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

Center for Health Student Health Service & Counseling Center

About BGSU State-assisted university founded in 1910State-assisted university founded in 1910 Main campus of over 20,000 studentsMain campus of over 20,000 students Small college town approximately 25 miles south of Toledo, OhioSmall 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 programsMore 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 Americas Best CollegesBGSU has once again landed in the U.S. News Americas Best Colleges

Student Health Service Barbara Hoffman, MSN, CNP

Student Health Service StaffingStaffing o Physicians o Certified Nurse Practitioners o Nurses o Medical Assistants o Lab Technicians o Pharmacists o Psychiatrists o Dietician

Student Health Service ServicesServices o Allergy & Immunization o Laboratory Services o Mens Health o Womens Health o Full Service Pharmacy o Nutrition Services

Student Health Service Diagnosis Comparisons

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

Counseling Center Garrett Gilmer, Ph.D.

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

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

Counseling Center National Trends ACHA-NCHA II, 2010, p. 15

Counseling Center National Trends ACHA-NCHA II, 2010, p. 14

Counseling Center National Trends ACHA-NCHA II, 2010, p. 13

Counseling Center National Trends ACHA-NCHA II, 2010, p. 14

Counseling Center National Trends ACHA-NCHA II, 2010, p. 14

Counseling Center Most 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

Counseling Center Prevalence 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

BGSU Pharmacy Lon Muir, Pharm.D., BSPS

BGSU Pharmacy Serve university students, faculty, and staffServe university students, faculty, and staff Services availableServices available o Prescription services Rxs from any provider Rxs from any provider Limited compounding Limited compounding o Third party billing Student Insurance plan Student Insurance plan Accept outside insurance plans Accept outside insurance plans

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

BGSU Pharmacy Hours Semester HoursSemester Hours o Monday and Tuesday 8am-7:30pm o Wednesday and Thursday 8am-6:30pm o Friday 9:30am-4:30pm Summer HoursSummer Hours o Monday- Friday 8am-4:30pm

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

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

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

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

The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program Carole W. Cranor, Barry A. Bunting, and Dale B. Christensen Objective - Assess outcomes of diabetic pharmaceutical care services up to 5 years after initiation of programObjective - Assess outcomes of diabetic pharmaceutical care services up to 5 years after initiation of program Design - Quasi-experimental, longitudinal prepost cohort studyDesign - Quasi-experimental, longitudinal prepost cohort study Setting - 12 community pharmacies located within Asheville, NC.Setting - 12 community pharmacies located within Asheville, NC. Patients or other participants Diabetic patients receiving benefits from employers self-insured health plans. Diabetic trained community pharmacists.Patients or other participants Diabetic patients receiving benefits from employers 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 patients physician.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 patients physician. Main outcome measure(s) - Changes in A1c, serum lipid concentrations and changes in diabetic and overall medical utilization costs.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 A1cs 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.Results - A1c levels decreased in greater than 50% of subjects compared to baseline. With each subsequent follow-up the number of patients experiencing optimal A1cs 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 A1cs and also had decreased annual direct medical costs.Conclusion(s) - Diabetic patients receiving advanced pharmaceutical care exhibited improved A1cs and also had decreased annual direct medical costs.

The Asheville Project: Long-Term Clinical, Humanistic, and Economic Outcomes of a Community-Based Medication Therapy Management Program for Asthma Barry 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) programObjective - Assess 207 adult asthmatic patients for clinical, humanistic, and economic outcomes of a community-based medication therapy management (MTM) program Design - Quasi-experimental, longitudinal prepost cohort studyDesign - Quasi-experimental, longitudinal prepost cohort study Setting -12 community pharmacies located within Asheville, NC.Setting -12 community pharmacies located within Asheville, NC. Patients or other participants Asthmatic patients receiving benefits from employer self- insured health plan. 18 trained hospital and community pharmacists.Patients or other participants 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 patients physician.Intervention(s) - Patients received Asthma education from trained pharmacist and were included in scheduled follow-ups, monitoring, and recommendations to the patients physician. Main outcome measure(s) - Changes in FEV 1, asthma severity, symptom frequency, degree to which asthma affected peoples lives, presence of an asthma action plan, asthma-related emergency department/hospital events, and changes in asthma-related costs over time.Main outcome measure(s) - Changes in FEV 1, asthma severity, symptom frequency, degree to which asthma affected peoples 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 FEV 1 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.Results - All asthma outcome measures improved and were sustained for 5 years, with significant changes in FEV 1 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-relatedConclusion(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.

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

MTM in College Health PrevalencePrevalence o Not a common practice Younger population with less chronic disease states Younger population with less chronic disease states o 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 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. The Role of a Psychiatric Pharmacist in College Health. Caley CF, Webber D, Kurland M, Holmes P. Applications within college healthApplications within college health o Same as non-college health settings Chronic disease states, poly-pharmacy, and patients needing additional pharmaceutical education Chronic disease states, poly-pharmacy, and patients needing additional pharmaceutical education

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

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

MTM Planning Documentation Reimbursement Implementation Training Outcomes Staffing

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

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

MTM Reimbursement CashCash o Designate a charge and bill each patient directly Barrier to treatment? Barrier to treatment? Third PartyThird Party o Medicare Part D patients The Pharmacist would perform an MTM visit and bill accordingly using the Medicare Part D MTM codes The Pharmacist would perform an MTM visit and bill accordingly using the Medicare Part D MTM codes

MTM Reimbursement cont… Third PartyThird Party o Non-Medicare patients office visit codes 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. 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 codes codes Counseling Risk Factor Reduction and Behavior Change Intervention Codes Counseling Risk Factor Reduction and Behavior Change Intervention Codes Similar procedures to billing option Similar procedures to billing option Better reflect Better reflect services provided?

