Treatment of mental illnesses has slowly shifted to primary care settings over the past decade. As more patients are identified as needing treatment for a mental illness, the availability of behavioral health (BH) practitioners has become more strained, leading to this shift towards primary care treatment. With more patients receiving psychiatric health care from their primary care providers (PCP), a need for dedicated BH practitioners within the primary care setting was developed.
This article describes a novel program where a clinical psychiatric pharmacist is utilized as the primary psychiatric provider within an integrated BH program of a busy primary care clinic in a major metropolitan area. Working under a collaborative practice agreement to prescribe, the pharmacist acts as the initial BH contact for the clinic, as well as a liaison between primary care and BH. Patients referred to the pharmacist from primary care are then evaluated and appropriate medication prescribed for their illness. Most patients are followed prospectively by the pharmacist, with more complex patients (i.e., those not appropriate for primary care-based BH treatment) referred to the BH clinic for follow-up care. The pharmacist serves on the intake committee for the BH clinic, and facilitates patient referrals to their clinicians.
Preliminary analysis of the program's effectiveness shows positive results. Within the first two months of the program, 28 patients were referred to the pharmacist (including five referred by BH clinic therapists through primary care). Most patients were referred for depression or anxiety, with attention deficit hyperactivity disorder, substance abuse, bipolar disorder, and psychosis also being treated. As such, antidepressants and anxiolytics were the most common agents prescribed, but most every class of psychotherapeutic agents was utilized. Patient wait times to meet with the pharmacist were generally less than a week, with exceptions being found for patients already being prescribed a psychotherapeutic agent by their PCP and being referred to the pharmacist for follow-up care, or for patients being referred by their existing therapist. Initial reviews of the program by patients, primary care staff, and BH staff have been positive, especially in regards to patient access to specialized BH services.
Incorporation of behavioral health services within primary care, often termed primary psychiatry or integrated behavioral health (IBH), has been promoted for some time. Traditionally this has been accomplished through the utilization of either psychiatrists, nurse practitioners or advanced-practice registered nurses, social workers, or other practitioners specifically trained in behavioral health. Clinical psychiatric pharmacists have not been historically utilized in this role until much more recently.
The goal of IBH is to provide more efficient and expedient access to behavioral health services to patients by having IBH clinicians within a primary care setting. One of the recommendations of the Patient-Centered Medical Home (PCMH) is the very concept of IBH: to allow patients better access to behavioral health services within the primary care setting.1,2 PCMH standards are being incorporated into third-party payor guidelines, including Medicare and Medicaid, and are recommended by the Agency for Healthcare Research and Quality. As this program becomes a mainstay of primary care medical treatment, the provision of behavioral health services must be adequately prepared to be a part of that treatment model.
Here we describe a novel placement for a clinical psychiatric pharmacist, board certified in psychiatric pharmacy (BCPP), as the main IBH clinician within a primary care clinic within an urban community health center in Boston. A large percentage of patients seen in the clinic are Hispanic and/or low-income, and with all ages represented. While pharmacists have been engaged in behavioral healthcare for decades, the utilization of a pharmacist for behavioral health in primary care, and not a mental health clinic, is unique. While there are published studies regarding pharmacists providing behavioral health services to primary care patients, there are substantial differences between this program and the program described in this study.3 In the published study, patients only had depression (no other mental illnesses), and the pharmacists could only modify existing antidepressant regimens. Our program allows for most any psychiatric diagnosis to be treated by the pharmacist, and allows the pharmacist to prescribe at their discretion, including controlled substances. While other programs similar to the one described here may exist, published information on these programs is not readily available. The development of the position, based upon the needs of the patients and the clinic, and other factors, is described below.
DETERMINING THE NEED FOR THE PRACTICE
Before a novel practice setting for any clinician can commence, a needs assessment must first be performed. This can be a formal or informal process, depending on the specific setting. Some facilities might want to perform some measure of cost-analysis for a new position and other formal review processes. In this instance, the process was more informal. The clinic is seeking to become PCMH-certified by the National Committee for Quality Assurance (NCQA). As explained previously, one of the recommendations of the PCMH program is that of IBH. At the time the clinical psychiatric pharmacist was initiated, the clinic was in the early stages of implementing IBH, and had applied for a grant specifically for this purpose. However, the program about to be implemented utilized only therapists, and not prescribing clinicians, for the IBH program. This was a potential concern with the IBH program at the clinic.
During discussions between the clinic administration and a local school of pharmacy, it was determined that a clinical pharmacist, trained in behavioral health, could be utilized for this purpose. The clinical psychiatric pharmacist is a full-time faculty member of a local school of pharmacy, and was placed within the clinic as part of his clinical faculty appointment. State laws and regulations for pharmacists had recently been amended to allow for limited pharmacist prescribing under the supervision of a physician within the clinic. This allowed the pharmacist to not only consult on behavioral health patients within the clinic, but also to provide medications when determined necessary for a given patient.
