Role of a psychiatric pharmacist in a Los Angeles "Skid-Row" safety-net clinic

Outcomes of the LEAP feasibility trial-A low-threshold, exercise programme with protein supplementation to target frailty and poor physical functioning in people experiencing homelessness and addiction issues

BACKGROUND

People experiencing homelessness are more likely to experience poor health with physical functioning deficits and frailty commonly reported. It is not well known how strategies to target physical functioning deficits and frailty work in practice in this group. The primary aim of this study was to explore the feasibility of an exercise intervention with protein supplementation to target physical functioning and frailty in people experiencing homelessness evaluated by recruitment and retention rates, adherence to the exercise sessions and protein supplement, adverse effects, programme feedback and characteristics of non-returners, sporadic and frequent attenders. The secondary aim was to evaluate changes in effectiveness outcomes of grip strength, muscle mass, lower extremity physical function, pain, frailty, and risk of malnutrition.

METHOD

This prospective single-arm study evaluated the feasibility of a 16-week rolling, low-threshold, 'drop-in' once weekly exercise programme with protein supplementation. The main recruitment site was a day-service centre for people who are homeless. Feasibility was assessed by the recruitment and retention rates, adherence to the exercise sessions and protein supplement as well as adverse effects, programme feedback and evaluation of characteristics of non-returners, sporadic (≤50% of available sessions) and frequent attenders (≥50% of available sessions). Effectiveness outcomes included pain (Visual Analogue Scale), physical functioning and performance (hand-grip dynamometry, limb circumference, the Short Physical Performance Battery), frailty (SHARE-FI and Clinical Frailty Scale) and nutritional status (Mini Nutritional Assessment).

RESULTS

Thirty-one participants were recruited mean (SD) age 45(16) years. There was a recruitment rate of a median (IQR) of 2(1-3) new participants per week. The retention rate was 45% (n = 14) to the main recruitment site. Adherence to the exercise sessions and nutritional intervention was 90% and 100% respectively. Three adverse events were recorded during 74 interventions over the 16-week programme. The acceptability of the programme was highlighted in participant feedback. Characteristics of frequent returners (≥50%) were older age, female, more stably housed and more stable in addiction. The programme did not induce any changes in effectiveness outcomes.

CONCLUSION

The feasibility of this programme was demonstrated. Overall, the programme was well received with higher retention rates in older participants, females, those more stably housed and those stable in addiction. A higher powered, more intense programme is needed to demonstrate programme effectiveness.

Systematic literature review of the impact of psychiatric pharmacists

Introduction

Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes.

Methods

A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version.

Results

A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes.

Discussion

The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.

Impact of Postgraduate Second-Year Pharmacy Training (PGY2) on Clinical, Financial, and Educational Outcomes: A Scoping Review

OBJECTIVE

A scoping review was conducted to screen the published literature on the clinical, financial, and educational effect of postgraduate second year (PGY2) pharmacy residency training.

FINDINGS

A search strategy was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Central and Web of Science without study design, language, or time restrictions (inception to March 2022). Articles were reported using the PRISMA reporting items list. Studies were included if a measurable clinical outcome, a cost-avoidance calculation and/or involvement in teaching or research activities was reported. Studies were excluded if there was no mention of a PGY2 training. Of the 2534 articles that were screened, 21 articles met our inclusion criteria. Seven studies reported clinical outcomes, five reported cost avoidance, six reported educational outcomes and three studies reported both clinical and cost-avoidance outcomes. Four of the studies evaluating clinical outcomes took place in a psychiatric clinic setting. Better disease control was reported in four articles. Two studies evaluated readmission and emergency department visits at 30 days but only one showed significant reduction. The estimated cost avoidance reported ranged from $22,380 to $5,387,679 and two studies reported the services billed by the resident. In two studies, PGY2 pharmacists were more likely to be involved in teaching activities and were more likely to participate in research activities.

