There are a serval emerging areas in integrated care, including the emergency department, geriatrics, and clinical pharmacy.
The following are the results of one program’s attempts to integrate behavioral health into an emergency department. There are many iterations currently being piloted across the country with more to come in future years. Credit for this goes to Dr. Mary Peterson and colleagues at George Fox University.
Emergency Department Trend Data
Crisis Assessments: Patients presenting to Emergency Department with risk to self or others.
Location: Yamhill County, population, 90,000
Coverage: After hours call, 5:00 pm – 8:30 am, weekends and holidays
The number of risk assessments tripled from 349 in 2013 to 1252 in 2017.
Disposition following assessment,
- 18% Patients placed in acute care following initial screen
- 64% Discharged to community following initial screen
- 18% Other
Risk Assessment protocol includes
- Overview of psychological history, medical history, family history, trauma/abuse, alcohol/substance usage
- Assessment of both risk factors (Columbia Suicide Severity Rating Scale, CAMS) and warning signs (Collaborative Assessment and Management of Suicidality, CAMS)
- Collateral Information
- Current Level of Functioning/Mental Status
- Diagnosis, referral and recommendations for hospital
Behavioral Health Crisis Consultation Team Training Process at George Fox University
Although the 24 hrs of didactics provides a knowledge base, the most important training component for the behavioral health providers (BHPs) is the shadowing and observation process. This process follows the classic training model of teaching, observation of experienced providers.
Phase 1: Multiple observations of experienced provider
Phase 2: Demonstration while being observed and evaluated by experienced providers including extensive debriefing
Phase 3: Demonstration and multiple observations by experienced by supervising psychologists to ensure competency.
24 hr supervision by licensed psychologists. New BHP’s are required to call and staff all cases. BHPs are required to contact supervising psychologist for all hospitalizations.
CFHA is referenced as a represented organization in a presentation on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients at the Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado.
“The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included:
- Recognizing the importance of educating patients and healthcare providers about the Value of assessing current and baseline cognition;
- Emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and
- Recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.”
Key takeaway conclusions:
- There is a need to educate the public regarding the difference between screening, which identifies individuals at risk within an asymptomatic population, and diagnosis of a specific condition such as delirium or a dementing disease.
- It is important to emphasize that cognitive impairment screening is a measure of brain health, which needs to be monitored regularly in at-risk individuals to determine the fidelity of brain functioning.
- Cognitive impairment in older adults has multiple possible causes, including medical and psychiatric conditions, such as endocrine and metabolic conditions, chronic pain, depression, sleep disturbance, medication side effects, delirium, and brain diseases causing dementia, with Alzheimer’s disease and MCI being the most common.
- Cognitive impairment is a clinically dominant co-morbidity. Cognitive impairment is so serious that it overshadows the management of other health problems. It influences the effectiveness of doctor-patient communication, treatment adherence, the likelihood of medical follow-up, the selection of appropriate medications, and likely medication side effects.
- Cognitive evaluation to determine the causes and remediable factors contributing to impairment is necessary to guide the appropriate choice of medications and management.
- Collaborative care models that include the expertise of specialists in the area of cognitive assessment (i.e., neuropsychologists, neurologists, and geropsychiatrist) may be cost-effective and provide better quality care. In the emerging value over volume payment models, inclusion of cognitive specialists fits well into new team-based payment models that emphasize overall wellness.
- The EHR presents a great deal of promise for risk stratification modeling and for monitoring changes in cognitive screen performance over time. EHR automated tools for assessing and recording the results of individual’s cognition over time need to be developed.
- There is a need to increase awareness of identifying risk factors beyond medical data that include social, behavioral, and functional information.
- No one size fits all when assessing for cognitive impairment. It is important to recognize that the goals and means of cognitive assessment depend on the clinical setting and differ between the ED and the primary care environment.
- There is an important role that care managers or coordinators play in ensuring that people stay on a care pathway, and may also increase patient and caregiver satisfaction.
- There are deficiencies in health services in rural and economically disadvantaged America, resulting in a large gap in access to care and differences in resources such as care coordinators and cognitive specialists.
- Assessment of cognition must be done in a linguistically and culturally appropriate way to obtain meaningful results.
- There is a great need to increase advocacy regarding Medicare coverage and payment for a range of services and supports for beneficiaries with cognitive impairment (for example, including reimbursement for psychologists on interdisciplinary teams).
