Efforts must continue to educate pharmacists on clinical pharmacy practice
Clinical Pharmacy Practice in a Community Mental Health Center
Introduction
Description of Facility
New roles and role models for pharmacists in patient care responsibility are slowly but steadily growing in number. Pharmacists have become actively involved in many aspects of medical care involving drug therapy. Examples include extended care facilities, rural health care, obstetrics, general medicine and mental health facilities. 1- 4 Expanded roles for pharmacists continue to be discussed as part of the expected future trends in pharmacy practice.s Schools of pharmacy are giving increased attention to clinical training of pharmacy students. 6 A crucial question is if these new roles for clinically trained pharmacists allow justification of the schools' effort, time and money to provide clinical training of the current magnitude. A perceptive criticism of many pharmacy students, as well as pharmacists in practice today, is that most clinical pharmacy roles exist only within the academic institution and have no relation to possible pharmacy practice outside the institution. Thus, there exists a clear need to document viable community-based clinical pharmacist roles. It is the purpose of this article to describe one such role. In March 1973, the city and county of San Francisco funded and hired a full-time clinical pharmacist for District V Mental Health Center. This position represents a true community-based clinical pharmacy practice and has definite implications for increasing clinical pharmacy involvement within community mental health centers.
Community mental health is a relatively new concept for mental health care delivery. Prior to the 1950s, the public had not begun to accept the idea that a mentally ill person could be treated and his illness controlled outside a mental hospital. Public attitudes began to change in the 1950s as the mass media publicized the potential of psychoactive drugs and improved treatment techniques. The public responded with interest, then hope, and then a growing demand for additional public funds to provide better treatment for the mentally ill. With strong support from President Kennedy, the Community Mental Health Centers Act was adopted in October 1963. The statute reflected the progress in treatment and the attendant shifting in public attitudes by establishing the location of the new mental health centers within the communities where patients and their families lived. s Each community mental health center has responsibility for providing mental health care to a specified number of people residing in a geographic area known as the "catchment area ." District V Mental Health Center is one of five community mental health centers serving the City and County of San Francisco. Mental health services are many and varied, includinginpatient crisis intervention, geriatric day treatment, adult day treatment, adolescent day treatment, three outpatient clinics, home visiting team, social skills program, board and care home enrichment program and a halfway house. As the clinical pharmacist for the entire district, involvement with most of the units mentioned above is primarily consultative. Direct patient care responsibility involves only the adult day treatment center and two of the outpatient clinics. These three areas were chosen based on where it was felt drug monitoring and information would best be directed. The day treatment center was chosen because patients at the center are most often just recently discharged from an inpatient service, their acute psychotic, depressive or suicidal episode not yet resolved, and their medication at large doses and causing significant adverse effects. Managing psychotropic medication at this stage is the most difficult and cha,lenging since the goal is to lower medication to maintenance levels, treat and prevent adverse effects, and still maintain therapeutic efficacy. Clinical pharmacy input at this point seemed to be most appropriate. Outpatient clinics were chosen
Origins In 1971 the director of District V Day Treatment Center invited pharmacy student participation to monitor patients' drug therapy and assist in drug distribution. Two' students began a three-month clerkship at the Day Treatment Center in September 1971 . The clerkship training program that emerged from this beginning has been previously described? From this student experience at the Day Treatment Center, it became clear that a clinically trained pharmacist could provide a valuable service as part of the mental health center staff. A proposal detailing the duties of a clinical pharmacist in a mental health facility was drawn up, and in March 1972 was presented to the director of the District V Mental Health Center. With his support and that of the Citizen's Advisory Board, the proposal was submitted as part of the budget, and was approved and funded by the City and County of San Francisco.
