Latest / Becker’s Healthcare Podcast / Optimizing Long Acting Injectable HIV Care with Dr. Jackie Kissel and Dr. Alvin Choy

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Optimizing Long Acting Injectable HIV Care with Dr. Jackie Kissel and Dr. Alvin Choy · Becker’s Healthcare Podcast

• 0:00
  Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  Healthcare. Thanks so much for tuning in to
• 0:04
  the Becker's Healthcare podcast series. Fantastic
• 0:07
  to have you. Today, we're talking about how
• 0:10
  provider organizations
• 0:11
  are leveraging EHRs and EMRs to coordinate care
• 0:15
  and navigate
• 0:16
  insurance requirements for HIV prep patients prescribed long
• 0:19
  acting interjectables
• 0:20
  or LAIs
• 0:22
  as we might refer to them here. Joining
• 0:24
  me for today's discussion, very excited to have
• 0:26
  him, doctor Jackie Kosel, director of clinical pharmacy
• 0:28
  at Equitas Health, and doctor Alvin Choi, long
• 0:31
  acting
• 0:32
  interjectable antiretroviral
• 0:33
  therapy program manager and clinical pharmacist also at
• 0:37
  Equitas Health. Doctor Kissel, doctor Choi, thanks so
• 0:39
  much for being here today. It's great to
• 0:41
  have you. Thanks for having us. Thank you.
• 0:43
  Absolutely. I wanna start off with introductions for
• 0:46
  our audience that might not know you yet.
• 0:49
  Doctor Kissel, we'll start off with you.
• 0:52
  Yeah. So,
• 0:53
  I'm doctor Kissel.
• 0:55
  I'm a pharmacist.
• 0:56
  My pronouns are she, her. And
• 0:59
  I've been doing this type of work for
• 1:02
  a really long time. So I graduated from
• 1:04
  pharmacy school in 2013,
• 1:07
  and I did a residency
• 1:09
  at the Ohio State University. And then I
• 1:11
  came over to Equitas Health, which is, at
• 1:13
  the time, was AIDS Resource Center Ohio. And
• 1:16
  I started off in the community pharmacy over
• 1:18
  there and then kind of worked my way
• 1:20
  into building a clinical program and then eventually
• 1:22
  became a director over those clinical programs within
• 1:26
  Equitas Health. So, really, I landed at Equitas.
• 1:29
  Love the work that we do, and I've
• 1:31
  been here for over eleven years.
• 1:33
  It's so great to have you on. Excited
• 1:35
  to hear from you. Doctor Choi, over to
• 1:36
  you.
• 1:37
  Hey. Hi, everybody. My name is doctor Alvin
• 1:39
  Choi. My pronouns are he, him. I'm a
• 1:42
  clinical pharmacist, and I also manage our HIV
• 1:45
  and PrEP injectables program here at Ecotah Health.
• 1:47
  I've been in the space, the HIV and
• 1:49
  PrEP space, not as long as Jackie.
• 1:51
  Hopefully getting there soon, but I, South
• 1:56
  Florida in 2021.
• 1:58
  I
• 1:59
  did a very similar residency to Jackie. I
• 2:01
  did the pharmacy residency here at Equitas,
• 2:04
  in 2021 and then have stayed on with
• 2:06
  Equitas ever since,
• 2:08
  to really manage our injectables program.
• 2:12
  Yeah. It's great to have you both. I
• 2:14
  wanna start off with sort of level setting
• 2:16
  everything. Give us a little bit of an
• 2:17
  introduction to what we're facing, what we're seeing
• 2:20
  here today, and what we're gonna hear about.
• 2:22
  We know that many clinics serving patients on
• 2:24
  long acting injectable prep face a lot of
• 2:27
  complex operational challenges. There's scheduling.
• 2:30
  There's dose timing, and we haven't even touched
• 2:32
  on the insurance piece. Right? The insurance navigation
• 2:35
  part is certainly, certainly important as well.
• 2:38
  Before
• 2:38
  optimizing
• 2:40
  EHR workflows,
• 2:41
  what were some of the biggest pain points
• 2:45
  you've seen your team encountered
• 2:47
  in coordinating care
• 2:50
  for the patients for these patients that you
• 2:52
  were seeing? Doctor Kissel, we'll start with you.
• 2:55
  Yeah. So we really started trying to build
• 2:58
  this program back in 2021,
• 3:01
  and
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  we were flying blind. Like, we did not
• 3:05
  know what we were doing, what we were
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  getting ourselves into. Individuals think, oh, you're just
• 3:09
  you know, you give the patient you get
• 3:10
  it approved by the insurance, you give an
• 3:12
  injection.
• 3:13
  Well, it's way more complicated than that. There's
• 3:16
  way more steps.
• 3:18
  Mhmm. And we
• 3:19
  really our first go at it,
• 3:22
  that program didn't even get off the ground.
• 3:24
  There was too many hands in the pot.
• 3:27
  Patients were being bounced from providers
• 3:29
  to nurses to clinical pharmacists,
• 3:32
  back to nurses, back to the provider.
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  And then how were we tracking these patients?
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  Who was following up with them if they
• 3:38
  no showed, like, what was going on? And
• 3:40
  it really came down
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  to eventually
• 3:44
  realizing that that was just we need a
• 3:46
  team. We need a team to really focus
• 3:49
  on these patients and watch them through the
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  continuum of care to make sure that they're
• 3:54
  getting everything that they needed versus trying to
• 3:56
  do it within our normal workflows
• 3:59
  of medical centers, which I think a lot
• 4:01
  of us tried to do that without having
• 4:03
  a centralized team, and we just realized that
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  that was not possible. So in 2022,
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  that's when we hired Alvin to kind of
• 4:12
  work with me to jump start
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  a new process
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  to really
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  figure out how we can utilize
• 4:20
  a team to get these patients through the
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  injectable
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  process.
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  Yeah. Doctor Troy, can you talk about that
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  process a little bit? Yeah. Absolutely.
• 4:29
  So before I kinda get into that, I
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  wanna really agree with Jackie. Having a method
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  to track all of these patients is incredibly
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  vital. There are just so many different steps
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  in the process. And like Jackie had mentioned,
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  it is
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  difficult
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  at first,
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  when you are kind of you don't know
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  what the steps are. It's a brand new
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  medication,
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  and it was everyone
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  was kinda just flying blind.
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  But some of the biggest steps that we've
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  kind of implemented moving forward
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  has
• 4:59
  been, instead of utilizing,
• 5:01
  like, our EHR per se, we utilize
• 5:05
  a customized tracker that integrates into a calendar.
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  And in this calendar,
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  this is where we operate all of our
• 5:12
  daily tasks from processing medications,
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  following up on deliveries,
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  following up on prior authorizations, whatever it is,
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  and just making sure everything is done off
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  of this calendar
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  is is how we operate and how we
• 5:25
  track all all of our patients.
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  I think there's definitely,
• 5:30
  use of the AHR. We use it mostly
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  from a clinical standpoint.
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  We obviously do all of our patients' appointments.
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  We schedule labs, or take labs, reschedule appointments,
• 5:40
  do vaccines, all that stuff within the EHR.
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  However, we utilize that tracker,
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  to track every touch point with our patients,
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  and it's a lot easier just to do
• 5:50
  it on that tracker instead.
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  So
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  that's that's tremendously improved the workflow piece in
• 5:55
  terms of being able to track things better.
• 5:57
  Is that correct? Very much so. Yeah. And
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  I'll jump in to say that when we
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  say a tracker, like, we hired someone to
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  code
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  programs to make
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  this so we can, you know, select our
• 6:10
  role, be able to see what were assigned,
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  see when patients miss appointments. Like, we have
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  it coded in a way that integrates with
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  the calendar to give us all the dates.
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  So anyone looking at a single date can
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  really
• 6:22
  say, okay. Today is
• 6:25
  November 13. This is everything I need to
• 6:27
  do for the day. And as a director,
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  I can look at that and see who's
• 6:32
  getting overwhelmed with too much work, what work
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  is getting done, when's it getting done. I
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  can ask people what's going on based on
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  all of that so I can have
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  oversight
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  of the program as well
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  by having that, tracker and that calendar.
• 6:46
  Doctor Choi, you mentioned, something important, which is
• 6:49
  the the
• 6:50
  electronic prior authorization process, which is certainly important.
• 6:53
  We also talk about enhanced medication administration records.
• 6:56
  Right? Those are certainly part of it as
• 6:58
  well. How did those tools change day to
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  day operations for you?
