The Multidisciplinary Approach to Managing People With HIV
In this multidisciplinary video roundtable discussion, Jeffrey Kwong, DNP, MPH, ANP-BC, interviews pharmacist Milena Murrah, PharmD, MS, psychologist David Vance, PhD, MGS, MS, and internist Jonathan Appelbaum, MD, about a collaborative approach to managing patients with HIV.
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TRANSCRIPTION:
Jeffrey Kwong, DNP, MPH, ANP-BC:
Hello, everyone, and welcome to our Multidisciplinary Roundtable Discussion on HIV Management. I'm your Moderator, Dr Jeffrey Kwong, and I'm a nurse practitioner and a professor in the Division of Advanced Nursing Practice at Rutgers University in Newark, New Jersey, and a practicing clinician at Gotham Medical Group in New York City.
Joining me today are three distinguished colleagues, Dr Jonathan Appelbaum is a physician who is Chair of the Department of Clinical Sciences, and a professor of internal medicine at Florida State University College of Medicine in Tallahassee, Florida.
Dr Milena Murray is a pharmacist and associate professor of pharmacy practice at Midwestern University College of Pharmacy, and a system-level HIV ID Pharmacist at Northwestern Medicine.
And finally, Dr David Vance is a psychologist and professor at the University of Alabama and Birmingham School of Nursing and is a leading researcher in the field of neurocognitive effects of HIV. Thank you all for joining me today.
David Vance, PhD, MGS, MS:
It's a pleasure to be here.
Jonathan Appelbaum, MD:
Nice to be here.
Milena Murray, PharmD, MS:
Thank you.
Jeffrey Kwong, DNP, MPH, ANP-BC:
For this segment, we'll be focusing on the role of a multidisciplinary team in caring for persons with HIV. Just to provide some background information for our audiences. In the US, it's estimated there are approximately 1.2 million persons living with HIV, and about 30,000 new infections occur annually. And the field of HIV is unique in that it impacts a wide variety of different populations and communities, many of whom face different challenges and social determinants of health. And we also know that stigma is associated with HIV and is one of the biggest issues that can impact diagnosis, access to care, and retention in the care. And in order to optimize care for persons with HIV, a variety of skill sets and specialties is often needed. So, just thinking about our group here as a multidisciplinary team, I'd like to just open the discussion here and go around and get your opinions on, what is the role of a clinician in your specialty in the management of care for persons with HIV. John? We'll start with you.
Jonathan Appelbaum, MD:
Yeah, thanks, Jeff. So having practiced working with people from multiple disciplines most of my career, I mean, it seems kind of natural and normal. I think when we're talking about patients living with HIV, particularly as they age, you're going to deal with HIV, but also lots of other illnesses, and one clinician can't manage everything. And so I think the role the team, the pharmacists, the advanced practice providers, social workers, specialists in getting prior approvals, referral coordinators are all really, really important to provide that comprehensive care and also to take advantage of wraparound services that may be available for the patient.
Jeffrey Kwong, DNP, MPH, ANP-BC:
Yes. Milena, your thoughts as a pharmacist?
Milena Murray, PharmD, MS:
Yeah, I think that it's been really wonderful being able to practice in a multidisciplinary clinic because people are right there, they're right down the hall. I think that's so important. Because as John said, we have to really be a one-stop shop for a lot of people, especially those who are aging and have other comorbidities that we're trying to manage. Sometimes HIV is not their number one priority. It could be blood pressure, diabetes, maybe it's food insecurity, maybe it's housing or mental wellness. So there's just a lot that we have to do and a lot of our colleagues that we need to lean on and be that liaison for our patients.
Jeffrey Kwong, DNP, MPH, ANP-BC:
Yeah. And David, your thoughts or perspectives?
David Vance, PhD, MGS, MS:
I absolutely agree with everything that was said. Even in our clinic when you go in you see the clinician, but you also see a dietician and a social worker. You see someone even from the research side coming in to see if they want to participate in research. So there are multi-layers involved.
