Introduction: Integrated, patient-centered clinical pharmacy services have been shown to improve patient outcomes in a variety of settings, including mental health. In this article, we describe and report the impact of a restructured clinical practice model that incorporated direct patient care by pharmacists implemented at a psychiatric facility in Edmonton, Canada. The purpose of redesigning the clinical pharmacy program was to deliver proactive pharmacist care through integrated clinical pharmacy services and to better align pharmacists' activities with those that have been reported to have a positive impact on patient outcomes.

Methods: Pharmacists' documentation notes in medical records for patients admitted and discharged from the hospital at four different time periods were reviewed. For each time period, the number, type, and documentation rate were measured and compared using a Student t test with correction for unequal variances. Significant change was defined as P < .05. Documentation rates were also compared for short-stay versus long-stay patients.

Results: A consistent and statistically significant increase was found in pharmacists' clinical notes per chart from 0.15 to 1.5 (P < .001) after implementation of the redesigned clinical practice model. The proportion of clinical notes also increased from 22% in the preimplementation period to up to 68% in the current period. This indicates that pharmacists were spending proportionally more time on proactive versus reactive care. Documentation rates also increased regardless of the patients' length of stay.

Discussion: The redesigned clinical practice model enabled a successful transition of the pharmacists' role, from being predominantly reactive to becoming more proactive and integrated.

Inpatient clinical pharmacy services have significantly changed in the past 20 years. The focus of pharmacy practice has shifted away from the dispensary to the provision of pharmaceutical care. Pharmaceutical care relies on pharmacists adopting a patient-centered model, proactively assisting with evidence-based medication selection, optimizing patient medication regimens in a collaborative manner with members of a multidisciplinary care team, and collectively taking responsibility for each patient.1,2  These integrated, patient-centered clinical pharmacy services have been shown to improve patient outcomes in a variety of settings, including mental health.39 

At the authors' site, a 305-bed, urban, tertiary care, psychiatric hospital, the delivery of clinical pharmacy services was considered reactive in nature; that is, pharmacists' interventions were mostly triggered by prescribing errors or in response to requests from other health care providers. Few pharmacists were involved in patient care rounds, and many pharmacists spent their clinical time reviewing patient profiles for drug interactions, clarifying orders, or answering drug information questions. Direct patient care was largely sporadic and mostly limited to resolving clinical issues identified by the dispensary.

Recognizing the need to consistently provide evidence-based clinical services, the leadership team undertook a restructuring of the clinical practice model to better align pharmacists' activities with those that have been reported to have a positive impact on patient outcomes. The goals of redesigning the clinical practice at the hospital were twofold: first, to deliver proactive pharmacist care, and second, to realign the clinical services provided by pharmacists with the clinical pharmacy practice vision for the institution, that is, pharmacists working to full scope of practice in support of quality care that is accessible and sustainable.

This report describes how the clinical pharmacy services were redesigned in a psychiatric hospital to incorporate proactive patient care by pharmacists and evaluates the impact of this realignment of clinical services by comparing the type of pharmacists' clinical activities as documented in the patients' medical charts before and after its implementation.

Redesigned Clinical Practice Model

This project was conducted at a 305-bed psychiatric hospital that treats patients with severe mental illnesses; units are dedicated to adult acute psychiatry, forensic psychiatry, and extended rehabilitation psychiatry for complex patients with multiple disabilities. The ratio of clinical pharmacists to patients at the time was 1:76, and pharmacists mostly provided reactive services. The redesigned clinical practice model was developed over a 9-month period (from March to October 2011) and implemented as of November 1, 2011.

