Implementation of a practice model for inpatient psychiatric clinical pharmacist practitioners with prescriptive authority at a veterans health care facility

Clinical pharmacists have long been recognized as valuable members of the collaborative health care team. The impact of clinical pharmacy services on patient care outcomes is well established, and with the emergence of postgraduate residency training programs, the clinical pharmacy practice model has evolved and become increasingly more specialized.¹  The development of psychiatric pharmacy residency training programs in the early 1970s and the recognition of psychiatric pharmacy by the board of pharmacy specialties in the early 1990s marked significant milestones for the profession.²  With the rising prevalence of psychiatric disorders and the relative shortage of trained mental health providers, it is imperative to explore how clinical pharmacists can be effectively utilized to bridge gaps in patient care.

Within the Department of Veterans Affairs (VA), clinical pharmacist practitioners (CPPs) have had the authority to practice comprehensive medication management (CMM) under a scope of practice for more than 4 decades.³  The core elements of a CPP’s scope of practice include performing assessments, ordering laboratory tests and diagnostic studies, and modifying medication therapy with prescriptive authority.³  Autonomous prescribing by CPPs has traditionally been applied in outpatient clinical settings. In inpatient settings, it is more common for CPPs to provide predominantly consultative services while working collaboratively with multiple providers to provide drug therapy management. Consequently, it is uncommon for CPPs to routinely practice autonomous CMM in this setting.

In a 2020 survey conducted by the American Academy of Psychiatric Pharmacists, nearly 50% of psychiatric pharmacists reported holding some form of prescriptive authority.⁴  The survey also found that psychiatric pharmacists in outpatient practice settings were over 3 times more likely to have prescriptive authority compared with those practicing in inpatient settings.⁴  The authors partially attribute this disparity to the difference in patient acuity observed in inpatient psychiatric settings. They noted that psychiatrists and other licensed independent practitioners are generally recognized as having the requisite training to perform certain tasks required at psychiatric admission, such as diagnosis and treatment planning. At the VA, CPPs are not authorized to diagnose or admit patients.³ 

Although several studies demonstrate positive outcomes (optimized medication therapy, improved access to care, decreased hospital readmission rates, etc.) from psychiatric clinical pharmacist practitioners (PCPPs) making recommendations in nontraditional clinic settings such as psychiatric consult liaison and substance use treatment teams, there has been limited research on their role independently providing CMM in the inpatient setting.^5–7  Notably, 1 study reported statistically significant outcomes when comparing psychotropic prescribing between pharmacists and physicians in an inpatient psychiatric setting. The evaluators found that pharmacists prescribed antipsychotics and antidepressants more appropriately than physicians, which suggests that pharmacists are well equipped to provide safe and appropriate CMM in this setting.⁸  Despite these findings, there is little guidance available for how to implement such a practice. The aim of this report is to describe a practice model that incorporates an inpatient PCPP providing CMM and other clinical services under a scope of practice with prescriptive authority.

The acute psychiatric inpatient unit at VA North Texas Health Care System is a collaborative interdisciplinary team that operates a 35-bed unit. The team consists of professionals from various specialties including nurses, mental health technicians, housekeeping staff, administrative professionals, kinesiotherapists, recreational therapists, occupational therapists, chaplains, peer support specialists, nurse practitioners, psychiatrists, psychologists, social workers, and pharmacists. One part-time PCPP is assigned to the 8-bed geriatric section of the ward, and the remaining patients are monitored by 1 full-time PCPP. The interventions outlined in this report target nongeriatric patients admitted to the psychiatric inpatient unit under the care of the full-time PCPP.

Due to COVID-19 regulations, the bed capacity of the acute psychiatric inpatient unit at VA North Texas was reduced by half. Despite the reduction, a shortage of mental health–trained practitioners threatened complete restriction to acute mental health care access at the facility. To address this unique challenge, discussions were held between the chiefs and supervisors of mental health and pharmacy services, leading to the implementation of a new practice model. The model would use a full-time PCPP working on-site 40 hours per week to function as an interim provider for patients admitted to the unit. To implement this CPP-led practice model, a board-certified PCPP with 2 years of residency training was hired. The model was implemented in November 2021.

