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Benefits of an On-Site Pharmacy for Behavioral or Community Health Organizations

Introduction

In this era of patient-centered health care integration, many behavioral and community health centers have begun exploring ways of offering more comprehensive services, including the incorporation of pharmacy services. Behavioral health organizations such as Community Mental Health Centers (CMHCs) have become increasingly more aware of the benefits of integrating with preventive services, such as primary care and dentistry. As the Medical Home model gains more traction, both nationally and within individual states,1-4 more attention is also being focused on the addition of ancillary services such as pharmacy and laboratory offerings. The foundation of the Medical Home model and other integration efforts is centralization of medical care, and offering comprehensive services to individuals in one physical location is considered the ideal model. In behavioral health, medications have become a cornerstone of treatment, and handling meds has therefore become an operational necessity for centers. The focus of this paper is to describe the various ways in which a behavioral or community health organization can benefit from the integration of an on-site pharmacy into their service delivery model.

Benefits of an On-Site Pharmacy

Medications can be an important component in the management of many medical and psychological conditions. While they may be only one element in the treatment plan, they are often a critical factor in the management of conditions addressed by behavioral and community health organizations. A 2011 review of medicine use in the United States published by the IMS Institute for Healthcare Informatics reported that 3.1 million consumers were treated for a variety of mental health conditions using antipsychotic medications.5 Also, during the ten year period between 2001 to 2010, the number of Americans taking prescription medications for mental health disorders dramatically increased to one in five persons, while antipsychotic and ADHD medication usage more than tripled.6

In addition, according to a report from the National Center for Health Statistics published in May of 2014, the percentage of physician office visits in which drugs were ordered or provided was 75.1%.7 Integrating a pharmacy into the service offering of a behavioral or community health center is therefore a logical step in offering comprehensive services. The benefits of an on-site pharmacy can be stratified into two main categories: those directly aimed at the end consumer, and those affecting the healthcare organization and system.

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Benefits of an On-Site Pharmacy for Behavioral or Community Health Organizations

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In May of 2014, the percentage of physician office visits in which drugs were ordered or provided was 75.1%.

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Access to Prescribed Medications

Like any treatment, medications are only effective if people utilize them. Although medications are prescribed often as part of the treatment plan for many mental illnesses, the rate of non-adherence is particularly high in this population. The following non-adherence rates have been reported: 30% to 66% for major depression, 30% to 65% for bipolar disorder, and 40% to 50% for schizophrenia.8 To learn more about the impact of medication adherence on clinical outcomes, read our separate white paper, “Medication Adherence: Identify, Manage, Track, Improve.” One benefit of an on-site pharmacy service within a community behavioral health organization is increased access to prescribed medication.

The moment a consumer leaves the building where they see their prescriber, additional variables influencing the likelihood of prescriptions getting filled are introduced. Many consumers with mental illnesses are also disabled, and still others may have difficulty maintaining a job. Consequently, ready access to transportation may be a challenge for many consumers with mental illnesses. Having access to prescribed medications at an on-site pharmacy imbedded within the place where the consumers already see their provider will help overcome this barrier significantly. Furthermore, if an on-site pharmacy is available, providers can easily verify whether the consumer received their medications.

An on-site pharmacy designed to meet the needs of the organization it is housed within is also more likely to stock specialty medications. In behavioral health, certain medications such as long-acting injectable antipsychotics or specialty drugs such as clozapine are not often stocked at local retail pharmacies. Additionally, pharmacists without much experience dispensing specialty medications may not be as comfortable counseling patients and precribers regarding its use as an on-site pharmacist would be.

Privacy

Privacy is important for any consumer of healthcare services, but can be of particular significance to those with mental illness. Despite efforts to destigmatize mental illnesses, many consumers perceive that they are treated differently due to their illnesses.9 Being able to fill their prescriptions in the privacy of the provider’s clinic without having to encounter stigma in a retail pharmacy environment, whether real or perceived, can remove an inhibition to getting prescriptions filled, and therefore result in improved medication adherence.10

Pharmacist Trust

Pharmacists are often cited as being one of the most trusted professions in the United States. According to a recent Gallup poll, pharmacists ranked as the second most trusted profession among Americans.11

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Being able to fill their prescriptions in the privacy of the provider’s clinic without having to encounter stigma in a retail pharmacy environment, whether real or perceived, can remove an inhibition to getting prescriptions filled, and therefore result in improved medication adherence.10

The opportunity to have consistent communication with a familiar and trusted on-site pharmacist can be particularly beneficial for a mental health consumer. It has been observed that persons with schizophrenia have a reduced ability to establish multiple trusting relationships. Often, they can have difficulty interacting and trusting people who they encounter less often.12 If a trusting relationship can be successfully developed between a consumer and the on-site pharmacist that they see each time they visit their behavioral health providers, they have a greater likelihood of receiving the drug therapy counsel which can be vital to their adherence with a treatment plan.13

Many barriers that prevent mental illness patients from following their prescription drug regimen can be overcome by the development of a trusted relationship between consumers and their pharmacy service provider. A person with schizophrenia may have symptoms of paranoia that can trick the mind into believing the medication is a poison, or they may hear voices advising against taking the drug. In addition, many medications prescribed for treating mental illness disorders can have undesirable side effects such as drowsiness, decreased libido, and weight gain. To further complicate matters, consumers may actually feel better when not taking their medication, such as during a manic episode of bipolar disorder.