Another concern for the clinic was the wait time for patients to be evaluated by the behavioral health clinic within the overall clinic setting. The clinic building houses not only a primary care clinic, but also a behavioral health clinic (as well as pediatric, obstetrics/gynecology, dental, and other clinics). Prior to the IBH program, patients were referred to the behavioral health clinic by primary care. This sometimes led to delays of a month or longer for patients to be seen in behavioral health, especially to see a prescribing clinician. This was due to high demand for these services and a lack of available clinicians to handle the high referral load.
One basic need for the clinic was for patients referred to behavioral health to be seen in a more expedient manner after referral. Ideally, implementation of IBH will allow for timelier behavioral healthcare compared to traditional processes, as IBH clinicians would be available to patients during the course of a primary care visit. The goal of our program was to also obtain quicker, easier access to behavioral healthcare for patients through the implementation of IBH and the incorporation of a clinical psychiatric pharmacist into the IBH program.
Within any primary care setting, determining the need for a clinical psychiatric pharmacist depends upon several factors. First, what are the behavioral health needs of the patient population being served within the clinic? Second, what is the level of availability and timeliness to behavioral health services for those patients? If the need for services are high and the availability (and timeliness) of services is low, then the situation could be right for the consideration of utilizing a clinical psychiatric pharmacist to fill the gap in services needed. Considerations such as salary for the pharmacist will also play a role, but if the need is great enough, and potential compensation for the pharmacist's services ample enough, then salary should not be as much of a concern. In our model, the pharmacist's salary was paid entirely through the school of pharmacy, but this is not likely to be available in all settings.
ESTABLISHING THE PRACTICE
Depending upon the specific laws and regulations for pharmacy practice within a given state, the role of the clinical pharmacist may be different. Until recently, pharmacists were not allowed to prescribe medications within our state but to only consult and provide recommendations to a physician for ultimate approval and implementation. However, several years ago the state legislature approved pharmacist collaborative practice agreements, allowing pharmacists with advanced clinical training (such as Board of Pharmaceutical Specialties certification) to have limited prescribing authority under the supervision of a physician.4 Prescribing is not a requirement for a clinical pharmacist to engage in an IBH role, but it is quite helpful. Without prescriptive authority, the pharmacist would have to send all recommendations to the primary care provider (PCP) for implementation. This could lead to delays in initiating medication therapy for a mental illness, which is one of the areas that IBH tries to improve. With this capability, the pharmacist can initiate treatment for a patient's illness.
Once the collaborative practice agreement was drafted and agreed upon by both the clinic medical director and the supervising physician, further steps were required. Again, depending upon state law, a state controlled substances registration and federal Drug Enforcement Administration (DEA) registration may be required, as was the case in this situation. Malpractice insurance and credentialing by the clinic administration will most likely also be needed.
After all the administrative steps have been completed, which can take several months depending on state requirements, the actual implementation of the practice can commence. One of the first steps is to determine the exact role the clinical psychiatric pharmacist will perform. This can depend upon several factors such as the exact need of the clinic, the capabilities of the pharmacist (including clinic time available) and state law. There should be clear expectations between the clinical psychiatric pharmacist and the clinical staff. For example, in our state, pharmacists are strictly prohibited from diagnosing patients. Patients seen by the pharmacist must be given at least a provisional diagnosis by the referring PCP for the pharmacist to work from. If the pharmacist discovers patient information that contradicts that diagnosis, he must report this to the PCP for modification of the IBH referral. Other items to consider for the pharmacist's role may include the ability to order labs related to treatment, initiate medications for adverse effects, renew medications not related to behavioral health, and need for continuing patient appointments with patients referred to the pharmacist.
A system for referral to the pharmacist by the PCP's must also be established. If the clinic utilizes an electronic medical record (EMR), which most clinics do, then it could be as simple as a referral within a progress note written by the PCP, or a more formal referral for the patient to meet with the clinical pharmacist. This is another area where state law might play a role, if it describes the documentation needs for a patient to see a clinical pharmacist under a collaborative practice act.
After the process of referral has been determined, the clinical staff need to be educated as to how to refer their patients to the clinical psychiatric pharmacist. This can be done through a staff inservice, especially if the process to complete a referral (such as through the EMR) is more complex, or through a memo to the staff about the new program. One key role in this regard is that of a “physician champion” for the pharmacist: a member of the medical staff who supports the clinical psychiatric pharmacist. This could be the medical director for the clinic or the supervising physician for the collaborative practice agreement. The person is important in helping to demonstrate the potential value of the clinical psychiatric pharmacist to the rest of the staff. During the inservice to the medical staff about the new clinical pharmacist program for IBH, this physician can help answer any questions the medical staff might have.
