Reducing Medication-Related Admissions for Psychiatric Disorders Lisa W. Goldstone, MS, PharmD, BCPS, BCPP Assistant Professor The University of Arizona Department of Pharmacy Practice and Science February 12, 2016

Statement of Disclosure The speaker has no conflicts of interest to disclose in regard to this presentation.

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Learning Objectives At the conclusion of the presentation, the audience member will be able to Describe the burden of medication-related admissions for psychiatric disorders Formulate a strategy for providing psychiatric pharmacy services for the purpose of reducing medication-related readmissions

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Burden of Psychiatric Medication-Related Admissions Psychiatric relapse is associated with a 2- to 5- fold increase in health care costs Mental/behavioral disorders account for 19.4% of Medicaid readmissions Nearly 90,000 emergency department (ED) visits annually are due to adverse effects from psychiatric medication Almost 20% of these ED visits result in a hospital admission

Markowitz et al. BMC Psychiatry. 2013;13(1):246. Trudnak et al. Health Affairs. 2014;33(8):1337-44. Hampton et al. JAMA Psychiatry. 2014;71(9):1006.

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Medication Nonadherence and Admissions Medication nonadherence results in $100 billion in yearly costs related to hospitalizations alone Patients with psychiatric disorders have some of the highest rates of medication nonadherence, ranging from 34-74%

Network for Excellence in Health Innovations. www.nacds.org/pdfs/2012/nehi-readmissions.pdf. Accessed on 7/24/14. Baldessarini et al. Hum Psychopharmacol Clin Exp. 2008;23:95-105. Lieberman et al. N Engl J Med. 2005;353:1209-53.

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Medical Readmissions and Psychiatric Disorders Readmissions for heart failure, acute myocardial infarction and pneumonia are 5% greater when a patient has a psychiatric comorbidity Higher likelihood of readmission for heart failure and pneumonia when a patient has a substance use and/or bipolar disorder A diagnosis of schizophrenia, depression, anxiety, and/or a neurocognitive disorder is associated with more medicine-related readmissions Ahmedani et al. Psychiatr Serv. 2015;66:134-40. Burke et al. J Hosp Med. 2013;8(8):450-5.

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Steps for Developing a Service Targeting Readmissions Identify Factors Leading to Readmission

Develop a Psychiatric Pharmacy Service and Determine Outcomes to Measure

Evaluate Outcomes and Share Results

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Factors Leading to Readmissions Lack of engagement in post-discharge care Medication nonadherence Substance use disorder comorbidities Increased number of psychiatric medications prescribed in the outpatient setting ***Also important to be aware of factors that may not lead to hospital readmissions***

Hamilton et al. J Eval Clin Pract. 2015;21:572-8. Regenstein et al. Qual Manag Health Care. 2014;23(1):20-42. Burke et al. J Hosp Med. 2013;8(8):450-5.

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Steps for Developing a Service Targeting Readmissions Identify Factors Leading to Readmission

Develop a Psychiatric Pharmacy Service and Determine Outcomes to Measure

Evaluate Outcomes and Share Results

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Example: Development of Services and Outcomes Service: Patient medication education group (PMEG) targeting specific factors leading to medication nonadherence Adverse effects and appropriate actions to take if these occur Importance of adherence Techniques to aid in remembering to take medication Effective communication with providers

Outcomes measured: Readmissions and patient attitudes/beliefs

Goldstone et al. Ment Health Clin. 2012;2(4):80-2.

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Outcome Measures Associated with Readmission Scores on Rating Scales Patient Health Questionnaire (PHQ-9) score predicts cardiac-related rehospitalization in patients with initial cardiac-related hospitalizations Each point on the PHQ-9 associated with a 9% greater likelihood of 6 month cardiac-related readmission

Beach et al. J Psychosom Res. 2013;75(5):409-13.

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Steps for Developing a Service Targeting Readmissions Identify Factors Leading to Readmission

Develop a Psychiatric Pharmacy Service and Determine Outcomes to Measure

Evaluate Outcomes and Share Results

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Outcomes: Reducing Medication-Related Admissions Medication evaluation and management including education resulted in a clinically significant improvement in PHQ-9 score Collaboration with a primary care physician including medication management and education resulted in a decrease in symptoms of depression and anxiety as measured by the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Anxiety Rating Scale (HAM-A)

Finley et al. J Am Pharm Assoc. 2011:51(1):40-9. Cabellero et al. Am J Health Syst Pharm. 2008;65(3):229-33.

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Outcomes: Reducing Medication-Related Admissions Filled prescriptions and medication education provided to patients at discharge resulted in a decrease in 30-day readmission rates. Provision of PMEG reduced readmissions related to medication nonadherence Percentage of patients readmitted due to nonadherence: 39% vs. 68% (p=0.03) Time to readmission: 94 days vs. 61 days (p=0.07)

Tomko et al. Hosp Pharm. 2013;48(4):314-20. Arterbury et al. J Pharm Pract. 2014;27(3):279.

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Value of Psychiatric Pharmacists Specialized training in psychiatric and neurologic disorders Board certification in Psychiatric Pharmacy (BCPP) indicates a pharmacist has both the knowledge and experience to work specifically with patients with psychiatric disorders

Qualified to provide services to patients with both psychiatric disorders and other general medical conditions Can partner with primary care physicians and generalist pharmacists to provide care for patients with complex comorbidities Goldstone et al. Ment Health Clin. 2015;5(1):1-28. McKee et al. Prim Care Companion CNS Disord. 2013;15(4).

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Future Directions Ensure every patient with a psychiatric and/or neurologic disorder has a psychiatric pharmacist on his or her healthcare team

Improve collaboration between acute and ambulatory care settings (transitions of care) Increase psychiatric pharmacy services in primary care and medicine settings

Advocate for increased mental health funding Reduce stigma

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Questions?

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