In New York State, one in five residents experience symptoms of mental illness each year. Half of those individuals live with mental illness serious enough to affect their ability to get an education, hold down a job and form relationships, according to the state Department of Health. Many are unemployed. Some have been homeless. All are at risk of harm or injury if left untreated. For those who seek help or are fortunate enough to get referred to the care system, treatment usually includes seeing clinicians and counselors who develop a detailed path to recovery. Appointments are made, peer groups are arranged and case managers are assigned. For some, medications are prescribed. All too often, patients’ care teams have little visibility into whether these medications ever make it to the end user.
It’s widely accepted that up to 50 % of prescribed medications are not taken. While non-adherence can be an issue in any patient group, the problem is magnified for those living with a mental illness. For them, almost one-third who experience challenges in accessing needed medications will experience treatment lapses or discontinuation with serious impacts. These include significantly higher rates of emergency room visits, hospitalizations, side effects that interfere with functioning, and even suicide.
The barriers to taking medication as prescribed also differ starkly for those with mental health issues. Cognitive impairment and substance misuse play a much greater role. Unfortunately, stigma associated with behavioral health issues and negative attitudes towards illness and medication therapy still play a large role. Other major barriers include costs and lack of transportation. For these reasons, collaboration among the various parts of the health care system is critical for people being treated for mental illness.
One Solution: Integrated Pharmacy
Integrating pharmacy services is an innovative solution that addresses many barriers to medication adherence. It is gaining prominence as more data comes to light about its effectiveness. Pharmacists are on the front lines of care, and have the expertise and problem-solving skills necessary to help people stay on their medications. Pharmacists have the clinical knowledge necessary to navigate the complex drug treatment plans and the technical know-how when it comes to Medicare, Medicaid and commercial payers. By integrating on-site pharmacy services, behavioral health organizations can leverage this resource and add value to their programs.
Having a pharmacy staff who understands behavioral health clients’ needs allows for more personalized service and a greater focus on treating this population. These pharmacies can provide solutions such as pre-filled pill organizers that feature a color-coded system developed specifically for people living with severe and persistent mental illness. They can also provide personalized refill reminder calls, synchronize medication refills, help clinic staff with prior authorization assistance, and provide free delivery and mail services. Since on-site pharmacies are focused on serving the client in their clinic, they can provide individualized service and offer these solutions to a bigger proportion of their client population, helping to address access and illness-related barriers. This approach also enables clients to develop a trusting relationship with another member of their care team – their pharmacist. This in turn, helps alleviate the stigma this population can face in a retail pharmacy environment.
Integrating pharmacy also gives the care team another point of contact who can see when clients are not taking their medications. During my time as a pharmacist with Genoa Healthcare, managing an integrated pharmacy on Long Island, I was often able to recognize when consumers weren’t taking their medications and share this with the therapist or prescriber. For example, one individual mentioned she had not been taking her anti-depressant because she didn’t feel that she needed it anymore. Another told me he only took his anti-depressant when he was “feeling down.” Pharmacists often come across such stories, but in a traditional retail setting they lack the connection required to share this information with the care team. By contrast, an on-site pharmacy enables close communications between the pharmacist and care team. Having a pharmacist as part of the care team can also help with prior authorizations. For example, a clinic may provide an on-site pharmacist read-only access to the electronic health record. This enables the pharmacist to know if requirements for prior therapy for a drug have been met and to prepare the paperwork for the prescriber’s signature. This takes the burden off the care team, freeing them to focus on other tasks. The integrated pharmacist can communicate the status of the authorization to the care team more efficiently, and ensure the client receives an alternative in the interim. Resolving prior authorizations quickly means fewer gaps in treatment for consumers.
Better Adherence: Improved Health Outcomes
The benefits of integrated on-site pharmacies are not just theoretical or anecdotal. A peer-reviewed study published by the Journal of Managed Care & Specialty Pharmacy correlated on-site pharmacy services with increased medication adherence rates and a reduction in emergency room visits and hospitalization rates. The study compared data from consumers of two community mental health centers to see if there were differences in medication adherence and outcomes between consumers who used on-site Genoa Healthcare pharmacies and those who used community pharmacies. Clients using on-site pharmacies had a medication adherence rate of over 90 %, a 40 % lower rate of hospitalizations and an 18 % lower rate of emergency department visits. Based on costs of hospitalizations and emergency department visits, these reductions translate to an approximate health care system cost savings of $700 for each client that utilizes on-site pharmacy services. (W.A. Wright, et al, Integrated Pharmacies at Community Mental Health Centers: Medication Adherence and Outcomes. Journal of Managed Care and Specialty Pharmacy. 2016 Nov; 22(11):1330-1336).
Integrating pharmacy services can also benefit organizations looking to negotiate value-based reimbursement contracts with payers. On-site pharmacies can provide actionable data that can help identify individuals or teams with low medication adherence and high hospital utilization rates. Individualized solutions can then be developed and implemented to help improve their adherence rates. The same data can also be utilized to demonstrate to payers the value an on-site pharmacy adds and to negotiate better rates.
Although reducing the cost of care is an important goal, what is most gratifying to me personally is seeing the positive health outcomes in the individuals I’ve been privileged to serve. Being able to provide this population with high-touch care can make a world of difference, as the following example illustrates. William (name changed for privacy) came to a Genoa Healthcare pharmacy in Tennessee through a community mental health center. Like many of Genoa’s consumers, by the time he walked through our doors, he had been through a lot. While filling his prescriptions, the pharmacy team learned that William had diabetes and was homeless. He hadn’t eaten in three days. He was depressed, he was angry, and he wasn’t sure how he was going to make it. In line with our mission at Genoa, the team went far beyond simply filling his medications, starting with getting him something to eat. The only thing they asked in return was that he come back so they could continue to check on his well-being. With support from his pharmacists and his care team, William turned his life around. He told the pharmacy team that if he hadn’t crossed paths with them, his story would have been very different. Knowing that they cared enough to keep him safe renewed his motivation to make tomorrow better than yesterday, he said.
William is now reunited with his wife and children. He’s in recovery now, has a permanent home, and he’s holding down a stable job. Stories like this demonstrate the potential to change lives for the better. Under the care of an integrated team of behavioral health, primary care and pharmacy professionals, many patients are able to improve their lives.