BOX 1:

Core services provided by pharmacists in the redesigned clinical practice model

Core services provided by pharmacists in the redesigned clinical practice model
Core services provided by pharmacists in the redesigned clinical practice model

Recognizing that the time and pharmacist human resources required to provide proactive care for all inpatients would exceed staffing levels at the institution, under the redesigned clinical practice model, pharmacists were to primarily provide proactive direct patient care services to all acute inpatients (including patients in acute forensic psychiatry) as integrated members of a multidisciplinary care team (Box 1). Reactive clinical pharmacy services were to continue being provided to all patients in nonacute beds. Reactive clinical pharmacy services included basic patient medication monitoring performed by a pharmacist in the dispensary during order entry or by nondispensary pharmacists, referred to as the “clinical float.” On a rotational basis, all clinical pharmacists were to perform the duties of a clinical float to patients in nonacute beds on request by staff in those units or as identified by the dispensary. Reactive services included activities that were already being performed by the pharmacists before the implementation of the redesigned clinical practice model (Box 2).

BOX 2:

Clinical services provided by clinical float pharmacists

Clinical services provided by clinical float pharmacists
Clinical services provided by clinical float pharmacists
BOX 3:

Description of the four audit periods

Description of the four audit periods
Description of the four audit periods

To ensure consistency in the provision of proactive clinical pharmacy services, and after several consultation meetings between the leadership team and front-line staff (including nurses and psychiatrists), pharmacists were assigned to a specific multidisciplinary care team in all acute care units. In addition, on a rotational basis, each pharmacist's schedule was modified to accommodate 1 week of clinical float services to all nonacute units. The target ratio of clinical pharmacists to patients was 1:35 for all acute care units and 1:76 for nonacute units.

BOX 4:

Description of clinical notes

Description of clinical notes
Description of clinical notes

Evaluation

Pharmacists' documentation notes in medical records for patients admitted and discharged from the hospital at four different time periods were reviewed. For each time period, the medical charts of discharged patients were randomly selected from units where pharmacists had been fully integrated into multidisciplinary care teams. The four audit periods are outlined in Box 3.

Pharmacist documentation was categorized as simple order clarifications that resulted from pharmacists' reactive practice or as clinical notes that resulted from pharmacists' proactive practice. Clinical notes reflect the core clinical activities that are expected of clinical pharmacists under the redesigned clinical practice model, as summarized in Box 1. Clinical notes were further categorized as described in Box 4.

Additional information that was gathered for each patient included age at admission, gender, medical diagnosis, and length of stay (LOS). The LOS was divided into short (for patients whose LOS was below the median for patients in the audited period) or long (for patients whose LOS was above the median). For patients who had their charts audited after their discharge (ie, the preimplementation, transitional, and postimplementation periods), the progress notes for the entire LOS were available for review and were included in the data. For charts of patients in the current period, progress notes were often thinned in the charts to keep them to a manageable size, in which case whatever was available on the unit was used to generate the data. This meant that a separate measure of “chart days,” as opposed to LOS, was used to describe the number of days' worth of progress notes that had been reviewed for the audit. For the chart audits of patients in the preimplementation, transitional, and postimplementation periods, the number of chart days was equal to the LOS, but in the current-period audit the number of charts days was less than the LOS. The use of chart days was important in that it could be used to describe the rate at which pharmacist documentations were included in patient charts for each of the four audit periods.

The documentation rate was defined as the average number of documented pharmacist interventions divided by the average number of chart days included in a given audit period. This method produces a measurement with units of documentations per chart day that was used to quantify and compare how often pharmacists were performing and documenting clinical activities. Rates were also calculated for patients who had short stays and those who had long stays. This was intended to provide a means of determining whether short-term patients received a different degree of clinical pharmacist interventions than long-term patients.

A two-tailed t test was used to compare average documentations per chart as well as documentation rates for each time period. An F-test determined that variances were not equal between all groups, so samples were compared using the Welch's t test to allow for unequal variances between sample groups. The threshold for significance was defined as P < .05.

A total of 140 patient medical charts were audited for pharmacists' documentation: 34 for the preimplementation period, 35 each for the transitional and postimplementation periods, and 36 for the current period. Table 1 presents the age, gender, and LOS for the patients whose charts were selected for the audit. The most frequent psychiatric diagnosis was schizophrenia (31%, 44/140) followed by bipolar affective disorder (25%, 35/140).

