Implementation Strategy: Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake
After developing the Best Practices Tool, ISCI researchers applied it to a set of research studies examining 18 implementation strategies with the goal of assessing reliable application of the rubric and criteria. The implementation strategies focused on promoting the adoption and uptake of PrEP.
By the end of the review process, ISCI researchers assigned one PrEP strategy the “Best Practice” evidence level, titled, “Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake: A Quality Improvement Project.” This project developed an evidenced-based PrEP Navigation (PN) tool to identify patient-reported barriers to uptake and to support process improvement at a large community health center in Washington, DC.
Are you interested in the strategy but not sure how it applies to your work?
Check out this video with the original project’s principal investigator Megan Coleman, DNP, MSN, FNP-BC, for a high-level overview of the project and an outline of how the strategy can apply to different populations and regions.
Detailed Strategy Guide
The primary problem this strategy is intended to address is PrEP prescription pickup to prevent HIV. In the original study, days from prescription to pick up were reduced by about a day and a half and the number of people successfully picking up their prescriptions also improved. Central to the approach is the PN tool, which was used to collect patients’ reported barriers. To identify patients who fail to pick up their prescription, prescription dispensary data was used to identify patients and examine them for common themes. Once barriers for patients were identified, the lead implementer worked to educate staff about common barriers and make changes in patient flow to address barriers using quality improvement processes.
To learn how to apply this strategy, take a look at the strategy guide below, which outlines essential strategy elements and step-by-step processes for implementation.
Overview
Equity Impact Potential
This strategy was used in an urban clinic where there is a high prevalence of HIV in the community. The clinic served HIV target populations who experience disproportionately high rates of HIV incidence, including men who have sex with men, African Americans, and Latinx individuals, and the approach demonstrated positive impacts with these groups. By using the PN tool, the approach also successfully engaged participants from the communities to identify the most relevant barriers.
Quick Links
In the rest of the strategy guide, you will find the following sections:
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- Strategy specifics: To consider before using the strategy, including elements of the strategy that are essential or helpful as well as places where the strategy may be adapted to better fit the context.
- Process for implementation: A step-by-step guide for implementors or teams to use the strategy.
Additional Supporting Materials
We have identified additional resources that can also support this approach, including:
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- The original PN tool
- Tips for forming teams
- Framework for understanding behavior change (the COM-B system)
- Plan-Do-Study-Act (PDSA) cycles for quality improvement
- The original full-length research article
Strategy Specifics
Below are the some of the specifics you need to consider before adopting this approach. Essential strategy elements are differentiated from helpful strategy elements. Some suggestions are noted for areas where adjustments or adaptations may be made to fit your context and organization better.
| What is the value? | The value of this strategy includes better PrEP initiation and improved care services for patients. |
| Who needs to be involved? | Essential: A designated person responsible for implementing the strategy. In the study, this was a clinician. Helpful: A pharmacist, other clinical staff, and administrative or supportive staff (e.g., patient navigators and front desk staff). Alternatives: Staff other than a clinician may be used to implement this strategy like a trained peer, outreach worker, or community health worker. Functioning as a team can also help with implementation. |
| What do they need to do? | Essential: Adjust and implement the PN tool (found at the end of this guide), and use patient responses to guide improvements. Helpful: Use COM-B to help organize reported barriers and generate ideas for improvements, and/or use Plan-Do-Study-Act (PDSA) cycles to help guide the process of evaluating barriers and making improvements. |
| How much time does it take? | Essential: In the original study, researchers estimate it took three to four hours per week to review records, call patients, analyze responses, and review responses with team. Helpful: A regular meeting with the implementation team to review barriers. In the original study, this was once a week. |
| Who is targeted by this strategy? | Essential: Patients who fail to pick up PrEP prescriptions within 7 days, and clinic staff who interact with patients. Helpful: Clinic staff who are willing to adjust patient flow in their setting. |
| How often is this strategy used? | Essential: Every time a patient fails to pick up their PrEP prescription. Possible: For follow up with every new and returning PrEP patient at least once, and/or for follow up at the frequency levels patients prefer. It can be used as needed to target local priority populations for HIV. |
| What are the key outcomes? | Essential: PN tool adoption and use with patients, and identifying patient barriers to PrEP initiation. Possible: Reduced patient barriers for PrEP initiation; improved PrEP initiation; improved care experiences for patients; improved staff knowledge; and/or improved clinic workflow. |
Processes for Implementation: A Step-by-Step Guide
This section includes step-by-step guidelines for implementing the strategy. It also describes the setting and existing resources of the original strategy site, and makes note of considerations and suggestions from the original strategy site that may be helpful when implementing it within your organization.
