Telemedicine in the Era of Covid-19

How to make an efficient and highly effective HIV telemedicine clinic Desert Expertise: DIY; How to make an Efficient and Highly Effective HIV Telemedicine Clinic Stephen A. Klotz, Cesar Egurrola, and Lawrence York 1 1 Disclaimer This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,278,366. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government. The views and opinions expressed in this presentation are not necessarily those of the Pacific AIDS Education and Training Centers (PAETC), the Regents of the University of California or its San Francisco campus (UCSF or collectively, University) nor of our funder the Health Resources and Services Administration (HRSA).Neither PAETC, University, HRSA nor any of their officers, board members, agents, employees, students or volunteers make any warranty, express or implied, including the warranties of merchantability and fitness for a particular purpose; nor assume any legal liability or responsibility for the accuracy, completeness or usefulness of information [,apparatus, product] or process assessed or described; nor represent that its use would not infringe privately owned rights. 2 2 Improving Access to Quality Medical Care Webinar Series Presented bySouthwest Telehealth Resource Center, Arizona Telemedicine Program & Pacific AIDS Education & Training Arizona and Petersen Clinics, Tucson, AZ Webinar Tips & Notes When you joined the webinar your phone &/or computer microphone was muted Time is reserved at the end for Q&A, please use the Chat function to ask questions. Questions will be answered at the end of the presentation Please fill out the post-webinar survey Webinar is being recorded Recordings will be posted on the ATP website Link to ATP website to view webinar recordings Desert Expertise: DIY; How to make an Efficient and Highly Effective HIV Telemedicine Clinic Stephen Klotz, MD Professor of Medicine and Community and Family Medicine Cesar Egurrola Program Coordinator Larry York, PharmD Clinical Infectious Diseases Pharmacist Objectives of Webinar 1 DESCRIBE A SUCCESSFUL HIV TELEMEDICINE CLINIC 14 YEARS IN THE MAKING 2 DESCRIBE THE PRINCIPAL PARTICIPANTS IN THE TELEMEDICINE CLINIC 3 DESCRIBE HOW PATIENTS GET MEDICATIONS REFILLED AND LABORATORY TESTS PERFORMED 4 DESCRIBE PATIENT REACTION TO A TELEMEDICINE CLINIC Quick-start Menu HIV PHYSICIAN HIV CLINICAL COORDINATOR HIV PHARMACIST EMR OPEN AND READY TO GO HIPAA COMPLIANT ZOOM OR SIMILAR CONNECTION HANDLED BY CLINICAL COORDINATOR LINK PATIENT BY PHONE OR VIDEO CONFERENCE Conduct of Clinic for Returning Patients Clinic coordinator controls all connections and brings the patient on the screen or telephone Physician greets patient and asks general health questions followed by a review of any recent labs or x-rays and when the next visit is to occur (5 minutes) Pharmacist goes over medication list; renews ART and determines compliance and explains how to take ART; orders vaccines if needed (5 minutes) Clinic coordinator asks questions about mental health and sexual practices; orders labs as needed; reviews patient's contact information; makes next appointment (5 minutes) Physician's Goals Determine if stable living conditions exist for the patient Every patient on ART Every patient undetectable for HIV-1 RNA Depending upon patient's age, preventive health measures are suggested Schedule follow-up appointment with telemedicine as needed (usual visit time for compliant patient, 1/year) Pharmacist's role Prior to Telemedicine Visit: Returning patient: update medication list New patient: Review any documents available for a new patient, update medications/vaccines During Telemedicine Visit: If returning patient: assess adherence and risk of drug/drug interactions, identify vaccination needs If new patient: additional time spent reviewing all relevant labs, answering all questions, setting up medication pick-up Last Item: Order Review Prior to Visit Complete medication and lab review Anticipate vaccination needs If timely or possible, check with pharmacy to assess fill history Ultimate Goals: Optimize visit Support diagnostic stewardship Prior to Visit Medication Review Compare medication to potential lab changes Focus on SCr, LFTs May also consider lipid panel, weight, CBC depending on medications Assess need for opportunistic infection prophylaxis CD4 absolute count and percentage, HIV RNA Evaluate need for chronic HBV coverage DHHS guidelines recommend dual coverage for those coinfected with HIV/HBV During Visit Medication Review Evaluate adherence If < 95%, identify strategies to improve adherence May refer to pharmacy-run adherence clinic for additional counseling as needed Identify new medications and OTC/herbal supplements Some supplements including multivitamins may affect commonly used ARV regimens During Visit Common Drug Interactions PPIs/H2RAs/antacids Major interactions/contraindications with rilpivirine regimens Odefsey, Juluca Steroids including inhaled and intranasal Major interaction with