Transcript 48x36 Poster Template - Antonio E. Puente, Ph.D.

A Novel Collaborative Practice Model (CPM) for the Treatment of Mental Illness of the Indigent and Uninsured
Davor N. Zink, Keenan Withers, Aaron Dedmon, Margie Hernandez, Tara Jackman, Hannah Lindsey, Lee Wiegand, Heather Hughes, Ahmed Fasfous, Jennifer Buxton, and Antonio E. Puente
University of North Carolina Wilmington
University of North Carolina Wilmington
University of North Carolina Wilmington
Introduction
We describe the development, implementation, and
evaluation of an innovative collaborative practice model (CPM)
designed to address the mental health needs of indigent and
uninsured patients.
The practice model consists of a program, started seven
years ago, to provide comprehensive psychopharmacological
and mental health treatment for individuals with clinically
significant mental disorders as well as limited economic
resources and no insurance coverage at a free clinic in
Wilmington, NC. Three aspects of the program are novel; 1)
it is comprehensive in that all forms of diagnostic and
therapeutic interventions are provided, 2) services are
provided in English and Spanish and 3) no direct physician
involvement is included.
The Collaborative Practice Program
The structure of the CPM includes four major
components: an initial evaluation (which will include an
interview and may include testing), psychotherapy
only, medication management only, and psychotherapy
plus medication management. Once a referral is made
and/or acceptance to the clinic is established, all
patients participate in a comprehensive initial interview
conducted jointly by a doctorate level clinical
neuropsychologist and the clinical pharmacist. Initial
interviews generally last one hour and conclude with a
suggested diagnosis followed by discussion and
implementation of the most feasible treatment plan.
Patients with difficult diagnoses or unclear etiologies
receive a more comprehensive evaluation which
includes psychological or neuropsychological testing,
as deemed appropriate by the psychologist who
conducts the initial interview. In 2006, a collaborative
practice agreement was established between the
volunteer pharmacist and the clinic’s medical
director (a practicing physician). In accordance
with state laws, the pharmacist obtained a Clinical
Pharmacist Practitioner (CPP) license from the
state boards of pharmacy and medicine. This
license allowed the pharmacist to participate in
patient interviews with the clinic’s psychologist
and prescribe medications based on the
psychologist’s diagnosis and assessment. Current
evidence suggests that optimal management of many
mental health conditions includes both psychotherapy
and medication management. Most patients referred
to the mental health clinic receive psychotherapy in
conjunction with pharmacotherapy. Medications are
selected based on American Psychiatric Association
(APA) guidelines for treatment and drug availability.
Visits occur every two weeks upon initiation of
medication therapy and during the acute phase of
treatment. These visits then decrease in number when
the patient transitions into the maintenance phase of
therapy with follow-up occurring every three to six
months.
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Method
Table 1
Mean ± S.D. age (yr)
No. (%) female
Procedure:
In order to determine the efficacy of the program, a series of pre-post measures were administered, including the SF-12, the PHQ-9, and the
AUDIT. Patients were tested prior to the onset of intervention and approximately three months after initiation of the intervention. The patient outcome
data collected for program evaluation is standardized and offered in both English and Spanish. After patients give consent to the regulations and
procedures of the clinic regarding patient conduct, attendance, and testing; a psychology student administers three questionnaires. The first is the
Alcohol Use Disorders Identification Test (AUDIT), which incorporates questions about the quantity and frequency of alcohol use in adults to
detect dependence as well as harmful or hazardous drinking. Scores range from zero to 40 with higher scores displaying increasing quantity and
frequency of alcohol use. The second questionnaire is the Patient Health Questionnaire for depression (PHQ-9). The PHQ-9 assesses and
monitors depression severity. Scores range from zero to 27 with higher scores indicating an increase in severity of depression. The third
questionnaire is the Short Form-12 (SF-12). This questionnaire assesses quality of life by quantifying overall physical and mental health via two
population-based scores: the physical component summary (PCS) and the mental component summary (MCS). Scores range from 0 to 100,
where a zero score indicates the lowest level of health measured by the scales and 100 indicates the highest level of health. Both Physical and
Mental Health Composite Scales can be compared to a national norm with a mean score of 50.0 and a standard deviation of 10.0.
Inclusion criteria. All adult patients (≥18 years of age) of the mental health clinic who received pre- and post-testing were eligible for inclusion in
the analysis. These patients received the same testing, but their data was not included in the study due to lack of questionnaire validation in
pediatric and adolescent age groups.
Exclusion criteria. Any pre- and post-test sets with an elapsed time of greater than 12 months were excluded from the study. Any incomplete
questionnaires (questions unanswered or ineligible writing) were also excluded.
Patient Demographics. The age and gender of the mental health clinic patient population based on pre-testing are displayed in Table 1.
Results
Pre and Post Test Results. Table 1 lists the pre- and post-testing results for the AUDIT, PHQ-9, and SF-12. The pre- and post-AUDIT mean
scores were 1.59 and 1.72 respectively. Prior to receiving treatment, 6.9% of patients had participated in harmful or hazardous drinking over the year
prior to treatment while 3.4% were likely alcohol dependent. After receiving treatment, none of the scores indicated harmful or hazardous drinking,
while 3.4% were likely alcohol dependent. A paired samples t-test was conducted to assess if there was a significant difference between the pre and
post AUDIT scores. Results showed no significant difference, t (28) = -0.190, p = 0.851, 95% CI (-1.62, 1.35).
