Role of the Pharmacist in Collaborative Care for Mental Health and Addiction Treatment in Medically Underserved Appalachia Sarah T. Melton, PharmD,BCPP,CGP Appalachian College of Pharmacy, Oakwood, VA CPNP Annual Meeting, 2009

Central Appalachian Region: Medically Underserved Poverty rate 75% higher Lower education levels Over 25% of population is disabled Mental health diagnoses for psychiatric and addiction disorders are proportionately higher in Appalachia The rate of increase in abuse of opiates and synthetics is Appalachia is higher, especially in coal mining areas Citizens of Southwest Virginia are 70% more likely to commit suicide than the rest of Virginia.

Barriers to Mental Health Treatment Wait to see psychiatrist for diagnosis and medication management is 4-6 months minimum Specific barriers to accessing treatment include: stigma transportation availability limited payment options privacy issues choice of facilities cultural and family barriers

C-Health, PC Compass, PC Private, family practice clinic with three physicians, five nurse practitioners, one physician assistant, a clinical psychologist, and 2 clinical pharmacists Medically underserved area with a diverse patient population. 20% of patients are covered by Medicaid 35% are covered by Medicare 35% by private insurance 10% are uninsured.

Provision of Patient-Centered Care Referral from provider Patient seen by appointment Appointments are typically one hour in length Average number of patients seen/day = 6 Disorders: Depression, bipolar, anxiety, dementia, schizoaffective, ADHD, eating, seizure, sleeping, addiction, chronic pain

Provision of Patient-Centered Care Group Medical Appointments Opiate dependence Chronic pain Tobacco cessation Electronic Medical Record E-MD’s TopsSuite Comprehensive patient notes and documentation Immediate feedback from physicians

Provision of Patient-Centered Care Patient/caregiver interview and assessment Medication therapy management, including prescribing Ordering and evaluating laboratory testing Referral to the clinical psychologist for counseling or cognitive behavioral therapy (CBT) Home visits Patient assistance program (PAP)

Outcomes Reimbursement Improved access to healthcare Billed incident to physician visit Sliding scale cash charge Improved access to healthcare Enhanced care through optimized drug therapy management Decreased drug-related problems Reduced costs through optimized medication regimens Through PAP, over $100,000 of medications are ordered and delivered to patients per year Experiential learning site (more than 35 students/year in IPPE/APPE rotations)

Conclusion This models demonstrates provision of an effective bridge to treatment with a psychiatrist in medically underserved, rural Appalachia. Effective interdisciplinary team collaboration between a psychiatric pharmacist, primary care physician and clinical psychologist. As a learning site for pharmacy students, the program provides real-life experiences in the provision of optimal, evidence-based, patient-centered care that addresses mental health and addiction disorders accompanied by cultural and economic challenges. Psychiatric pharmacists can be reimbursed for clinical services in the ambulatory care setting.