Jerry McKeeMore than occasionally I am asked, by individuals who are sincere, yet uninformed, why healthcare needs a psychiatric pharmacy specialist or why the Board of Pharmacy Specialties (BPS) recognizes psychiatric pharmacy as a clinical specialty. My response typically proceeds as follows, in an attempt to elevate the questioner’s understanding of the complexity of care for persons with mental illness, why comprehensive care of this population should be important to payers, and why pharmacists with specific demonstrated expertise in this area are critical to the improving their care.

Persons with severe and persistent mental illnesses, such as schizophrenia, bipolar disorder, and treatment resistant depression often have difficulties accessing care and as a result, may receive suboptimal general medical care. One related effect of this care gap is the documented up to twenty-five year decrement in lifespan in this population compared to those without serious mental illness. Medicaid beneficiaries with a mental illness or substance use disorder (MI/SUD) have approximately 70 percent higher healthcare costs and are 4-5 times more likely to be hospitalized than matched cohorts without MI/SUD. Pharmacists with an expertise in working with these populations, as a member of the health care team, are essential for improving outcomes and reducing overall health care costs. As such, this population represents a huge opportunity for board certified psychiatric pharmacists (BCPPs).

Integration of Behavioral Health and Primary Care Needs
The separation between primary care and behavior health care has evolved over many years through interpretations of confidentiality guidelines, issues of stigma, managed care carve-out programs, and inadequate benefit coverage for behavioral health treatments, among other issues. As the above data point out, it has become increasingly evident that this “siloed system of care” not only provides little to no coordination of care, but it also is dangerous for the patients we serve. No longer can a care model be supported that ignores the reality that patients frequently have mental and physical co-morbidity factors, and one cannot be optimally managed in the absence of optimal management of the other condition. It is critical that barriers to coordinated/integrated care be eliminated to allow for a full exchange of information that can help ensure the safe management of both medical and behavioral conditions. As just one example, the need to share information among providers regarding the concomitant use of medications with potentially serious interactions (e.g., opioid pain medications, skeletal muscle relaxants, and benzodiazepines) along with the awareness of certain aspects of care that must be carefully evaluated and monitored (e.g., metabolic syndrome) are crucial to best practice models of care.

In the behavioral health arena, an often overlooked solution to the dual issues of poor access to care and lack of integration of the physical and behavioral health care models (and the associated dearth of care coordination and related integrated management of medication related issues) is to more effectively utilize appropriately trained board certified psychiatric pharmacists to support patient-focused care. According to Terry McInnis, M.D., (co-lead of the medication management task-force of the Patient-Centered Primary Care Collaborative (PCPCC)), “The need is clear for patients with chronic disease who frequently see multiple providers or transition between sites of care. As a physician, bringing clinical pharmacists into the “team” that are both capable and willing to collaboratively deliver this level of service represents the most transformational paradigm shift in healthcare.”

Working as part of the multi-disciplinary team, pharmacists have a unique set of knowledge and skills that are ideal for providing comprehensive medication management. In this regard, board certified psychiatric pharmacists embrace the concept of team-based care that involves the psychiatric and medical team, patient, and family members. With the documented significant impact of multiple chronic diseases (with the behavioral health disorder either primary or underlying) and corresponding multiple medications on health care resource utilization, the benefit of pharmacists’ engagement in medication management has been clearly outlined. Patients not meeting clinical goals are at an increased risk for emergency department visits or hospital admissions. It has been demonstrated that patients who may derive the most benefit from pharmacist engagement are those who have not achieved or maintained therapeutic goals of treatment, who may be experiencing adverse medication effects (which may impact adherence), who may have difficulty in understanding and following the medication regimen, and who are frequently admitted or readmitted to the hospital or receive care through emergency departments. Integrated and comprehensive medication management is effective in solving drug therapy problems to ensure that medications are appropriate, effective, safe, and taken as intended. BCPPs, by virtue of demonstrated skills and training in both general medicine and psychiatry, can assist in bridging the gap between primary care and psychiatric specialty providers in serving patients with psychiatric and medical comorbidities.