CONCLUSION

Even though few studies evaluated the benefits of PGY2 pharmacy trainings, they showed to improve patient care, enhance involvement in teaching activities, and decrease financial burden for health-care systems. More studies should be done to reinforce the merits of such training.

Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California

BACKGROUND

Access to water and sanitation is a basic human right; however, in many parts of the world, communities experience water, sanitation, and hygiene (WaSH) insecurity. While WaSH insecurity is prevalent in many low and middle-income countries, it is also a problem in high-income countries, like the United States, as is evident in vulnerable populations, including people experiencing homelessness. Limited knowledge exists about the coping strategies unhoused people use to access WaSH services. This study, therefore, examines WaSH access among unhoused communities in Los Angeles, California, a city with the second-highest count of unhoused people across the nation.

METHODS

We conducted a cross-sectional study using a snowball sampling technique with 263 unhoused people living in Skid Row, Los Angeles. We calculated frequencies and used multivariable models to describe (1) how unhoused communities cope and gain access to WaSH services in different places, and (2) what individual-level factors contribute to unhoused people's ability to access WaSH services.

RESULTS

Our findings reveal that access to WaSH services for unhoused communities in Los Angeles is most difficult at night. Reduced access to overnight sanitation resulted in 19% of the sample population using buckets inside their tents and 28% openly defecating in public spaces. Bottled water and public taps are the primary drinking water source, but 6% of the sample reported obtaining water from fire hydrants, and 50% of the population stores water for night use. Unhoused people also had limited access to water and soap for hand hygiene throughout the day, with 17% of the sample relying on hand sanitizer to clean their hands. Shower and laundry access were among the most limited services available, and reduced people's ability to maintain body hygiene practices and limited employment opportunities. Our regression models suggest that WaSH access is not homogenous among the unhoused. Community differences exist; the odds of having difficulty accessing sanitation services is two times greater for those living outside of Skid Row (Adj OR: 2.52; 95% CI: 1.08-6.37) and three times greater for people who have been unhoused for more than six years compared to people who have been unhoused for less than a year (Adj OR: 3.26; 95% CI: 1.36-8.07).

CONCLUSION

Overall, this study suggests a need for more permanent, 24-h access to WaSH services for unhoused communities living in Skid Row, including toilets, drinking water, water and soap for hand hygiene, showers, and laundry services.

Global Advancement in Pharmacy Services for Mental Health: A Review for Evidence-Based Practices

The symptoms of psychiatric infirmities have variability, and selected drug regimens for mental illness are comparatively complex and individualized; therefore, pharmacy services vary with respect to patients, diseases, healthcare settings, community structures, and countries. Clinical pharmacy services for mental health (MH) are continuously being upgraded. A structured search of the literature was performed in the Cochrane, PubMed (Medline), PsycINFO, Google scholar, Scopus, Science Direct, and Springer Links databases. The title and abstract of each retrieved article were evaluated for relevance. To remove uncertainty and ambiguity, the full-text articles were retrieved and examined for relevance. The articles were further assessed on the basis of inclusion and exclusion criteria. Narrative synthesis was performed, creating new categories and relevant subcategories and further subsections. The articles and the results were assessed for quality and bias. Pharmacists have a range of expertise in psychiatric care. The services can be classified as conventional, extended, and advanced pharmacy services. Conventional services include the quality use of medicines in healthcare settings and medication support services in communities that ensure medication adherence. Pharmacists perform extended roles in collaborative medication therapy management, multidisciplinary community mental health teams, collaborative care, patient education, home medication review, hospital-to-home transit, and screening services. In the USA, the role of pharmacists was advanced by prescribing as collaborative and interim prescribers. Australia launched an accredited program for psychiatric first-aid pharmacists. Pharmacists can provide mental care to rural populations using health technology. The role of pharmacists in MH is appreciated either independently or as a team member. Patients and healthcare providers rank the services of pharmacists in MH highly. Still, there is a margin for improvement in the training of pharmacists. Pharmacists cannot provide sufficient time to their patients. Public awareness about the role of pharmacists in MH needs more attention. Moreover, the training of psychiatric pharmacists should be standardized around the world.