For example, existing practices and resources of the clinic include:
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- Existing PrEP care delivery procedures that included screening for HIV and initiating PrEP on the same day
- A standard of scheduling patients for a follow-up visit in one month, then quarterly follow-up appointments (in accordance with CDC recommendations for PrEP)
- Peer PN staff members who assisted patients in navigating the health system and insurance processes and provided linkage to care providers
Considerations:
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- Existing staff and care procedures at the site the strategy originally took place at should be examined. Differences in staff and care procedures may influence the results and effectiveness of this strategy at other sites.
- Modifications to treatment approaches and support services may be needed for this strategy to be implemented at other health centers and systems.
- While the individual and system level barriers at the original strategy site matched common barriers found in the quality improvement team’s literature review, other health centers and systems may find different barriers when implementing this strategy.
- The goal of the PN tool is to increase PrEP uptake and provide a basis for process improvements in care delivery. It is intended to be used in a continuous, ongoing fashion. To read the original study in full, visit the PubMed site.
Step 1: Review the PN Tool and Create a Team
Develop a PN tool that will work for your setting and will capture the information that you need. This may be easier with the support of an implementation team that represents aspects of the clinic that are important for supporting PrEP initiation.
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- Review the PN tool
- Create a process map of the flow of PrEP at your site from initial patient contact to prescription pickup to understand where a patient may run into challenges to PrEP initiation
- Invite people within the organization who are integral to supporting PrEP initiation to join the team
- Adjust the PN tool to fit your context and experience
Step 2: Review PrEP Dispense Data
Review the available information you have about whether patients who are prescribed PrEP are filling their prescriptions. Helpful information may include details about patients who are:
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- Successfully filling their prescriptions
- Not successfully filling their prescriptions after approximately seven days
- Delayed more that one or two days in filling their prescriptions
Step 3: Develop Protocol for PN Tool Use
Using the information from dispensation data, develop a standard protocol for the PN tool use. Decide the following:
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- Who is eligible to take the PN tool
- Patients who do not pick up their prescription within seven days should be contacted and asked the questions on the PN tool
- Who will be responsible for contacting eligible patients
- In the original study, this was a nurse practitioner, but based on feedback from the lead investigator, this could be anyone from the clinic who is capable and comfortable working with patients (e.g., a patient or peer navigator, or community health worker)
- How often the responses will be reviewed
- Every one to four weeks is recommended based on patient volume, time availability, and information volume
- How the responses will be analyzed or organized
- The responses to the questions should be recorded and used by the quality improvement team for discussions on process improvement
- A thematic analysis based on the COM-B framework is recommended because the themes generated can then be used for discussions, trainings, and process improvements
- Who is eligible to take the PN tool
Step 4: Using PDSA Cycles to Address Barriers
Based on the themes generated, system level changes and process improvements should be implemented to decrease the barriers reported. These improvements should be a part of a continuous process of quality improvement at the strategy site.
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- For example, communication issues and insurance concerns were reported as barriers at the original strategy site. As a result, prescription pickup instructions were included by clinicians during end-of-visit discussions, the PN team was electronically notified of patients with possible insurance coverage issues/concerns, and pharmacy staff were retrained on enrolling patients into pharmacy copay assistance plans.
- At the original strategy site, opportunities for improvements became identifiable within two to three weeks.
- Eventually, a strategy site may move from directly using the PN tool to integrating the principles of the PN tool into clinical procedures, operations, and employee work responsibilities.
Throughout the strategy, data should be collected from the PN tool on barriers reported by patients. This should be used to continuously generate updated themes.