Recognizing the limitations in ability to admit, diagnose, or discharge patients, it was decided that the PCPP would not be the first or last provider to assess a patient on admission or discharge, respectively. To fully use the PCPP’s scope of practice, the PCPP would perform all activities related to CMM in addition to traditional clinical services provided by the previous inpatient PCPP (Table). Psychiatry staff was notified of the PCPP’s services and limitations with regards to diagnosing and assessing patients on admission or discharge. CMM patients were assigned to the PCPP by psychiatric attendings on a day-to-day basis depending on their needs (typically based on patient load and other tasks such as accepting admissions). The assigned patients were independently seen and evaluated by the PCPP on-site. There were no restrictions placed on the types of patients referred to the PCPP, the disease states that could be managed, or medications adjusted (aside from medications requiring a Drug Enforcement Administration number to prescribe). Any major medication adjustments were discussed with the attending provider to foster interdisciplinary collaboration and facilitate continuity of care. The number of referrals was limited to a maximum of 4 per day to allow time for routine clinical services to be completed. Diagnoses managed included but were not limited to major depressive disorder, posttraumatic stress disorder, psychotic disorders, bipolar disorder, and various substance use disorders. Documentation for each CMM encounter was published into the electronic health record in place of the attending provider’s daily note. Note documentation included details on medication interventions, mental status assessments, education and counseling, and additional consults. No supplemental documentation or cosignature from the attending provider was required.

From historical census data, the goal was to achieve a minimum of 60 total patient encounters per month (including CMM and non-CMM service-related encounters). From November 2021 to June 2023, the PCPP recorded a total of 1919 patient encounters, resulting in an average of 96 patient encounters per month (Figure). Of those encounters, 229 (12%) were CMM-focused, which averages out to approximately 2 patient referrals per day. As a psychiatrically trained prescriber, the PCPP helped to manage patients and keep the unit functioning at an acceptable capacity. Psychiatry staff reported an appreciation of the interdisciplinary collaboration and the freed-up time to complete documentation, take admissions, and tend to other administrative responsibilities.

There are certain limitations with the practice model that are worth acknowledging. The primary limitation was the lack of human resources. With only 1 full-time PCPP available, it was difficult to maintain consistency in the services provided, especially when accounting for planned and unplanned time off. Additionally, it is likely that the non-CMM encounter interventions are underestimated as the part-time PCPP would often help with nongeriatric patient encounters when coverage was requested. VA North Texas recently awarded funding for an additional full-time PCPP to sustain the spectrum of PCPP clinical services at full unit capacity.

Timeline is another important consideration in evaluating this intervention. At the start of its implementation, the team consisted of 1.5 psychiatrists and 1 PCPP. The team later expanded to 2.5 psychiatrists in July 2022, followed by 2 mental health nurse practitioners. These additions, coupled with the limited capacity to admit patients due to COVID-19 regulations, reduced opportunities for PCPP-provided CMM services at select periods of the intervention.

In May 2023, the psychiatric inpatient unit opened to full capacity and returned to pre-COVID regulations. Although an increase in admissions and patient encounters is anticipated, improved psychiatry staffing shortages may deprioritize the necessity for PCPP-provided CMM services. However, it remains a fact that the assistance provided at the beginning of the intervention period was imperative at the time, and the PCPP remains available to assist with CMM when additional help is needed. This holds true in situations in which other providers are unexpectedly unavailable, occupied with administrative duties, or overloaded with patient encounters. Pharmacy and mental health services may continue to collaborate to make PCPP-provided interim CMM a standard of practice in the inpatient setting.

The success of this model on the inpatient psychiatric unit at VA North Texas highlights the value of psychiatric pharmacists and may offer insight for other facilities considering a similar approach to providing mental health care. PCPPs at other facilities can feasibly implement a similar practice model with adequate resources, provider education and buy-in, and support from the facility. Although this model was implemented to address staffing challenges, the effects support the feasibility of utilizing PCPP-led CMM in the inpatient setting. Future efforts should focus on further quantifying the value and outcomes of PCPP-led CMM compared with standard of practice care provided by other practitioners in inpatient mental health settings.