Best practice model for outpatient psychiatric pharmacy practice, part 2: Confirmation of the attribute statements

Introduction

The American Association of Psychiatric Pharmacists (AAPP) used multiple modalities to develop and refine 28 attribute statements to describe a best practice model for outpatient psychiatric pharmacists. Before addressing implementation, assessment, and field testing, it was necessary to finalize and confirm the statements and their supporting narratives among stakeholders. The objective of this project was to confirm the attribute statements and supporting justifications for a best practice model for outpatient psychiatric pharmacists providing direct patient care.

Methods

The 4 phases that resulted in the 28 attribute statements and supporting narratives have been described and published elsewhere. As part of phase 5, the confirmation survey was distributed to pharmacists and resident members of AAPP in November 2021 for 3 weeks.

Results

The survey respondents (n = 74; 6.1%) were licensed pharmacists for an average of 15.6 years (SD = 12.0) and had been practicing as psychiatric pharmacists for an average of 11.3 years (SD = 10.4). Slightly more than half (54.2%) of the respondents reported practicing in the outpatient setting and three-fourths (74.3%) were Board Certified Psychiatric Pharmacists. For each of the 28 statements, more than 90% of respondents either agreed or agreed with minimal reservations.

Discussion

Given the high degree of agreement on the proposed practice model statements, they will be used as the basis for the outpatient psychiatric pharmacist best practice model. Next steps in developing this model include establishing implementation guidance, determining appropriate metrics for evaluation of these statements in practice, and establishing appropriate field-testing methods.

Pharmaceutical Care in the Treatment of Substance Use Disorders in Jordan: A Randomized Controlled Trial

BACKGROUND

Substance Use Disorder is a chronic relapsing disease that is characterized by compulsive drug seeking and use, despite harmful consequences. The aim of this study was to evaluate the impact of clinical pharmacist intervention/recommendation on the treatment of patients admitted to addiction rehabilitation centers in Jordan.

METHODS

A randomized controlled trial was conducted in two public addiction treatment centers in Amman. Patients (n = 93) were randomized into 2 groups (control and intervention). Medication review was conducted for both groups at baseline, during stay and at discharge. Treatment related problems (TRPs) were identified by the clinical pharmacist and recommendations provided to the therapeutic team in the intervention group. Additionally, quality of life and quality of sleep were assessed at baseline and 2 weeks later.

RESULTS

A total of 392 TRPs were identified during the study period. The mean number of TRPs ± SD was 4.22 ± 2.58 per patient. The clinical pharmacist intervention led to a reduction in the mean number of TRPs at discharge by 2.2 ± 0.85 (p < 0.001) in comparison to the control group (by 0.23 ± 0.27, p = 0.066). After 2 weeks of admission, there was an improvement of physical health (p = 0.035) and of the overall sleep status (p = 0.048) in the intervention vs. control groups.

CONCLUSION

Clinical pharmacy services provided to patients with substance use disorder reduced the number of TRPs and improved other outcomes such as physical health and quality of sleep during detoxification. Long term studies with larger sample sizes are needed.

Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

BACKGROUND

Achieving equity of access to primary healthcare requires organizations to implement innovations tailored to the specific needs and abilities of vulnerable populations. However, designing pro-vulnerable innovations is challenging without knowledge of the range of possible innovations tailored to vulnerable populations' needs. To better support decision-makers, we aimed to develop a typology of pro-vulnerable organizational innovation components - akin to "building blocks" that could be combined in different ways into new complex innovations or added to existing organizational processes to improve access to primary healthcare.

METHODS

To develop the typology, we used data from a previously conducted a) scoping review (2000-2014, searched Medline, Embase, CINAHL, citation tracking, n = 90 articles selected), and b) environmental scan (2014, online survey via social networks, n = 240 innovations). We conducted a typological analysis of the data. Our initial typology yielded 48 components, classified according to accessibility dimensions from the Patient-Centred Accessibility Framework. The initial typology was then field-tested for relevance and usability by health system stakeholders and refined from 2014 to 2018 (e.g., combined similar components, excluded non-organizational components).

