Transcript A Novel Collaborative Pharmacy Practice Model (CPPM) for

A Novel Collaborative Mental Health
Practice Model for the Treatment of
Mental Illness of the Spanish Speaking
Indigent and Uninsured
Davor Zink, Margie Hernandez, Hannah Lindsey,Vala Burton, Tara
Jackman and Antonio E. Puente
University of North Carolina Wilmington
Jennifer Buxton and Allison Altendorf
New Hanover Regional Medical Center
Presented at the annual meeting of the
Southeastern Council of Latin American Studies
March 17, 2011
Wilmington, NC
U.S. Population: Hispanic
 US:
 US
301,621,159 (100.0%)
Hispanics:
46,943,613 (15.4%)
 Largest
& Fastest Ethnic Minority Group in the United
States (and undercounted). Will be the Largest Group in
the United States by Approximately 2050.
Source: U.S. Census Bureau, 2007 American Community Survey, Pew 2009
3
4
5
6
Percent Latino of the Total Population
in the United States: 1970 to 2050
Census
Projections
*Projected Population as of July 1
7
Source: U.S. Census Bureau, 1970, 1980, 1990, and 2000 Decennial Censuses; Population Projections, July 1, 2010 to July 1, 2050
Expected Growth Hispanics in the
U.S.
60,000,000
50,000,000
40,000,000
2009
30,000,000
2050
20,000,000
10,000,000
0
Projections of Hispanic Population 2009-2050
Source: U.S. Census Bureau figures
11/12/2009
8
Top Five States by Latino Growth
Rate: 2000 to 2006
(For states with 100,000 or more Latinos in 2006)
9
Rank
State
Growth Rate
(percent)
1
Arkansas
60.9
2
Georgia
59.4
3
South Carolina
57.4
4
Tennessee
55.5
5
North Carolina
54.9
Source: U.S. Census Bureau, Population Estimates July 1, 2000 to July 1, 2006
NC Population: Hispanic

NC:
9,061,032 (100%)

Hispanics (or Latino any race): 639,623 (7.1%)
Mexican :
Puerto Rican :
Cuban :
Other Hispanic or Latino:
408,782 (4.5%)
51,867 (0.6%)
14,876 (0.2%)
164,098 (1.8%)

Current/Expected Growth:
400-500% annually

Second fastest growing after Alabama
(due to increasing US and foreign born migration & birth rates)
Source: U.S. Census Bureau, 2007 American Community Survey
Latest Figures

North Carolina Growth = 111% (20002010)
Main Problems in the Hispanic
Population
Low education
 Poverty
 Language barriers
 Mental Health/Health Problems

U.S. Hispanic Educational
Attainment
Graduate or Professional Degree:
10.1%
 Bachelor’s Degree:
17.4%
 Associate Degree:
7.4%
 Some College (no degree):
19.5%
 High School Graduate:
30.1%
 9th-12th grade (no diploma):
9.1%
 Less than 9th grade:
6.4%
 Note: Nationwide, 47% of undocumented
Hispanics have less than a high school degree

Source: U.S. Census Bureau, 2007 American Community Survey
Language & Poverty Co-variates
People who speak only English at home
(219,092,969) are:
o below (11.2%) poverty line
o above (88.8%) poverty line

People who only speak Spanish or any other
language at home (33,833,322) are:
o below (20.0%)
o above (80.0%)

Source: U.S. Census Bureau, 2007 American Community Survey
Language Concerns
Variation of Spanish
 Spanish as a Second or Even Third
Language
 Limits and Perils of Translations
 Importance of Non-Verbal
Communication
 Difficulties With Learning English

“Typical” Mental Health Problems
Depression
 Anxiety
 Substance Abuse
 Domestic Violence

 (from literature and 5 years of clinical service at
Tileston Mental Health Clinic)
Origins Of Mental Health Problems
Acculturation & Isolation
 Language Limitations
 Health Disparities
 Decreased Social Support
 Financial Limitations
 Poor Education
 Lack of Religious Affiliation

The Tileston Health Clinic
A non-profit clinic that has been serving
low-income and uninsured patients in
southeastern North Carolina for 20
years.
 Mission:

