Care Management - Pharmacy Effectiveness Enhancement

In order for medications to produce their optimal impact, they must be appropriately prescribed by physicians and taken as prescribed by patients. Regarding the quality of prescribing, a variety of trends support the use of programs such as BPM to be a foundation component of care management. These trends include changes in the traditional prescriber base of psychotropic medications, the growing number of these medications, and the multiple care providers required by individuals with SPMI and medical co-occurring illness.

While psychiatrists have often been responsible for the care of patients with SPMI, a large number of primary care physicians (PCPs) now treat patients with SPMI, given the growing recognition of medical co-occurring illnesses among these individuals. While consensus and evidence-based guidelines for this population have been developed, many PCPs are not familiar with these best practice guidelines and continue to lack knowledge regarding the risks and monitoring recommendations of psychotropic medications. Our growing pharmacopoeia also places psychiatrists at risk for being challenged by the need to stay current on rapidly evolving approaches to care. Therefore, physician education, monitoring and peer-to-peer consultations are critical in the successful management of healthcare conditions and costs for this population. Also critical is coordination of care among multiple caregivers – a situation far more frequent with the SPMI population than with general medical cases.

Pharmacy Effectiveness Enhancement: Treatment Adherence
Regarding treatment adherence, growing evidence identifies non- or partial use of prescrbed medication as a major public health issues across all of medicine, made more acute by the presence of SPMI. In addition to the solutions for psychotropic prescribing quality provided by BPM, attention to patient adherence is critical to the ensuring the effectiveness of any particular treatment regimen. Medication adherence is fundamental to the management of chronic conditions, made extremely complex with multiple co-occurring conditions. For people with SPMI, medication adherence is particularly important since medication is also critical to the management of symptoms and the ability to live successfully in the community. However, medication adherence rates for those with SPMI are significantly lower than among the general population with chronic medical conditions. Poor medication adherence is associated with worsening of disease, higher mortality and increased healthcare costs. In a recent NIMH-sponsored study, up to 75% of patients with SPMI stopped taking or switched their antipsychotic medication within an 18 month period.

Further, studies have clearly indicated that poor adherence results in higher rates of relapse and hospitalization. It is estimated that at least 40% of all SPMI relapses are a result of non-adherence. While believed that short gaps in medication filling (and taking) did not have a significant impact on a patient’s need for re-hospitalization, new data suggests that even a gap of less than 10 days can double the risk of hospitalization for patients with schizophrenia. Since medication therapies for the SPMI population are part of a lifelong burden, requiring patients to understand their condition and the role of medication in staying well, limited insight is often a contributor to poor adherence and resultant outcomes over the long-term. Equally disruptive to adherence are the challenges of cognitive dysfunction, illicit drug use and under-developed social networks faced by patients with SPMI. The case illustration of Sheila helps illuminates these facts.

Effective treatment adherence programs for patients with SPMI require

Healthcare practitioners to have accurate and timely information on a patient’s adherence behavior readily available in order to effectively support and intervene. Adherence is misjudged by practitioners and underestimated by patients. With adequate information, practitioners are in the best position to assess clinical need, barriers to and levers for maximizing treatment adherence. Pharmacy data analytics using medication possession ratios and dates of medication refill provide a cost efficient and practical method to inform prescribers on adherence behavior.
Healthcare practitioners to be adequately educated and embrace the importance of addressing adherence behavior in patient care. Healthcare practitioners need to be educated on the most recent findings regarding treatment adherence. Practitioners need practical resource tools to support their adherence interventions. Patient-specific information combined with easy-to-use adherence algorithms provide the practitioner with the tools needed to improve adherence behavior.
A positive relationship between patients and healthcare practitioners at every level of care delivery. The literature shows that patients who have poor insight into their disorder and lack clear treatment instructions do poorly in adhering to medication treatment.
Easy to use adherence-education information for patients when engaged in a supportive provider of care relationship. Patients often are unclear on many aspects of their medication treatment. Lack of insight, unclear treatment instructions, and poor communication skills can contribute to non-adherence behavior. Given the many challenges associated with psychiatric care of the severely ill, efforts to maximize information gathering for practitioners, facilitate practitioner-patient communication and mutual decision-making should significantly contribute to improving behavioral health treatment adherence.

Components of CNS’ approach to treatment adherence for patients with SPMI include:

Retrospective drug utilization review to determine the patterns of total and partial compliance for the purpose of creating a priority group of patients who need special intervention and continuous monitoring.
Continuous pharmacy surveillance for early notification of a prescription non-refilling for chronic mental or physical conditions.
National call center to contact a prearranged responsible party (a case manager and/or physician’s office) to provide notice of a delay in acquiring high priority medications.
Medication Possession Ratio (MPR) notification to designated parties with formal care management responsibilities to alert providers to ongoing MPR status or changes in refill gapsthat should be of concern.
Adherence awareness educational seminars for Community Mental Health Centers and other organized systems of care that can benefit from additional training on the research and methods found to best motivate patients to remain in treatment.
Adherence algorithm protocols for physicians of targeted patients to promote patient adherence that are provided with best practice guidelines on improving medication adherence. Adherence algorithm protocols are intended for interviews with patients during prescription refill visits.
Educational materials for consumers on treatment adherence can also be available upon request to be used by local clinicians and case managers.
No direct contact by CNS with patients. Instead, CNS relies on providing timely, well-organized information and direct contact with physicians and other caregivers that have established formal relationships with the patients targeted with CNS services.