RESULTS

The selected articles (n = 90 studies) and survey responses (n = 240 innovations) were mostly from the USA, Canada, Australia and the UK. Innovations targeted populations with various vulnerabilities (e.g., low income, chronic illness, Indigenous, homeless, migrants, refugees, ethnic minorities, uninsured, marginalized groups, mental illness, etc.). Our final typology had 18 components of organizational innovations, which principally addressed Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Components included navigation & information, community health worker, one-stop-shop, case management, group visits, defraying costs, primary healthcare brokerage, etc. CONCLUSIONS: This typology offers a comprehensive menu of potential components that can help inform the design of pro-vulnerable organizational innovations. Component classification according to the accessibility dimensions of the Patient-Centred Accessibility Framework is useful to help target access needs. Components can be combined into complex innovations or added to existing organizational processes to meet the access needs of vulnerable populations in specific contexts.

Establishing a pharmacist-managed outreach clinic at a day shelter for homeless veterans

INTRODUCTION

The US Department of Veterans Affairs (VA) has developed a homeless patient aligned care team (H-PACT) model to provide clinical outreach to homeless veterans. This model has not been implemented by the VA Sierra Nevada Health Care System; however, a day shelter for homeless veterans does exist. Currently, clinical staff at the shelter consists of licensed clinical social workers.

METHODS

A half day per week pharmacy clinic was established and managed by a postgraduate year-2 psychiatric pharmacy resident. Data regarding provider and emergency department (ED) visits, psychotropic medication adherence, and interventions made during visits were collected and analyzed to provide support for need of additional clinical staff and the establishment of an H-PACT at the Reno VA.

RESULTS

Over 5 months, 52 veterans were seen, including some over multiple visits, with a total of 77 encounters. There were an average of 4 visits per clinic day. Total interventions equaled 205 and included medication review, patient education, and adverse drug reaction detection among other interventions. Provider visits and psychotropic medication possession prior to and following clinic visits were tracked.

DISCUSSION

This pharmacist-managed outpatient clinic provided a comfortable walk-in environment for homeless veterans. The difference in provider visits, medication possession, and ED visits before and after walk-in clinic visits provided clinical significance with 205 documented interventions, and the clinic was well received by veterans.

[Pharmaceutical Assistance in Mental Health: a diagnosis of Psychosocial Care Centers]

The study evaluated the conditions of Pharmaceutical Assistance (PA) in Psychosocial Care Centers (CAPS) through a cross-sectional study in 15 CAPS located in the Médio Paraopeba region of the State of Minas Gerais. Data collection was conducted through direct observation of CAPS and interviews with pharmacists and managers of PA. The instruments were based on indicators proposed by the WHO, technical documents for the organization of PA, from legislation and recommendations seeking pharmaceutical Best Practices. There were 13 dispensing units, nine of them within the CAPS. The services presented updated lists of essential medicines with high availability of the main drugs used in mental health treatment. All of the cities participated in an inter-municipal consortium for the purchase of medicines. The complete identification of drugs was present in only seven services and all had failings in traceability of medicines dispensed. In the CAPS there is only one pharmacist during part of the operating period. The need for greater participation of the pharmacist was observed in the control and standardization of the activities of CAPS and especially in care activities comprising the benchmark team in Mental Health.