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
as a second area of direct patient care involvement since outpatients often present with problems of noncompliance, persistent adverse effects necessitating drug therapy modification and other medical illnesses being treated by other prescribing physicians. Role of the Clinical Pharmacist Perhaps no other specialty of medicine has better accepted a team approach to health care delivery as has psychiatry. Community mental health has widely accepted a team approach-with mental health care responsibility shared among psychiatrists, psychologists, psychiatric nurses, psychiatric social workers and . community workers. For this reason it was easier to discuss with mental health administrators the need for clinical pharmacy involvement. To propose that an additional discipline be added to an already multidisciplinary team could sound unnecessary. What had to be documented was that the role of a clinical pharmacist in community mental health is unique and is not a duplication of existing roles . In addition to the unique contributions clinical pharmacy can make, the following description of duties demonstrates the blurring of his own role to make him an active member of the staff. Some duties in fact are not directly related to drug therapy. There must be a willingness to participate as an active member in mental health care delivery, which includes, but is not limited, to clinical pharmacy-related activities. Adult Day Treatment Center The primary function is to monitor patients' total drug therapy . The clinical pharmacist has his own group of patients to follow weekly for medication evaluation and adjustment. Assessment of drug therapy response and adverse effects is made , and appropriate drug or dosage changes are made. Consultation with a psychiatrist is available for questions or problems. Close contact is maintained with each patient's primary therapist for additional information regarding the patient's progress that should be reflected in medication needs. Medication prescribed by physicians for other medical illnesses as well as use of non-prescription drugs is monitored to insure prevention of potential adverse effects or interactions. Some new patients also are assigned to the clinical pharmacist for medication needs. This can involve initiating drug therapy as well as changing drug or dosage. In addition to his own patients, the clinical pharmacist is responsible for the monitor-
400
-
By Glen L. Stimmel
ing of drug therapy of patients who are interviewed and followed by pharmacy students. A second major function ·is consultation with other staff members regarding specific drug therapy problems or questions. This includes not only psychiatrists but also other staff members whose patients are on medication. Responding to these questions requires a fair knowledge of the patient, his particular symptoms and past history, so that the response is clinically relevant and applicable to the patient. Within a year it became easier to become acquainted with most of the 120 patients and their particular medication-related problems. A third major function is as a primary therapist for patients. The clinical pharmacist carries a small caseload of patients for whom he is primary therapist. He sees most of his patients individually for psychotherapy sessions, with a few assigned to small group therapy. The role of primary therapist denotes much more than doing psychotherapy, however. As a primary therapist, the clinical pharmacist does initial intake interviews, may meet with the fa mily of the patient, makes referrals to other programs such as vocational rehabilitation , helps the patient to plan living and financial arrangements, arranges for hospitalization of his patients if necessary, and arranges for follow-up treatment when patients are discharged from the Day Treatment Center. Obviously there is much sharing among staff in making many such decisions, but the responsibility for these duties lies with the individual primary therapist. This aspect of the clinical pharmacist's duties is essential for his involvement as part of the staff, and equally as important, helps to place the use of drugs into a proper perspective as one of many treatment methods for psychiatric disorders. Being totally involved in patient care allows a proper evaluation of various treatment methods and their respective roles in a total treatment plan for patients. A fourth responsibility is supervision of pharmacy students and administration of their psychiatric clerkship program. The clinical pharmacist teaches pharmacy students in an elective community psychiatry clerkship offered by the University of Californ ia school of pharmacy, San Francisco. The clinical pharmacist supervises students as they monitor patient drug therapy at the Center, and teaches a weekly conference on psychiatric disorders and drug treatment. A last responsibility at the Day Treat-
Vol. NS15, No. 7, July 1975
