Opportunities to partner with clinical pharmacists in ambulatory psychiatry

Initial meetings included ambula­tory care site leadership in psychiatry to increase awareness and understanding of pharmacists’ potential role in direct patient care. Achieving site leadership support was critical to successful implementation of pharmacist services in psychiatry. We also obtained approval from the Chair of the Department of Psychiatry to elicit sup­port from faculty group practice.

Psychiatry leadership perspective
As fiscal pressures intensify at academic health centers, it becomes increasingly important for resources to be used as efficiently and effectively as possible. As a greater percentage of mental health patients with more “straightforward,” less complex conditions are being managed by their primary care providers or non­prescribing psychotherapists, or both, the acuity and complexity of cases in patients who present to psychiatric clinics have intensified. This intensification of patient needs and clinical acuity is in heightened conflict with the ongoing demand for clini­cian productivity and efficiency.

Additionally, the need to provide care to a seemingly ever-growing number of moderately or severely ill patients dur­ing shorter, less frequent visits presents a daunting task for clinicians and clinical leaders. Collaborative care models appear to offer the best hope for managing the seemingly overwhelming demand for services.

In this model, the patient, who is the critical member of the team, is expected to become an “expert” on his or her ill­ness and to partner with members of the multidisciplinary team; with this support, patients are encouraged to develop a broad range of self-management skills and strat­egies to manage their illness. We believe that clinical pharmacists can and should play a critical role, not only in deliver­ing direct clinical services to patients but also in developing and devising the care models that will most effectively apply each team member’s unique set of knowl­edge, skills, and experience. Given the large percentage of our patients who have multiple medical comorbidities and who require complex medical and psychiat­ric medication regimens, the role of the pharmacist in reviewing, educating, and advising patients and other team members on these crucial pharmacy concerns will be paramount.

In light of these complex medication issues, pharmacists are uniquely posi­tioned to serve as a liaison among the patient, the primary care provider, and other members of their treatment team. We anticipate that our ambulatory psychiatry pharmacists will greatly enhance the com­fort and confidence of patients and their primary care providers during periods of care transition.

Potential roles for pharmacists in ambulatory psychiatry
One potential role for pharmacists in ambulatory psychiatry is to perform polypharmacy assessments of patients receiving complex medication regimens, prompted by physician referral. The poly­ pharmacy intake interview, performed to obtain an accurate medication list and to identify patients’ concerns about their medications, can be conducted in per­son or by telephone. Patients’ knowledge about medications and medication adher­ence are discussed, as are their perceptions of effectiveness and adverse effects.

After initial data gathering, pharma­cists complete a review of the medications, identifying any problems associated with medication indication, efficacy, tolerance, or adverse effects, drug-drug interactions, drug-nutrient interactions, and nonadher­ence. Pharmacists work to reduce medica­tion costs if that is a concern of the patient, because nonadherence can result. A medi­cation care plan is then developed in con­sultation with the primary care provider; here, the medication list is reconciled, the electronic medical record is updated, and actions to address any medication-related problems are prioritized.

Other services that might be offered include:• group education classes, based on patient motivational interviewing strate­gies, to address therapeutic nonadherence and to improve understanding of their dis­ease and treatment regimens• medication safety and monitoring• treatment intensification, as needed, following established protocols.

These are a few of the ways in which pharmacists can be relied on to expand and improve access to patient care ser­vices within ambulatory psychiatry. Key stakeholders anticipate development of newer ideas as the pharmacist’s role in ambulatory psychiatry is increasingly clarified.

Reimbursement model
In creating a role for pharmacy in ambu­latory psychiatry, it was essential that the model be financially viable and appeal­ing. Alongside its clinical model, our insti­tution has developed a financial model to support the pharmacist’s role. The lump-sum payment to the health centers from Blue Cross Blue Shield of Michigan afforded the ambulatory care clinics an opportunity to invest in PCMH pharma­cists. This funding, and the reimbursement based on T-code billing (face-to-face visits and phone consultation) for depression and other conditions requiring chronic care, provides ongoing support. From our experience, understanding physician reimbursement models and identifying relevant changes in health care reform are necessary to integrate new providers, including pharmacists, into a team-based care model.

Implementation
Promoting pharmacy services. To fos­ter anticipated collaboration with clini­cal pharmacists, the medical director of outpatient psychiatry disseminated an announcement to all providers regard­ing the investiture of clinical pharmacists to support patient care activities, educa­tion, and research. Clinicians were edu­cated about the pharmacists’ potential roles and about guidelines and methods for referral. Use of our electronic health record system enabled us to establish a relatively simple referral process involv­ing sharing electronic messages with our pharmacists.

Further, as part of the planned integra­tion of clinical pharmacists in the ambula­tory psychiatry setting, pharmacists met strategically with members of various disciplines, clinical programs, specialty clinic programs, and teams throughout the center. In addition to answering questions about the referral process, they empha­sized the role of pharmacy and opportuni­ties for collaboration.