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  Yeah. Absolutely.
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  So, we use different databases to do our
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  electric prior authorizations,
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  and we just utilize those to keep track
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  of all of our patients. But then we
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  also
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  tie that into our tracker to show, okay.
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  This prior authorization is about to expire on
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  this day and making sure we're renewing that
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  prior auth before the patient comes in, before
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  it even expires.
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  But utilizing electronic databases
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  to track these prior auths has been really
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  easy, one, to submit it, but also to
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  tie it into our in house tracker to
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  make sure that things are not kinda lost.
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  I would say from the enhanced medication administration
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  records,
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  we don't actually use as many of those
• 7:47
  MARS per se. Within the outpatient space,
• 7:51
  outpatient health care space, we don't have that
• 7:54
  many medications that we administer to the patient.
• 7:56
  It's mostly these long acting injectables,
• 7:59
  vaccines, and a few other injectables.
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  I would assume within the
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  inpatient space. I don't work in the inpatient
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  space, so definitely correct me if I'm wrong.
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  But I would assume that they're giving more
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  IVs, more medications,
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  and more things you have to track on
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  that
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  actual administration
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  record. So,
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  enhanced Mars is not something that we actually
• 8:19
  utilize within our works, flow as much.
• 8:21
  Yeah. That makes sense.
• 8:23
  Doctor Kissel, I wanted to come back on
• 8:26
  something that you mentioned earlier, which is, again,
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  the the team aspect of this and the
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  optimization part of it, which is really, really
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  key. The the too many hands in the
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  pot, right, can certainly become an an issue
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  as you said.
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  And coordinating prep LAI care really involves multidisciplinary
• 8:43
  teams, lot of system touch points as we've
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  just outlined throughout the conversations.
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  Can you share how collaboration across
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  those teams, the teams that you're working with
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  supported all of this optimization
• 8:56
  and what kind of impact you've seen there?
• 8:59
  Yeah. So,
• 9:00
  really, every single day, this team for the
• 9:03
  injectable program is interacting with billing. They're interacting
• 9:06
  with pharmacy. They're interacting with nurses. They're interacting
• 9:09
  with providers. They're interacting with insurance companies.
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  And so what we've done is created
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  communication channels
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  for all of those different teams to make
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  sure that they have access
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  to Alvin, to his,
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  we call them pharmacy care coordinators,
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  to answer any questions they have, to let
• 9:28
  us know if anything goes wrong.
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  And they can just send us a message.
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  We get it. Someone on that team will
• 9:34
  address it, and then we will get back
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  to them pretty much instantaneously,
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  which is great to solve patient issues on
• 9:40
  the spot. The other thing that we implemented
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  is monthly meetings with each of those teams
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  to talk through workflow issues to continue to
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  enhance our workflow, make it better for the
• 9:51
  future, or find any gaps. If something happens,
• 9:54
  we always wanna get to the root cause.
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  So then we'll have meetings about, okay, why
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  did that happen? How do we keep it
• 9:59
  from happening in the future? And even as
• 10:01
  you know, in this past year, we learned
• 10:04
  a lot, and we even changed the workflows
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  probably sometime in February
• 10:08
  or March to help with some of those
• 10:10
  gaps.
• 10:11
  Under Troy, I'm assuming you had tremendous impact
• 10:13
  on your work as well.
• 10:15
  Yes. Very much so. Something I do wanna
• 10:17
  echo off of Jackie is,
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  one of the biggest takeaways is just having
• 10:21
  really strong communication,
• 10:23
  really strong coordination skills is vital for keeping
• 10:26
  track of all of these patients, especially as,
• 10:29
  different companies, different organizations start to ramp up
• 10:32
  and get into, like, hundreds of patients. It
• 10:34
  takes a lot a lot of communication between
• 10:38
  different,
• 10:38
  teams and different departments to make sure these
• 10:41
  are going smoothly. Like, just for example, yesterday,
• 10:45
  one of our providers was out sick, but
• 10:47
  they have patients that they're gonna see. So
• 10:49
  just managing where those patients are gonna go,
• 10:51
  are they still gonna be seen, are they
• 10:53
  still gonna get their injection? Like, all of
• 10:55
  that takes a tremendous amount of, communications across
• 10:59
  departments.
