Abstract

Background

Increasing shortages of primary care and specialist physicians in the US health care system, coupled with increased patient demand, have led to decreased access for patients.¹ These shortages are acute in mental health (MH) care as the number of psychiatrists and other MH providers continues to decrease.^2-4 Retirement, burnout, and structural factors that incentivize psychiatrists to practice in cash-only private settings means that these MH providers are also distributed unevenly across the country.^5,6 These shortages are especially prevalent in MH care, as fewer providers are pursuing psychiatric specialization.⁷

While primary care providers may be able to expand access when encountering conditions that they feel confident in managing, this may not apply to conditions that require treatment with antipsychotics or mood stablizers.⁸ Even specialized MH clinics face barriers to managing medication therapy. There are reports of antipsychotic underutilization or misutilization owing to complex monitoring and coordination requirements as well as concerns for adverse events.^9-11

MH clinical pharmacy specialists (CPS) are increasingly functioning as integral providers in MH care teams. These CPS address shortages by taking on some of the providers' medication management tasks and increasing availability to MH care for patients in community settings.^12,13 The inclusion of CPS in MH teams has been shown to increase patient satisfaction, decrease wait times, improve patient clinical outcomes and medication adherence, and improve access to care.^14,15 In the Veterans Health Administration (VHA), CPS are advanced practice providers with the authority to prescribe and modify medications based on an established diagnosis, making collaboration essential.^16,17 MH CPS have the skills and expertise to collaboratively and independently provide comprehensive medication management (CMM) as members of multidisciplinary MH care teams and by contributing knowledge about medication interactions and navigating the sometimes labyrinthian systems of referrals and medication authorization and documentation.^18-20

The US Department of Veterans Affairs Office of Rural Health and Pharmacy Benefits Management Services Clinical Pharmacy Practice Office implemented a nationwide initiative to improve rural veterans' access to care with MH CPS through the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) Initiative.¹³ In VHA, rural is determined by accounting for how closely a community is socioeconomically linked to larger urban centers. The MH CPS role in VHA is focused on the provision of CMM services to improve patient-centered care and medication outcomes as a primary MH provider, thereby supporting the needs of the veterans, caregivers, and teams.^20-22

In this evaluation, we examine provider and CPS perceptions of the contributions of CPS to MH clinical teams. We examine the roles and functions of CPS in MH clinics to gain insight into how the introduction of CPS into these teams facilitated patient care and enhanced the efforts of the team, as well as what challenges and barriers were encountered with integration. When new members are introduced to clinical teams who are unaccustomed to working with them, there is a need to define and reconfigure roles within the team.^23,24 Perceptions of team members are a key part of role clarity and team integration in interprofessional care teams.²⁵ This evaluation measures perceptions of MH CPS roles and contributions, as well as the perceptions of these roles and contributions by other MH team members through a mixed-methods approach.

Methods

As part of a multi-year mixed-methods project (2017-2020) to evaluate the CRVA initiative, we conducted surveys and qualitative interviews with MH CPS and other members of the clinical teams on which they worked as part of an assessment of the CRVA initiative. The survey pool comprised all MH CPS who had been employed as part of the CRVA initiative for over 6 months (n = 39) and health care professionals on the same clinical teams (n = 335). Local facility pharmacy leadership, such as the assistant or associate chief of pharmacy, assisted in identifying providers who worked in teams where MH CPS had been introduced. Providers were sent an email inviting them to participate in the survey. The survey used a self-administered questionnaire in REDCap, a web-based platform designed to support data capture for research studies.²⁶ Email reminders and an instant message from the project manager were sent to people who had not yet responded. There was a 100% response (n = 39) for MH CPS participation in the survey and 80% (n = 335) for other team members (82% combined response rate). Table 1 includes demographic data for survey respondents.

Table 1 Survey respondent demographics

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The survey measured integration of MH CPS into MH clinical teams by comparing CPS' and team members' perceptions of the role of MH CPS using a modified version of the medication use process matrix (MUPM) developed by Farrell et al.²⁷ The MUPM facilitated the assessment of the perceived contribution of team members on tasks related to CMM, grouped into 5 key domains of medication management (evaluation and management, medication monitoring, medication review, documenting care, and medication education).²⁸ The MUPM was administered to MH CPS and to other providers, assessing their own roles in CMM as well their perceptions of the MH CPS contributions (see Table 2 for MUPM domains and items). Item scores range from 0 (no contribution) to 3 (major contribution), with higher scores indicating greater integration into the team. Standardized composite scale scores, computed as unweighted averages across the 5 domains, were used in analysis of variation in MUPM across VHA stations. Additional survey elements measured perceptions of job-related work environment factors by survey participants.

Table 2 Medication use process matrix items

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In addition to surveys using quantitative measures (MUPM),²⁷ qualitative interviews were conducted to assess MH team member perceptions. We conducted qualitative interviews with 7 MH CPS and 9 other providers (psychiatrists, nurse practitioners, registered nurses [RNs], and social workers) on MH clinical teams who had completed the MUPM survey (see Table 1). We selected a purposive sample of MH CPS, psychiatrists, and other providers who had completed the survey and were identified by site champions and confirmed by MH CPS as working with each other in MH clinical teams. Demographic information about interview participants was not collected during the interview nor linked to survey results. Interviews addressed the roles the MH CPS performed in their clinic, interactions between MH CPS and other team members, perceptions and details of how MH CPS contributed to MH teams' function and perceived patient satisfaction, as well as any challenges that having MH CPS in these teams presented for other providers (see Table 3 for select interview questions). Interview questions were evaluated by CRVA leadership and practicing CPS prior to the beginning of interviewing and were continuously refined throughout the study, as necessary. Data collection and analysis were performed by a highly experienced qualitative team of 2 PhD anthropologists and 1 PhD sociologist.

