants of primary nonadherence with prescribed medication in primary care: a cohort study. Ann Intern Med. 2014;160:
New patient visits increased 175% for the two participating providers (total of 0.8 FTE), and this increase was sustained over the time interval studied. The percentage of all hypertensive patients (enrolled and unenrolled) seen by all providers with a controlled BP (<140/90) is demonstrated. This was not decreased by the intervention.