boosted regimens (ritonavir, cobicistat) Recommend beclomethasone or flunisolide Birth control/gender-affirming therapies Often have major interactions with boosted regimens (ritonavir, cobicistat) IUDs, injectable agents generally fine with common first line regimens During Visit - Adherence Generally recommend use of a phone alarm or app Offer free pillboxes, keychain pill holders Pharmacy-managed treatment adherence clinics offered During Visit Vaccination Review Pneumococcal, tetanus/diphtheria/pertussis, meningococcal Easy to overlook later doses/boosters due to lengthy timing Check hepatitis A and B serologies DHHS guidelines recommend confirming immunity after at least HBV vaccine HPV, shingles, seasonal influenza as needed During Visit Rapid ART Obtain medication or arrange for drop off prior to visit Hand deliver to patient for first dose Once physician visit has concluded, answer all remaining questions Often in-depth discussion about HIV, expectations, next steps After Visit Obtain prior authorizations as needed for medications Follow up in 2-3 days with rapid ART patients to review results, answer questions Pharmacist's Goals Ensure all patients can easily access medication Ensure medication is appropriate in regard to comorbidities and past resistance Address barriers to adherence Identify and mitigate any possible drug/drug interactions Administer necessary vaccinations Review orders to ensure accuracy Telemedicine Clinic Director Background- 14 years in the making HIPAA compliant virtual consult platform Research other Telehealth programs- "Frankenstein" approach Clinic Buy-in Patient Buy-In 20 Successful Telemedicine Components Patients are scheduled for virtual consult Link to phone number or to Zoom provided to patients a week prior to appointment Reminder call day of (or before) appointment Follow up appointment and care plan determined during consult Telemedicine Clinic Structure Clinical Coordinator's role Prior to Telemedicine Visit: Determine visit type Provide instructions for access to virtual consult Assure patient's necessary clinical data is available During Telemedicine Visit: Complete Ryan White healthcare access assessment Order follow-up lab work as directed by physician or pharmacists Summarize follow-up care plan After Telemedicine Visit Emails patient follow-up plan Assures patients are linked to any referral services determined during clinical assessment Serve as point of contact between appointments Prior to Visit Determine visit type (Video/Phone call) and provide instructions for access to virtual consult Provide TA to patients, as needed Assure patient has lab orders to complete prior to visit; remind patients as needed Collect clinical data from outside sources; provide to care team for review prior to appointment For high-acuity patients: coordinate care with other entities ASO Case Managers BH Care Managers During Visit "Check-in" patients once they connect to consult; check patients out Call patients who do not connect Make sure clinic flow is running smoothly Keep track of time Inform other patients if consult is running late Complete HRSA required patient assessments focusing on Behavioral Health, Sexual Health and access to social services needed to supplement HIV care Order follow up lab work as directed by Physician or Pharmacists Summarize follow up care plan for care team and patient; assure patient has a clear understanding of next steps Determine date of next appointment if possible After Visit Follow Up Plan Email patient's follow up plan, lab orders and next appointment information Including STI Swab Kits when necessary Ensures patients are linked to any referral services determined during clinical assessment Ensure follow up lab work or orders are completed in accordance to patient's care plan For patients seen yearly, collects lab results 6mo after appointment Schedule follow up appointment if not already scheduled Ongoing Clinical Coordination Serve as point of contact between appointments Order HIV related lab work and schedule patient appointments, as needed Works closely with care team to assure patient's HIV care needs are being met Coordinate care with outside entities and providers as needed Clinical Coordinator's Goals Ensure all patients can easily access HIV medical care Ensure patients in need of behavioral health, substance use, or social services are connected to resources they need Link collaborating agencies and providers to assure patient's needs are being met Ensure patients have a clear understanding of their care plan Serve as a patient advocate, as needed to successfully navigate their medical care Describe the principal participants in the Telemedicine Clinic In our experience, a successful and efficient HIV Telemedicine Clinic needs to have 3 different clinical participants: Clinical Coordinator to get patients to their consult Clinical Pharmacist to maximize adherence and understanding around ARV Physician to oversee and lead patient's care Q &A Q & A Thank you! 30 30