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

Number of Physical Symptoms

6-7 >8 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

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Indication for use

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Efficacy

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Safety – adverse effects, drug interactions

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Adherence

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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 medication related 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_06 2010_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), knowledge score (53% vs 77%) ↓ of 1.32 meds/pt/month, improvement in pt’s drug Brianne Fairchild – BECVAMC, Pa Gray et al. Contemp Pharm Pract 1979;2:108-16.

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 Brianne Fairchild – BECVAMC, Pa Lobeck et al. Hosp Commun Psychiatry 1989;40:643-4.

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: 1089 1096, 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?

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