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- At the original strategy site, weekly meetings were held between the quality improvement team, medical staff, pharmacy staff, and other center personnel to review responses, discuss the generated themes, and develop system level changes and processes improvements for implementation. Additionally, data on prescription pickup times and rates were updated weekly and used in weekly team meetings.
PDSA figure citation: A visual diagram of a Plan-Do-Study-Act (PDSA) Cycle. ResearchGate. Accessed March 21, 2024. https://www.researchgate.net/figure/A-visual-diagram-of-a-Plan-Do-Study-Act-PDSA-Cycle_fig1_319377456.
Additional Materials
PN Tool
Hello, my name is [name] and I am calling from [clinic name] and wanted to follow up with you on your recent visit to the clinic on [date].
1) I wanted to follow up with you because we noticed you have not yet picked up your prescription for Truvada at the pharmacy. We wanted to make sure that you knew it was ready and see if you have any issues picking it up. Were you aware that it was ready for you to pick up?
If YES then: Do you have any concerns about or challenges to starting the medication?
If NO then inform them of operating hours, the seven-day restocking rule for pharmacy and 1a) ask them if they have any concerns or anticipate any challenges to starting the medication. Document note in a telephone encounter (TE) and send to the provider.
2) If YES to question 1 or YES to 1a) then counsel under category of barriers to PrEP uptake:
a) Concerns about side effects: Counsel or ask if they would like you to have their provider contact them or to set up a follow up appointment to discuss further.
b) Concerns about health care access and cost: Provide counseling on automatic co-pay assistance program at WWH pharmacy, assess for further questions regarding co-pays and navigation of insurance. Provide insurance counseling and education.
c) Concerns about time as a barrier (includes follow up visits, quarterly lab work): Discuss PrEP clinic as an option for them, if they are interested send a telephone encounter (TE) via EMR to their provider documenting the conversation.
d) Concerns or questions about personal HIV risk and communal HIV risk assessment: Counsel on personal risk of HIV infection, CDC and WHO recommendations on who a candidate for PrEP is, discuss if any inherent risk in community of partners they are sexually active with.
e) Concerns for need for daily adherence and need for support around establishing routines: Provide counseling on establishing routines such as daily pill box and reminders, linking to another daily activity.
f) Concerns about stigma and disclosure: Counsel on social support, groups at [clinic], on-line forums and other options in community.
g) Other concerns not mentioned: Counsel as appropriate or refer to provider for follow up (send TE via EMR).
Forming Teams
Click here for a brief text article with tips and an example to forming teams from the Institute for Healthcare Improvement. Watch the short ten-minute YouTube video below from the Stanford Medicine Improvement Team on quality improvement teams. The video covers team member roles and team functions with examples.
PDSA Cycle
Click here to read a brief text article explaining the PDSA cycle from the Minnesota Department of Health website. Check out this explanation of the PDSA cycle with step-by-step guidelines and examples in text format from the Agency for Healthcare Research and Quality. There is also free access within the article to a worksheet with directions for conducting a PDSA cycle. Watch this three-minute YouTube video on PDSA cycles from BMJ Quality:
COM-B
Read this short text guide (with an example) for the COM-B framework by the Social Change UK. Watch the short YouTube video by Active Break below that explains the COM-B framework:
Other Reviewed Strategies
There were 17 other PrEP uptake and adherence strategies examined in this review process and although none of them were assigned a Best Practice or Promising evidence level overall, many of them have individual criteria that are assigned Best Practice or Promising. Learn more about the strategies and their evidence levels for specific criteria by clicking the button below, or reading the following systematic review:
Merle, James L., Nanette Benbow, Dennis H. Li, Juan P. Zapata, Artur Queiroz, alithia zamantakis, Virginia McKay, et al. “Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions.” AIDS and Behavior 28, no. 7 (April 2, 2024): 2321–39. https://doi.org/10.1007/s10461-024-04331-0.
Study article citation: Coleman, Megan, Ashley Hodges, Sarah Henn, and Crystal Chapman Lambert. “Integrated Pharmacy and Prep Navigation Services to Support Prep Uptake: A Quality Improvement Project.” Journal of the Association of Nurses in AIDS Care 31, no. 6 (June 9, 2020): 685–92. https://doi.org/10.1097/jnc.0000000000000182.