Interdisciplinary Quality Improvement Initiative: Pharmacy-Initiated Medication Reviews to Facilitate Safety and Efficacy

Monitoring in Primary CareElizabeth Zeidler Schreiter, M.A., Psy.D., Chief Behavioral Health Officer, Access Community

Health Centers

Casey Gallimore, Pharm.D., M.S., Associate Professor CHS, University of Wisconsin-Madison School of Pharmacy; Access Community Health Centers

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # B6aSaturday, October 17, 2015

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the

past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:• Describe an integrated care process involving

interdisciplinary collaboration that can be implemented to improve safety and efficacy monitoring of psychotropic medication.

• Identify how the electronic health record (EHR) can function to enhance collaboration within an interdisciplinary team.

• Brainstorm ways in which the quality improvement project presented may be transferred and utilized to improve psychotropic medication monitoring and use in each participants unique practice setting.

Bibliography / Reference1. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health

services in the United States: Results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:629-640.

2. Shin P, Sharac J, Mauery DR. The role of community health centers in providing behavioral health care. J Behav Health Serv Res. 2013;40:488-496.

3. Kisely S, Campbell LA. Taking consultation-liaison psychiatry into primary care. Int’l J Psychiatry In Medicine. 2007;37:383-391.

4. Robinson PJ, Reiter JT. Behavioral Consultation and Primary Care. NY: Springer Science, 2007.—where is this cited in slides?

5. Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of psychiatric consultations in a community primary care center. Primary Care Companion Journal of Clinical Psychiatry, 3, 190-194.

6. Zeidler Schreiter EA, Pandhi N, Fondow MDM, et al. Consulting psychiatry within an integrated primary care model. J Health Care Poor Underserved. 2013;24:1522-1530.

7. Access Community Health Centers (Access) Integrated Primary Care Consulting Psychiatry Toolkit 2013. Available from: http://www.hipxchange.org/Access.

Bibliography / Reference8. Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists

belong in the medical home. Health Affairs. 2010;29:906-913.

9. McKee JR, Lee KC, Cobb CD. Psychiatric pharmacist integration into the medical home. Prim Care Companion CNS Disord. 2013;15:e1-e5.

10. Burke JM, Miller WA, Spencer AP, et al. American College of Clinical Pharmacy (ACCP) White Paper: Clinical pharmacy competencies. Pharmacotherapy. 2008;28:806-815.

11. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

12. Plan-Do-Study-Act (PDSA) Cycle, Institute for Health Care Improvement. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx. Accessed on September 14, 2015.

13. American Psychiatric Association Practice Guidelines. Available at: http://psychiatryonline.org/guidelines. Accessed on September 24, 2015.

Bibliography / Reference14. American Diabetes Association; American Psychiatric

Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. (2004). Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care, 27, 596-601.

15.Marder SR, Essock SM, Miller AL, et al. (2004). Physical health monitoring of patients with schizophrenia. Am J Psychiatry, 161, 1334-1349.

16.Rush JA Jr. (2000). Handbook of Psychiatric Measures, American Psychiatric Association, 166-168.

17.Harriman McGrath S, Snyder ME, Garcia Duenas G, et al. Physician perceptions on pharmacist-provided medication therapy management: qualitative analysis. J Am Pharm Assoc. 2010;50:67-71.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Access Community Health Centers Federally Qualified Health Center in

Madison, WI More than 26,000 people

call Access their health care home

Patients receive a wide array of services in one clinic location (medical, dental, behavioral health, pharmacy, community resources)

3 primary care clinic locations all certified as Patient Centered Medical Homes

PCBH In Action at Access 1 in 5 medical patients

annually sees a BHC Over 400 consulting

psychiatry chart reviews and 208 face-to-face consults in 2014

Over 3000 care management chart reviews

6.3 FTE Psychologists/Social Workers; .25 FTE Consulting Psychiatrist

Train 5-10 psychology and social work trainees annually & 8 psychiatry residents annually

Increasing Complexity of Patient Population in Primary Care

Mental health care within primary care sector continues to grow with majority of patients receiving treatment for mental health concerns from primary care clinicians.1,2

It has been estimated that up to 50% of patients in primary care have a mental health condition.3

Supporting Primary Care CliniciansPrimary care clinicians prescribe approximately

60% to 70% of the psychotropic medications prescribed in the United States.5

Consultation with BHC and psychiatry services is highly beneficial for both patients and primary care clinicians by supporting collaboration to provide efficient, whole-person care. 6

http://www.hipxchange.org/Access 7

Psychotropic medications have potential for adverse side effects and routine monitoring is often sub-optimal within primary care.

How Can a Pharmacist Help? 8-9 Comprehensive medication reviewsFacilitate resolution of medication-related

problemsSharing pharmacology expertise/knowledge with

patients and other healthcare providersReduce burden to primary care clinicians by

facilitating monitoring of medications on a population level

Support medication adherenceOptimize cost-effective medication management

options

Pharmacist Roles 10

• PharmD degree• RPh licensure

• 1-2 year residency in primary care / family medicine clinic

• Possible board certification

• Non-dispensing role in clinic, team member

• Direct patient care• Medication reviews• Drug information• Quality improvement

• May complete community residency

• Traditional dispensing role in a pharmacy

• Consultation for Rx and self-care medications

• Clinical services (varies depending on pharmacy site)

Ambulatory Care Pharmacist Community Pharmacist

Ambulatory Care Pharmacist Role at Access

• Residency trained in am care and academia• Faculty member at University of Wisconsin-

Madison School of Pharmacy– 0.2 FTE in clinic supported via the college– Clinical practice aligns with teaching responsibilities

and interest in psychiatric pharmacy and QI• Collaboration with BHC to provide psychiatric

pharmacy services, focus in population-based care

Model for Improvement11-12

• Framework for facilitating improvement in health care processes and outcomes

• Institute for Healthcare Improvement (IHI)

• Model components:1. Fundamental QI questions2. Plan-Do-Study-Act (PDSA) cycle

Plan

DoStudy

Act

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.

