Supplementing Student Mental Health Care with Medication Therapy Management

1. We have NO actual or potential conflict of interest in relation to this educational activity or presentation.

2. Supplementing Student Mental Health Care with Medication Therapy Management Garrett Gilmer, Ph.D. Barbara Hoffman, MSN, CNP Lon Muir, Pharm.D., BSPS

3. Center for Health Student Health Service & Counseling Center

4. About BGSU • State-assisted university founded in 1910 • Main campus of over 20,000 students • Small college town approximately 25 miles south of Toledo, Ohio • More than 200 undergraduate majors and programs, 47 master's degree programs and 17 doctoral degree programs • BGSU has once again landed in the U.S. News’ “America’s Best Colleges”

5. Student Health Service Barbara Hoffman, MSN, CNP

6. Student Health Service • Staffing • Physicians • Certified Nurse Practitioners • Nurses • Medical Assistants • Lab Technicians • Pharmacists • Psychiatrists • Dietician

7. Student Health Service • Services • Allergy & Immunization • Laboratory Services • Men’s Health • Women’s Health • Full Service Pharmacy • Nutrition Services

8. Student Health ServiceDiagnosis Comparisons

9. Student Health ServicePsychiatric Appointments For 2010 Psychiatric Services are housed in the Student Health Service * Combined, Dr. Hoelzle and Dr. Schwendiman work approx. 12 hours a week

10. Counseling Center Garrett Gilmer, Ph.D.

11. Counseling CenterStaffing • Associate Director for Counseling Services • Assistant Director/Training Director • 3 full-time psychologists • 1 part-time psychologist • 1 part-time AOD counselor • 1 part-time clinical social worker • 1 part-time case manager • 3 full-time pre-doctoral interns • 4 clinical psychology graduate assistants • 1 masters level counseling intern

12. Counseling CenterServices • Individual/Group/Couples Counseling • Alcohol and Drug Educational Counseling • Case Management • Consultation • Crisis intervention • Outreach Approximately 5% of student body seen in Counseling Center each year

13. CounselingCenterNational Trends ACHA-NCHA II, 2010, p. 15

14. CounselingCenterNational Trends ACHA-NCHA II, 2010, p. 14

15. CounselingCenterNational Trends ACHA-NCHA II, 2010, p. 13

16. CounselingCenterNational Trends ACHA-NCHA II, 2010, p. 14

17. CounselingCenterNational Trends ACHA-NCHA II, 2010, p. 14

18. CounselingCenterMost Prevalent Presenting Concerns • Depression 20.6% primary concern; 9.9% secondary concern • Anxiety 13.7 % primary concern; 8% secondary concern • Romantic Relationship 12.3 % primary concern; 6.7% secondary concern • Academic/Career Concern 59.2% indicated that presenting concern was affecting their academic performance 21.3% were considering leaving the University

19. Counseling CenterPrevalence of Prior Treatment • 40% of students who sought counseling services this year reported a prior history of mental health services • 37.1 % of students who sought counseling services this year reported a history of treatment by psychotropic medication

20. BGSU Pharmacy Lon Muir, Pharm.D., BSPS

21. BGSU Pharmacy • Serve university students, faculty, and staff • Services available • Prescription services • Rx’s from any provider • Limited compounding • Third party billing • Student Insurance plan • Accept outside insurance plans

22. BGSU Pharmacy • Services cont… • Over-the-counter products • Wide variety of OTC products, DME, Diabetic supplies and special order products • BGSU Pharmacy facts • ~29,000 scripts/year • ~510 sq feet • 2.1 FTE Pharmacist, 1.4 FTE Technician • Located within the Student Health Service building • Training site for 6th year PharmD students

23. BGSU Pharmacy Hours • Semester Hours • Monday and Tuesday 8am-7:30pm • Wednesday and Thursday 8am-6:30pm • Friday 9:30am-4:30pm • Summer Hours • Monday- Friday 8am-4:30pm

24. MTM • What is Medication Therapy Management? • Service provided by pharmacists to optimize therapeutic outcomes for individual patients • May include: • Medication therapy reviews • Pharmacotherapy consults • Anticoagulation management • Immunizations • Health and wellness programs • Many other clinical services

25. What Makes Up an MTM? • First component- Evaluate a patient’s therapy for safety and effectiveness • Second component- Meet with the patient and discuss: • Purpose of the medication • Importance of taking the medication properly • possible side effects, drug-drug interactions, drug-food interactions • any other support to ensure positive outcomes with medication therapy • Third component – follow up with patient & provider

26. Difference Between MTM and Rx Counseling • Rx Counseling • Required OBRA90 • No reimbursement • Pertains to current medication being dispensed • MTM • Reimbursable • Comprehensive disease state management/review • Integration of pharmacy with existing clinical treatment team • Opportunities for collaborative practice agreements

