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University of North Carolina Wilmington

A Novel Collaborative Practice Model (CPM) for the Treatment of Mental Illness of the Indigent and UninsuredDavor N. Zink, Keenan Withers, Aaron Dedmon, Margie Hernandez, Tara Jackman, Hannah Lindsey, Lee Wiegand, Heather Hughes, Ahmed Fasfous, Jennifer Buxton, and Antonio E. Puente

University of North Carolina Wilmington

Introduction

The Collaborative Practice Program

Method

Acknowledgments

Health professionals and volunteers at the Cape Fear Community Clinic

puente@uncw.edu

Discussion

University of North Carolina Wilmington

Results

We describe the development, implementation, and evaluation of an innovative collaborative practice model (CPM) designed to address the mental health needs of indigent and uninsured patients.

The practice model consists of a program, started seven years ago, to provide comprehensive psychopharmacological and mental health treatment for individuals with clinically significant mental disorders as well as limited economic resources and no insurance coverage at a free clinic in Wilmington, NC. Three aspects of the program are novel; 1) it is comprehensive in that all forms of diagnostic and therapeutic interventions are provided, 2) services are provided in English and Spanish and 3) no direct physician involvement is included.

Procedure: In order to determine the efficacy of the program, a series of pre-post measures were administered, including the SF-12, the PHQ-9, and the

AUDIT. Patients were tested prior to the onset of intervention and approximately three months after initiation of the intervention. The patient outcome data collected for program evaluation is standardized and offered in both English and Spanish. After patients give consent to the regulations and procedures of the clinic regarding patient conduct, attendance, and testing; a psychology student administers three questionnaires. The first is the Alcohol Use Disorders Identification Test (AUDIT), which incorporates questions about the quantity and frequency of alcohol use in adults to detect dependence as well as harmful or hazardous drinking. Scores range from zero to 40 with higher scores displaying increasing quantity and frequency of alcohol use. The second questionnaire is the Patient Health Questionnaire for depression (PHQ-9). The PHQ-9 assesses and monitors depression severity. Scores range from zero to 27 with higher scores indicating an increase in severity of depression. The third questionnaire is the Short Form-12 (SF-12). This questionnaire assesses quality of life by quantifying overall physical and mental health via two population-based scores: the physical component summary (PCS) and the mental component summary (MCS). Scores range from 0 to 100, where a zero score indicates the lowest level of health measured by the scales and 100 indicates the highest level of health. Both Physical and Mental Health Composite Scales can be compared to a national norm with a mean score of 50.0 and a standard deviation of 10.0.

Inclusion criteria. All adult patients (≥18 years of age) of the mental health clinic who received pre- and post-testing were eligible for inclusion in the analysis. These patients received the same testing, but their data was not included in the study due to lack of questionnaire validation in pediatric and adolescent age groups.

Exclusion criteria. Any pre- and post-test sets with an elapsed time of greater than 12 months were excluded from the study. Any incomplete questionnaires (questions unanswered or ineligible writing) were also excluded.

Patient Demographics. The age and gender of the mental health clinic patient population based on pre-testing are displayed in Table 1.

We present a novel approach to the assessment and intervention of mental health problems in a community clinic for indigents. However, the implementation of an innovative CPM in the mental health clinic was not associated with significant improvements in PHQ-9 depression scores, SF-12 quality of life scores, or AUDIT alcohol abuse scores despite increased access to mental health care and medications among clinic patients. Several flaws in study design and data collection limited the usefulness of the pre-and post-test data. The lack of statistical differences could be due to the small sample size, the varied elapsed time at post testing, and the instruments themselves. Despite the results, clinical data illustrates improvement in the patient’s symptoms.

Clinic patients were provided access to mental health care and medications that were previously unavailable within the community. In 2009 alone, clinic patients received over $139,000 in free mental health care and prescription medications. The most common diagnosis was depression and most commonly prescribed medications include citalopram, escitalopram, fluoxetine, buproprion, venlafaxine, paroxetine, trazodone, and quetiapine.

More importantly, this model provides a novel approach in that is bilingual, comprehensive, and does not involve typical medical intervention for the provision of psychopharmaceutical intervention. The model is now being presented as a cost effective way to provide mental health intervention in “free clinics” throughout North Carolina, especially in a changing demographic environment.

Numerical Transformation Comparison. Patient demographics for the post-tested population are listed in Table 1. Table 2 quantifies the amount of free healthcare provided in 2009 by estimating the hourly cost of each service provided. A total of 165 hours of free care were provided by mental health clinic practitioners with a total estimated value of $15,580.88.

Prescription data was also collected from the pharmacy computer system and analyzed for the year 2009. This data is summarized in Table 3. A total of 775 prescriptions were issued by the CPP and were associated with a total patient cost savings of $123,699.29.

