The first legal mobile retail pharmacy in Connecticut, a project conceived by a Yale School of Medicine (YSM) professor, has become a reality. The “Integrated Mobile Opioid Treatment and Infectious disease cOordinated care in your Neighborhood” project (InMOTION), aspires to bring care to people where they live who are at risk or living with infectious diseases, such as HIV, as well as those with substance use disorders, such as opioid use disorder (OUD). The initiative, led by Sandra Springer, MD, professor of medicine (infectious diseases), aims to coordinate efforts with the Ending the HIV Epidemic plan, a federal project seeking to halt the decades-long HIV epidemic in the United States by 2030. It’s a big and lofty goal, says Springer, who was one of two people nationally awarded grants in 2022 by the National Institute on Drug Abuse (NIDA) for the Avant Garde Award Program for HIV and Substance Use Disorder Research. When issuing grants, the National Institutes of Health (NIH)—NIDA’s parent agency—usually asks for a detailed step-by-step documented plan. But here, they just asked for the researcher applicants to share a big and creative idea to solve a problem. “So, my idea was to create a new mobile health care system,” Springer says. Springer’s vision was for a mobile care system that includes a retail pharmacy and a clinic on wheels designed to provide care to people where they are, with both clinical and pharmacy services, improving accessibility for patients with HIV, hepatitis C, and substance use disorder (SUD). Connecticut is the only state in the U.S. where retail pharmacies are legalized to be mobile. Why is this novel health care model necessary? It’s because “people have difficulty accessing and navigating health care systems, transportation being a major issue, and also experience other competing needs, particularly socioeconomic needs,” says Alysse Schultheis, MA, project director for InMOTION. “Health care may not be the primary thing they are focused on when they don't have shelter,” but she says improving access can help them prioritize their health outcomes. Springer adds, “Bringing the care to them to overcome the barriers they face, like transportation and stigma, is critical.” Osama Abdelghany, PharmD, executive director of the oncology pharmacy at Yale New Haven Health, part of the team operationalizing the mobile pharmacy, says that pharmacists have always been among the most accessible health care providers, and the mobile pharmacy will add an urgently needed and innovative dimension to pharmacy care. “Access to medications and comprehensive medication management is especially challenging for underserved populations. Not only do they lack convenient access to a pharmacy, but they can also be unable to navigate programs designed to help them address their medication needs. This is where the mobile pharmacy can really make a difference,” he says. How the mobile pharmacy initiative runs InMOTION's first step is taking is training people as community health outreach coordinators (CHOCs) in different communities affected by drug overdose to test for HIV, hepatitis C, and SUD, particularly for opioid use disorder. This is the first time, in my whole academic and clinical career, that I feel like I'm actually doing something that might change how we deliver care to people and how it should really be done.Sandra Springer, MD The CHOC system the team designed is based on the work of Sheela Shenoi, MD, MPH, associate professor of medicine (infectious diseases) and associate director of the office of global health at YSM. Springer says that Shenoi has worked to improve clinical outcomes of those with HIV and/or tuberculosis in South Africa and other areas by training individuals living in the communities to offer screenings to their peers and connect them to treatment, as needed. The CHOCs are also identifying people who do not have HIV and are eligible to receive pre-exposure prophylaxis (PrEP), which helps prevent the virus, or to receive HIV treatment. The virus that can lead to AIDS is still a major concern. According to data gathered by the Connecticut State Department of Public Health, 174 new cases of HIV were diagnosed in the state in 2020 and 24% of those diagnosed developed AIDS within a few months. There were 10,665 people living with HIV in Connecticut in 2020. The InMOTION team is also integrating the use of medications like buprenorphine and naloxone to treat OUD and prevent drug overdose, according to Springer. Community health care workers bridge key gaps CHOCs are native to the areas they serve or have pre-existing relationships with community members, as community health workers who can tend to people’s socioeconomic needs such as housing, food insecurity, clothing, and employment. They are being trained to access telehealth services and become the bridge between health care provider and patient. Telehealth