27. History of MTM • Asheville Project • 1996 pharmacist began providing MTM services to patients suffering from diabetes, asthma, hypertension, and high cholesterol • MTM services began yielding positive results including decreased A1C levels, lower total health care costs, fewer sick days, and increased patient satisfaction with pharmacist’s services • Eventually led to outcomes studies regarding the services provided

28. The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care ProgramCarole W. Cranor, Barry A. Bunting, and Dale B. Christensen • Objective - Assess outcomes of diabetic pharmaceutical care services up to 5 years after initiation of program • Design - Quasi-experimental, longitudinal pre−post cohort study • Setting - 12 community pharmacies located within Asheville, NC. • Patients or other participants - 136 Diabetic patients receiving benefits from employer’s self-insured health plans. Diabetic trained community pharmacists. • Intervention(s) - Patients received diabetic education from the community pharmacists and were included in scheduled follow-ups, clinical assessments, goal setting, monitoring, and collaborative practice agreements with the patient’s physician. • Main outcome measure(s) - Changes in A1c, serum lipid concentrations and changes in diabetic and overall medical utilization costs. • Results - A1c levels decreased in greater than 50% of subjects compared to baseline. With each subsequent follow-up the number of patients experiencing optimal A1c’s increased. 50% of patients also showed improvements in lipid levels during the follow-up time-frame. Average annual direct medicals costs decreased $1,200 to $1,872 per year. • Conclusion(s) - Diabetic patients receiving advanced pharmaceutical care exhibited improved A1c’s and also had decreased annual direct medical costs.

29. The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for AsthmaBarry A. Bunting and Carole W. Cranor • Objective - Assess 207 adult asthmatic patients for clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program • Design - Quasi-experimental, longitudinal pre−post cohort study • Setting -12 community pharmacies located within Asheville, NC. • Patients or other participants - 207 Asthmatic patients receiving benefits from employer’ self-insured health plan. 18 trained hospital and community pharmacists. • Intervention(s) - Patients received Asthma education from trained pharmacist and were included in scheduled follow-ups, monitoring, and recommendations to the patient’s physician. • Main outcome measure(s) - Changes in FEV1, asthma severity, symptom frequency, degree to which asthma affected people’s lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time. • Results - All asthma outcome measures improved and were sustained for 5 years, with significant changes in FEV1 and severity classification. The number of patients with asthma action plans increased to 99% from 63%, ER visits decreased to 1.3% from 9.9%, and hospitalization decreased from 4% to 1.9%. Patients spent more on asthma medications, spent less on total asthma-related costs, and had less asthma related medical claims. Total annual direct and indirect costs decreased on average by $725/patient and $1230/patient respectively. • Conclusion(s) - Asthmatic patients receiving education and MTM services experienced significant improvements in control of disease state and a significant decrease in overall asthma-related costs.

30. Applications of MTM Services • MTM services can be implemented for: • Diabetes, asthma, hypertension, hyperlipidemia, psychological disorders, GI issues, and other chronic disease states. • Patients with multiple disease states experiencing poly-pharmacy • MTMs can occur in almost any healthcare setting • Retail pharmacy, hospital, college-health, mental health institutions, clinics, community health departments, doctor’s offices, etc…

31. MTM in College Health • Prevalence • Not a common practice • Younger population with less chronic disease states • Documentation of established programs • Model for Medication Therapy Management in a University Clinic. Mary Ann Kliethermes, Anne Marie Schullo-Feulner, Jessica Tilton, Shiyun Kim, and Annette Nicole Pellegri • The Role of a Psychiatric Pharmacist in College Health. Caley CF, Webber D, Kurland M, Holmes P. • Applications within college health • Same as non-college health settings • Chronic disease states, poly-pharmacy, and patient’s needing additional pharmaceutical education

32. MTM for Mental Health • Services could be provided to patients with depression, bipolar, anxiety, schizoaffective disorders etc… • Medications used to treat these disease states: • Exhibit complex side effect profiles • Require additional lab monitoring • Potential for multiple drug interactions • May have narrow therapeutic windows • Adherence is extremely important

33. MTM for Mental Health • Benefits include: • Additional point of symptom monitoring • Identifying, preventing and resolving medication-related problems • Actively monitor patients medication treatment plan, labs and progress • Integration of pharmacy with existing treatment team • Readily available to answer medication related questions • Student education • Disease state • Side effects • Goals • Evaluate outcomes • Medication adherence • Hopefully…adherence improves with increased patient education

34. Reimbursement Staffing Training MTM Planning Outcomes Documentation Implementation

35. MTM Training *Any Pharmacist may provide MTM services* • Levels of involvement: • Depends on staffing and also established relationships with providers Basic Involvement Reviewing therapy and educating patient High Involvement Modifying therapy and ordering labs