This model, in several variations, has been in place for many years in the Veterans Healthcare system, state funded psychiatric inpatient hospitals and centers for persons with intellectual disabilities, Kaiser, many federally qualified healthcare centers, and others. However, the current need for such services clearly outstretches the implementation at present.

Opportunities for Growing Successful Care Integration
To more fully implement this team based, integrated practice model in a more widespread fashion, clearly more board certified psychiatric pharmacists (currently <900) are needed. Intensive and collaborative efforts at growing the specialty have been in place for the last decade. Fundamental elements include exposing students in training to pharmacy faculty with clinical training and expertise in psychiatric and neurologic pharmacy, along with adequate time within the curriculum to cover the material adequately. The College of Psychiatric and Neurologic Pharmacists (CPNP) and the American Association of Colleges of Pharmacy are developing surveys for schools of pharmacy programs and their faculty members to assess teaching, psychiatry focused advanced practice training sites, and residency training in psychiatry and neurology. As one benchmark of early success in growing the specialty efforts, in the last six years, the number of PGY-2 psychiatry specialty residency positions has quadrupled to the present seventy-three, in an effort to meet this burgeoning demand for well-trained psychiatric pharmacist practitioners.

As the capstone to post-doctoral training and clinical skills preparation, board certification through BPS is the gold standard for determining which pharmacists are qualified to contribute at the advanced practice level in psychiatric pharmacy practice. Being recognized as a BPS Board Certified Psychiatric Pharmacist brings instant professional recognition and credibility as an expert in psychopharmacology and behavioral health matters among clinical colleagues and peers. It is vitally important that BPS continue to aggressively market the significance of board certification (in all specialties) for patients, professional colleagues, care teams, employers, and payers. Pharmacy must share the impact of what we do outside of the circle of pharmacy. Additional outcomes data further substantiating the value that BPS certified pharmacy specialists bring to health care will only serve to assist the ongoing quest for continued growth of the specialties, obtaining provider status, and receiving appropriate reimbursement for clinical services.

Until we move closer to reaching the objectives outlined above in terms of growing the number of BCPP practitioners, board certified psychiatric pharmacists must find creative yet effective mechanisms to extend their reach via collaboration with ambulatory care pharmacy specialists and community pharmacists to assure appropriate and improved care for persons with mental illness. Such initiatives could be characterized as pharmacy’s efforts at internal care integration.

In conclusion, there is much work to be done to more fully integrate psychiatric pharmacists into multidisciplinary care teams, and in integrating psychiatry and primary care services in general throughout the healthcare system. With the support of BPS, pharmacy education leadership, as well as pharmacy professional association leadership, the ground work and infrastructure is being built to be successful, and with ongoing and sustained efforts, the future is beckoning for us to be engaged in supporting persons with mental illness in all of our healthcare communities.

Jerry McKee PharmD, MS, BCPP
McKee currently serves as Assistant Director-Pharmacy Operations and Payer Programs with Community Care of North Carolina. Previously he was Regional Dean and Associate Professor of Pharmacy with Wingate University-Hendersonville. He is a past president of the College of Psychiatric and Neurologic Pharmacists and past member and chair of the BPS Psychiatric Pharmacy Specialty Council. His professional interests include psychiatry and mental health services

Suggested References

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Final report for the President’s new freedom commission on mental health. In: Achieving the promise: Transforming mental health care in America. Vol SMA 03-3832. Substance abuse and mental health services administration: SAMHSA’s National Mental Health Information Center; 2003:1-84.; Accessed July 24, 2015.

Druss BG, Walker ER. Mental disorders and medical comorbidity. Synth Proj Res Synth
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Boyd C, Leff B, Weiss C, et al. Clarifying multimorbidity patterns to improve targeting and delivery of clinical services for medicaid populations. Center for Health care strategies.
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Croghan TW, Brown JD. Integrating mental health treatment into the patient centered medical home. In: Mathematica policy research. AHRQ Publication No. 10-0084-EF ed. Rockville, MD: Agency for Healthcare Research and Quality; June 2010.

McKee JR, Lee KC, Cobb CD. Psychiatric Pharmacist Integration into the Medical Home. The Primary Care Companion to CNS Disorders 08/2013; 15(4).