Today the pharmacist role is expanding beyond the once traditional medication “dispensing” role to that of an integrated, team-based care role. Pharmacists practicing within these expanded roles in a variety of healthcare settings are often termed “clinical pharmacists”. Most recently there has been an emergence of clinical pharmacist integration into primary care settings, with the goal of supporting patient-center, team-based care within medical homes. Trained as medication experts, pharmacists are poised to assist patients and primary-care teams in improving the quality and safety of medication use.
How are clinical pharmacists trained and prepared to participate in primary care teams:
- Doctor of Pharmacy (PharmD) curriculums train student pharmacists to provide patient-centered, population-based care, with a focus on health and wellness
- Within didactic and practice experiences, student pharmacists are trained in the principles of interprofessional collaboration, and given the opportunity to actively engage and participate in healthcare teams.
- The majority of clinical pharmacists have completed post-graduate residency training to further develop their clinical and team-based skills; residency training varies in length from 1-2 years.
- Following or during residency pharmacists may pursue board certification to demonstrate expertise in a specialized area of practice such as ambulatory care, pharmacotherapy, or psychiatric practice.
How can pharmacists support patient-centered, team-based care within medical homes?
- Chronic disease state/therapy management (CDTM or DSM)1
- Collaboration and shared responsibility for the management of chronic conditions such as hypertension, cardiovascular disease, diabetes, asthma, anticoagulation, depression, and others
- Assess medication effectiveness, provide recommendations to optimize medication costs, and perform interventions to improve medication adherence
- Comprehensive medication review/management (CMR or CMM)2,3
- Systematic review of a patient’s entire medication regimen including both prescribed and self-care medications, with the goal of:
- Assessing each medication for appropriateness, efficacy, safety and adherence
- Working with the patient and care team to develop and implement a personalized medication plan
- Documenting the plan within the medical record and communicating with other team members
- Population health initiatives4
- Review of patient registries to improve medication use, quality and safety
- Drug utilization reviews for high-risk medications
- Spearhead QI programs aimed at achieving performance and quality measures/goals related to medication use
- Education regarding evidence-based medication use
- Medication reconciliation and care transitions1
- Reviewing medication regimens post-discharge following hospitalization and providing necessary recommendations and education to prevent medication errors
What benefits can be expected by integrating clinical pharmacists into medical homes?
- Research across a variety of settings has demonstrated that pharmacy services are associated with:
- Improvements in therapeutic and safety outcomes related to medication use including hemoglobin A1c, LDL cholesterol, blood pressure, and adverse drug events5
- Favorable impacts on humanistic outcomes including medication adherence, patient knowledge, and quality of life5
- Cost savings related to decreased hospital admissions and appropriate medication use1
- Outcomes research related to pharmacist integration into medical homes is promising, but still in the early stages. There is a need for continued and expanded medical home demonstration projects involving clinical pharmacy.
Proposed aims of pharmacist integration within primary care:
- Support the care team in providing patient-centered, coordinated, comprehensive, accessible, and quality care, by providing services that optimize medication outcomes and promote safe, cost-effective medication use.1,3
- AHRQ Healthcare Innovations Exchange. Pharmacist-Led Medication Therapy Management Innovations. Available at: https://innovations.ahrq.gov/node/8397?utm_source=issueanc&utm_medium=email&utm_campaign=20160909
- Skaggs School of Pharmacy and Pharmaceutical Sciences. Clinical Pharmacy Resources: Incorporating Clinical Pharmacists in the PCMH Resource Toolkit. Available at: http://www.ucdenver.edu/academics/colleges/pharmacy/AcademicPrograms/clinical-pharmacy-toolkit/Pages/clinical-pharmacy-resources.aspx.
- Nigro SC, Garwood CL, Berlie H, et al. Clinical pharmacists as key members of the patient-centered medical home: an opinion statement of the ambulatory care practice and research network of the American College of Clinical Pharmacy. Pharmacotherapy. 2014;34:96-108. DOI: 10.1002/phar.1357
- McKee JR, Lee KC, Cobb CD. Psychiatric pharmacist integration into the medical home. Prim Care Companions CNS Disord. 2013;15:e1-e5. DOI: 10.1002/phar.1357
- Smith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists belong in the medical home. Health Affairs. 2010;29:906-913. DOI: 10.1377/hlthaff.2010.0209
- Coe AB, Choe HM. Pharmacists supporting population health in patient-centered medical homes. Am J Health-Syst Pharm. 2017;74:1461-1466. DOI: 10.2146/ajhp161052
- Chisholm-Burns MA, Lee JK, Spivey CA, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010;48:923-933. DOI: 10.1097/MLR.0b013e3181e57962