ment Center is participation on various committees. The clinical pharmacist, with the director, initiated a psychiatric library for staff use. A library committee was formed and a half-time librarian named to continue improvement and expansion of the library. Other committees are the trainee committee and medical records committee. Outpa tient Clinics The major function of the clinical pharmacist in the outpatient clinics is participation on a regular basis in several medication groups. The psychiatrist and clinical pharmacist see patients together for medication evaluation and renewal. Advice regarding appropriate drug therapy and adverse effects is given as necessary, and drug therapy is mostly a mutual decision. Direct involvement with the outpatient clinic medication groups has varied depending on the psychiatrist involved and available time . Earlier, three different psychiatrists ' medication groups were regularly attended by the clinical pharmacist, but turnover in psychiatrists and increasing patient care responsibility at the Center has resulted in a continuation of involvement in one outpatient medication group weekly with about 25 patients. The other major responsibility in the outpatient clinics is consultation regarding drug-related problems or questions. Telephoned consultations are frequent from psychiatrists in the various outpatient clinics as well as from other staff members. Most of the consults are in regard to dru'g therapy questions or problems with individual patients. Response is thus directed to being specific and relevant to the particular patient involved. Drug information given most often is reflected in the patient's prescriptions. District- Wide Responsibility District-wide responsibility essentially involves scheduled lectures and discussions regarding some aspect of drug therapy. Initially, this function developed slowly, but has escalated markedly to the point where now one or two lectures per week is average. Lectures first were given to staff of
the outpatient clinics and the Center. Because of the large number of mental health services provided by District V, there are many more units who work with patients on psychotropic drugs, and these units requested inservice education by the clinical pharmacist. Such talks have included the staff of the halfway house, social skills program, and the board and care home enrichment program. Talks regarding psychotropic medication also have been given to the various trainees in the District, including psychology, nursing, social work and pharmacy students. A specific scheduled inservice series is held for the psychiatrists employed by District V Mental Health. These sessions are held every other month, and topics include specific issues of recent concern or new literature information on specific topics. The format consists of the clinical pharmacist presenting information, followed by discussion among the group, often comparing literature information with clinical experiences and impressions. These conferences are an excellent vehicle for the clinical pharmacist to bring new information to all the prescribing psychiatrists in the District, as well as discuss problems observed by the clinical pharmacist as reflected by prescribing habits. Specific topics have included-indications for tricyclic antidepressants, rational use of antiparkinson agents, fluphenazine enanthate versus fluphenazine decanoate, sedative-hypnotics versus sedating phenothiazines for insomnia, and limitations of antianxiety agents in psychiatry. The second major responsibility of the clinical pharmacist for the District is supervision and administration of the drug distribution system. Since there had not been pharmacy involvement in this community mental health district before, the drug distribution system was in definite need of improvement. Prescription medications and stock drugs were still being sent back and forth from the county hospital (across town) to the various clinics through messenger. Lag time between prescription (continued on page 413)
Glen L. Stimmel
Glen L. Stimmel, PharmD. , is assistant professor of pharmacy at the University of Southern California school of pharmacy. Before joining the USC faculty in 1974, he served as the clinical pharmacist for District V Mental Health Center 1973-1974. He received his PharmD. in 1972 and residency certificate in clinical pharmacy in 1973 from the University of California at San Francisco. He presently serves on the ASHP Advisory Panel on Pharmacy Services in Mental Health Facilities. His professional memberships include APhA, ASHP and the California Pharmaceutical Association.
401
Clinical Pharmacy Practice in a Community Mental Health Center
Introduction
Description of Facility
New roles and role models for pharmacists in patient care responsibility are slowly but steadily growing in number. Pharmacists have become actively involved in many aspects of medical care involving drug therapy. Examples include extended care facilities, rural health care, obstetrics, general medicine and mental health facilities. 1- 4 Expanded roles for pharmacists continue to be discussed as part of the expected future trends in pharmacy practice.s Schools of pharmacy are giving increased attention to clinical training of pharmacy students. 6 A crucial question is if these new roles for clinically trained pharmacists allow justification of the schools' effort, time and money to provide clinical training of the current magnitude. A perceptive criticism of many pharmacy students, as well as pharmacists in practice today, is that most clinical pharmacy roles exist only within the academic institution and have no relation to possible pharmacy practice outside the institution. Thus, there exists a clear need to document viable community-based clinical pharmacist roles. It is the purpose of this article to describe one such role. In March 1973, the city and county of San Francisco funded and hired a full-time clinical pharmacist for District V Mental Health Center. This position represents a true community-based clinical pharmacy practice and has definite implications for increasing clinical pharmacy involvement within community mental health centers.
