Development of Collaborative Drug Therapy Management and Clinical Pharmacy Services in an Outpatient Psychiatric Clinic

Abstract

Collaborative drug therapy management (CDTM) is a written agreement that allows a pharmacist to initiate, modify, or continue pharmacotherapies under a physician's scope of practice. While available literature pertaining to cardiometabolic and respiratory CDTM services is growing, publications are sparse in psychiatry, particularly outside Veterans Health Administration medical centers. A descriptive study was undertaken to demonstrate how a board-certified psychiatric pharmacist would begin organizing a protocol for clinical pharmacy services at an outpatient, community treatment center for mental health and substance abuse disorders. The primary CDTM service proposed was metabolic monitoring for atypical antipsychotics, though profile reviews for medication reconciliation, drug level monitoring, and insurance coverage were also considered. Potential obstacles identified and worked through during the project included pharmacist-prescriber relationships, federal and state law requirements, pharmacy informatics development, and pharmacy services billing. Discussions with both administrative and medical stakeholders across the health system were essential in helping a pharmacist detail professional qualifications, justify positive impacts on patient outcomes, and navigate these legal and financial issues. The systematic approach arrived at through the study addresses current literature gaps concerning how pharmacists can evolve their practices from ancillary to collaborative design by nature within psychiatric settings.

<p>Medication Therapy Management: Current Challenges</p>

“…The barriers identified in this narrative review align with those noted in prior reviews and demonstrates that barriers to MTM implementation have persisted since Medicare Part D was implemented in 2006. 10,[15][16][17][18][19]21,22,25,26,[30][31][32][33][34][35][36]40,41,[43][44][45][46][47][48] More work is needed to overcome these challenges and produce consistently positive outcomes from MTM. 48 The literature points to considerations for potential solutions for overcoming each of the identified challenges to MTM delivery and these are summarized below.…”

“…The literature demonstrates that physicians see the expansion of pharmacist roles as a threat to their practice's independence and autonomy. 34 Older physicians simply want to stick to "their own system of evaluating things" and concerns regarding pharmacists' clinical skills were unknown. 21 Technology A challenge that affects MTM delivery within the community pharmacy as well as across the health care continuum is technology.…”

“…Ambiguity and uneasiness amongst stakeholders surrounding the legality of billing for pharmacists' services also exists. 34 Collectively, low volume and low reimbursement make it difficult for many community pharmacies to make a business case for MTM delivery. 44…”

“…19 Pharmacists stated, unfortunately, some of our patients just aren't comfortable with the idea and others believe we are infiltrating their protected patient-provider relationship and counteracting or complicating the original therapeutic plan. 34 This disconnect between patient expectations and the services their pharmacist provide was identified by Bislew and Sorensen to be largely the reason why patients lack interest in pharmacist services. 46 In addition, limited studies demonstrated that patients were referred from physicians to pharmacists for MTM.…”

Assessment of the current practice of psychiatric pharmacists in the United States

“…11,12 However, these clinical services may be inconsistently provided nationwide due to variability in state pharmacy practice regulations, the inability to bill for pharmacy services, pharmacy informatics infrastructure, and the nature of pharmacist-prescriber relationships. 12,13 Pharmacists' impact, although embedded in clinical services, has been documented only on a small scale at certain practices 7-11 and may not necessarily reflect nationwide practice. The Professional Affairs Committee of the College of Psychiatric and Neurologic Pharmacists (CPNP) conducted a survey of psychiatric pharmacists to determine the types and scope of clinical practices in which psychiatric pharmacists are engaged.…”