Pre-PHQ-9 testing identified 37.9% patients as having severe depression. The mean test score was 15.7 and the mean number of symptoms
was 7.3. Post-testing revealed 34.4% of patients remained severely depressed. The mean post-test score was 14.4 and the mean number of
symptoms was 6.8. A paired samples t test was conducted to assess if there was a significant difference between the pre and post PHQ-9 scores.
Results showed no significant difference, t (28) = 0.925, p = 0.363, 95% CI (-1.55, 4.1).
Pre-SF-12 testing provided a mean and standard deviation MCS of 30.9 ± 12.1, and a mean and standard deviation PCS of 35.3 ± 11.7. The
mean and standard deviation post-test MCS was 36.7 ± 37.4. The mean and standard deviation post-test PCS was 37.4 ± 12.5. A paired sample t
test was conducted to assess if there was a significant difference between the pre and post SF-12 scores (PCS, MCS). Results showed no
significant difference between pre and post PCS scores, t (19) = -0.641, p = 0.529, 95% CI (-5.73, 3.04), and pre and post MCS scores, t (19) = 1.75, p = 0.95, 95% CI (-14.24, 1.24).
Numerical Transformation Comparison. Patient demographics for the post-tested population are listed in Table 1. Table 2 quantifies
the amount of free healthcare provided in 2009 by estimating the hourly cost of each service provided. A total of 165 hours of free care were
provided by mental health clinic practitioners with a total estimated value of $15,580.88.
Prescription data was also collected from the pharmacy computer system and analyzed for the year 2009. This data is summarized in
Table 3. A total of 775 prescriptions were issued by the CPP and were associated with a total patient cost savings of $123,699.29.
Mental Health Clinic Patient Demographics and Data
Variable
Demographic Data
(n=81)
44.4 ± 11.2
63 (77.8)
Value
Pre-testing
Data
Post-Testing
Data
46.7 ± 9.3
21 (72.4)
Language of testing (no. [%])
English
Spanish
58 (71.6)
23 (28.4)
21 (72.4)
8 (27.6)
2.4 ± 5.0
6 (7.4)
n=20
1.59 ± 3.3
1.72 ± 5.2
2 (6.9)
1 (3.4)
AUDIT
(Mean ± S.D. score)
No. (%) patients with harmful or hazardous drinking in last year
(score 8 – 19)
No. (%) patients with alcohol dependence likely (score > 20)
2 (2.5)
0 (0)
1 (3.4)
PHQ-9
Mean ± S.D. score
n=29
15.7 ± 7.3
14.4 ± 7.9
15.0 ± 7.6
Mean ± S.D. number of symptoms (out of 9)
No. (%) patients with severe depression (score ≥ 20)
SF-12
6.7 ± 2.5
26 (32.1)
n=63
7.3 ± 1.8
11 (37.9)
Mean ± S.D. MCS (Mental Health Scale)
34.9 ± 13.1
30.9 ± 12.1
36.7 ± 37.4
Mean ± S.D. PCS (Physical Health Scale)
38.2 ± 11.6
35.3 ± 11.7
37.4 ± 12.5
6.8 ± 2.7
10 (34.4)
n=20
Table 2
2009 Estimated Value of Free Care Based on the 2010 Medicare Fee Schedule
Service
Cost (per hour)
Initial interview
$146.85
Psychotherapy
$87.14
Psychotherapy E & M
$119.24
Neuropsychological Testing
$58.01
Totals
Hours
Provided
19
100
23
23
165
Total Free Care
$2,790.15
$8,714.00
$2,742.52
$1,334.23
$15,580.88
Table 3
2009 Prescription Data
No. prescriptions written by CPP
No. patients who received prescriptions
Mean prescriptions/patient
Mean cost of medications/patient
Overall cost of prescription medications
775
55
14
$2,249.08
$123,699.29
Discussion
We present a novel approach to the assessment and
intervention of mental health problems in a community clinic for
indigents. However, the implementation of an innovative CPM in
the mental health clinic was not associated with significant
improvements in PHQ-9 depression scores, SF-12 quality of life
scores, or AUDIT alcohol abuse scores despite increased access
to mental health care and medications among clinic patients.
Several flaws in study design and data collection limited the
usefulness of the pre-and post-test data. The lack of statistical
differences could be due to the small sample size, the varied
elapsed time at post testing, and the instruments themselves.
Despite the results, clinical data illustrates improvement in the
patient’s symptoms.
Clinic patients were provided access to mental health care
and medications that were previously unavailable within the
community. In 2009 alone, clinic patients received over $139,000
in free mental health care and prescription medications. The most
common diagnosis was depression and most commonly
prescribed medications include citalopram, escitalopram,
fluoxetine, buproprion, venlafaxine, paroxetine, trazodone, and
quetiapine.
More importantly, this model provides a novel approach in
that is bilingual, comprehensive, and does not involve typical
medical intervention for the provision of psychopharmaceutical
intervention. The model is now being presented as a cost
effective way to provide mental health intervention in “free clinics”
throughout North Carolina, especially in a changing demographic
environment.
Acknowledgments
Health professionals and volunteers at the Cape Fear
Community Clinic
[email protected]