TABLE 1:

Demographics of patients selected for medical chart audit for each study period

Demographics of patients selected for medical chart audit for each study period
Demographics of patients selected for medical chart audit for each study period

Table 2 presents information on the total number of charts reviewed and the type of pharmacists' documentation notes identified with a breakdown for the number of order clarifications and clinical notes identified for each of the study periods. Overall, the number of charts that contained pharmacist documentation increased from 47% in the preimplementation period to 81% in the current period.

TABLE 2:

Charts containing pharmacists' documentation notes for each study period

Charts containing pharmacists' documentation notes for each study period
Charts containing pharmacists' documentation notes for each study period

A consistent increase in the number of pharmacists' clinical notes per chart was noted throughout all of the periods audited; the difference between periods was also statistically significant when comparing the preimplementation period to the transitional, the postimplementation, and the current periods (P = .02, P < .01, and P < .001, respectively); and also when comparing the transitional and the postimplementation periods to the current period (P = .02 and P < .01, respectively). This trend is illustrated in Figure 1. The number of order clarification notes per chart was generally consistent throughout all periods, and no statistically significant differences between the four audited periods were found. Because the number of clinical notes increased and the number of order clarification notes remained the same, the proportion of clinical notes increased from 22% in the preimplementation period to 68% in the current period. This indicates that pharmacists were spending proportionally more time on proactive versus reactive care.

FIGURE 1:

Pharmacists' average clinical notes per chart reviewed in each audit period. Pre=Pre-implementation period, Trans=Transitional period, Post=Post-implementation period, Curr=Current period, *p < 0.01 compared to pre-implementation period, #p < 0.01 compared to post-implementation period

FIGURE 1:

Pharmacists' average clinical notes per chart reviewed in each audit period. Pre=Pre-implementation period, Trans=Transitional period, Post=Post-implementation period, Curr=Current period, *p < 0.01 compared to pre-implementation period, #p < 0.01 compared to post-implementation period

Close modal

Documentation rates (number of documentation notes per chart day) for the long-term group of patients showed an 11-fold increase from the preimplementation period to the current period (from 0.002 to 0.023); the differences between periods were statistically significant between the preimplementation and all the other periods (P = .03, P = .02, and P < 0.01 for the transitional, postimplementation, and current periods, respectively). No other statistically significant differences between the four periods audited were found for the long-term group of patients. In the short-term group of patients, there was also a consistent increase in the documentation rate throughout all of the periods audited (from 0.007 in the preimplementation period to 0.058 in the current period), although the difference was only statistically significant when comparing the preimplementation to the current periods (P < .01) or the transitional to the current periods (P = .02). These results are illustrated in Figure 2. The rates of order clarifications were generally consistent through all periods, and there was no statistical significant difference between the average rates for any of the patient groups or when comparing between periods.

FIGURE 2:

Documentation rate in patients with short and long lengths of stay. Pre=Pre-implementation period, Trans=Transitional period, Post=Post-implementation period, Curr=Current period, *ast;p < 0.01 compared to pre-implementation period, Short=Documentation rate for patients with short lengths of stay, Long=Documentation rate for patients with long lengths of stay, Total=Documentation rate for all patients regardless of their length of stay

FIGURE 2:

Documentation rate in patients with short and long lengths of stay. Pre=Pre-implementation period, Trans=Transitional period, Post=Post-implementation period, Curr=Current period, *ast;p < 0.01 compared to pre-implementation period, Short=Documentation rate for patients with short lengths of stay, Long=Documentation rate for patients with long lengths of stay, Total=Documentation rate for all patients regardless of their length of stay

Close modal

The types of pharmacists' documentation notes for each study period are illustrated in Figure 3. In comparison to the preimplementation period, documentation of core clinical activities, particularly initial assessment and formulation on the care plan, treatment recommendation, and ongoing assessment and medication monitoring, had the most notable growth between the preimplementation and current periods.