Community mental health is a relatively new concept for mental health care delivery. Prior to the 1950s, the public had not begun to accept the idea that a mentally ill person could be treated and his illness controlled outside a mental hospital. Public attitudes began to change in the 1950s as the mass media publicized the potential of psychoactive drugs and improved treatment techniques. The public responded with interest, then hope, and then a growing demand for additional public funds to provide better treatment for the mentally ill. With strong support from President Kennedy, the Community Mental Health Centers Act was adopted in October 1963. The statute reflected the progress in treatment and the attendant shifting in public attitudes by establishing the location of the new mental health centers within the communities where patients and their families lived. s Each community mental health center has responsibility for providing mental health care to a specified number of people residing in a geographic area known as the "catchment area ." District V Mental Health Center is one of five community mental health centers serving the City and County of San Francisco. Mental health services are many and varied, includinginpatient crisis intervention, geriatric day treatment, adult day treatment, adolescent day treatment, three outpatient clinics, home visiting team, social skills program, board and care home enrichment program and a halfway house. As the clinical pharmacist for the entire district, involvement with most of the units mentioned above is primarily consultative. Direct patient care responsibility involves only the adult day treatment center and two of the outpatient clinics. These three areas were chosen based on where it was felt drug monitoring and information would best be directed. The day treatment center was chosen because patients at the center are most often just recently discharged from an inpatient service, their acute psychotic, depressive or suicidal episode not yet resolved, and their medication at large doses and causing significant adverse effects. Managing psychotropic medication at this stage is the most difficult and cha,lenging since the goal is to lower medication to maintenance levels, treat and prevent adverse effects, and still maintain therapeutic efficacy. Clinical pharmacy input at this point seemed to be most appropriate. Outpatient clinics were chosen
Origins In 1971 the director of District V Day Treatment Center invited pharmacy student participation to monitor patients' drug therapy and assist in drug distribution. Two' students began a three-month clerkship at the Day Treatment Center in September 1971 . The clerkship training program that emerged from this beginning has been previously described? From this student experience at the Day Treatment Center, it became clear that a clinically trained pharmacist could provide a valuable service as part of the mental health center staff. A proposal detailing the duties of a clinical pharmacist in a mental health facility was drawn up, and in March 1972 was presented to the director of the District V Mental Health Center. With his support and that of the Citizen's Advisory Board, the proposal was submitted as part of the budget, and was approved and funded by the City and County of San Francisco.
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
as a second area of direct patient care involvement since outpatients often present with problems of noncompliance, persistent adverse effects necessitating drug therapy modification and other medical illnesses being treated by other prescribing physicians. Role of the Clinical Pharmacist Perhaps no other specialty of medicine has better accepted a team approach to health care delivery as has psychiatry. Community mental health has widely accepted a team approach-with mental health care responsibility shared among psychiatrists, psychologists, psychiatric nurses, psychiatric social workers and . community workers. For this reason it was easier to discuss with mental health administrators the need for clinical pharmacy involvement. To propose that an additional discipline be added to an already multidisciplinary team could sound unnecessary. What had to be documented was that the role of a clinical pharmacist in community mental health is unique and is not a duplication of existing roles . In addition to the unique contributions clinical pharmacy can make, the following description of duties demonstrates the blurring of his own role to make him an active member of the staff. Some duties in fact are not directly related to drug therapy. There must be a willingness to participate as an active member in mental health care delivery, which includes, but is not limited, to clinical pharmacy-related activities. Adult Day Treatment Center The primary function is to monitor patients' total drug therapy . The clinical pharmacist has his own group of patients to follow weekly for medication evaluation and adjustment. Assessment of drug therapy response and adverse effects is made , and appropriate drug or dosage changes are made. Consultation with a psychiatrist is available for questions or problems. Close contact is maintained with each patient's primary therapist for additional information regarding the patient's progress that should be reflected in medication needs. Medication prescribed by physicians for other medical illnesses as well as use of non-prescription drugs is monitored to insure prevention of potential adverse effects or interactions. Some new patients also are assigned to the clinical pharmacist for medication needs. This can involve initiating drug therapy as well as changing drug or dosage. In addition to his own patients, the clinical pharmacist is responsible for the monitor-
400
-
By Glen L. Stimmel