These additional factors may further decrease the likelihood of a person with a mental illness from filling and taking their prescribed medications. Thus, establishing a trusted relationship with a pharmacist can be critical to helping combat these barriers to medication adherence. Pharmacists can clearly explain the benefits and risks of medications, and can counsel consumers regarding how to minimize side effects and achieve optimal treatment.

Although pharmacists can provide this service in any physical setting, it can be more difficult to have a private, one-on-one discussion in a busy retail pharmacy environment. Additionally, larger establishments may employ multiple pharmacists, decreasing the likelihood that the consumer will encounter the same pharmacist each time they visit the pharmacy. Thus, an onsite-pharmacy model is more likely to provide the optimal environment where a trusted relationship between the pharmacist and mental health consumer can develop.

Resource for Center Staff

Many behavioral or community health centers do not directly employ pharmacists, yet a pharmacist can be a valuable asset to the Inter-Disciplinary Team (IDT).14 The pharmacist working in the on-site pharmacy can serve this role. Some of the benefits are informal, such as medical staff being able to readily access the pharmacist for consumer-specific concerns or medication regimen inquiries.

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An onsite-pharmacy model is more likely to provide the optimal environment where a trusted relationship between the pharmacist and mental health consumer can develop.

Other benefits to this role can be structured more formally, such as involving the pharmacist in the center’s medical staff meetings or Pharmacy and Therapeutics (P&T) Committee.

As more drugs become available on the market, and payers institute formularies to contain costs, additional barriers such as Prior Authorizations may become more prevalent. On-site pharmacists can often assist with the Prior Authorization (PA) process by helping provide documentation to the payer, as well as notifying the prescriber as soon as the need for a Prior Authorization arises. This immediate notification from an on-site pharmacist can often occur the day the medication is prescribed, rather than the prescriber getting a call after a consumer attempts to fill the prescription at an off-site pharmacy. Often, by the time the PA gets resolved at an outside pharmacy, the consumer has likely left the store and may have difficulty arranging transportation to go back. In the meantime, the consumer likely goes without the necessary medication.

Additional Benefits Provided by an On-Site Genoa Pharmacy

The preceding benefits discussed above are generally realized whether a CHMC has opted for either an in-sourced or an out-sourced on-site pharmacy model. However, partnering with a pharmacy like Genoa Healthcare ("Genoa"), may provide additional services and benefits that go beyond the service offerings of a typical CMHC in-source pharmacy.

Specialty Packaging

Genoa’s Convenient Adherence Packaging, internally developed in 2008, is a color-coded multi-medication adherence packaging system that was developed specifically for individuals living with severe and persistent mental illness.

Because this specialty packaging has perforations around each sealed medication bubble, it is easier to use while people are on-the-go at vocational and social activities. One pack contains a seven day supply of medications, and each bubble provides: consumer’s name, date and day of week medication should be taken; color coordination for time of day medication is to be taken; list of

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Figure 1: Convenient Adherence Packaging

medications contained inside each bubble; an easy-open bubble using simple peel-back technology (which prevents the challenges of using a rigid foil back push-through technology to gain medication bubble access); a spacious medication bubble with sufficient room to accommodate all medications at all dosage intervals, including the often crowded morning interval; and a detailed medication listing at the top of each Convenient Adherence Packaging card.

Refill Management – Refill Reminder Calls and Medication Synchronization

Each Genoa pharmacy runs a weekly report to identify all consumers that are nearing the time for a refill of their chronic medications. One of the pharmacy staff members then calls the individual to remind them of their upcoming refills and discuss any concerns they may have. This process helps ensure continued adherence and facilitates quality communication and collaboration with the care team.

Genoa also works with consumers and providers to synchronize refills so that individuals can refill all their medications at the same time. The convenience of filling all medications at the same time can provide cost savings and may also reduce confusion, which should increase the likelihood that consumers are adhering to their prescribed drug therapy regimens.

Mail or Delivery Services

Genoa can mail prescriptions to consumers’ homes and can deliver medications to residential programs, ACT teams, and satellite locations, again reducing the transportation barrier that is very real to many persons with mental illnesses.

340B Pricing

As integrated care models expand, more behavioral health centers are partnering with Federally Qualified Health Centers (FQHCs) or becoming FQHCs (or FQHC Look-Alikes) themselves. One of the benefits for FQHCs and Look-Alikes is access to drug discounts through the 340B Program.

Genoa has vast experience with the 340B program, to include pharmacies that are actually located on-site within FQHCs. If a center is eligible for the 340B Drug Discount Program, Genoa is authorized to be one of the selected contracted pharmacies.

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The convenience of filling all medications at the same time can provide cost savings and may also reduce confusion, which should increase the likelihood that consumers are adhering to their prescribed drug therapy regimens.