Jeffrey Kwong, DNP, MPH, ANP-BC:
Representing nurses and advanced practice providers, I think definitely it is, as John alluded to, "One person can't do everything." I think really having that coordination of care and having different perspectives is also important. Just in terms of thinking about team-based care and the range of the services that we provide, what do you think, just in terms of coordination of care, how has that worked in your facility or in your experience? Although we all may work in the same building sort of, sometimes we still get siloed. How do you deal with that or address that in some of your practice settings?
Jonathan Appelbaum, MD:
I can go ahead and start. So I've had the luxury as you know, Jeff of having worked at a FQHC, and it was a Ryan White Clinic, where we had the luxury of multiple services under one roof. And I kind of missed that. Where I'm working now, it's not a Ryan White site. We do have multiple services under one roof, but not everything. So for instance, we have to send patients needing mental health services elsewhere. So I think the idea of having as much as possible under one roof, it's certainly great from the clinician's standpoint, but also from the patient's standpoint. They don't have to travel. Sometimes they don't have to deal with referrals. And there's hopefully greater communication between the various providers.
Milena Murray, PharmD, MS:
My first thought is that there are two different ways I can think of that we would know of an issue of someone coming in. So maybe they've already contacted us ahead of time and they've said, "Hey, I've lost my insurance, or I have an issue with a medication side effect." So we know coming in, they're either going to see the social worker for the insurance issue or myself for a medication issue. And then there's also a patient who comes in, sees the physician or the provider, and then something comes up during and then they have to get referred out. So I think that those are two different pathways. So, really it's all about communication I think, especially if something comes up during the visit and say they have to now go to see an endocrinologist and try to get that referral for them. But also reaching out to endocrinology and saying, "Hey, we're sending this person and this is why. What's the soonest you can get them in so that they're not waiting for six, nine months for an appointment."
And then from my side, they're coming in with a known issue trying to get that resolved, trying to work with the provider/prescriber to figure out if we're changing, if we're not, is there other monitoring allowing pharmacists or others to order labs if needed, or other referrals to put in the computer? So then it just reduces that one step of me sending it to the provider to sign off on. So I think there's a lot of behind-the-scenes work that we can do to streamline things because we know we're going to run up against barriers such as time to get an appointment at other places.
David Vance, PhD, MGS, MS:
And I concur with all of that. And in addition, just having everyone under the same roof is very important. We also have an intake kiosk where patients start answering questions about signs and symptoms. And in fact, one of the symptoms is suicidal ideation. And so if they indicate that sort of symptom, mental health is already on the scene. So they know to go see that patient while they're in the visit. So anything you can do to automate.
Jeffrey Kwong, DNP, MPH, ANP-BC:
Absolutely. I think technology is really opening the doors for many of us in ways that we have yet to really maximize or take advantage of in terms of providing team-based care. I think back as John alluded to, working at an FQHC and also working at a larger academic medical center, we would have interdisciplinary rounds every week and we'd bring up cases. And it was a great opportunity because many times we see a patient for our 15-minute or 30-minute interval and we just see one segment. And really having the opportunity to share all segments together and bring people to one table or one meeting is very valuable in terms of providing holistic care. So that's great. We're almost out of time here. Are there any last things that you would like to add in terms of the benefits or the challenges of working on an interdisciplinary or multidisciplinary team? Anybody?
Milena Murray, PharmD, MS:
One last thought I have is, that it's very important that the person knows why they're getting referrals. So say they say something during a visit and now they're going to have to go see the social worker or go see the pharmacist. If they're not aware of why, A, we obviously don't want them to be upset, but B, if they don't understand the importance, they might just say, "Oh, I have to leave. I have somewhere to be." So I think it's really important to educate the patients on why we're referring them and what the benefits of those referrals are.
Jonathan Appelbaum, MD:
And I'll just add, Jeff, that I think it's important that everybody leaves their egos out and really be patient-centered, and for everyone to work at the peak of their license. I think it's a great way for us as physicians to really understand what our non-physician colleagues are able and can do and bring to the table. Remember, we're all trying to give the patient the best care possible.
David Vance, PhD, MGS, MS:
I think it all boils down to communication.
Jeffrey Kwong, DNP, MPH, ANP-BC:
And on that note, thank you all for your insights and perspectives. I think this has been very valuable and helpful and hopefully insightful for our audience. And thank you to our audience for tuning in to this Consultant360 Multidisciplinary Roundtable discussion.