Psychiatric Pharmacist Integration Into the Medical Home
Submitted: March 20, 2013; accepted May 3, 2013.
Corresponding author: Jerry R. McKee, PharmD, MS, BCPP, Wingate University Hendersonville, 220 5th Ave E, Hendersonville, NC 28792 ([email protected]).
Published online: August 22, 2013.
Prim Care Companion CNS Disord 2013;15(4):doi:10.4088/PCC.13com01517
© Copyright 2013 Physicians Postgraduate Press, Inc.
People with severe and persistent mental illnesses, such as schizophrenia, often receive inadequate general medical care1–6 and are documented to have a 25-year shorter lifespan than those without serious mental illness.7–10 Individuals with severe and persistent mental illnesses are frequently stigmatized, are often impoverished, frequently have co-occurring alcohol and/or substance use disorders, and are incarcerated in such large numbers that jails and prisons have become the new mental “institutions.”11–14 Additionally, more than 68% of adults with a mental disorder have at least 1 medical condition,8 resulting in decreased quantity and quality of life, increased symptom burden, and increased health care costs.15–17
Due to the long-standing lack of integration between mental health and primary care services, the “Final Report for the President’s New Freedom Commission on Mental Health”8 recommended use of evidence-based models to improve patient care at the interface of general medicine and mental health. Patients often present to their primary care providers with physical complaints; however, careful evaluation determines that, in many instances, the visit is driven by mental health or substance abuse issues. A Center for Health Care Strategies analysis found that, among Medicaid patients with chronic conditions, a comorbid mental health or substance use disorder predicted 60%–75% higher health care costs compared to those without comorbid mental health or substance use disorders. Further, patients with comorbid mental health or substance use disorders were 4 to 5 times more likely to be hospitalized than those without.16 The Center for Health Care Strategies offered ways to address these patient needs including use of multidisciplinary health care teams for patients with multiple complex needs, integration of behavioral health and physical health care, and financial incentives to care integration.
COMPREHENSIVE MEDICATION
MANAGEMENT AND INTEGRATED CARE
One often overlooked solution to the lack of integration of physical and behavioral health care models and the associated dearth of care coordination and related medication management problems is to more effectively utilize appropriately trained pharmacists to support patient-focused care. Engaging patients to promote effective medication management can be accomplished through a multidisciplinary health care team model. Working as part of the team, pharmacists have a unique set of knowledge and skills that are ideal for providing comprehensive medication management. Patients can benefit from pharmacists’ expertise in pharmacology, pharmacokinetics, drug-drug and drug-disease interactions, and optimization of medication adherence. Patients with mental illness can especially benefit from psychiatric pharmacists’ unique training in psychopharmacology and patient education about the risks and benefits of treatment. Psychiatric pharmacists embrace the concept of team-based care that involves the psychiatric and medical team and patient and family members; they also promote patient empowerment in the recovery process.
With the documented significant impact of multiple chronic diseases and medications on health care resource utilization, the benefit of pharmacists’ engagement in medical home medication management has been clearly outlined.18 One of the main benefits of team-based care including comprehensive medication management is to identify patients who are not meeting goals of therapy and to help them achieve those goals. Patients not meeting clinical goals are at an increased risk for emergency department visits or hospital admissions. Comprehensive medication management is effective in solving drug therapy problems to ensure that medications are appropriate, effective, safe, and taken as intended.18,19 A health system structure comprised of providers with distinct knowledge and skills can foster the philosophy of team-based care and ensure a productive, effective medication use system.19 It has been demonstrated that patients who may derive the most benefit from pharmacist engagement are those who have not achieved or maintained therapeutic goals of pharmacotherapy, who may be experiencing adverse medication effects (which may impact adherence), who may have difficulty in understanding and following the medication regimen, and who are frequently admitted or readmitted to the hospital or receive care through emergency departments.20 Unfortunately, many patients with chronic mental and medical illnesses struggle with these medication therapy challenges and need additional support from their health care providers.
The College of Psychiatric and Neurologic Pharmacists (CPNP; http://cpnp.org/) is a national organization with over 1,200 pharmacists who work with patients with mental illness and mental health providers. The CPNP advocates the provision of comprehensive medication management, as defined by the Patient-Centered Primary Care Collaborative.20 Comprehensive medication management includes an assessment of a patient’s medication regimen for indication, effectiveness, safety, and adherence. It employs the tenets of pharmaceutical care, pharmacy’s professional practice, and identifies and provides solutions to a patient’s drug therapy problems. Care should be coordinated among those who provide care for a given patient, and goals of therapy should be communicated among team members, including the patient.18 Comprehensive medication management is a reiterative process. An organized care delivery process can help patients achieve desired drug treatment goals and avoid drug therapy problems that may be impeding progress toward those goals. Examples of practice models that demonstrate improved clinical, economic, and educational outcomes can be found in Table 1.
