Background/Purpose: Adherence is a complex behavior and rates among patients with rheumatic diseases are especially poor. To date, the impact of interventions on adherence and disease outcomes has been inconsistent. We developed a patient-centered intervention using navigators, college-educated individuals trained to provide education, advocacy, mental health support and care coordination services tailored to each patient’s needs, to understand and improve adherence to disease modifying antirheumatic drugs (DMARDs).

Methods: Two board-certified rheumatologists designed a training curriculum for the navigators that included education about systemic rheumatic diseases. Collaborating with a pharmacist, materials were developed on DMARD pharmacokinetics, administration, drug interactions, monitoring, and adverse effects. The drug and disease-specific training consisted of three two-hour modules. A health behavior epidemiologist provided a two-day motivational interviewing training. To familiarize the navigators with available resources, meetings were arranged with a social worker, psychiatry department leadership, a financial counselor, clinic administrators and outpatient pharmacists. Individual structured interviews were conducted between the navigators and four rheumatologists to better understand the needs and perspectives of providers. The navigators also shadowed nurse practitioners during medication education sessions and rheumatologists during clinic visits.

Results: We identified and trained three patient navigators, one of whom is fluent in Spanish. Patients receiving care at an academic medical center with a rheumatic disease who recently started an oral DMARD were eligible. Patients could self-refer, be referred by their rheumatologist, or be identified by electronic medical record review and were contacted after approval from their rheumatologist. 25 of the 32 practicing rheumatologists referred patients. We sent letters to 553 patients, 313 of whom were reached by a navigator. Of these, 114 enrolled and 102 completed baseline surveys. During the ongoing two-year study, patients are followed for a 6-month period. There have been 360 patient encounters (phone calls or in person meetings) and 20 patients have completed the 6-month intervention. Navigators have established a rapport with rheumatologists and opened a channel of communication between patients and providers. They have identified medication errors, recognized and addressed mental health issues and adverse events, and coordinated care across providers to facilitate adherence to rheumatologists’ recommendations. They developed a system with the psychiatry department to expedite referrals based on needs they uncover and routinely work with pharmacies, insurance companies and the financial counselor to ensure that patients obtain their prescribed medications.   

Conclusion: A patient navigator program is a feasible strategy to facilitate care coordination and promote adherence to oral DMARDs. Next steps include evaluation of the impact of rheumatology-specific navigators on clinical outcomes and long-term adherence.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/design-and-implementation-of-a-patient-centered-navigator-program-to-improve-adherence-to-disease-modifying-antirheumatic-drugs/