◦ Provide quality health services at no cost
◦ No form of health insurance
◦ Income falls within the federal poverty
guidelines
◦ English and Spanish
The Tileston Health Clinic
•
•
•
•
Medical services
Dental services
On-site pharmacy
Staff
– Healthcare professionals (MAs, CPPs, PhDs and MDs)
– Support staff (undergraduate, graduate)
– All volunteers
•
Budget
– Grants, donations, and money collected from fundraisers
All services and medications provided by the clinic
and its affiliates are free of charge to all of the clinic’s
patients.
• Daily (8-5)
•
The Mental Health Clinic
•
•
Founded by A. E. Puente, a clinical
neuropsychologist and UNCW professor, 10
years ago.
Psychotherapy and Counseling
– Clinical Psychologists, counselors
•
Medication Management
– PharmD./CPP, Clinical Psychologist, MD
•
Psychological and neuropsychological testing
– Graduate students
•
Administration
– Undergraduate and graduate students
By the Numbers
•
Number of patients = 56 (2009)
– Total served =
– Total per night = 20 approx.
Number of hours per month clinic is open = on
average = 10 hrs
• Number of volunteers = 12
• Number of psychotherapy encounters = 200
•
– Average encounter = 30 mins
– Average # of sessions per pt =
•
Number of testing encounters = 100 (including
treatment outcome)
– Average testing protocol = 6 hrs/patient
The Collaborative Pharmacy
Practice Model (CPPM)
Clinical Pharmacist Practitioner (CPP)
license.
 Allowed the pharmacist to prescribe
medications based on the psychologist’s
working diagnosis.
 Overseeing physician

◦ Review all clinic notes
◦ Endorse the pharmacist’s medication
recommendations
The Collaborative Pharmacy
Practice Model (CPPM)






Clinical psychologist and the clinical
pharmacist see patients together
Pharmacist prescribes psychotropic
medications based on psychologist diagnoses
Initial evaluation
Psychotherapy
Medication management
Testing
Typical presenting problems
Depression
 Anxiety
 Substance Abuse Disorder/Alcoholism
 Children- Learning Disability, ADHD

The Collaborative Pharmacy
Practice Model (CPPM)

Most patients receive psychotherapy in
conjunction with pharmacotherapy

Patients with substance abuse disorders
and actively suicidal and/or psychotic are
ineligible for mental health clinic services
Testing
•
Diagnostic purposes
– Psychological and neuropsychological testing
– Facilitate diagnosing the patients and to
– Acquire standardized data for the patient’s records
– Research purposes
•
Treatment outcome
– Pre-test data is
• Gathered upon the initial clinic appointment
• Provide an overall picture of the patient’s current physical and
mental health status
– Post-test data is
• Gathered approximately six months after the start of therapy
• Evaluate the patient’s response to therapy
Treatment Outcome
•
Alcohol Use Disorders Identification Test
(AUDIT)
– quantity and frequency of alcohol or substance
use
– detect dependence as well has harmful or
hazardous drinking
•
Patient Health Questionnaire for depression
(PHQ-9)
– assesses and monitors depression severity
•
Short Form-12 (SF-12)
– assesses quality of life
Pre and Post Testing
•
No significant results were found
– Measures were not sensitive enough
– Small sample size
– amount of time between pre and post tests
• Lack of staff
• Limited hours
– Patients did not follow-up with their treatment
plan
•
•
•
•
Became employed or insured
Moved
No exit interview
Attrition
Pre and Post Testing
Anecdotal evidence suggest patients are
improving with treatment
 The biopsychosocial well being of the
patients was the primary reason for
termination of treatment
 The effectiveness of treatment was
evident to the staff

Case Study T.P.
•
Depression and Anxiety
– Patient has no energy, cannot get out of bed, very
anxious, helpless, physical pain, unemployed,
marital problems = cannot function in society
•
Medication + Psychotherapy
– Paroxetine
– Individual and couples psychotherapy sessions
– CPPM sessions
– All treatment was provided in Spanish
•
After a year: no depression, anxiety under
control, no physical pain, patient familial
situation is stable, patient has a stable job.
Economic Impact In 2009
56 patients for a total of 316 visits.
 A total of 165 hours of free care, total
estimated value of $15,580.88.
 A total of 775 prescriptions were issued
by the CPP, total patient cost savings of
$123,699.29.
 Clinic patients received over $139,000 in
free mental health care and prescription
medications.

Limitations
More patients than available volunteers
 Large waiting list
 Volunteers availability
 Funding

The Tileston Mental Health Clinic
•
Is one of the few institutions in the state of NC that
is able to provide free medical and mental care for
uninsured Hispanics; and only one that provides
bilingual services.
•
The CPPM used in the clinic is a novel approach
worth of replication and further improvements.
– Only psychiatrists prescribe medications, limiting the
availability of this kind of treatment, especially for the
clinic’s patient population (low income, uninsured,
Hispanics).
•
Volunteering and learning opportunity for students
and professionals in the community.
Problems for North Carolina
•
Number of Hispanics in North Carolina (111%
growth)
•
Some SE NC counties have over 50% of the
population that are Hispanics
•
Number of Doctoral Level Psychologists that are
Hispanic in North Carolina = 1
•
Major mental health crisis looming in the horizon
•
One possible solution = Proposed UNCW PhD
program (requires knowledge of Spanish)
Conclusion

Wilmington, we have a problem…

Gracias!

Preguntas?