• 11:00
  But I do wanna echo also what Jackie
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  said earlier too is just be careful with
• 11:04
  how many touch points,
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  because it does get very messy as more
• 11:08
  people start to come into the program. So
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  having a
• 11:12
  small knit core team is is vital,
• 11:15
  for for this program.
• 11:17
  Everything gets filtered back to me, Alvin, or
• 11:20
  his team, and that's really nice so we
• 11:21
  know exactly what's happening
• 11:23
  at any point with any issues that arise.
• 11:26
  Yeah. It and, again, like, it's so important
• 11:28
  because it trickles down to the to the
• 11:29
  patient experience. Right? Oh, yeah. Those people that
• 11:32
  100%. That enter that come through the door,
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  and and that's so such a critical component
• 11:36
  of it, which is so key.
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  It's so great to have you both on.
• 11:40
  Thank you so much for sharing these insights
• 11:42
  with us. What a great conversation. I do
• 11:43
  wanna turn the floor over to you.
• 11:46
  Anything else that you'd like to share with
• 11:47
  the audience? Anything else that that comes to
• 11:49
  mind that that folks might not know or
• 11:51
  that you'd like folks to know, based on
• 11:53
  our conversation today that we haven't touched on?
• 11:55
  Doctor Kissel, we'll start off with you.
• 11:58
  So
• 11:59
  for those of you who aren't familiar with
• 12:01
  PrEP or might might not familiar with HIV,
• 12:04
  The reason it's so important to have
• 12:08
  these processes in place is because when they
• 12:10
  miss a patient misses an injection
• 12:13
  or an injection isn't given on time, it
• 12:15
  can be detrimental
• 12:17
  to their health in so many ways. And
• 12:19
  other injections in health care are like that
• 12:21
  as well,
• 12:22
  but I feel like this is a different
• 12:24
  level of how much it can impact a
• 12:27
  patient,
• 12:28
  especially for prep. If they are on time
• 12:33
  and they, you know, acquire HIV,
• 12:35
  then you've just possibly
• 12:38
  don't have certain treatment options available to you.
• 12:40
  And so it's really important to not just
• 12:44
  not have these processes and think through how
• 12:46
  you're gonna keep these patients in care and
• 12:47
  follow them because letting them, you know, not
• 12:50
  come to their appointments or they don't have
• 12:52
  an appointment set up just really can be
• 12:53
  detrimental overall.
• 12:55
  Yeah. Doctor Choi?
• 12:57
  Yeah. I I do wanna echo up that
• 12:58
  too. And
• 12:59
  having some of these medications that are
• 13:02
  cutting edge technology.
• 13:03
  Before any of these long acting injectables, we
• 13:06
  only had oral
• 13:07
  prep options and oral HIV treatment options. So
• 13:11
  having
• 13:12
  options for an injection that lasts months at
• 13:15
  a time. Many of my patients have told
• 13:18
  me that just without
• 13:19
  like, they struggle with taking a pill every
• 13:21
  day. So having,
• 13:22
  an option for a long acting injectable has
• 13:25
  just had literally saved their lives. But outside
• 13:27
  of that, one other thing I did wanna
• 13:28
  mention too is just
• 13:30
  the benefit
• 13:32
  of having a clinical pharmacist on the team.
• 13:35
  I know I'm biased because I am clinical
• 13:36
  pharmacist, but medication access as a pharmacist
• 13:40
  is our absolute bread and butter. It's what
• 13:42
  we do every single day, making sure that
• 13:44
  the patient is able to get their medication,
• 13:46
  making sure it's able to be affordable,
• 13:48
  and making sure that, you know, they're able
• 13:50
  to continue their care
• 13:52
  in the long term. So I I would
• 13:55
  say and there's multiple studies to back this
• 13:57
  up, but having a clinical pharmacist
• 13:59
  on the team, especially in a program such
• 14:01
  as this where access is the name of
• 14:03
  the game is is so so vital to
• 14:06
  the success of the program.
• 14:08
  Absolutely.
• 14:09
  Doctor Kissell, doctor Choi, thanks so much for
• 14:11
  being here today, taking some time for us.
• 14:12
  It's great to have you. Thank you. For
• 14:14
  having us. Nice to meet you. Yes. And
• 14:16
  you can tune in to more podcasts from
• 14:17
  Becker's Healthcare by visiting our podcast page at
• 14:19
  beckershospitalreview.com.