FIGURE 3:

Types of pharmacists' clinical notes for each study period. Legend: TR=Treatment Recommendation, OA/M=Ongoing Assesment and Medication Monitoring, PE=Patient Education, IA/CP=Initial Assessment and Formulation on Care Plan, SC=Seamless Care, MH=Medication History

FIGURE 3:

Types of pharmacists' clinical notes for each study period. Legend: TR=Treatment Recommendation, OA/M=Ongoing Assesment and Medication Monitoring, PE=Patient Education, IA/CP=Initial Assessment and Formulation on Care Plan, SC=Seamless Care, MH=Medication History

Close modal

By auditing the documentation of pharmacists' activities in the patients' medical charts before and after the implementation of a redesigned clinical practice model in a psychiatric setting, we observed an overall increased pharmacist documentation rate over the four time periods studied and an increased proportion of documentation of proactive clinical activities. The documentation of activities resulting from pharmacists' reactive or consultative services consistently decreased from 78% in the preimplementation period to 32% in the current period.

In addition, compared with the preimplementation period, documentation of core clinical activities, particularly initial assessments/formulation of care plans, treatment recommendations, and ongoing assessment/drug therapy monitoring, had the most notable growth between the preimplementation and the current periods. These results support findings in other settings that pharmacists in direct patient care roles are better positioned and better equipped for the provision of evidence-based clinical pharmacy services.8,1014 

Documentation of core clinical activities for short-term and long-term patients also increased, which suggests that the provision of clinical pharmacy services for all patients, regardless of their acuity, improved after implementation of the new model. It appears that both, the integration of pharmacists within the acute psychiatry multidisciplinary care team and the availability of the clinical float pharmacist in nonacute units allowed for the provision of more proactive and consistent clinical pharmacy services. Other researchers have described similar findings and have reported that restructured clinical pharmacy services at their institutions had a positive impact on stakeholder satisfaction.8,11,12 

The documentation rates observed in the current period also suggest that the practice of evidence-based clinical pharmacy has been sustainable over time. Several factors may have contributed to the success and sustainability of the results obtained from restructuring the clinical pharmacy program in our hospital. Perhaps the most important one is that pharmacists embraced the challenge and worked with the clinical leadership to develop the skills necessary for the provision of proactive, direct patient care, such as patient interviewing and assessment skills, as well as instituting clinical documentation strategies. Also, in presenting the proposed changes to the hospital staff, we highlighted the benefits of the redesigned clinical practice model as supported by the available evidence, including the provision of quality care to a smaller group of patients and the benefits of pharmacists being integrated into the multidisciplinary care team without compromising the reactive clinical pharmacy services that were already being provided.24,11,15,16 

This project has several limitations, including potential pharmacists' documentation bias and the retrospective nature of the audits. It is also possible that not all interventions performed by clinical pharmacists were captured in the retrospective review of the patients' medical charts. In addition, this project did not measure a clinical outcome directly; rather, it was assumed that patients received improved care as a result of more direct patient care provided by pharmacists.

The results obtained from the four documentation audits suggest the redesigned clinical practice model enabled a successful transition of the pharmacists' role from being predominantly reactive to becoming more proactive and integrated, as evidenced by an increase in the documentation of pharmacists' core clinical activities after its implementation.

We would like to acknowledge the support of the all the pharmacists at Alberta Hospital Edmonton for their input and engagement in the redesign and implementation of the restructured clinical practice model. We also acknowledge the following summer pharmacy students from 2012 and 2013 who collaborated in the literature review and data collection: Patricia (Yunhee) Jee, Ashley Dunstan, and Heidi Banash.