Form the teamSet aims

Establish measuresSelect changesTest changes

Implement changesSpread changes

What are we trying to accomplish?

How will we know that a change is an

improvement?

What changes can we make that will result in

improvement?

Model for Improvement11-12

http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.

APPLICATION TO ACCESS QI INITIATIVE: PSYCHOTROPIC MEDICATION REVIEWS

Forming the Team

Behavioral health

consultants (BHC)

Primary care

providers (PCP)

Am care pharmacist

Quality department

Setting Aims

Goal: Improve safety and efficacy monitoring for psychotropic medicationsSpecific Aims:

1. Increase percentage of patients up-to-date on recommended monitoring parameters and Abnormal Involuntary Movement Scale (AIMS) for psychotropic medications

2. Minimize percentage of patients at risk for clinically relevant drug interactions

What are we trying to

accomplish?

Establishing Measures

Outcome Measure Defining CriteriaUp-to-date on monitoring parameters

Guideline† recommended laboratory / diagnostic parameters most recently checked within advised timeframe for antipsychotic, carbamazepine, lithium and valproic acid (i.e. FLP, CBC, EKG).

Up-to-date on AIMS AIMS last performed within previous 12 months for second-generation antipsychotic, 6 months for first-generation antipsychotic, 3 months for previous AIMS score ≥ 3.

At risk for drug interaction

Potential interaction present between two or more medications with moderate to high likelihood of resulting in an adverse patient outcome.

Measureable Evidence-based Well defined

How will we know that a change is an

improvement?

† American Psychiatric Association Practice Guidelines, Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes, Mount Sinai Conference Consensus recommendations, and individual medication monographs 13-16

Selecting ChangesIdentify patients who received one time consult with clinic

psychiatrist in previous quarter

EHR review performed by pharmacist to assess for:

Monitoring parameters Drug interaction AIMS

Recommendations sent to PCC/BHC & follow-up phone call to patient if needed

Document review in patient’s EHR

Data entry in database

What changes can we make that

will result in improvement?

Care Management• Given psychiatric complexity of patients and

psychosocial stressors increased risk for lack of engagement

• Pharmacy chart reviews served as mechanism for routine tracking of engagement post-psychiatric consultation– Ensure patient has seen medical provider to implement

and/or monitor changes– Needed monitoring and/or drug interactions addressed

• Utilization of BHC team if suboptimal engagement

Testing Changes

Data entry in database

Retrospective EHR review 3mo later to assess for:

Monitoring up-to-date

Drug interaction present

AIMS up-to-date

Data entry in database

Electronic survey to collect provider feedback

Post data collection

Baseline data

collection

Statistical analysis to compare data baseline and post

Plan

DoStudy

Act

Results

Monitoring parameters (n=111)

Drug interaction (n=144) AIMS (n=52)0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

54.1%

43.8%

75.0%*72.1%

*24.3%

63.5%

Baseline Post-Review

* p ≤ 0.0001

Plan

DoStudy

Act

ResultsClinician perception of utility and quality of pharmacist psychotropic

medication reviewsN = 14 clinicians Agreed /

Strongly AgreedPharmacists should continue to perform psychotropic medication reviews.

93%

Other federally qualified community health centers would benefit from pharmacist-initiated psychotropic medication reviews.

86%

The psychotropic medication chart reviews provided by the pharmacist are thorough.

93%

Psychotropic medication reviews by a pharmacist allows me to spend less time reviewing medications

43%

The “in-basket" messages summarizing recommended monitoring or follow up are helpful.

79%

Plan

DoStudy

Act

Results

Clinician perception of achievement of QI project objectivesN = 14 clinicians Very / Somewhat

HelpfulFacilitating achievement of appropriate lab monitoring

86%

Identifying and managing drug interaction 86%

Facilitating provision of AIMS 79%

Facilitating the scheduling of follow-up visits 57%

Plan

DoStudy

Act

Challenges & Barriers

• Challenges to AIMS provision in primary care settings• Ideal workflow limitations due to EHR restrictions• Limited face-to-face interaction between pharmacist

and some clinicians17

• Targeted nature of reviews (focus on psychotropic medications only)

• Psychiatric consultation as surrogate marker • One-time nature of medication reviews• Limitations on pharmacist time

Plan

DoStudy

Act

Lessons Learned• Pharmacist assistance with monitoring of

psychotropic medication regimens can significantly improve overall monitoring rates and decrease potential interaction risks.

• Pharmacists are uniquely qualified to provide population-based medication monitoring support to facilitate safe psychotropic medication use.

Future Directions• Utilization of pharmacist to assist with

overall metabolic monitoring• Focus on larger population (e.g. all

patients prescribed specific drug class)• Provider education• Increased face-to-face time with

pharmacist• Evaluating outcomes of increased

monitoring

Future Directions

• Consideration of tracking adherence through verification of prescription fills at pharmacy level

• How do we use this information and skills of pharmacist as part of healthcare team to optimize patient outcomes?– Prevention of adverse medication outcomes– Proactive support of overall healthy lifestyle

behaviors

Transferability to Other Health Systems

Leveraging EHR Ensuring goodness of fit of pharmacist within clinic care

teams and clinic culture Financial implications Resources (space, EHR access, computer, medication

references, phone, etc) Building in evaluation plan at the outset Clinic needs assessment both from provider and patient

perspective Focus on continuous quality improvement process

Question & Answer

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!