Originally run in the March 2017 edition of Perspective, this guest column is back by popular demand in this edition of CPNP Perspective.
Lori J. Golterman, PharmD, National Director of VA Residency Programs and Education
Anthony P Morreale, PharmD, MBA, BCPS, FASHP, Assistant Chief Consultant Clinical Pharmacy Services and Healthcare Services Research
Pharmacy Benefits Management VA Central Office.
VA has made the treatment of mental health disorders a consistent top priority. The wars in Afghanistan and Iraq are the longest combat operations since Vietnam. The number of mental health patients seen within the VA has increased by 80% from 2005-2015 as an increasing number of Veterans return from active duty. This number will continue to rise in the coming years as our country remains at war and we become more aware of the psychiatric implications war has on our Veterans. Fifteen percent or more of Veterans of the Vietnam War and 1991 Gulf War have received diagnoses of post-traumatic stress disorder (PTSD).1 Studies have found that 17% of Veterans returning from Iraq showed signs for major depression, generalized anxiety, or post-traumatic stress disorder and that combat duty was associated with high utilization of mental health services.2-3 Another study found that 31% of Operation Enduring Freedom and Iraqi Freedom (OEF/OIF) Veterans received mental health and/or psychosocial diagnoses.4 In 2005, 19% of VA users received mental health services, in 2015, the figure was 28%. These numbers emphasize the need to prepare for increased mental health care. In response to a growing demand for Mental Health (MH) Care services, VA has increased the number of mental health patient encounters and increased mental health staffing, but more mental health professionals are needed to keep pace with the increase in demand.
In a memorandum written by the former Deputy Under Secretary Feeley, in 2008, VHA recommended that clinical pharmacists be included on care teams in MH services. At this time, VA had several board certified psychiatric pharmacists (BCPPs) to meet this demand, but clearly more specialty MH trained pharmacists were required. VA’s supported this need and in doing so committed funds for the training of a broad professional group dedicated to mental health care. This group included psychiatrists, psychologists, social workers, chaplains and pharmacists. From 2011-2016, VA Medical Centers were asked to compete for funds to expand their training programs, and pharmacy aggressively competed for these funds. Over the past five years, pharmacy residency trainees grew from 11 residents to over 75 mental health residents and residency programs that began at 5 and grew to over 55 programs nationwide. VA pharmacy residency programs are now the largest training program nationally for post-graduate year two in psychiatry. Our ASHP accredited programs have filled our trainee positions consistently and we have worked proactively to hire our residents to meet VA’s demand for increased Mental Health care professionals. This would not have been possible without our MH board certified Residency Program Directors and our MH Clinical Pharmacy Specialists (CPS’s) that serve as preceptors, mentors and role models for VA residents.
Psychiatric CPS’s have advanced knowledge in psychopharmacology and the application of safe and effective use of medications utilized in the treatment of neuropsychiatric disorders. Psychiatric CPS’s address the needs of mental health patients through their involvement in an inter-disciplinary treatment and learning teams or as primary psychiatric care providers. The CPS is responsible for optimizing patient care by recommending and implementing appropriate treatment plans, monitoring patient response, and identifying medication-related problems (i.e., drug interactions, adverse drug reactions, therapeutic duplications). This is particularly important with psychotropic agents. Furthermore, elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death compared to those treated with placebo. The pharmacy specialist is uniquely qualified to monitor, educate and manage these clinical issues.
In VA, the CPS is an Advanced Practice Provider who is authorized, under a scope of practice, and VA policy5 to autonomously prescribe and monitor medications in a variety of practice settings. There is an essential need for trained and experienced providers to bridge the gaps in access to care and the Mental Health CPS’s serve to meet those needs. They expand access to care by minimizing the patient’s need to see multiple providers, by conducting medication assessments and evaluations which allows the provider time to be utilized for patient evaluation including identification of illnesses and assessment of severity, crisis management, and provision of non-pharmacological treatment. VA Pharmacy currently has approximately 3,675 of more than 8,200 CPS’s that work under a scope of practice serving as Advanced Practice Providers. The CPS plays an increasingly larger role in Mental Health where the number of pharmacists with a scope of practice in MH has grown over 175% since 2011. There are over 314 MH CPS’s with a scope of practice and prescriptive privileges in Mental Health in 116 VA Medical Centers and their associated Community Based Outpatient Clinics. Moreover in fiscal year 2016, there were over 176,000 MH encounters documented by CPS.
There is strong evidence that CPS improve access, clinical outcomes and cost effectiveness when properly deployed. Studies have shown that the Return on Investment (ROI) for every $1 invested in Clinical Pharmacy Services, more than $4 in benefit is seen8. As discussed earlier, the MH CPS serves in many key roles to improve patient-centered care and medication outcomes by applying the principles of team based care and population management. The CPS can provide same day access for patient needs related to medication management and is an integral member of the healthcare team, advocating for the patient to assure safe medication practices are delivered. These many roles of a MH CPS establishes a shared care decision making environment between the provider and the patient and ensures the Veteran receives the very best care and access to care when necessary.
The growth of MH CPS’s has been accelerating as VA leadership has recognized their training, skills and abilities to bridge the gaps in access to care. The MH CPS is a MH prescriber who is an asset to the MH team by providing essential medication management services, acts as preceptors in training residents, serves to educate other health care team members, provides immediate access to care for Veterans and will provide a continuity of care for the Veterans they serve. VA is not unique in the need for pharmacists with advanced MH skills. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), nearly half of the American adults who perceived a need for MH care did not pursue it due to cost. More importantly, 11.8 million Americans reported they had unmet needs for additional MH services. Other agencies report unmet MH needs for adolescents and the elderly. Clearly, the need for MH professionals is in demand and the demand will continue to grow. Well trained MH clinical pharmacists offer patients of any age the opportunity to have a professional discuss MH issues and provide much needed care.