Collaborations to Improve Care: Psychiatric and Ambulatory Care Pharmacists

Austin Campbell, PharmD, BCPP
Clinical Pharmacy Specialist – Psychiatry
University of Missouri Health Care

As the health care environment continues to adapt and grow, more and more services are being provided through outpatient clinics. This drastic shift in delivery has created a multitude of opportunities for pharmacists to demonstrate their value in primary care settings. At a session entitled “Collaborations to Improve Care: Psychiatric and Ambulatory Care Pharmacists,” Dr. Steven Chen, Pharm.D., FASHP, FNAP, Associate Professor at the USC School of Pharmacy and the Hygeia Centennial Chair in Clinical Pharmacy, presented compelling information regarding the need for expanded roles by pharmacists.

Mental Health in Primary Care

With the majority of mental health disorders being treated by primary care, there is a growing need for specialist involvement.^{1, 2} Mental health disorders have been associated with an increase in chronic disease development leading to greater utilization of services and, ultimately, inflated costs.³ During his session, Dr. Chen presented statistics on the lack of available services for patients suffering from mental illness, as well as the numerous barriers (i.e., stigma) individuals face when seeking treatment.^4,5 He went on to further illustrate the higher rates of potentially harmful adverse drug reactions (ADRs) experienced by patients prescribed psychotropic medications in primary care.⁶ Dr. Chen speculates a limited expertise in psychiatry and psychopharmacology is largely to blame. All of these factors taken together highlight large gaps in the provision of health care, gaps which Dr. Chen believes should be filled by pharmacy practitioners. 

Integrating Clinical Pharmacy Services

The integration of clinical pharmacy services into outpatient clinics could be one solution to the many fundamental barriers, such as access to health care. The unique skillset and knowledge base offered by clinical pharmacists has routinely demonstrated significant improvements in patient care across multiple settings.^7-10 As a leader in ambulatory care pharmacy, Dr. Chen shared the details of one of his most successful collaborations. He is the Co-Investigator and clinical manager of a $12 million CMMI grant that partners USC with AltaMed Health Services. The goal of this grant was to assess the impact of 10 clinical pharmacy teams, each consisting of a clinical pharmacist, a pharmacy resident, and a clinical pharmacy technician, compared to usual medical care. The program evaluated the following outcome measures: healthcare quality, safety, total cost, patient and provider satisfaction, and patient access. In addition to MD referrals, Dr. Chen’s group utilized numerous electronic health record-embedded triggers to identify high risk patients that would qualify for comprehensive medication management (CMM) services. To date, more than 6,000 patients have been enrolled. The pharmacist-led teams have demonstrated and sustained significant reductions in blood pressure, hemoglobin A1c, hospitalizations, and emergency room visits versus the control group. Additionally, patient and provider satisfaction with the program has been extraordinarily high. After 2 years in operation, more than 93% of patients have rated the service as a 9 or 10. Additionally, greater than 90% of physicians surveyed supported having the teams at the clinic and “strongly agree” that the pharmacy teams were respectful, knowledgeable, and had a positive impact on patient care.

Implementation, Demonstrating Value, and Sustainability

To round out this session, Dr. Chen drew upon his wealth of experience with inter-professional collaborations to present ten “Practice Integration and Sustainment Keys.” They were as follows:

1. Secure support from senior medical leadership
2. Align programs with stakeholder incentives
3. Target high-risk populations with greatest potential for benefit from clinical pharmacy services
4. Develop collaborative practice agreements for targeted populations and integrate program processes into existing workflow
5. Ensure reliable data is available for evaluating program impact
6. Host frequent team and leadership calls and integrate into key committees
7. Pay attention to hazardous or misaligned partnerships
8. Maximize efficiency and productivity; “pay a pharmacist to be a pharmacist” 
9. Share impact results with data and powerful stories
10. Seek opportunities for sustained funding

Take Home Points

Current deficits in psychiatric services have resulted in the majority of patients with mental health disorders seeking treatment in primary care clinics. The relative lack of expertise in managing psychotropic medications within this setting presents psychiatric pharmacists with a unique opportunity. By emulating the successes of our colleagues in ambulatory care pharmacy, psychiatric pharmacists can work to integrate themselves into outpatient clinics. 

References

1. Lang AJ. Mental health treatment preferences of primary care patients. J Behave Med 2005; 28(6):581-86
2. Dunningham P, McKenzie K, Taylor EF. The struggle to provide community-based care to low-income people with serious mental illness. Health Affairs 2006; 25(3):694-705
3. Melek SP, Norris DT, Paulus J. Economic Impact of Inegrated Medical-Behavioral Healthcare: Implications for psychiatry. Milliman American Psychiatric Association Report. 2014
4. Kim PY, Thomas JL, Wilk JE, et al. Stigma barriers to care and use of mental health services among active duty and national guard soldiers after combat.  Psychiatric Services 2010; 61(6):582-88
5. Konrad TR, Ellis AR, Thomas KC, et al. County-level estimates of need for mental health professionals in the United States. Psychiatric Services; 60(10):1307-14
6. AHQR Mental Health Research Findings, AHQR 2009 Pub. No. 09-P011
7. Doherty RB, Crowley RA, Health and Public Policy Committee of the American College of Physicians. Principles supporting dynamic clinical care teams: an American College of Physicians position paper. Ann Internal Medicine 2013;159(9):620-627.
8. McInnis T, Webb CE, Strand LM. The Patient Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. Patient Centered Primary Care Collaborative; June. (2nd Edition) 2012:1-28
9. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication therapy management: 10 years of experience in a large integrated health care system. J Manag Care Pharm 2010;16(3):185-95
10. McKee JR, Lee KC, Cobb CD. Psychiatric pharmacist integration into the medical home. Prim Care Companion CNS Disord 2013;15(4):e1-5.
11. Poon LH, Lee AJ, Chiao TB, et al. Pharmacist’s role in Parkinson’s disease and movement disorder clinic. AJHP 2012; 69(6):518-20