The structure of the CPM includes four major components: an initial evaluation (which will include an interview and may include testing), psychotherapy only, medication management only, and psychotherapy plus medication management. Once a referral is made and/or acceptance to the clinic is established, all patients participate in a comprehensive initial interview conducted jointly by a doctorate level clinical neuropsychologist and the clinical pharmacist. Initial interviews generally last one hour and conclude with a suggested diagnosis followed by discussion and implementation of the most feasible treatment plan. Patients with difficult diagnoses or unclear etiologies receive a more comprehensive evaluation which includes psychological or neuropsychological testing, as deemed appropriate by the psychologist who conducts the initial interview. In 2006, a collaborative practice agreement was established between the volunteer pharmacist and the clinic’s medical director (a practicing physician). In accordance with state laws, the pharmacist obtained a Clinical Pharmacist Practitioner (CPP) license from the state boards of pharmacy and medicine. This license allowed the pharmacist to participate in patient interviews with the clinic’s psychologist and prescribe medications based on the psychologist’s diagnosis and assessment. Current evidence suggests that optimal management of many mental health conditions includes both psychotherapy and medication management. Most patients referred to the mental health clinic receive psychotherapy in conjunction with pharmacotherapy. Medications are selected based on American Psychiatric Association (APA) guidelines for treatment and drug availability. Visits occur every two weeks upon initiation of medication therapy and during the acute phase of treatment. These visits then decrease in number when the patient transitions into the maintenance phase of therapy with follow-up occurring every three to six months.

Pre and Post Test Results. Table 1 lists the pre- and post-testing results for the AUDIT, PHQ-9, and SF-12. The pre- and post-AUDIT mean scores were 1.59 and 1.72 respectively. Prior to receiving treatment, 6.9% of patients had participated in harmful or hazardous drinking over the year prior to treatment while 3.4% were likely alcohol dependent. After receiving treatment, none of the scores indicated harmful or hazardous drinking, while 3.4% were likely alcohol dependent. A paired samples t-test was conducted to assess if there was a significant difference between the pre and post AUDIT scores. Results showed no significant difference, t (28) = -0.190, p = 0.851, 95% CI (-1.62, 1.35). Pre-PHQ-9 testing identified 37.9% patients as having severe depression. The mean test score was 15.7 and the mean number of symptoms was 7.3. Post-testing revealed 34.4% of patients remained severely depressed. The mean post-test score was 14.4 and the mean number of symptoms was 6.8. A paired samples t test was conducted to assess if there was a significant difference between the pre and post PHQ-9 scores. Results showed no significant difference, t (28) = 0.925, p = 0.363, 95% CI (-1.55, 4.1). Pre-SF-12 testing provided a mean and standard deviation MCS of 30.9 ± 12.1, and a mean and standard deviation PCS of 35.3 ± 11.7. The mean and standard deviation post-test MCS was 36.7 ± 37.4. The mean and standard deviation post-test PCS was 37.4 ± 12.5. A paired sample t test was conducted to assess if there was a significant difference between the pre and post SF-12 scores (PCS, MCS). Results showed no significant difference between pre and post PCS scores, t (19) = -0.641, p = 0.529, 95% CI (-5.73, 3.04), and pre and post MCS scores, t (19) = -1.75, p = 0.95, 95% CI (-14.24, 1.24).

Table 2

Service Cost (per hour) Hours Provided

Total Free CareInitial interview $146.85 19 $2,790.15 Psychotherapy $87.14 100 $8,714.00 Psychotherapy E & M $119.24 23 $2,742.52 Neuropsychological Testing $58.01 23 $1,334.23 Totals 165 $15,580.88

2009 Estimated Value of Free Care Based on the 2010 Medicare Fee Schedule

Table 3

No. prescriptions written by CPP 775No. patients who received prescriptions 55Mean prescriptions/patient 14Mean cost of medications/patient $2,249.08 Overall cost of prescription medications $123,699.29

2009 Prescription Data

Table 1

VariableDemographic Data

(n=81)Pre-testing

Data Post-Testing

DataMean ± S.D. age (yr) 44.4 ± 11.2 46.7 ± 9.3No. (%) female 63 (77.8) 21 (72.4)

Language of testing (no. [%])

English 58 (71.6) 21 (72.4)Spanish 23 (28.4) 8 (27.6)

AUDIT

(Mean ± S.D. score) 2.4 ± 5.0 1.59 ± 3.3 1.72 ± 5.2No. (%) patients with harmful or hazardous drinking in last year (score 8 – 19)

6 (7.4) 2 (6.9) 1 (3.4)

No. (%) patients with alcohol dependence likely (score > 20) 2 (2.5) 0 (0) 1 (3.4)

PHQ-9Mean ± S.D. score 15.0 ± 7.6 15.7 ± 7.3 14.4 ± 7.9

Mean ± S.D. number of symptoms (out of 9) 6.7 ± 2.5 7.3 ± 1.8 6.8 ± 2.7No. (%) patients with severe depression (score ≥ 20) 26 (32.1) 11 (37.9) 10 (34.4)

SF-12 n=63

Mean ± S.D. MCS (Mental Health Scale) 34.9 ± 13.1 30.9 ± 12.1 36.7 ± 37.4

Mean ± S.D. PCS (Physical Health Scale) 38.2 ± 11.6 35.3 ± 11.7 37.4 ± 12.5

Mental Health Clinic Patient Demographics and DataValue

n=20

n=29

n=20