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

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

Documentation cont…

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

Outcomes Surveys for patientsSurveys for patients o Satisfaction, increased adherence, improved symptoms Surveys for physiciansSurveys for physicians o Satisfaction, disease state improvement Chart ReviewChart Review o Disease state improvement, kept appointments, clinical progress Other outcomesOther outcomes o Academic retention, cost reduction

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

Obstacles ReimbursementReimbursement o Work closely with billing department to track reimbursement history Obtaining referrals from providersObtaining referrals from providers o Continue to educate and promote MTM services

Patient # 1 19yo F, undergraduate, has previously been treated for other mental health disorders in the past19yo F, undergraduate, has previously been treated for other mental health disorders in the past Diagnosis: Mood D/O NOS, social phobia, anxiety, panic D/ODiagnosis: Mood D/O NOS, social phobia, anxiety, panic D/O PMH: Reflex sympathetic dystrophy, asthma, headaches, psychotropic seizuresPMH: Reflex sympathetic dystrophy, asthma, headaches, psychotropic seizures Reason Referred: Counseling Center referral due to academic probation, non-complianceReason Referred: Counseling Center referral due to academic probation, non-compliance Current Medications:Current Medications: o Abilify 30 mg daily o Trazodone 100 mg one-two tablets at bedtime o NuvaRing o Gabapentin 600 mg three times daily o Omeprazole 20 mg daily o OTC naproxen or ibuprofen when needed Utilization of other psychological services: currently sees psychiatrist (has history of compliance with appointments)Utilization of other psychological services: currently sees psychiatrist (has history of compliance with appointments)

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

Patient # 1 Outcome Clinical NotesClinical Notes o 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.

Patient # 2 21yo F undergraduate21yo F undergraduate Diagnosis: Depression, compulsive behaviorDiagnosis: Depression, compulsive behavior PMH: FibromyalgiaPMH: Fibromyalgia Reason referred: patient self referral – had multiple questions regarding medications, SE, benefits, MOA, etc.Reason referred: patient self referral – had multiple questions regarding medications, SE, benefits, MOA, etc. Current MedicationsCurrent Medications o Lyrica 75 mg daily o Lamotrigine 50 mg twice daily o Mirtazapine 15 mg at bedtime o 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 servicesUtilization of other psychological services: psychologist, unhappy with counseling services

Patient # 2 Outcome MTM SessionMTM Session o Established goals of learning more about medication and obtaining positive mood without side effects o Reviewed current therapy o Discussed Buspar vs. Lamictal o Educated on diagnosis, risks and benefits of medications and importance of adherence Clinical NotesClinical Notes o 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

Patient # 2 Outcome cont… Patient FeedbackPatient Feedback o Enjoyed talking to the pharmacist about her medications. Thought it was beneficial and gave her a better understanding of her medication regimen

Patient # 3 26yo M, undergraduate26yo M, undergraduate Diagnosis: Bipolar, DepressionDiagnosis: Bipolar, Depression PMH: Ewings SarcomaPMH: Ewings Sarcoma Reason Referred: Physician referral – patient had questions about SE, benefits, and interactions. Also wanted to discuss smoking cessation options with his medicationsReason Referred: Physician referral – patient had questions about SE, benefits, and interactions. Also wanted to discuss smoking cessation options with his medications Medications:Medications: o Depakote ER 500 mg daily o Has tried SSRI but developed side effects and stopped taking it Utilization of psychological services include counseling services weekly and psychiatristUtilization of psychological services include counseling services weekly and psychiatrist

Patient # 3 Outcomes MTM SessionMTM Session o Established goals of obtaining better control of bipolar disease state o Reviewed current therapy o Discussed safety of medications and beginning smoking cessation products o Educated on diagnosis, risks and benefits of medications and importance of adherence o Recommended for PCP to monitor LFT, CBC, vision, EPS Clinical NotesClinical Notes o The patient enjoyed talking to the pharmacist about his medications o Monitoring parameter within normal limits

Patient # 3 Outcomes cont… Patient FeedbackPatient Feedback –Based on patient satisfaction survey the student thought MTM was extremely valuable with an increase in medication compliance from 70-80% to %. The patient also feels like his symptoms are extremely controlled and that he has achieved better academics since the MTM. He also would recommend MTM services to others.

Looking Forward BGSU Mental Health MTMBGSU Mental Health MTM o Phase 2- Include specific inclusion criteria Narrow therapeutic medications, Poly-pharmacy, specific disease states, etc…. Narrow therapeutic medications, Poly-pharmacy, specific disease states, etc…. Fall 2011 Fall 2011 BGSU MTM programBGSU MTM program o Offer services for other disease states requiring high levels of education Asthma and diabetes Asthma and diabetes

References American College Health Association-National College Health Assessment II: Reference Group Executive Summary Fall Linthieum, MD: American College Health Association; Bunting BA, Smith BH, Sutherland SE. The Asheville Project: clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48: Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43: Kliethermes MA, Schullo-Feulner AM, Tilton J, Kim S, Pellergri AN. Model for medication therapy management in a university clinic. Am J Health Syst Pharm. 2008;65(9): Caley CF, Webber D, Kurland M, Holmes P. The role of a psychiatric pharmacist in college health. J Am Coll Health. 2010;58(4):393-3.

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