Development of Collaborative Drug Therapy Management and Clinical Pharmacy Services in an Outpatient Psychiatric Clinic

Collaborative drug therapy management (CDTM) is a written agreement that allows a pharmacist to initiate, modify, or continue pharmacotherapies under a physician's scope of practice. While available literature pertaining to cardiometabolic and respiratory CDTM services is growing, publications are sparse in psychiatry, particularly outside Veterans Health Administration medical centers. A descriptive study was undertaken to demonstrate how a board-certified psychiatric pharmacist would begin organizing a protocol for clinical pharmacy services at an outpatient, community treatment center for mental health and substance abuse disorders. The primary CDTM service proposed was metabolic monitoring for atypical antipsychotics, though profile reviews for medication reconciliation, drug level monitoring, and insurance coverage were also considered. Potential obstacles identified and worked through during the project included pharmacist-prescriber relationships, federal and state law requirements, pharmacy informatics development, and pharmacy services billing. Discussions with both administrative and medical stakeholders across the health system were essential in helping a pharmacist detail professional qualifications, justify positive impacts on patient outcomes, and navigate these legal and financial issues. The systematic approach arrived at through the study addresses current literature gaps concerning how pharmacists can evolve their practices from ancillary to collaborative design by nature within psychiatric settings.

Improving medication-related outcomes for patients with psychiatric and neurologic disorders: Value of psychiatric pharmacists as part of the health care team

Psychiatric pharmacists have specialized knowledge, skills, and training or substantial experience working with patients with psychiatric or neurologic disorders. As part of the collaborative team with a physician, psychiatric pharmacists can provide comprehensive medication management (CMM), a direct patient care service, to patients with psychiatric or neurologic disorders. CMM is a standard of care in which all medications for an individual patient are assessed to determine appropriateness, effectiveness, safety, and adherence. Studies have shown that when psychiatric pharmacists are included as part of the collaborative team with a physician, medication-related outcomes for patients with psychiatric or neurologic disorders improve. Despite the evidence supporting the value of psychiatric pharmacists as part of the health care team, the very limited mechanisms for compensation for CMM limit the numbers of patients with psychiatric or neurologic disorders who have access to services provided by a psychiatric pharmacist. We believe that all patients with psychiatric or neurologic disorders should have access to CMM provided by a psychiatric pharmacist.

New roles for pharmacists in community mental health care: a narrative review

Medicines are a major treatment modality for many mental illnesses, and with the growing burden of mental disorders worldwide pharmacists are ideally positioned to play a greater role in supporting people with a mental illness. This narrative review aims to describe the evidence for pharmacist-delivered services in mental health care and address the barriers and facilitators to increasing the uptake of pharmacist services as part of the broader mental health care team. This narrative review is divided into three main sections: (1) the role of the pharmacist in mental health care in multidisciplinary teams and in supporting early detection of mental illness; (2) the pharmacists' role in supporting quality use of medicines in medication review, strategies to improve medication adherence and antipsychotic polypharmacy, and shared decision making; and (3) barriers and facilitators to the implementation of mental health pharmacy services with a focus on organizational culture and mental health stigma. In the first section, the review presents new roles for pharmacists within multidisciplinary teams, such as in case conferencing or collaborative drug therapy management; and new roles that would benefit from increased pharmacist involvement, such as the early detection of mental health conditions, development of care plans and follow up of people with mental health problems. The second section describes the impact of medication review services and other pharmacist-led interventions designed to reduce inappropriate use of psychotropic medicines and improve medication adherence. Other new potential roles discussed include the management of antipsychotic polypharmacy and involvement in patient-centered care. Finally, barriers related to pharmacists' attitudes, stigma and skills in the care of patients with mental health problems and barriers affecting pharmacist-physician collaboration are described, along with strategies to reduce mental health stigma.

Nonpsychiatric medication interventions initiated by a postgraduate year 2 psychiatric pharmacy resident in a patient-centered medical home

OBJECTIVE

Studies have demonstrated the benefits of incorporating comprehensive medication management into primary care, but no study describes the types of nonpsychiatric medication-related interventions provided by a psychiatric pharmacist while providing comprehensive medication management.

METHOD

A chart review of Center for Community Health patients enrolled in the University of Southern California Psychiatric Pharmacy Clinic, Los Angeles, between July 1, 2013, and January 10, 2014, was conducted. Progress notes were reviewed to collect medication recommendations and interventions. The number and types of interventions were compared between groups based on substance abuse history, comorbid medical conditions, number of psychiatric diagnoses, and number of medications. An anonymous survey was distributed to primary care providers (PCPs) regarding perceptions and attitudes toward a postgraduate year 2 psychiatric pharmacy resident's interventions pertaining to nonpsychiatric medications.

