Comprehensive medication management for patients with mental illnesses

Debbie is a 59-year-old white female who was referred by her primary care physician (PCP) for a comprehensive medication review. She had been feeling weak and dizzy and her physician was concerned about adverse effects and drug interactions from her twenty-two medications, including six psychiatric medications. She was prescribed medications by multiple physicians, including her PCP and psychiatrist. Upon review of her medications, duplicate benzodiazepines and tricyclic antidepressants (TCA) were identified. Laboratory studies revealed a very low hemoglobin and hematocrit. Although her medication list included an iron tablet, while meeting with the patient it was determined that she had stopped taking it due to a misunderstanding about which supplements were required after her gastric bypass surgery. She initially lost over 100 pounds, but has gained some weight back after she restarted drinking two liters of regular cola a day. One of the benzodiazepines and one of the TCAs was discontinued. She cut back on her soft drink intake. She continued with alternating visits with the PCP and pharmacist over several months while these changes were gradually implemented. She has reported less dizziness, improved sleep, and increased energy.

This case illustrates the complexity of the patients that often present for healthcare. The focus of the pharmacist on this patient's medication-related problems was instrumental in improving her quality of life. Patients like Debbie represent thousands who are admitted to emergency departments and hospitals every day, at the cost of billions of dollars a year, due to drug-related problems such as non-adherence and inappropriate medication use.

Comprehensive medication management (CMM) is defined by the Patient-Centered Primary Care Collaborative as “the standard of care that ensures that a patient's medications are appropriate, effective, safe, and taken as intended”. ¹ CMM is a patient-care practice done in a manner consistent with other patient-care practices. It includes a patient assessment, development of a care plan, and follow-up to assess the outcome of the care provided. It must be interactive with the patient and cannot be done while performing other tasks. It must include a review of all of the patient's medications including prescriptions, over the counter medications, supplements, tobacco, caffeine, and alcohol as well as a review of the patient's clinical data such as vital signs and laboratory results. The review must be documented and made available to the patient and his or her physicians.

In 2008, Isetts and colleagues published the results of an evaluation of CMM in 285 intervention patients and 254 controls in a commercially insured population in Minnesota.² Six hundred and thirty-seven drug-therapy problems were identified and resolved. In patients with hypertension, 71% of intervention patients met clinical goals while 59% of the control group met goals. Fifty-two percent of intervention patients and 30% of controls met diabetes goals. For 186 patients who were insured for the year before and the year after the intervention actual claims data showed a decrease of 31.5% in actual expenditures. Of note was that drug expenditures increased by 20% while facilities' fees (such as hospital charges) dropped 58%. The return on investment was calculated as 12:1, meaning that for every dollar spent on CMM, costs were reduced by 12 dollars.

Over a 10-year period from 1998–2008 Fairview Health System in Minnesota provided CMM services to 9069 patients.³ Results showed that 55% of patients had an improvement in clinical status of a condition and 95% reported an improvement in their health and well-being. The cost of providing the service was calculated to be $2,258,302 while the estimated savings to the health system was $2,913,850. The most common drug-therapy problems were the need for additional drug therapy, dose too low or poor adherence. This is of interest as adding medications or increasing doses may increase medication costs but reduce overall healthcare costs. The return on investment in this project was 1.3 to 1.

In 2009 the Fairview system undertook a care model innovation initiative to redesign healthcare delivery.⁴ Four clinics were designated innovation clinics which included pharmacist-provided CMM while 38 clinics served as controls. Eight hundred and twenty-three patients underwent 1754 encounters with a pharmacist. Endpoint assessments included the Minnesota diabetes benchmarks of HbA1c, LDL, blood pressure (BP), aspirin, and smoking cessation. At baseline only 5% of systems reporting these benchmarks met goals. At 5 years, 15% of systems met benchmarks while 38% of the innovation clinics studied achieved these goals. Financial data showed that per member per month costs rose only 3.7% in the innovation clinics over a 15 month period while control clinics saw costs rise 14.7% per member per month. Once again, data showed that patients needed additional medications or higher doses, along with improvements in adherence to the regimen.

In addition to the Minnesota data, recently published preliminary data from the Centers for Medicare and Medicaid Services (CMS) show promising results from Medicare Part D MTM programs in 2010.⁵ Results showed that patients with chronic obstructive pulmonary disease (COPD) and heart failure had an improvement in medication quality and reduced costs after receiving a comprehensive medication review. Improved medication quality included better adherence, increased use of generics, decreased duplications of therapy, and discontinuation of high-risk medications. All cost hospital savings were $62 and $82 per member per month for patients with COPD and heart failure, respectively.

There are currently no published trials of the clinical and economic impact of CMM in patients with mental illnesses. However some pilot programs are underway to evaluate the effects of medication management in this population.

In 2011, Merit Medication Consultants, a pharmacist-owned medication management private practice, received a grant from the Montana Mental Health Settlement Trust to provide CMM for people with mental illnesses. One hundred and fifty-five patients have completed 256 visits. The most common psychiatric conditions evaluated were depression, insomnia, anxiety disorders, and bipolar disorder. Estimated cost savings per patient was estimated to be $586 for a return on investment of 3.1 to 1 based on the data collected. In contrast to the previous reports, the most common drug therapy problems identified were adherence, adverse reactions, and unnecessary medications. Most of the estimated cost savings was due to a reduction in drug expenditures as it was not possible to obtain data on avoidance of ED visits or hospitalizations. Cost savings are likely underestimated because of this. An improvement in clinical status was reported in 55% of patient conditions, consistent with previous reports. A patient survey found that 93% of patients reported that the service was extremely or very helpful and 93% would recommend it to friends or family (IRB exempted, data on file). Publication of the full results of this retrospective evaluation is pending.

This data provides evidence that patients can benefit from CMM and that health-systems can achieve cost savings. What can be done to expand the service to those who could so greatly benefit?

The first thing that pharmacists can do is to provide CMM as defined by the PCPCC to their patients.¹ Pharmacists must be able to demonstrate a consistent patient care process so that others begin to experience and understand the value of the service. Pharmacists must show patients, physicians, and payers that they can provide patient care services in addition to dispensing services as may be the perception of much of the public.

Next legislators need to be convinced that pharmacist-provided CMM has sufficient value to justify adding pharmacists to the list of “providers” under the Social Security Act.

In addition, pharmacists must work with innovative models of care such as patient-centered medical homes (PCMH) and accountable care organizations (ACO) to ensure that CMM is included as an essential service. For patients with chronic illnesses, the first step in improving outcomes is to establish an ideal medication regimen in order to achieve goals of treatment. This coordination of care is essential for the success of a PCMH or ACO model.

Psychiatric pharmacists understand the contribution that pharmacists can provide to the patient care team, especially for patients with mental illnesses. In order for others to appreciate that value, pharmacists should learn about CMM, use the CMM toolkit available to members on the CPNP website,⁶ and implement the elements of CMM in their own practices. The CPNP Foundation CMM Network can assist pharmacists in advancing their practices by exchanging ideas and collecting data with other pharmacists involved in practice transformation. During the practice transformation process, pharmacists should document and publish the benefits of CMM. Pharmacists must become active advocates for CMM with administrators, payers and legislators. Schools of pharmacy and residency programs should include training about CMM in their curricula. CMM should be available to all patients who can benefit from pharmacists' patient-care services.