Table 3 Qualitative interview questions

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Telephone interviews were audio recorded and transcribed verbatim. Transcription was performed by a VA-approved vendor. A process of critical review and consensus building was used to develop a codebook based upon impressions from the interviews and a priori concepts from the larger mixed-methods project. Codes were clearly defined to enable consistent use among coders.²⁹ Analysis followed a modified grounded theory approach, informed by the initial codebook with the additional codes being included as they emerged from inspection of the data. Summaries of coded data facilitated the identification of thematic elements that pertained to participants' perceptions of MH CPS contributions in MH clinical teams.^30-33 This evaluation was reviewed by the IRB at VA Bedford Healthcare System, and the IRB determined that the evaluation fit in the category of quality improvement. In VHA, quality improvement studies are not subject to IRB oversight. However, the elements of informed consent were adhered to, and participant confidentiality was followed.

Findings

Survey Findings

Perceptions of the MH CPS' contributions to the MH team were consistently positive across all domains of the MUPM (Table 4). Average ratings were between 2 and 3, indicating moderate to major contribution. Ratings varied by role. On the composite score, the MH CPS rated themselves more highly (94 out of 100) than they were rated by psychiatrists (81 out of 100) or other providers (90 out of 100). Results for the domains show the same pattern of MH CPS rating themselves higher than they were rated by others. These scores reflect very positive perceptions of MH CPS as members of MH teams. While there were statistically significant differences in some MUPM domains between how MH CPS rated themselves and how they were rated by other team members, these differences were small (see Table 4).

Table 4 Perception of clinical pharmacy specialist (CPS) role by mental health (MH) CPS and others

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All 3 categories of participants reported high levels of job satisfaction but also reported elevated levels of burnout. Psychiatrists reported greater satisfaction with communication between MH team members than MH CPS or other providers, while other providers on these teams reported significantly lower perceptions of interprofessional collaboration (see Table 5). Communication measured levels of agreement of healthy conflict resolution and perceptions of constructive work relationships, while interprofessional collaboration measured the frequency of interactions that comprise collaborative behavior, such as information sharing.

Table 5 Perception of work environment

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Discussion

A strength of this mixed-methods study is the use of qualitative (interview) data to contextualize the results of the quantitative (survey) data. The experiences we gathered from MH team members are a valuable source of data for assessing how they feel MH CPS are currently integrated into these teams, the value they assign to the contributions of MH CPS, and efforts to achieve integration within their MH clinical teams. The degree to which perceptions of team member contributions are concordant is an indicator of integration.

An important finding from our data is that MH CPS are generally received well by other providers in MH teams and that these team members recognize and appreciate the contributions of MH CPS in CMM. This is reflected in both the survey and interview data. These data about perceptions were instrumental in understanding the extent of integration of MH CPS in MH clinical teams. Greater detail about variation across teams in the degree and quality of CPS' integration has been published elsewhere,²⁵ finding that CPS integration has been successful on many levels.

These findings echo those of other reports^38,39 of CPS integrating into primary care teams. Misconceptions about MH CPS scopes of training often results in poorly defined roles for MH CPS, leading to lower collaboration in patient care. Collaboration with CPS by MH care team members is not only a result of integration but also a driver of that integration.²⁵

CPS in MH clinics providing CMM were viewed by others as potentially increasing access to veterans who have medication management care needs.¹³ The perception among members of MH clinical teams was that this could extend the capacity of the other providers on the team to provide patient care. The knowledge and training of CPS was reassuring to providers who frequently turned to them with questions about medications. The ability of MH CPS to manage and navigate clozapine prescribing was particularly useful in MH clinics in VHA. This is a cumbersome and time-consuming process that requires obtaining certification to prescribe, and other providers noted how valuable it was to have MH CPS able to assist.

MH CPS also provide direct patient care that was perceived to be received well by patients, increasing their satisfaction with the care they receive. Additionally, MH CPS might remain part of MH teams, while other providers rotate through more frequently, MH CPS were perceived to offer greater continuity of care to patients because they do not frequently rotate off MH teams, unlike other providers.^37,40

Integration of new members to a clinical team takes time. While acceptance and integration of MH CPS is not automatic, it does improve over time. It is important to consider that introducing an MH CPS into a clinical team in an MH setting is a process that takes effort by all members of the team. MH CPS found it necessary to educate others, especially psychiatrists, about their scopes of practice and roles, and to navigate the necessary reconfiguration of the roles of others on the team.

This study has limitations. MH CPS in this study were sometimes simultaneously members of multiple care teams, and integration within each may have varied. The experiences and degree of integration of CPS in MH teams may be different in VHA MH clinics than in community MH clinics. Therefore, it is possible that our conclusions may not be generalizable. There are biases in how clinical team members assess the contributions of MH CPS. These biases are expected and allow us to compare the discrepancies in how MH CPS and other MH team members perceive these contributions. Perceptions of MH CPS contributions are an important indicator of integration. This study does not report on patient outcomes following the inclusion of MH CPS in clinical teams. Important next steps include assessing patient satisfaction with MH care where MH CPS are part of clinical teams, the effect of MH CPS on wait times, and the impact MH CPS have on access in rural settings.

Conclusion

Overall, the integration of MH CPS into VHA MH teams was highly successful and well received by team members. Over time MH CPS have become important members of the MH team. When CPS are integrated in MH care teams, providing CMM, there is greater and more productive collaboration among team members. This resulted in perceptions of improved access to health care, improved quality of patient care, and enhanced workflow. Based on the results of this assessment, strong consideration should be given to assuring that all MH teams and patients have access to a highly trained MH CPS.