Peer Supported NCD Care

I wanted to share a new project starting at AMPATH and am actively seeking other collaborators in the OpenMRS community. This is a research project aiming to augment the AMPATH care delivery system in the community setting by leveraging peers to facilitate medication delivery and simple data collection with a focus on hypertension and diabetes care. The following is a fairly in depth description of the project. If you have any interested in collaborating with the design and development of an OpenMRS 3.x module, please let me know.


Peer Delivery: This component will involve trained and paid peer-delivery agents who will cover a prescribed catchment area associated with each health facility in the intervention arm. Peers will play two roles: 1) Drug delivery: peers will deliver medication refills to the patient at a convenient location and time. Upon enrollment, clinical data from the OpenMRS, including the participant’s current prescription and the next refill date, will be sent by OpenMRS to the pharmacy staff, in order for them to package the medication. Each patient’s prescriptions will be individually packed in standard manufacturer-issued blister packs, which will be packaged in single-seal bags to prevent pilferage. A prompt will also be sent by OpenMRS to the peer, who will confirm with the patient delivery details (which drugs, quantity, location, date, and time for delivery). The peer will pick up the medication package from the pharmacy at the health facility and then deliver the medication to the patient, who will confirm receipt by digitally signing on the HIT tool. The peer will then request the next installment of medications from the pharmacy (via OpenMRS), accounting for any pills that the patient did not consume and are remaining in the blister pack. The peer will continue this cycle of medication delivery until the patient returns to the health facility for a follow-up clinic visit, when a new prescription will be issued by the clinician to the patient. The peer will then start a new prescription refill cycle for the patient. 2) Psychosocial support and adherence counseling: leveraging the peer-patient relationship, and using the HIT-generated adherence data, the peer will provide adherence counseling and psychosocial support to patients at the time of medication delivery to address individual-level adherence barriers and any new issues. Enhance patient activation: peers will use health coaching strategies to address concerns regarding medications, hypertension and other NCDs, and relationship with clinicians, thereby enhancing patient activation.

@dmunson @ball @mksd @grace @aojwang

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Like low tech Amazon :smiley: Or “Amazon for Adherence”. Very cool project.

For 1) Drug Delivery: I guess they would use an offline form & encounter that syncs to the EMR pt record when the peer worker has connection? Neat way to leverage the Offline forms work ongoing via Ampath/Mekom in 3.x squad.