VA Clinical Pharmacy Practice Evolution in Mental Health

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Tera Moore, PharmD, BCPS, BCACP
National Program Manager
Clinical Practice Integration and Model Advancement, Clinical Pharmacy Practice Office
San Antonio, TX

Julie Groppi, PharmD, FASHP
National Program Manager
Clinical Pharmacy Practice Policy and Standards, Clinical Pharmacy Practice Office
Palm Beach Gardens, FL

Lori Golterman, PharmD
National Director of VA Residency Programs and Education
Pharmacy Benefits Management (PBM) Service
Department of Veterans Affairs Central Office
Washington D.C.

Mental Health Care in the VA 

The U.S. Department of Veterans Affairs (VA) is committed to providing timely access to high-quality, recovery-oriented, evidence-based mental health care and prioritizes the health and well-being of Veterans as the forefront to their mission. Mental Health (MH) care in the VA has evolved to provide comprehensive treatments and services to meet the needs of each Veteran through the development and integration of team based care delivery. VA provides a continuum of outpatient, residential, and inpatient mental health services across the country. Points of access to care span 168 VA medical centers, 1,053 Community Based Outpatient Clinics, 300 Vet Centers, and 80 mobile Vet Centers. Veterans and their families learn about mental health services through several outreach efforts by 300 local Suicide Prevention Coordinators, VA staff working on college and university campuses, and within the Veterans Crisis Line. In addition, VA has integrated mental health care into primary care medical home settings, where Veterans are routinely screened for mental health conditions.1

  • In fiscal year (FY) 2017, more than 1.7 million Veterans received MH treatment in a VA mental health program; this number has risen each year from 900,000 in FY2006. 1
  • VA conducted more than 1.2 million MH visits in primary care settings in FY2017, an increase of 4 percent from FY2016 and up 20 percent from FY2014. 1
  • Nearly one-third (29.2 percent) of these patients received care from a MH care provider working in the primary care clinic, while 350,000 (70.8 percent) had their depression documented by providers who exclusively practice primary care. 1

VA Clinical Pharmacy Specialists

In VA, the Clinical Pharmacy Specialist (CPS) is recognized as an Advanced Practice Provider who is authorized, under a scope of practice, to autonomously provide comprehensive medication management (CMM) services in a variety of practice settings. The scope of practice includes prescriptive authority, executing therapeutic plans, physical and objective disease assessment, ordering labs and clinically relevant tests, taking independent corrective action for identified drug-induced problems, making referrals and obtaining and documenting informed consent for treatments and procedures. The Mental Health CPS provider is a core team member providing CMM expertise to our Veterans and MH teams. These comprehensive teams include psychiatrists, psychologists, nurse practitioners and social workers as well as a variety of other clinicians who care for our Veterans mental health needs.

The MH CPS provider practice spreads across the continuum of care in general and specialty mental health clinics, behavioral health clinics embedded in primary care, residential rehabilitation facilities, specialty mental health programs, and on inpatient mental health units to improve access, quality and safety through the provision of medication management services. In the face of current psychiatrist shortages and the projected increase to this deficit (an estimated 25% deficit by the year 2025), MH CPS providers deliver timely access to care serving as a MH prescriber.2 The integration of the MH CPS provider has expanded significantly where the number of pharmacists with a scope of practice in Mental Health has grown over 125% since 2015. Currently, there are over 407 MH CPS providers practicing within the MH setting across 119 VA facilities. In fiscal year 2018, there were 340,106 patient encounters by a CPS provider in MH, which was a 19% increase from the previous year. These individuals are highly trained, with the vast majority possessing post-graduate residencies as well as board certification in pharmacotherapy. In fact, VA is a leader in clinical pharmacy practice in MH, graduating over 600 pharmacy residents annually, of which over 75 have specialized post graduate year 2 (PGY2) MH pharmacy residency training.