One key question to answer in establishing the practice concerns the appropriate availability of the clinical psychiatric pharmacist. Under the recommendations of the PCMH, IBH services should be available most, if not all, times this clinic is open to see patients. In this way, any and all patients can have this service available to them when they visit the clinic for primary care. This may not be feasible in all settings due to time constraints on the pharmacist and other factors. In our setting, the clinical psychiatric pharmacist is generally available during normal business hours during the week, with no evening or weekend hours. Exceptions to the pharmacist's availability include time requirements of the school (e.g., lectures, faculty meetings), but predominantly they are at the clinic for the majority of the work week. Ideally the PCP can hand the patient off directly to the clinical pharmacist for near immediate evaluation, but this is not always realistic. Patients seen by the PCP's during times the pharmacist is not available are contacted by the pharmacist when he is next in the clinic and seen within several days, depending upon the acuity of the patient.
In terms of reimbursement for these clinic visits with the clinical psychiatric pharmacists, there is no straightforward approach. As some states recognize pharmacists as providers for billing purposes and others do not, and even some third-party payers do and do not, this must be taken on a setting-by-setting basis. Ideally, the recent proposal before the United States House of Representatives to recognize pharmacists as non-physician providers will assist pharmacists and clinics to obtain reimbursement for the clinical pharmacy services described within this article.5 Within our clinic, all patient billing encounter forms are cosigned by either the patient's PCP or the supervising physician for the collaborative practice agreement. In this way the clinic can bill for the pharmacist's patient visits as a non-physician provider within primary care, when allowed by the patient's insurance program. This may be an important consideration in determining if/how to establish a similar program within your clinic: potential reimbursement models that could be used by the pharmacist in your setting. This may be especially important if the pharmacist's salary needs to be supported in part or wholly by any revenues generated by patient visits.
DEVELOPING AND MONITORING THE PRACTICE
Once the program has been initiated, it may be several weeks for it to start engaging patients in a significant number. This can depend on the number of PCP's actively referring patients to the clinical psychiatric pharmacist and the exact need of the clinic patients for IBH services. Over the course of time, and as the clinical staff become more familiar with the referral process and capabilities of the program, the number of referrals should increase. Since our program was initiated, the number of referrals per week increased from 1–3 to 10–12 in several months. Combined with the number of patients being seen by the clinical psychiatric pharmacist on a continuing basis, the average number of clinic visits per week is now approximately 20–25.
One of the goals of this program at our clinic was to decrease wait times for patients who needed behavioral health services. At baseline, the wait time for patients in our clinic was approximately 2–4 weeks for a therapist appointment, and 1-2 months for a psychiatrist/prescriber appointment. Specific data had not been collected on these baseline wait times, but have been estimated based upon consensus of primary care and behavioral health clinic staff. Preliminary data collected over the first few months of the IBH pharmacy program show that patients are now seen generally within seven days of referral, with many patients (approximately one-third) seen on the same day or next day after referral. In keeping with the notion of the PCMH, this has been a dramatic decrease in wait time and increase in behavioral health availability to patients.
As with any new program, quality assessment and monitoring should be performed. The clinical staff were surveyed at baseline about their satisfaction with the behavioral health referral program prior to IBH implementation. Once the full IBH program has been established and running for several months (the therapy component of the program has only recently been activated) then we intend to conduct a second survey to determine any changes in provider satisfaction with the behavioral health referral process. Plans are also under way to survey patients about their satisfaction with the IBH program as well. These types of assessment are required under the PCMH model, in particular patient satisfaction.1,2 Once these data have been collected and analyzed, then modifications to the IBH program, including that of the clinical psychiatric pharmacist, can be made. Initial anecdotal information gathered from both clinicians and patients would indicate a positive response to the IBH pharmacy program.
Clinical pharmacists specializing in psychiatry have been utilized in predominantly psychiatric settings, such as psychiatry clinics and hospitals, for many years. Placement of these clinicians within the primary care setting as the primary prescriber for psychotropic medications has not been done with any regularity. With our knowledge of medications in general as well as other disease states, it could be argued that the utilization of a clinical psychiatric pharmacist in this role, where general medicine and behavioral health meet, would be ideal. Often being asked to bridge the gap between primary care and psychiatry, clinical pharmacists can take this experience to providing behavioral health services within primary care, utilizing the knowledge of both areas to provide the highest quality of care for patients.
As primary care clinics across the country move towards the PCMH practice model, the need for IBH services within the clinics will become increasingly larger. The need for providers to fill these roles will also increase with time. Clinical psychiatric pharmacists can play a key part in meeting these needs with our specific expertise in both psychotropic and general medicine medications. In order to establish ourselves within these settings, care should be taken in determining the needs of the clinic and its patients, aligning the role of the clinical pharmacist to meet those needs, establishing good working relationships with the clinicians that will be referring patients to the pharmacist, and constant monitoring and modification of the IBH program as it progresses. The potential for a novel, unique role for the clinical psychiatric pharmacist within the IBH recommendations of the PCMH model appears vast as clinics across the country move towards PCMH accreditation.