White PaperBenefits of an On-Site Pharmacy for Behavioral or Community Health Organizations

An understanding of the complexities of the 340B Program and years of experience allows a Genoa pharmacy to help simplify processes. The convenience, visibility, and services of an on-site Genoa pharmacy can also maximize the benefits of the 340B Program to the center.

Analytics

Genoa’s suite of web-based tools, called Genoa Online, provides partner center staff with easy access to valuable clinical and medication utilization information. This online tool-set can be conveniently accessed by center staff from any computer or device via the internet. Each unique Genoa Online user is assigned to his or her specific group of consumers. The system is also HIPAA compliant so consumer profiles will be protected from unauthorized access. Genoa Online provides tools to help assess medication utilization, including assistance in identifying individuals that might not be using their medications the way they were prescribed. In a rapidly transforming healthcare landscape where service providers are increasingly measured and assessed based on their ability to produce outcomes, Genoa Online was developed to provide tools that enable partner center staff the ability to recognize trends and identify individuals that might be at a higher risk of re-hospitalization due to a medication adherence issue.

Summary

The benefits of having an on-site pharmacy are extensive, and can help improve consumer outcomes, increase access and adherence to prescribed drug therapy regimens, and create efficiencies in the healthcare delivery model. The different business models to consider when exploring an on-site pharmacy model are discussed in a separate paper, “On-Site Pharmacy Models for Behavioral or Community Health Organizations: In-Sourcing, Out-Sourcing, and Joint Ventures.”

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White PaperBenefits of an On-Site Pharmacy for Behavioral or Community Health Organizations

Citations

1. Health Care Plan, Health Plan Accreditation Organization: National Committee for Quality Assurance (NCQA). (n.d.). Retrieved March 27, 2015 from the NCQA web site: http://www.ncqa.org/HomePage.aspx

2. History: Patient Centered Primary Care Collaborative (PCPCC). (n.d.). Retrieved March 27, 2015 from: http://www. pcpcc.org/content/history-0

3. The PCMH and Delivery System Reform: Patient-Centered Primary Care Collaborative (PCPCC). (n.d.). Retrieved March 27, 2015 from: http://www.pcpcc.org/content/pcmh-and-dellivery-system-reform

4. Statements of Support: Patient Centered Primary Care Collaborative (PCPCC). (n.d.) Retrieved March 27, 2015 from: http://www.pcpcc.org/content/statements-support

5. IMS Institute for Healthcare Informatics. (2012). The Use of Medicines in the United States: Review of 2011. Retrieved from: http://www.imshealth.com/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/IHII_Medicines_in_U.S_Report_2011.pdf

6. Rudow, R. (2011, November 17). More than One in Five Americans Use Prescriptions for Mental Health Problems. Retrieved from Counseling Today website: http://ct.counseling.org/2011/11/more-than-one-in-five-americans-use-prescription-medications-for-mental-health-problems/

7. Centers for Disease Control/National Center for Health Statistics. (2010). National Ambulatory Medical Care Survey: 2010 Summary Tables. Retrieved from: http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

8. Lee, K., & Dearing, G. (2013, June). Improving Medication Adherence in Patients with Severe Mental Illness. Pharmacy Today, 19(6), 69-80. Retrieved from http://elearning.pharmacist.com/portal/files/learningproducts/8e1241c42b5047829a1c dc44598e6ebe/assets/0613_pt_80_final.pdf

9. Sirey, J., Bruce, M., Alexopoulus, G., Perlick, D., Raue, P., Friedman, S., & Meyers, B. (2001, March). Perceived Stigma as a Predictor of Treatment Discontinuation in Young and Older Outpatients with Depression. American Journal of Psychiatry, 158, 479-481. Retrieved from http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.158.3.479

10. Rubio-Valera, M., Chen, T., & O’Reilly, C. (2014). New Roles for Pharmacists in Community Mental Health Care: A Narrative Review. International Journal of Environmental Research and Public Health, 11, 10967-10990. doi:10.3390/ijerph111010967

11. Riffkin, R. (2014, December 18). Americans Rate Nurses Highest on Honesty, Ethical Standards. Gallup.Retrieved from: http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx

12. Psych Central Staff. (n.d.). Paranoid Personality Disorder Symptoms. Retrieved March 27, 2015 from: http://psychcentral. com/disorders/paranoid-personality-disorder-symptoms/

13. Rubio-Valera, M., Chen, T., & O’Reilly, C. (2014). New Roles for Pharmacists in Community Mental Health Care: A Narrative Review. International Journal of Environmental Research and Public Health, 11, 10967-10990. doi:10.3390/ijerph111010967

14. Chisolm-Burns, M., Lee, J., Spivey, C., Slack, M., Herrier, R., Hall-Lipsey, E., Zivin, J. …Wunz, T. (2010, October). US Pharmacists’ Effect as Team Members on Patient Care: Systematic Review and Meta-Analyses. Medical Care, 48(10), 923-933.Retrieved from http://www.dmhc.ca.gov/Portals/0/AbouttheDMHC/RCI/PromisingBestPractices/

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White PaperBenefits of an On-Site Pharmacy for Behavioral or Community Health Organizations

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