RESULTS

177 nonpsychiatric medication interventions were documented. Fifty interventions required PCP approval, and 45% of those were accepted. Having a diagnosis of diabetes (P < .0001), hypertension (P < .0001), gastroesophageal reflux disease (P < .0001), ≥ 9 medications (P < .0001), or ≥ 5 medical diagnoses (P < .0001) were all associated with an increased mean number of interventions. Of the PCPs, 66% viewed the psychiatric pharmacist as a resource for addressing medical interventions by providing drug information. The PCPs were agreeable to having a psychiatric pharmacist provide drug information and monitor the patient but reported mixed opinions on whether a psychiatric pharmacist should comanage nonpsychiatric conditions.

CONCLUSIONS

Psychiatric pharmacists can successfully collaborate with PCPs in primary care clinics to provide comprehensive medication management that optimizes pharmacotherapy for patients with medical and psychiatric conditions. Continued efforts are needed to promote interdisciplinary approaches to provide comprehensive medication management services for patients with both psychiatric and medical disorders.

The relationship between medication-related problems and behavioural health condition among patients served by a health care for the homeless centre

Objectives

To evaluate the association between behavioural health conditions and the presence of a medication-related problem (MRP) and the association between the type of MRP and the presence of a dual diagnosis.

Methods

We used an existing database from a behavioural health clinic for homeless persons. Logistic regression was used to assess the relationship between the type of behavioural health condition and MRP presence, and whether the type of MRP varied with the presence of a dual diagnosis.

Key findings

A total of 426 patients were eligible. The majority were black (61%) and women (53%). Patients were 44.7 ± 10.2 years old, taking 3.4 ± 2.4 medications and had 2.3 ± 0.9 behavioural health conditions. The majority (53%) had a dual diagnosis, 44% had depression, 30% had a bipolar disorder, 26% had a personality disorder and 12% had an anxiety disorder. Bipolar [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.8–8.9] and anxiety disorders (OR 3.1, CI 1.0–9.2) and a dual diagnosis (OR 2.1, CI 1.2–3.8) were independently associated with the presence of an MRP. Patients with a dual diagnosis were more likely to have ineffective drug therapy (OR 1.7, CI 1.1–2.8) and less likely to have an adverse effect (OR 0.5, CI 0.3–0.9).

Conclusions

Patients with bipolar or anxiety disorders and/or a dual diagnosis may benefit from a pharmacist intervention to address MRPs. Pharmacists can make recommendations to improve the effectiveness of patients' medication therapy and help to resolve adverse effects.

Impact of pharmacists in mental health over the past decade

Purpose: As healthcare moves towards an interdisciplinary approach to improve clinical outcomes, it has become increasingly important for health care providers to collaboratively work together. Pharmacists have been working with psychiatrists for several decades to improve patient outcomes. However, their utility in psychiatry has not been recently elucidated. The purpose of this article is to describe and evaluate the impact of pharmacists in psychiatric settings over the past ten years.

Methods: A literature search was conducted using PubMed and CINAHL Plus with Full Text. Studies published between 2002 and 2011 were included. Additional studies were identified through references contained within the studies. Case reports and case series were excluded.

Results: Seventeen studies met the inclusion criteria: 15 studies in outpatient settings, two in inpatient settings. Outcomes measured included: patient symptoms, economic outcomes, medication adherence, and patient satisfaction. The majority of studies found improvements (e.g., resolution of symptoms, cost savings). However, controlled trials found no significant difference in clinical improvement from pharmacists' interventions.

Conclusion: Although the majority of studies suggest pharmacists provide positive outcomes, the trials vary widely in quality and measured outcomes. Additional controlled trials with more standardized methods are recommended to support the role of pharmacists in psychiatric settings.