BETHESDA, MD 10 Jul 2014—The Missouri Department of Mental Health’s decision to approve a pharmacist for the role of psychiatric care provider has enabled an assertive community treatment team to serve clients more efficiently, according to the team leader.
“There’s no way we could get our clients the kind of close psychiatric attention, medical attention, that they would need without her—no way,” said Nicole Morani, leader of the Places for People–IMPACT Team in St. Louis.
Morani was speaking about pharmacist Kelly Gable.
In mid-January, the department informed Places for People by letter that Gable had been approved “to provide medication and consultation services through the collaborative practice agreement with and under the supervision of a physician.”
Further, Gable had been approved to participate as a member of the community psychiatric rehabilitation treatment team, plan treatments, and “approve the treatment plan for individuals for whom she provides medication management services.”
And, the letter stated, the medication and consultation services Gable provides through the collaborative practice agreement to people enrolled in community psychiatric rehabilitation programs are reimbursable by Medicaid.
“It’s been such a relief,” Morani declared.
Shortage of mental health providers. The IMPACT Team is 1 of 4 assertive community treatment teams operated by Places for People, a community psychiatric rehabilitation provider, and 1 of 10 such groups recognized by Missouri’s mental health department.
Morani described the teams’ clients as the greatest users of mental health services.
Assertive community treatment emerged as a service delivery model several decades ago when psychiatric hospitals deinstitutionalized their residents, releasing them to community settings.
Missouri requires its certified providers of assertive community treatment services to engage a multidisciplinary team. At a minimum, a team must have “adequate prescribing capacity”; adequate capacities in nursing, substance abuse treatment, and vocational specialization; a peer specialist; a program assistant; and a team leader who is a qualified mental health professional.
Because Places for People operates in an area that the federal government has designated as a Mental Health Professional Shortage Area, the state’s requirement for prescribing capacity can be satisfied by having a psychiatrist available 10 hours per week to serve no more than 50 clients; an allowable alternative is to have an advanced practice nurse available 16 hours weekly for the same client load.
In addition, the psychiatrist or advanced practice nurse must attend at least two team meetings per week.
But finding a psychiatrist who wants to practice community psychiatry is difficult, Morani said.
“Community psychiatry is going out in the community to people’s homes, restaurants, [in places] like under bridges—wherever you can find them—to provide psychiatric support,” she said.
A psychiatric medical resident could serve in the role of psychiatrist, Morani said, but the resident could not bill Medicaid for services unless they were provided in the presence of an attending physician. “So now you either have a resident and an attending and a case worker all going out to the client’s house, or case workers are spending time picking up a client, bringing them here [to Places for People’s building] for services, and then bringing the client back home.
“None of the driving is billable,” she continued. “So you’re basically wasting a lot of clinician time bringing someone in to see someone. Or you can have someone like Kelly who enjoys community work, goes out in the community, and can bill herself.”
Psychiatric care provider. Gable, an associate professor at Southern Illinois University Edwardsville’s School of Pharmacy, said she spends 20 hours a week of prescriber time on the IMPACT Team.
In that time with clients, she said, “you’re assessing for safety, you’re assessing for the safe administration and taking of medications and also what best meets their needs. Maybe it’s a long-acting injection. Maybe their blood pressure is extremely elevated and [the best course is] a hospital admission or an emergency room visit.”
Yet, sometimes, her prescriber role encompasses much more than prescribing.
“At times when a patient’s homeless and they have schizophrenia and they’re struggling with where they’re going to sleep and where they’re going to get food, of importance to them is not whether or not they get medication—it’s survival,” she said.
Being skilled in motivational interviewing and other therapeutic interventions is a necessity, Gable said of her partipcation on the team.
Not necessary is her white coat. In terms of her own survival, Gable said she avoids the white-coated healthcare professional look, adding, “We avoid unsafe situations where maybe there’s high drug activity.” Team members also avoid dressing in attire characteristic of an attorney or someone who works for a legal firm.
Mirela Marcu, the psychiatrist with whom Gable has a collaborative practice agreement, said the two met at Places for People six or seven years ago as a result of their university teaching assignments.
Gable enhances the quality of the services that Places for People provides to its clients, Marcu said, and supplies an expertise in medications that extends beyond psychiatric medications.
“It’s a great asset to have that expertise,” she said.
The two meet once a week to review Gable’s clients. “But our collaboration is much more interactive than just that,” Marcu said. “We talk all the time. . . . We talk about her patients, and likewise I may ask about some other psychopharmacology cases of mine.”
Morani said Gable received a 5—the highest score possible—during the state’s most recent annual review of the team’s fidelity to the model of assertive community treatment.
Collaboration as the start. In April, the Missouri Board of Pharmacy reported that, as of March 21, 17% of pharmacists with an active state license had received a “certificate of medication therapeutic plan authority.”
The board’s rules regarding the certificate went into effect in August 2012. Soon thereafter, Gable said, she received her certificate, which allowed her to engage in collaborative drug therapy management, and Places for People petitioned the mental health department to approve her to function as a psychiatric care provider and prescriber at the agency.
“I was qualified and capable,” she said.
Places for People formed its IMPACT Team in November 2012.
In announcing the new team, the state’s Assertive Community Treatment Newsletter listed Gable as “Clinical Pharmacist/Psychiatric care provider.”
The newsletter stated that the mental health department was approving clinical pharmacists on a case-by-case basis “to fulfill the role of psychiatric care provider.”