Pharmacist Assisted Management of Complex Psychiatric Patients in Primary Care Casey Gallimore, PharmD, Assistant Professor of Pharmacy Ken Kushner, M.A., PhD, Professor Department of Family Medicine Elizabeth Zeidler Schreiter, M.A., Psy.D., Behavioral Health Consultant Lead Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session # B3c Friday, October 11, 2013

Faculty Disclosure I 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 provider 1 More than half of patients receiving mental health treatment in primary care are prescribed a psychotropic medication 1 Estimated 74% of antidepressants are prescribed by primary care provider 2

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 tripled 3 Mental health/substance abuse has surpassed hypertension as the most common reason for clinic visits 3

Primary Care Versus Specialty Percent of patients receiving minimally adequate mental health treatment 4 – 12.7% in general medical settings – 48.3% in mental health specialty settings Patients prescribed antidepressant by primary care provider vs psychiatrist more likely to 2 – 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 challenges Side 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 – messages – CC’d patient charts

N = 80 consultations Provider requesting consultation Mode of consultation

Results 70% of consultations patient specific Average age 43yo; range 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 N = 68

Psychotropic Medication Class N = 70

Type of Medication Consultation

Discussion Overall positive experience but lower than desired utilization during 1 st 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 the evaluation form to the classroom monitor before leaving this session. Thank you!

References 1.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: 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: Druss BG, Bornemann T, Fry-Johnson YW, et al. Trends in mental health and substance abuse services at the nation’s community health centers: Am J Public Health. 2006;96: Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States. Arch Gen Psychiatry. 2005;62: