Pharmacist Assisted Management of ComplexPsychiatric Patients in Primary Care

Casey Gallimore, PharmD, Assistant Professor of PharmacyKen Kushner, M.A., PhD, Professor Department of Family Medicine

Elizabeth Zeidler Schreiter, M.A., Psy.D., Behavioral Health Consultant Lead

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session # B3c Friday, October 11, 2013

Faculty DisclosureI have not had any relevant financial relationships

during the past 12 months.

Objectives

1. Discuss rationale for multidisciplinary collaboration in the care of patients prescribed psychotropic medications in primary care.

2. Identify key areas where a pharmacist can support management of psychotropic medications in primary care.

3. Describe potential challenges of incorporating clinical pharmacy onto a multidisciplinary team focused on behavioral health in the primary care setting as well as strategies to overcome these barriers to collaboration

Learning Assessment

In your clinic or practice site…

1. What challenges exist in providing care to patients on psychotropic medications regimens?

2. What methods have been used to minimize these challenges?

Access Community Health Centers

• Federally Qualified Health Care Centers in Madison, WI area

• Provides affordable care to low income and medically underserved communities

• Wingra Family Medical Center, William T. Evjue Clinic

• South Side Clinic, Sun Prairie Clinic, Dodgeville Dental Clinic

Access Community Health Centers

Services Providers• Prenatal care• Pediatric & adolescent care• Adult care• Chronic disease care• Behavioral health services• Pharmacy services• Dental services

• Family physicians• Resident physicians• Pediatricians• Physician assistants• Nurse practitioners• Health educators• Behavioral health providers• Pharmacists• Dental providers

Primary Care Setting

• Majority of patients diagnosed with mental health condition in primary care receive treatment from their primary care provider1

• More than half of patients receiving mental health treatment in primary care are prescribed a psychotropic medication1

• Estimated 74% of antidepressants are prescribed by primary care provider2

Community Health Centers

• Over a 5 year period the number of patients diagnosed and treated for a mental health/substance abuse disorder was more than tripled3

• Mental health/substance abuse has surpassed hypertension as the most common reason for clinic visits3

Primary Care Versus Specialty

• Percent of patients receiving minimally adequate mental health treatment4

– 12.7% in general medical settings– 48.3% in mental health specialty settings

• Patients prescribed antidepressant by primary care provider vs psychiatrist more likely to2

– discontinue early, miss doses and receive lower doses

Wingra Clinic Psychotropic Rx

• ~250 prescriptions for antipsychotic and mood stabilizing medications for ~150 individual patients per year

• ~400 patients prescribed an antidepressant medication per year

Medication management

challengesSide effects

Low adherence

rates

Extensive monitoring

Low response and

remission rates

Drug interactions

Pilot Project

• Ambulatory care pharmacist focused on assisting primary care providers managing complex psychiatric patients via multidisciplinary care teams embedded within primary care.

Pilot Project

• Pharmacist in clinic 2 half days per week for psychotropic consultation:– Comprehensive medication reviews– Medication and dosing recommendations– Medication adherence and pillbox set-up– Side effect management– Medication histories– Patient education– AIMS assessment

Pilot Project

• Warm-handoffs in clinic during patient care• Scheduled pharmacy visits

• 3 scheduled slots per afternoons• Asynchronous communication via electronic

medical record– Email messages– CC’d patient charts

31%

25%

23%

8%

8%6%

BHCNurse PracitionerFamily Physician Resident PhysicianPhysician AssistantNurse

Real time in person

Electronic asynchronous

Scheduled visit0%

10%

20%

30%

40%

50%

60%

70%65%

33%

2%N = 80 consultations

Provider requesting consultation

Mode of consultation

Results

• 70% of consultations patient specific• Average age 43yo; range 10-80 years• 64% female; 35% male

• ~2-3 consultations per week• Average time per consult ~20 min • Turn around time for consults between 0-4 days

Mental Health Diagnoses

Depression

Bipolar Disorder

ADHD

Anxiety Disorder

Dual Diagnosis

Insomnia

Pain

AODA

0% 5% 10% 15% 20% 25% 30% 35%

34%

13%

12%

7%

7%

6%

6%

6%

N = 68

Psychotropic Medication Class

Antidepressant

Mood Stabilizer

Stimulant

Antipsychotic

Sedative

Antianxiety

Pain Medication

Addiction Medication

Herbal

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

49%

16%

11%

7%

6%

4%

3%

3%

1%

N = 70

Type of Medication Consultation

25%

19%

15%

7%

7%

7%

20%

New med recommendation

Side effect

Dosing

Comprehensive med review

Evaluate appropriateness ex-isting med

Switching or augmenting

Other

Discussion• Overall positive experience but lower than

desired utilization during 1st year– Pharmacist presence in clinic during active patient

care important

– Need for pharmacist to be proactive

– Continued discussion of roles and responsibilities of each member of multidisciplinary team

Future Directions

• Participation of pharmacy resident• Comprehensive medication reviews of medically

complex patients (MTM visits)• Quarterly chart reviews of complex psychiatric

patients (referral to consulting psychiatrist)– Medication regimen evaluation– Laboratory monitoring– AIMS assessment

Future Directions

• Collaboration with data management specialists to identify patients prescribed psychotropic medications requiring complex monitoring– Lithium– Carbamazepine, valproic acid– Antipsychotics

Learning Assessment

In your clinic or practice site…

1. What challenges exist in providing care to patients on psychotropic medications regimens?

2. What methods have been used to minimize these challenges?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

References1. van Rijswijk E, Borghuis M, van de Lisdonk E, Zitman F, van Weel C. Treatment of

mental health problems in general practice: a survey of pyschotropics prescribed and other treatments provided. International J Clin Pharmacol and Therapeutics. 2007;45:23-29.

2. Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the National Comorbidity Survey Replication. J Clin Psychiatry. 2008;69:1064-1074.

3. Druss BG, Bornemann T, Fry-Johnson YW, et al. Trends in mental health and substance abuse services at the nation’s community health centers: 1998-2003. Am J Public Health. 2006;96:1779-1784.

4. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States. Arch Gen Psychiatry. 2005;62:629-640.