Introduction

Pharmaceutical care was described decades ago as direct, responsible provision of medication-related care in order to achieve definite outcomes that improve a patient's quality of life.¹ Health care continues progressing to more collaborative care between physicians and other health care professionals, including pharmacists, to optimize care and improve outcomes. For years, pharmacists have been shown to improve outcomes and access to care for patients in primary care, including management of diabetes mellitus, hypertension, and anticoagulation, with cost avoidances ranging from $55 000 to more than $300 000 per year.^1-5 Currently, there is limited evidence demonstrating pharmacists' impact in mental health.^6,7

In recent years, the Veterans Health Administration and Department of Defense have seen a dramatic rise in the number of patients with mental health conditions, challenging the resources currently available to appropriately care for these patients. Nearly 2 million Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans have become eligible for Veterans Affairs (VA) health care since 2002, more than 1 million (61%) of whom have obtained such care.⁸ As of March 2015, 58% (685 540 veterans) of those who obtained VA care had received at least a provisional mental health diagnosis, the second most common diagnostic category after musculoskeletal concerns.⁸ The most common mental health diagnoses were post-traumatic stress disorder (PTSD, 55.2%), depressive disorders (45.0%), and anxiety disorders other than PTSD (43.1%).⁸

The primary care–mental health (PC-MH) service agreement at the South Texas Veterans Health Care System (STVHCS) outlines methods for management and referral of patients with mental health conditions. Uncomplicated mental health conditions, such as depression, anxiety, and PTSD, should be managed through at least 2 adequate antidepressant medication trials, if appropriate, prior to referral. Patients with schizophrenia, bipolar spectrum disorders, complicated depression or anxiety (eg, with suicidal ideation or psychosis), treatment-resistant depression, and other more complicated conditions, should be referred to specialty mental health.

Primary care providers (PCPs) may not be as experienced or as available as mental health clinical pharmacy specialists (CPSs) for managing medications for mental health conditions and providing the requisite close follow-up. At STVHCS, electronic consults (e-consults) may be submitted by health care providers to mental health CPSs for recommendations regarding optimal management of psychotropic medications for mental health conditions. The responding CPS has 7 days to review the patient's chart, including medical and mental health conditions, reason for consult submission, and prior psychiatric medication trials, if any, and then document this review and provide recommendations through a note in the chart. Recommendations vary but are typically to initiate, change, or continue psychotropic medication(s) or, in a small subset, to refer patients to specialty mental health if they meet PC-MH referral criteria.

The primary goal of the service is to manage patients with uncomplicated mental health conditions in primary care. This would leave specialty mental health providers more available for patients who meet PC-MH service agreement referral criteria and provide a more general arena to obtain mental health–related treatment for patients hindered by barriers, such as social stigma. The e-consults theoretically decrease time to care for patients with uncomplicated mental health conditions as these consult reviews and recommendation implementation do not require additional visits. This should subsequently decrease specialty mental health visits among patients not meeting criteria for such care, improving access for patients who need specialty services. The service was initiated at STVHCS in May 2014, and its value has not previously been assessed.

This quality improvement project was developed to evaluate the effectiveness of the mental health e-consult service by exploring the management and maintenance of patients in primary care following the e-consult as long as patients did not initially meet criteria for specialty mental health services. The apparent efficacy may be used later to guide service improvements.

Methods

Information was collected through a retrospective chart review of STVHCS veterans. The initial study population included any “PharmD MH Cons E-consult” note placed in patients' charts from May 2014 through December 2015. Patients who were already followed by a VA psychiatrist or other specialty mental health prescriber, whose consult reason did not align with the e-consult purpose, or who did not receive follow-up within STVHCS following the consult were excluded from analyses. Patients' mental health diagnoses were recorded along with consult submission and response dates, reason, recommendation(s) made, whether the recommendation was implemented (and if so, the outcome since implementation), and, finally, whether the patient was subsequently maintained in primary care or referred to mental health.

The primary outcomes as markers of effectiveness of the service were the number of recommendations implemented and, more notably, the number of patients maintained in primary care. Theoretical time- and cost-savings were secondarily reviewed as markers of access to care and impact on wait times for patients meeting criteria for specialty mental health. Cost-savings were based on average annual wages for psychiatrists and pharmacists in the United States: $200 000 and $120 000, respectively.^9,10 If no consult service was available and all patients were referred to specialty mental health, each would be seen roughly 4 times within the first year of referral, including an initial 60-minute intake visit and three 30-minute follow-up visits. Clinical pharmacy specialists average 30 minutes to review and respond to each consult regardless of the reason for submission or whether the patient already sees specialty mental health. For calculation purposes, a CPS or psychiatrist full-time equivalent (FTE) is 40 h/wk for 52 wk/y.

Results

Consults were submitted for 353 unique patients plus 8 reconsults, totaling 361 consults in 20 months (Figure). Thirty-one patients were not included in the primary analysis due to being submitted for inapplicable reasons, which left 322 patients potentially eligible for maintenance in primary care. Patients' mental health diagnoses at the time of consult included depression, anxiety, PTSD, insomnia, bipolar disorder, and alcohol/substance use disorders (Table 1). Many patients had more than 1 relevant diagnosis.