ing of drug therapy of patients who are interviewed and followed by pharmacy students. A second major function ·is consultation with other staff members regarding specific drug therapy problems or questions. This includes not only psychiatrists but also other staff members whose patients are on medication. Responding to these questions requires a fair knowledge of the patient, his particular symptoms and past history, so that the response is clinically relevant and applicable to the patient. Within a year it became easier to become acquainted with most of the 120 patients and their particular medication-related problems. A third major function is as a primary therapist for patients. The clinical pharmacist carries a small caseload of patients for whom he is primary therapist. He sees most of his patients individually for psychotherapy sessions, with a few assigned to small group therapy. The role of primary therapist denotes much more than doing psychotherapy, however. As a primary therapist, the clinical pharmacist does initial intake interviews, may meet with the fa mily of the patient, makes referrals to other programs such as vocational rehabilitation , helps the patient to plan living and financial arrangements, arranges for hospitalization of his patients if necessary, and arranges for follow-up treatment when patients are discharged from the Day Treatment Center. Obviously there is much sharing among staff in making many such decisions, but the responsibility for these duties lies with the individual primary therapist. This aspect of the clinical pharmacist's duties is essential for his involvement as part of the staff, and equally as important, helps to place the use of drugs into a proper perspective as one of many treatment methods for psychiatric disorders. Being totally involved in patient care allows a proper evaluation of various treatment methods and their respective roles in a total treatment plan for patients. A fourth responsibility is supervision of pharmacy students and administration of their psychiatric clerkship program. The clinical pharmacist teaches pharmacy students in an elective community psychiatry clerkship offered by the University of Californ ia school of pharmacy, San Francisco. The clinical pharmacist supervises students as they monitor patient drug therapy at the Center, and teaches a weekly conference on psychiatric disorders and drug treatment. A last responsibility at the Day Treat-
Vol. NS15, No. 7, July 1975
ment Center is participation on various committees. The clinical pharmacist, with the director, initiated a psychiatric library for staff use. A library committee was formed and a half-time librarian named to continue improvement and expansion of the library. Other committees are the trainee committee and medical records committee. Outpa tient Clinics The major function of the clinical pharmacist in the outpatient clinics is participation on a regular basis in several medication groups. The psychiatrist and clinical pharmacist see patients together for medication evaluation and renewal. Advice regarding appropriate drug therapy and adverse effects is given as necessary, and drug therapy is mostly a mutual decision. Direct involvement with the outpatient clinic medication groups has varied depending on the psychiatrist involved and available time . Earlier, three different psychiatrists ' medication groups were regularly attended by the clinical pharmacist, but turnover in psychiatrists and increasing patient care responsibility at the Center has resulted in a continuation of involvement in one outpatient medication group weekly with about 25 patients. The other major responsibility in the outpatient clinics is consultation regarding drug-related problems or questions. Telephoned consultations are frequent from psychiatrists in the various outpatient clinics as well as from other staff members. Most of the consults are in regard to dru'g therapy questions or problems with individual patients. Response is thus directed to being specific and relevant to the particular patient involved. Drug information given most often is reflected in the patient's prescriptions. District- Wide Responsibility District-wide responsibility essentially involves scheduled lectures and discussions regarding some aspect of drug therapy. Initially, this function developed slowly, but has escalated markedly to the point where now one or two lectures per week is average. Lectures first were given to staff of
the outpatient clinics and the Center. Because of the large number of mental health services provided by District V, there are many more units who work with patients on psychotropic drugs, and these units requested inservice education by the clinical pharmacist. Such talks have included the staff of the halfway house, social skills program, and the board and care home enrichment program. Talks regarding psychotropic medication also have been given to the various trainees in the District, including psychology, nursing, social work and pharmacy students. A specific scheduled inservice series is held for the psychiatrists employed by District V Mental Health. These sessions are held every other month, and topics include specific issues of recent concern or new literature information on specific topics. The format consists of the clinical pharmacist presenting information, followed by discussion among the group, often comparing literature information with clinical experiences and impressions. These conferences are an excellent vehicle for the clinical pharmacist to bring new information to all the prescribing psychiatrists in the District, as well as discuss problems observed by the clinical pharmacist as reflected by prescribing habits. Specific topics have included-indications for tricyclic antidepressants, rational use of antiparkinson agents, fluphenazine enanthate versus fluphenazine decanoate, sedative-hypnotics versus sedating phenothiazines for insomnia, and limitations of antianxiety agents in psychiatry. The second major responsibility of the clinical pharmacist for the District is supervision and administration of the drug distribution system. Since there had not been pharmacy involvement in this community mental health district before, the drug distribution system was in definite need of improvement. Prescription medications and stock drugs were still being sent back and forth from the county hospital (across town) to the various clinics through messenger. Lag time between prescription (continued on page 413)
Glen L. Stimmel
Glen L. Stimmel, PharmD. , is assistant professor of pharmacy at the University of Southern California school of pharmacy. Before joining the USC faculty in 1974, he served as the clinical pharmacist for District V Mental Health Center 1973-1974. He received his PharmD. in 1972 and residency certificate in clinical pharmacy in 1973 from the University of California at San Francisco. He presently serves on the ASHP Advisory Panel on Pharmacy Services in Mental Health Facilities. His professional memberships include APhA, ASHP and the California Pharmaceutical Association.
401