Board-certified psychiatric pharmacists are uniquely positioned to partner with primary care providers and generalist pharmacists to target patients with complex medical and mental health disorders who are not meeting goals of therapy. Psychiatric pharmacists can provide added clinical, economic, and humanistic value to management of diseases that often lead to treatment nonadherence, high resource utilization, and overall poor quality of life. Clinical pharmacists are currently providing a range of patient-centered services by working directly with patients and families, physicians, psychiatrists, nurses, and social workers. Recognition of pharmacists as clinical service providers and associated payment for services to enable these services to be both financially sustainable and scalable is a goal of the CPNP, which is working with other state and national pharmacy organizations in pursuit of this objective. According to an Institute of Medicine report: “Pharmaceuticals are the most common medical intervention, and their potential for both help and harm is enormous. Ensuring that the American people get the most benefit from advances in pharmacology is a critical component of improving the national health care system.”23(p13)
Presently, at least 18 state Medicaid programs reimburse medication therapy management services that are provided by qualified pharmacists as cited by the National Conference of State Legislatures.24 Published reports, including the “US Public Health Service Report on Advanced Pharmacy Practice to the US Surgeon General,”24–26 suggest that pharmacist-provided medication management services have demonstrated a significant return on investment (as high as 12:1 and an average of 3:1 to 5:1).25–27 By coordinating our efforts within existing or novel patient care models, such as patient-centered medical homes, together we can improve access to care, improve health care–related outcomes, and decrease overall health care costs for patients with mental illness and medical comorbidities. The CPNP has adopted a position statement on the integration of behavioral health and primary care, specifically around the inclusion of pharmacists in the medical home model (http://cpnp.org/govt/position/medical-home-model).
It is clear that there is a shortage of primary care workforce in the United States, and this trend is predicted to increase with the aging population and Medicaid expansion via the Affordable Care Act. The unique skills of the pharmacist complement those of other members of the health care team. Incorporating the clinical pharmacist into a multidisciplinary team can improve efficiency of care. It is estimated that over one-third of primary care provider time is spent on chronic care management. The pharmacist can use comprehensive medication management to allow physicians the opportunity to more effectively use their time in physician-specific patient care activities.28 This can be accomplished by pharmacists who can ensure accurate medication lists for each patient, provide pharmacotherapy recommendations, solve drug therapy problems, and educate patients about their treatment plan. This model also offers the opportunity to improve quality of care endpoints via shared responsibility with the team.28,29 An excellent, comprehensive review of why pharmacists belong in the medical home, and the value to both patients and other team members, has been prepared by Smith and colleagues.30 Further, a recent meta-analysis compiled, analyzed, and reviewed pharmacists’ contributions in this practice arena and found that the use of pharmacists as described above is a viable solution to many of the access to and coordination of care issues in our US health system.31
The issue of payment continues to loom large as a major barrier in the provision of pharmacist-provided primary care services, as effective and sustainable reimbursement models are lacking. As the models highlighted in Table 1 will attest, pharmacists embedded in practices are often funded through pilot programs and demonstration projects or are staffed via academic programs.30 Payment systems must be devised and implemented to support, sustain, and enable growth of this practice model. For large primary care practices, pharmacists may be employed by the practice or may contract for time. Smaller practices may contract for a defined number of hours per week.18,30,32 Primary care physicians and practices with interest may identify collaborating psychiatric pharmacists in their region through the assistance of organizations such as the CPNP and Board of Pharmaceutical Specialties (http://www.bpsweb.org).
In summary, the CPNP supports the integration of psychiatric pharmacists into primary care practices to provide comprehensive medication management as part of an integrated health care team to improve access to care, improve quality of care, decrease costs, and improve provider and patient satisfaction for patients with both serious mental illnesses and chronic medical conditions. The ultimate goal in promoting collaboration between mental and medical care is to improve the lives of persons with chronic mental illness and the lives of their families.
Drug names: clozapine (Clozaril, FazaClo, and others).
Author affiliations: Wingate University School of Pharmacy, Hendersonville, North Carolina (Dr McKee); Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California (Dr Lee); and RiverStone Health, Billings, Montana (Dr Cobb).
Potential conflicts of interest: Dr Cobb has received grant/research support from Montana Mental Health Trust. Drs McKee and Lee report no conflicts of interest related to the subject of this article.
Funding/support: None reported.
Acknowledgments: The authors acknowledge the support of the College of Psychiatric and Neurologic Pharmacists Comprehensive Medication Management Task Force in developing this position statement.
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