Labeling files of clients who have adherence challenges facilitates easy identification and provision of appropriate counselling and psychological support to the clients

Sr. Ayo Grace Anywar -In charge Gulu RRH
Tuesday, July 7, 2015
Context: What was the issue or process affected? What was the root cause of the challenge?: 

For the period April - June 2012, 116 clients enrolled in HIV care and treatment services at Gulu Regional Referral Hospital missed their scheduled appointments for drug refills. In the previous quarter (January-March 2012), 104 missed the appointments.

The Hospital ART clinic team identified the following as root causes:

  • - Some clients would send treatment supporters (or other family members) to collect ARV and other drugs on their behalf, thereby reducing the frequency of client-counsellor interactions to assess and provide appropriate adherence counseling and support.

    -Several clients were reported to have been regularly forgetting to take their daily doses of drugs, leading to eventual accumulation of pills previously prescribed. In such scenarios, the clients would wait until all the pills are used up before returning for refills.

    - Lack of enough money to pay for transport, especially for those from very distant communities.

    -Absence of a clear method for timely identification of clients with adherence challenges to enable appropriate interventions.  

What Happened: How was the challenge or gap addressed or improved?: 

- The ART Clinic team (including adherence staff) resolved, during their regular Monday clinic operations review meetings, to begin labeling files for clients with adherence issues

The following were developed as additional action points:

 Clinicians and triage nurses were to:

 -Escort clients identified to have adherence issues to an adherence support counsellor within the clinic  

- Allow treatment supporters to pick up drugs on behalf of clients only once in a quarter

- Give shorter appointments dates to patients with adherence problems to enable close  adherence support counselling

Adherence counseling and support teams were given the following tasks:

- Labeling client files with adherence issues with a sticker for easy identification and provision of supportive counselling on subsequent visits e.g. the sticker reads, “Offer adherence support counseling at every visit” or “offer adherence support for ARV regimen switch”

- Recording or attaching any additional information about the client and their specific adherence challenges in the client file for clinicians to review on the next visit

-Remove sticker from client file when they have attained the desired level of support and/or adherence

Nugget: What is the lesson for others?: 

Label files of clients with adherence issues for easy identification and provision of appropriate adherence counselling and support at every visit

Impact: What are the results of applying the nugget?: 

- The number of clients missing scheduled clinic visit appointments reduced to 35 clients July-September 2012 Quarter.

- Expert clients and triage staff were trained on how to identify and support clients with adherence issues, bridging the knowledge gap

- Gulu RRH has since registered a markedly improved retention in care. Since October 2013, the average retention rate has consistently been above 80%. 

Implementation: What steps are needed to apply the lesson?: 

In cases where a large number of clients are identified to have adherence challenges, the ART Clinic team should hold weekly meetings to discuss, design and implement possible solutions, including the following:

- Encourage clinicians, counsellors or pharmacy teams to escort any client with an identified adherence issue to the adherence counsellor

- Assign responsibility for who should label client files (for example clinicians, adherence counsellors, or community linkages coordinator)

- Clinicians to schedule clients with adherence issues (giving shorter appointments) for frequent supportive counselling sessions

- Adherence counsellors should record and /or attach any information on the client’s adherence challenges  and the plan to address them in the client file for review by the clinicians on the next visit

- Encourage teams, including counsellors, to discuss with clients who come from distant communities the option of transfer-out/referral to nearby healthcare facilities 

Action: Who is this for? Where does this nugget to go next?: 
  • Clinicians
  • Counsellors
  • Pharmacy
  • ART Clinic In-charges
  • Community Linkages Coordinators
Gulu RRH staff Dr. Gladys Aloyo – Clinical Care Coordinator, Otika Robert - Adherence Counselor, Torach Denish Martine – Community Linkages Coordinator, Laker Sarah – Adherence Counselor