Transcript Role of Clinical Pharmacist in Mental Health

Role of Clinical Pharmacist in Psychiatry
Alam Sher, PharmD, MBA
MHC Cl. Pharmacist, Togus VAMC, Augusta, Maine
Adj. Assoc. Prof. Pharmacy Practice, MCPHS, Boston, Mass
Cl. Assoc. Prof. Family Med. (Psychiatry), UNE Col Of Osteopath Medicine
HEC Visiting Scholar, Islamia Uni of Bahawalpur, Pakistan
President, NA Sher Foundation for Health, Education & Humanities
www.sherfoundation.org - Wikipedia Article: Nasreen & Alam Sher Foundation
Road Map
• Definitions
•
•
•
Psychiatry / Mental Health
Psychiatric Pharmacist
History of Psychiatric Pharmacy
• Is there a need for it?
• What Does a Psychiatric Pharmacist Do?
• Psychiatric Pharmacist Skills
•
•
Assessment and Interview Skills
Comprehensive Medication History
• Literature Review
• Other Notable References
• Q/A
Psychiatry or Mental Health
 Psychiatry is devoted to the study and treatment of
mental disorders. These mental disorders include
various affective, behavioral, cognitive and perceptual
abnormalities.
 The term was first coined by the German physician
Johann Christian Reil in 1808, and literally means the
'medical treatment of the mind' (psych-: mind; from
Ancient Greek psykhē: soul; -iatry: medical treatment;
from Gk. iātrikos: medical, iāsthai: to heal).
Wikipedia - 2011
The Psychiatric Pharmacist
 PharmD with relevant clinical experience in
Psychiatry
 Additional residency and fellowship in psychiatric
medication use
 Board certified in psychiatric pharmacy
 Most work in academics, MH facilities, VA
 Increasing interest in the Patient-Centered Medical
Home (PCMH)
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Brief History of Psychiatric Pharmacy Practice
 For over 40 years, some pharmacists have specialized in




psychiatric pharmacy
In 1992, the Board of Pharmacy Specialty recognized
psychiatric pharmacy as a specialty of pharmacy
As of 2011, there are 627 board-certified pharmacists
(BCPP)
In 1998, the College of Psychiatric and Neurologic
Pharmacists (CPNP) was founded
In 2011, CPNP membership grew to 1,130
Glen Stimmel, PharmD, Manifesto - Psychiatric Pharmacy, CPNP
Is there a need?
 Mental/behavioral health problems are under
diagnosed and often untreated
 Untreated MH = more health care costs
 Many of these conditions can be successfully treated in
primary care
 80% of patients prefer to get their behavioral health
care from their family doctor
 Up to 70% of primary care visits have a behavioral
health basis
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Number of Physical Symptoms and Likelihood of
Mental Illness
70%
50%
30%
10%
0-1
2-3
4-5
6-7
>8
Number of Physical Symptoms
Frank deGruy (2010). Kentucky Policy Summit
Fit in the PCMH
 Fits with NCQA, HEDIS, ACO, NQF measures
 Depression screening
 Medication reconciliation
 Hospital follow-up, care transitions
 Develop care plans
 Self-management goal setting
 Care coordination
 High-risk populations and medications
 Evidence-based guidelines
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
What Does a Psychiatric Clinical Pharmacist Do?
 Teach pharmacy, nursing, medical






students/residents/practitioners
Lead medication education groups
Assist with formulary decision processes
Work collaboratively with teams to optimize
pharmacotherapy
Provide direct patient care via assessment and medication
management
Conduct research/publish
Patient advocacy
The University of Texas Medical Branch at Galveston (UTMB) - CPNP - 2011
Psychiatric Pharmacist Skills
 Interview techniques
 Comfort with patients with mental illnesses and their