1
Hepler
CD
,
Strand
LM
.
Opportunities and responsibilities in pharmaceutical care
.
Am J Hosp Pharm
.
1990
;
47
(
3
):
533
-
43
.
PubMed PMID: 2316538
.
2
Woods
TM
,
Lucas
AJ
,
Robke
JT
.
Making a case for a patient-centered integrated pharmacy practice model
.
Am J Health Syst Pharm
.
2011
;
68
(
3
):
259
-
63
. DOI: .
3
Bond
CA
,
Raehl
CL
,
Patry
R
.
Evidence-based core clinical pharmacy services in United States hospitals in 2020: services and staffing
.
Pharmacotherapy
.
2004
;
24
(
4
):
427
-
40
.
PubMed PMID: 15098796
.
4
Bond
CA
,
Raehl
CL
.
Clinical pharmacy services, pharmacy staffing, and hospital mortality rates
.
Pharmacotherapy
.
2007
;
27
(
4
):
481
-
93
. DOI: . PubMed PMID: 17381374.
5
Kaboli
PJ
,
Hoth
AB
,
McClimon
BJ
,
Schnipper
JL
.
Clinical pharmacists and inpatient medical care: a systematic review
.
Arch Intern Med
.
2006
;
166
(
9
):
955
-
64
. DOI: . PubMed PMID: 16682568.
6
Kucukarslan
SN
,
Peters
M
,
Mlynarek
M
,
Nafziger
DA
.
Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units
.
Arch Intern Med
.
2003
;
163
(
17
):
2014
-
8
. DOI: . PubMed PMID: 14504113.
7
Gillespie
U
,
Alassaad
A
,
Henrohn
D
,
Garmo
H
,
Hammarlund-Udenaes
M
,
Toss
H
,
Kettis-Lindblad
A
,
Melhus
H
,
Mörlin
C
.
A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial
.
Arch Intern Med
.
2009
;
169
(
9
):
894
-
900
. DOI: . PubMed PMID: 19433702.
8
Virani
A
,
Crown
N
.
The impact of a clinical pharmacist on patient and economic outcomes in a child and adolescent mental health unit
.
Can J Hosp Pharm
.
2003
;
56
(
3
):
158
-
62
.
9
Finley
PR
,
Crismon
ML
,
Rush
AJ
.
Evaluating the impact of pharmacists in mental health: a systematic review
.
Pharmacotherapy
.
2003
;
23
(
12
):
1634
-
44
. DOI: .
10
Shalansky
S
,
Nakagawa
R
,
Wee
A
.
Drug-related problems identified and resolved using pharmaceutical care versus traditional clinical monitoring
.
Can J Hosp Pharm
.
1996
;
49
(
6
):
282
-
8
.
11
Mysak
TM
,
Rodrigue
C
,
Xu
J
.
Care providers' satisfaction with restructured clinical pharmacy services in a tertiary care teaching hospital
.
Can J Hosp Pharm
.
2010
;
63
(
2
):
105
-
12
.
PubMed PMID: 22478965
.
12
Hwang
S
,
Koleba
T
,
Mabasa
VH
.
Assessing the impact of an expanded scope of practice for pharmacists at a community hospital
.
Can J Hosp Pharm
.
2013
;
66
(
5
):
304
-
9
.
PubMed PMID: 24159233
.
13
Stanislav
SW
,
Barker
K
,
Crismon
ML
,
Childs
A
.
Effect of a clinical psychopharmacy consultation service on patient outcomes
.
Am J Hosp Pharm
.
1994
;
51
(
6
):
778
-
81
.
PubMed PMID
: .
14
Morton
WA
,
Mendenhall
AR
,
Windsor
PG
,
Lydiard
B
.
Clinical psychopharmacy consultations: acceptance of recommendations on an adult inpatient psychiatric unit
.
Hosp Pharm
.
1995
;
30
(
9
):
786
-
90
.
PubMed PMID: 10151283
.
15
McBride
J
.
Should clinical pharmacist resources be equally distributed across an institution to ensure a consistent level of clinical service for all patients? The “pro” side
.
Can J Hosp Pharm
.
2007
;
60
(
3
):
205
-
6
.
16
Makowsky
MJ
,
Koshman
SL
,
Midodzi
WK
,
Tsuyuki
RT
.
Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676]
.
Med Care
.
2009
;
47
(
6
):
642
-
50
. DOI: . PubMed PMID: 19433997.

Author notes

2

Pharmacy Manager, Alberta Hospital Edmonton Pharmacy, Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada

3

Third-Year Pharmacy Student, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada

Disclosures: No funding or outside support was provided for this study. The authors have no conflicts of interest. This research was presented as a poster at the Canadian Society of Hospital Pharmacists Annual Banff Seminar in Banff, Alberta, Canada, on March 21, 2014, and at the College of Psychiatric and Neurologic Pharmacists Annual Meeting in Phoenix, Arizona, on April 28, 2014.