Bridging Gaps in Mental Health Care

The Patient-Centered Primary Care Collaborative published a resource guide in 2012 entitled "Integrating Comprehensive Medication Management to Optimize Patient Outcomes." This guide outlines how pharmacists promote the safe, appropriate, and effective use of medications with a demonstrated return on investment by providing effective medication management.3 Specific to a psychiatric population, the benefits of incorporating a MH CPS provider to improve both access and the quality of care to patients with mental illness has been reported in the literature.4-12 In a 2013 pilot program, pharmacist-delivered comprehensive medication management provided for patients with psychiatric disorders was demonstrated to improve clinical outcomes, reduce overall healthcare cost, and improve patient satisfaction.13 Additionally, in a VA setting, MH CPS, also known as psychiatric pharmacists, on a Primary Care Mental Health Integration (PCMHI) team have demonstrated ability to help patients achieve clinical goals as measured by validated clinical rating scales.14

VA CPS Provider roles also extend into areas where pain management and mental health come to a crossroad. CPS Providers are a key member of team-based care and critical to addressing the opioid epidemic from the standpoint of prevention and treatment of opioid use disorder and overdose.15,16 Evidence shows that CPS providers increase access to OUD treatment and improve treatment retention rates.17,18 Recognizing the importance of the CPS Provider in improving access to care, the CPS Provider role continues to grow in mental health, pain management and substance use disorder, including OUD, as VA health-systems develop strategies to combat the opioid epidemic and recognize the skills of the CPS Provider resource as the medication expert. The specialized training of the MH CPS provider makes them experts in psychopharmacology. By them practicing at the top of their license as a primary mental health provider, access to high quality medication management improves.

With expertise in addressing medication management needs of patients with defined diagnoses, management of medication-related adverse events, and ongoing and acute medication monitoring, and collaboration with other healthcare providers for management of new diagnoses, the MH CPS providers are in prime position to bridge gaps in the provision of mental health care.

Successful Integration into Mental Health Clinical Practice

The VA MH clinical pharmacy practice has continued to evolve and identified several elements that have been recognized as keys to successful integration of the CPS into MH clinical practice. These elements when implemented ensure success and clearly delineate the roles of the team caring for the Veteran. These include:

  • Defining the CPS Role: Identification where the MH CPS Provider can be most effective is an important first step in implementing or expanding MH Clinical Pharmacy Practice. This evaluation begins with identification of facility gaps related to performance measures that would be improved with a MH prescriber. Clinical Pharmacy, Mental Health and Primary Care leadership work collaboratively to identify the role of the MH CPS Provider as an integral member of the team. This includes a focus on the flow of patients to the team with integration of the CPS as an advanced practice provider and consideration of optimizing other team members. Patient care coordination includes the consultation requirement with a psychiatrist or appropriate provider for advanced patient care management beyond the MH CPS’s scope of practice. Moreover, MH CPS Providers often serve as Residency Program Directors (RPD) or preceptors to continue the development of well-trained MH CPS Providers.
  • Development of Care Coordination Agreements (CCAs) to Define Care: Successful strategies for integrating MH CPS Providers into the mental health clinic include implementation of CCAs for how the CPS functions as a part of the team. This is used as an adjunct document to the VA CPS Scope of Practice. The CCA describes how patient care referrals are made, roles and responsibilities of CPS practicing in MH, responsibilities of both pharmacy and MH leadership, and other team members. Agreements are developed and approved in a collaborative fashion through an interdisciplinary approach generally with input from all stakeholders. In relationship to the MH CPS Provider, it is essential to add clarity related to:
    • Defining the practice area(s) in which the CCA applies in the various MH team based care
    • Outlining the referral process to the CPS
    • Outlining the role, responsibilities and activities of the CPS in their practice area
    • Defining how and when communication will occur between the CPS and other team members including the consultation with a psychiatrist or appropriate provider for advanced patient care management beyond the MH CPS scope of practice
  • Clinic Workflow Optimization: Optimization of the MH CPS clinic workflow is essential to increasing access. The MH CPS Provider time should be 75 to 85% in face-to-face or telephone care. The 50 scheduled slots for full-time MH CPS Provider are a mix of face-to-face, CVT, telephone and are delivered through scheduled intake/follow up appointments and same day access. There is also unscheduled clinical time to generate encounters such as e-consults, secure messaging, unscheduled phone calls, and completion of CPRS alerts. Additional time is designated for population management and team meetings.
  • Ensure Ancillary Support and Space for the CPS Provider: Ancillary support for the CPS working as a direct care provider is essential to improving operational efficiencies. Support must include clerical support for appointment management and administrative functions and nursing support for care coordination and education. This includes outpatient pharmacy support in order to avoid the MH CPS Provider being responsible for operational items such as prescription processing and dispensing, medication storage and troubleshooting, and prescription delivery (local mail, CMOP, UPS tracking, etc.). To optimize ability of the CPS to provide medication management services, the CPS should be provided adequate space for direct patient care functions similar to that provided for other clinicians. In addition, physical proximity and co-location of the CPS to the MH team optimizes services and operational efficiencies.