families
Measurement-based care
Evidence-based treatment guidelines
Access to affordable medications
Patient medication education
Team-based care
Referral to therapy, support
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Assessment
 Indication for use
 Efficacy
 Safety – adverse effects, drug interactions
 Adherence
 Comprehensive Medication Management
Comprehensive Medication Management Defined
 Meet with the patient and family or NOK, if needed, to
help them identify their medication-related goals
 Review all medications
 Rx, OTC, supplements
 Caffeine, tobacco, alcohol, illicit drugs
 From all providers
 As they actually take them
 Obtain pertinent vital signs, labs especially UDS, TSH,
Vit. B12, Folate, and Vit. D3
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Comprehensive Medication Management
 Focus on medication use
 Goal to prevent or identify and resolve medicationrelated problems
 Referred to as Medication Therapy Management
(MTM) by Medicare Part D
 See Patient-Centered Primary Care Collaborative
(PCPCC )Document developed by the Medication
Management task force
www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_062010_final.pdf
www.pcpcc.net/files/medmanagement.pdf - 2010
Comprehensive Medication Management (cont’d)
 Identify medication-related problems
 Untreated indications
 Glucose, lipids, hypertension
 Not meeting goals
 Adverse effects, drug interactions
 Adherence, Cost
 Complete medication list to patient, provider
 Care plan with recommendations to resolve
problems to provider(s)
 Follow-up with patient to assess outcomes
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Meds Non-Adherence - Quotes for the Day
“Drugs don’t work in patients who don’t take them.”
- C. Everett Koop, M.D.
The most expensive pill is that which is not taken or
taken inappropriately.
Model Programs
 Federally Qualified Health Center (FQHC) in Billings, MT
 Family Medicine Residency
 Integrated behavioral health with PsyD and 2 mental
health/addiction counselors
 Integrated medication management with PharmD,
pharmacy residents and students
 Available for brief interventions in clinic daily
 Longer appointments can be scheduled for comprehensive
medication assessments
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
North Carolina Medicaid
 Currently have “generalist” pharmacists imbedded in
selected practices
 Pharmacists involved in medication reconciliation for
all Medicaid patients entering hospital
 “Boot-camp” training on behavioral health
medications ongoing
 Assess impact of training on outcome metrics
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
2010 Medicare Part D Medication Therapy
Management (MTM) Programs
www.cms.gov/PrescriptionDrugCovContra/Downloads/MTMFactSheet_2010_06-2010_final.pdf
Accessed 11/11
Reimbursement
 Varies by state
 Pharmacy schools
 Medicare Part D
 Employers
 Medicaid in some states
 New payment structures???
Medication Management Services: Resource-Based Relative Value Scale
Source: Minnesota Department of Human Services, MHCP Provider Manual, Medication Management Therapy
Services, - HIPAA– Compliant MTMS CPT Codes, Revised 1/5/2010. Accessed 11/11
Value