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TABLE 1 Mental health diagnoses at the time of consult submission

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Most recommendations were implemented (87.7%), and the overwhelming majority of these patients were maintained in primary care. Recommendations were consistent and similar across all CPSs, and examples of recommendations are provided in Table 2. Of the 322 patients, 301 (93.5%) were maintained in primary care for at least 3 months whereas 21 patients (6.5%) were not. Of those not maintained in primary care, most recommendations were implemented (15/21, 71.4%). However, patients had specialty mental health intake concurrently with or within fewer than 3 months of the consult in a majority of cases (19/21).

TABLE 2 Examples of pharmacist recommendations for patients maintained in primary care

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Reasons 21 patients were not maintained in primary care included mental health referral despite appropriateness for primary care (n = 8); 2 or more medication trials and/or persistent symptoms that warranted mental health referral (n = 6); recommendation to consult mental health (n = 2); noncompliance with treatment plan (n = 2); patient or family request for mental health (n = 2); and persistent adverse events (n = 1). Those referred to mental health despite appropriateness for primary care included inadequate medication trial(s) in primary care, provider not agreeable to managing the recommendation, or provider referring to specialty mental health instead of implementing the recommendation.

Most providers implemented the recommendation(s) or at least reached out to the patient to discuss the recommendation within 0 to 5 days of CPS response (n = 194). Twenty-eight providers responded within 6 to 10 days, 9 within 11 to 20 and 21 to 30 days, and 19 responded after 30 days. Time to requesting provider's response was not considered for patients already followed by mental health or in cases in which the recommendation was not implemented, was to continue what the patient was already taking, or was for nonpharmacological measures or referral to mental health.

Discussion

The mental health CPS e-consult service is utilized by providers in every primary care clinic within STVHCS. The predominant diagnoses, depression, anxiety, and PTSD, mirrored the most common mental health diagnoses documented in veterans who have become eligible for VA health care since 2002.⁸ These are common conditions that may not require referral to specialty mental health and therefore are appropriate to manage in primary care.

Most recommendations were implemented, and patients were typically maintained in primary care for at least 3 months as a result of the service. The largest subset not maintained in primary care was referred to mental health despite appropriateness for primary care. These 8 patients could have been reconsulted or referred to behavioral health providers embedded in primary care for closer management and follow-up.

Clinical pharmacy specialists responded to the vast majority of consults within 1 to 2 days, and most providers acted on the recommendation within 10 days. This decreased time to care for such patients as they did not have to wait for a face-to-face visit with another provider. Theoretical time- and cost-savings support the value of the e-consult service. Mental health CPSs have specialized training in psychiatry and are widely utilized in STVHCS to help manage any severity of mental health conditions. Utilizing this service allows PCPs to obtain recommendations from medication experts in mental health while saving the time of other specialty mental health providers. Although the estimated $40 000 saved by the service does not cover a psychiatrist or mental health CPS FTE, contributing this money toward a mental health CPS position offers another provider to help meet the clinic access needs of the overwhelming number of veterans with mental health conditions while sufficiently covering the time spent reviewing and responding to the e-consults (0.052 FTE).

A limitation of this review is its retrospective nature as the duration of time from consult submission to chart review ranged from a few months to 1.5 years. Therefore, a comprehensive assessment of subsequent mental health referral is not possible. Additionally, relying on prescriptions and notes written in veterans' charts limits a complete understanding of veterans' conditions, preferences, past trials, and discussions with providers regarding medications. For many patients, there was no documentation following consult response, or a prescription was entered with no subsequent documentation regarding medication success or lack thereof. Last, time- and cost-savings calculations are limited as they compare psychiatrists and CPSs without considering other specialty mental health providers with prescribing privileges. However, the authors believe this limitation is somewhat mitigated by the fact that CPSs are medication experts and are well equipped to effectively manage these conditions. Additionally, utilizing e-consults in lieu of specialty mental health providers (psychiatrists, midlevel providers, or other mental health providers with prescribing privileges) leaves these providers more available for individuals needing more specialized care.

The rate of implemented recommendations and maintenance of patients in primary care lends credence to the CPSs' clinical judgment and their value in helping maintain patients in primary care according to the PC-MH service agreement. This service is not and should not be used to replace specialty mental health consults for veterans who may need specialized care and who meet PC-MH service agreement criteria for referral. However, it should encourage further consideration by PCPs regarding the appropriate management setting as a number of patients had a consult for specialty mental health submitted concurrently with the e-consult. If unsure about the appropriate level of care, it is prudent for providers to submit the e-consult so that a mental health CPS can review the veteran's history and make a recommendation accordingly.

Conclusion

The mental health pharmacist-managed e-consult service impacts mental health care—and its access by patients—by promoting successful management and maintenance of less complicated patients in primary care. Despite 10 different mental health CPSs responding to the consults, the recommendations were uniform across providers, and an overwhelming majority of these were implemented even in patients later referred to specialty mental health. This service offers evidence-based recommendations to manage uncomplicated mental health conditions in primary care and, in doing so, may improve access to specialty mental health for veterans who need it.