The VA is known across the country over for providing high-quality, evidenced based health care and recognized as a leader in clinical pharmacy practice. The innovative practice models developed and deployed within the VA have positioned our MH CPS Providers as key MH team members critical to ensuring our Veterans receive the care they so rightly deserve. There is strong evidence that MH CPS improve access, clinical outcomes and cost effectiveness when properly deployed. We are exceedingly proud of the robust practices across the system and will continue to strive to ensure that all our Veterans have access to excellent medication management services provided by our MH CPS Providers.

References

  1.  VA Office of Mental Health and Suicide Prevention Guidebook June 2018. (accessed 1/14/19)
  2. Shortage Definition: Health Professional Shortage Areas & Medically Underserved Areas/Populations. U.S. Department of Health and Human Services. Available at http://www.hrsa.gov/shortage/. Accessed on October 17, 2017.
  3. McInnis T, Strand LM, Webb CE. The Patient Centered Medical Home: Integrating Comprehensive Medication Management to Optimize Patient Outcomes. 2nd ed. Washington, DC: Patient Centered Primary Care Collaborative, 2012. 
  4. Al-Jumah KA, Qureshi NA. Impact of pharmacist interventions on patients’ adherence to antidepressants and patient-reported outcomes: a systematic review. Patient Prefer Adherence 2012; 6: 87-100.
  5. Rubio-Valera M, Chen TF, O'Reilly CL. New roles for pharmacists in community mental health care: a narrative review. Int J Environ Res Public Health. 2014;11(10):10967-90.
  6. Arterbury A, Bushway A, Goldstone LW. Effect of a pharmacist-led medication education group on hospital readmissions due to medication non-adherence for patients with previous inpatient psychiatric admissions. J Pharm Pract. 2014; 27: 279.
  7. Herbert C, Winkler H, Moore T. Outcomes of mental health pharmacist-managed electronic consults at a Veterans Affairs health care system. Mental Health Clinician. 2017; 7 (3): 131-136.
  8. Lynum KB, Hill AM. Psychiatric Services: a platform for MTM. J Pharm Pract 2015;28:13-20.
  9. McKee J, Lee K, Cobb C. Psychiatric pharmacist integration into the medical home. Primary Care Companion CNS Disorders 2013;15(4).
  10. Tallian, KB, Hirsch, JD, Kuo, GM. Development of a pharmacist-psychiatrist collaborative medication therapy management clinic. J Am Pharm Assoc (2003). 2012;52(6).
  11. Chung B, Dopheide JA, Gregerson P. Psychiatric pharmacist and primary care collaboration at a skid-row safety-net clinic. J Natl Med Assoc. 2011 Jul;103(7):567-74.
  12. Nazarian PK, Dopheide JA. Psychiatric Pharmacist Management of Depression in Patients With Diabetes. Prim Care Companion CNS Disord. 2013; 15(5). 
  13. Cobb CD. Optimizing medication use with a pharmacist-provided comprehensive medication management service for patients with psychiatric disorders. Pharmacotherapy. 2014 ;34(12): 1336-40.
  14. Harms M, Haas M, Larew J, DeJongh B. Impact of a mental health clinical pharmacist on a primary care mental health integration team. Mental Health Clinician. 2017; 7(3): 101-105.
  15. Reynolds V, Causey H, McKee J, Reinstein V, Muzyk A. The Role of Pharmacists in the Opioid Epidemic: An Examination of Pharmacist-Focused Initiatives Across the United States and North Carolina. NCMJ. 2017 May;78(3):202-205.
  16. ASHP Statement on the pharmacist’s role in substance abuse prevention, education, and assistance. Am J Health Syst Pharm. 2016;71(3):243-246.
  17. Dipaula B, Menachery E. Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients. J Am Pharm Assoc. 2015;55:187-192.
  18. Suzuki J, Matthews ML, Brick D. Implementation of a collaborative care management program with buprenorphine in primary care: A comparison between opioid-dependent patients and chronic pain patients using opioids non-medically. J Opioid Manag. 2014;10(3):159-168.
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