clinicians see patients and, if they need to write prescriptions, “we are able to have electronic scripts sent to our mobile pharmacy,” Schultheis says. Patients then collect their medications either at the mobile pharmacy or through a distribution network made up of small vans. Schultheis adds that the program also offers support to people in the community involved in the justice system who might also have SUD setbacks, “and really take a harm reduction approach as well.” She says that Springer’s ideas “were aimed at fixing those two gaps,” which are medical treatment and socioeconomic needs. “I went into infectious disease because I wanted to take care of patients with HIV, and I wanted to do this better. I knew that it's not just prescribing antiretroviral therapy; it's also taking care of the other needs including substance use disorder treatment,” Springer says. “And this is the first time, in my whole academic and clinical career, that I feel like I'm actually doing something that might change how we deliver care to people and how it should really be done.” Springer adds: “What's the point [of the clinical, and research work we do] if we're not really reaching people, and improving their care? I had an opportunity, and I said, ‘Let's go for it.’ I didn’t think I would submit it because I thought it was too big an idea, and that no one would fund it. But I said, ‘Ah, what the heck. We'll give it a shot. Maybe someone will listen.’” To address transportation and health care access challenges, the mobile pharmacy and clinic also offers primary care. People can be checked for chronic diseases like diabetes and heart disease, monitor their blood pressure, and receive wound care and mental health care. Mobile pharmacy pilot launched in Waterbury Before the official program launches, Springer and her team are running a pilot program in the city of Waterbury to identify gaps, needs, and locations they can serve. They started the program there with CHOCs on September 25, and will have the mobile pharmacy operating by October 23. With a stated desire to avoid reinventing the wheel, Schultheis notes the initiative is “partnering with organizations that are already established in the communities in order to fill the gaps.” That way, they can receive feedback from community partners on the program design and adapt in real time. Current partners include the Connecticut State Department of Public Health and such organizations as Stay Well Health Centers and McCall Behavioral Health Network to identify additional communities in Connecticut that require the most attention and services. A law that makes retail mobile pharmacies legal When Springer received the NIDA grant last summer, her first task was to address the need to make such services legal in the state of Connecticut. She and Cynthia Frank, PhD, RN, who started the InMOTION project with Springer and directs her research program InSTRIDE (Integrating Substance Use Treatment Research with Infectious Disease for Everyone), worked with pharmacists from Yale New Haven Health—Osama Abdelghany, PharmD, and Prashant Patel, PharmD—and other collaborators to author and submit the necessary legislation. “An Act Concerning Pharmacies and Pharmacists” is the law that was passed and signed by Governor Ned Lamont which included the legalization of retail pharmacies. It went into effect on July 1, 2023. For their work, the InMOTION team received the third annual Pharmacy Vision Award for Public Policy Excellence given by Vizient, a health care performance improvement company. Mobile retail pharmacies became legal, but with a catch: When current Drug Enforcement Administration (DEA) rules were written at the federal level, they did not contemplate the possibility of storing and distributing controlled substances at a mobile retail pharmacy, so DEA cannot authorize it. Springer and her group are now working closely with DEA as it contemplates revising those rules. Not only is DEA’s current policy confusing, Springer says, but it also limits her team’s ability to dispense such medications as buprenorphine, which is prescribed to treat OUD, especially when it is related to heroin and fentanyl use. The ability to dispense buprenorphine would help treat those with OUD since only one person in five is receiving the treatment they need, as documented in a research letter recently published in JAMA, Springer notes. “I'm still pretty hopeful. I'm pretty confident that the federal DEA, with the NIDA backing, and having this new legislation passed in Connecticut, will allow us to be able to carry forward being able to provide buprenorphine on the mobile retail pharmacy,” said Springer. This challenge does not threaten InMOTION’s overall viability, but having this option would add to the good that the program can do. In the interim, InMOTION will collaborate with fixed-location pharmacies that provide it with the controlled substances.