Return on investment varies, average 5:1
Improves patient outcomes
Improves access to care
Decreases resource utilization, admissions
Improves patient satisfaction
May increase drug spend
 Untreated indications, adherence improves
 Decreases overall cost
C. Cobb and J. McKee of The Col. of Psychiatric and Neurologic Pharmacists (CPNP) - 2011
Bond et al
 Intervention: Drug monitoring
 Pt population: Schizophrenia
 Study design: Retrospective chart review
 Study duration: 1 year
 N = 25
 Results: ↓ in hospital readmissions (42 vs 3), ↓
in AEs reported (38 vs 4), 39% ↓ in fluphenazine
dosage requirements, 42% ↓ in anticholinergic
use
AE = Adverse Effect
Bond et al. J Clin Psychiatry 1979;40:501-3.
Brianne Fairchild – BECVAMC, Pa
Gray et al
 Intervention: Treatment recommendations b/f
clinic visit & education to pts
 Pt population: Various
 Study design: Retrospective chart review
 Study duration: 3 months
 N = 19
 Results: ↓ in AEs reported (61 vs 20), ↓ of 1.32
meds/pt/month, improvement in pt’s drug
knowledge score (53% vs 77%)
Gray et al. Contemp Pharm Pract 1979;2:108-16.
Brianne Fairchild – BECVAMC, Pa
Lobeck et al
 Intervention: Drug monitoring & weekly groups
 Pt population: Undisclosed
 Study design: Retrospective chart review &
provider satisfaction survey
 Study duration: 3 months
 N = Unknown (total of 4734 visits b/f intervention
& 2662 visits after)
 Results: 66% of recommendations were
implemented, very favorable provider response to
survey (4.41 on a 1-5 scale), saved $22,241
Lobeck et al. Hosp Commun Psychiatry 1989;40:643-4.
Brianne Fairchild – BECVAMC, Pa
Lee et al
 600 VA pharmacist recommendations reviewed
 92% were accepted by providers
 Improved clinical outcomes in >30%
 Avoided harm in 90%
 Total cost avoidance = $420,155
Lee et al. Am J Health-Syst Pharm 2002;59:2070-7.
Brianne Fairchild – BECVAMC, Pa
ACCP Task Force
 Evidence of economic benefit of clinical pharmacy
services: 1996-2000
 No. of studies = 59 (12 were VA)
 100% demonstrated positive findings
 Benefit:cost ratio range = 1.74:1 – 17.0:1 (median =
4.68:1)
Schumock et al. Pharmacotherapy 2003;23:113-32.
Brianne Fairchild – BECVAMC, Pa
Other Notable Publications
 JH Colman, III, RL Evans and SA Rosenbluth. “Extended clinical roles for the pharmacist
in psychiatric care”; AJHP, 30:1143-1146 (Dec) 1973
 KK Roe, JA Doheide, and MZ Wincor. “Developing a Partnership With NAMI and
Psychiatric Pharmacists”; Schizophrenia Bulletin, 28 (3), 2002
 N Sanghera, PO chan, ZF Khaki, Claire Planner, KKC Lee, NE Cranswick, and ICK Wong.
“Interventions of hospital Pharmacists in Improving Drug Therapy in Children”; Drug
Society 29(11): 1031-1047, 2006
 P Tait, and D Hall. “Pharmacy Involvement on a Psychiatric Unit at St. Paul’s Hospital”;
The Canadian Journal of Hospital Phramacy, Vol XXXI, Nov-Dec, 1978
 GL Ellenor, and BR Dishman. “Pharmaceutical Care Role Model in Psychiatry-Pharmcist
Prescribing”; Hosp Pharm, 30(5):371-373, 377-378, 1995
 MH Jenkins, and CA Bond. “The Impact of Clinical Pharmacists on Psychiatric Patients”;
Pharmacotherapy, 16(4): 708-714, 1996
 WA Morton, AR Mendenhall, PG Windsor, B Lydiard. “Clinical Psychopharmacy
Cosultations: Acceptance of Recommendations on an Adult Inpatient Psychiatric Unit”;
Hosp Pharm, 30(9), 786-790, 1995
 CA O’Reilly, JS Bell, and TF Chen. “Pharmacists’ beliefs about Treatment and Outcomes
of Mental Disorders: “A Mental Health Literacy Survey”; Aust N Z J Psychiatry 44: 10891096, 2010
 JE Duga, AA Cardoni, and PG Pierpaoll. “Pharmacists Should Serve on Psychiatric
Patients’ Units”; Hospitals, J.A.H.A., 49, Sept 16, 1975
Summary
 Pharmacist interventions improve:
 Better Patient Care
 Prescribing patterns


↓ the dosage & absolute number of psychotropic drugs
↓ the potential AE burden of the psychotropic agents
administered
 Access to prescribers
 Cost-Effective
 Patient and medication safety
28
For every $1 invested in clinical
pharmacy services, more than
$4 in benefit is expected.
Schumock et al. Pharmacotherapy 2003;23:113-32.
Brianne Fairchild – BECVAMC, Pa
Thank you !
Questions & Comments?
30