36. MTM Training cont… • Training • Pharmacy Schooling • Skills developed during pharmacy curriculum • Continuing Education • Focus on mental health disease state • In-services • Provided by specialist (e.g. Rph, Nurse, Physician) • BGSU received training support from a local college of pharmacy instructor • MTM specialty training • Usually provided by Schools of Pharmacy • Online? • Board Certified Psychiatric Pharmacist • Board of Pharmacy Specialties

37. MTM Reimbursement • Cash • Designate a charge and bill each patient directly • Barrier to treatment? • Third Party • Medicare Part D patients • The Pharmacist would perform an MTM visit and bill accordingly using the Medicare Part D MTM codes 99605-99607.

38. MTM Reimbursement cont… • Third Party • Non-Medicare patients • 99211-99215 office visit codes • Per protocol Rph would provide MTM service and a physician would review the form, sign and also sit with the patient for a moment to review the results. • 99401-99404 codes • Counseling Risk Factor Reduction and Behavior Change Intervention Codes • Similar procedures to 99211-99215 billing option • Better reflect services provided?

39. Staffing • Situational • Not all pharmacies/SHS clinics have the same staff available • Single pharmacist provide service • Multiple pharmacists providing MTM services • External per diem staffing • BGSU has a single pharmacist providing services

40. Documentation • Develop form(s) containing: • Clinical information • Patient demographics, medical history, family history, social history, current medications, relevant lab work, patient’s goals, etc… • Evaluations • MMSE, PHQ9, AIMS assessments • Reimbursement information • Topics covered and length of time spent with patient covering specific topics

41. Documentation cont…

42. Implementation • Entire program implementation • Multi-phase approach • Phase 1- Referral based • Phase 2- Include specific inclusion criteria • Narrow therapeutic medications, Poly-pharmacy, specific disease states, etc…. • Educate providers regarding MTM services • Need support from clinical staff • BGSU adopted a multi-phase approach and is in Phase 1

43. Outcomes • Surveys for patients • Satisfaction, increased adherence, improved symptoms • Surveys for physicians • Satisfaction, disease state improvement • Chart Review • Disease state improvement, kept appointments, clinical progress • Other outcomes • Academic retention, cost reduction

44. Outcomes cont… • BGSU MTM program: • Utilizing patient surveys and chart review • Retention • Increased adherence • Satisfaction • Clinical improvement

45. Obstacles • Reimbursement • Work closely with billing department to track reimbursement history • Obtaining referrals from providers • Continue to educate and promote MTM services

46. Patient # 1 • 19yo F, undergraduate, has previously been treated for other mental health disorders in the past • Diagnosis: Mood D/O NOS, social phobia, anxiety, panic D/O • PMH: Reflex sympathetic dystrophy, asthma, headaches, psychotropic seizures • Reason Referred: Counseling Center referral due to academic probation, non-compliance • Current Medications: • Abilify 30 mg daily • Trazodone 100 mg one-two tablets at bedtime • NuvaRing • Gabapentin 600 mg three times daily • Omeprazole 20 mg daily • OTC naproxen or ibuprofen when needed • Utilization of other psychological services: currently sees psychiatrist (has history of compliance with appointments)

47. Patient # 1 Outcome • MTM Session • Reviewed individual medications • Established goals • Stressed importance of adherence to obtain goals • Provided patient with daily pill reminder

48. Patient # 1 Outcome • Clinical Notes • Most recent psychiatrist visit: Patient was doing very well, no troubles sleeping, appetite good, no further mood swings, declines side effects and anxiety. Feels like she is in better control of her emotions and less irritable. Currently enrolled in classes.

49. Patient # 2 • 21yo F undergraduate • Diagnosis: Depression, compulsive behavior • PMH: Fibromyalgia • Reason referred: patient self referral – had multiple questions regarding medications, SE, benefits, MOA, etc. • Current Medications • Lyrica 75 mg daily • Lamotrigine 50 mg twice daily • Mirtazapine 15 mg at bedtime • Has tried Effexor, Cymbalta, Celexa, Buspar, and Prozac but has been noncompliant with all due to side effects • Utilization of other psychological services: psychologist, unhappy with counseling services

50. Patient # 2 Outcome • MTM Session • Established goals of learning more about medication and obtaining positive mood without side effects • Reviewed current therapy • Discussed Buspar vs. Lamictal • Educated on diagnosis, risks and benefits of medications and importance of adherence • Clinical Notes • Patient appeared to benefit from discussing medications with the pharmacist. Was very pleased with those services. Current regimen is allowing her symptoms to become better controlled with few side effects