Assessing need for pharmacist involvement to improve care coordination for patients on LAI antipsychotics transitioning from hospital to home: A work system approach

Transitional care programs to improve the post-discharge experience of patients with multiple chronic conditions and co-occurring serious mental illness: A scoping review

The transition from hospital to home can be especially challenging for those with multiple chronic conditions and co-occurring serious mental illness (SMI). This population tends to be Medicaid-insured and disproportionately experiences health-related social needs. The aim of this scoping review was to identify the elements and outcomes of hospital-to-home transitional care programs for people diagnosed with SMI. A scoping review was conducted using Arksey and O'Malley's methodology. Three databases were searched; ten articles describing eight transitional care programs published from 2013 to 2024 met eligibility criteria. Five programs focused on patients being discharged from a psychiatric admission. Five of the interventions were delivered in the home. Intervention components included coaching services, medication management, psychiatric providers, and counseling. Program lengths ranged from one month to 90 days post-hospitalization. These programs evaluated quality of life, psychiatric symptoms, medication adherence, readmissions, and emergency department utilization. Notably, few programs appeared to directly address the unmet social needs of participants. While the focus and components of each transitional care program varied, there were overall positive improvements for participants in terms of improved quality of life, increased share decision making, and connections to primary and specialty care providers.

Status after Hospital Discharge: An Observational Study of the Progression of Patients' Mental Health Symptoms Six Weeks after Hospital Discharge

(1) Background: Transitioning from mental health inpatient care to community care is often a vulnerable time in the treatment process where additional risks and anxiety may arise. We collected data for this study as part of a pragmatic cluster-randomized, longitudinal approach in Alberta. As the first phase of the ongoing innovative supportive program, this paper assessed the progression of mental health symptoms in patients six weeks after hospital discharge. Factors that may contribute to the presence or absence of anxiety and depression symptoms, as well as well-being, following return to the community were investigated. This provides evidence and baseline data for future phases of the project. (2) Methods: An observational study design was adopted for this study. Data on a variety of sociodemographic and clinical factors were collected at discharge and six weeks after via REDCap. Anxiety, depression, and well-being symptoms were assessed using the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire-9 (PHQ-9), and the World Health Organization-Five Well-Being Index (WHO-5), respectively. Descriptive, chi-square, independent t-tests, and multivariate regression analyses were conducted. (3) Result: The survey was completed by 88 out of 306 participants (28.8% response rate). The chi-square/Fisher exact test and independent t-test revealed no significant change in the mental health conditions from baseline to six weeks after discharge. It was found that the only significant factor predicting symptoms six weeks after discharge from inpatient treatment was the baseline symptoms in all three logistic regression models. It was four times more likely for those who experienced anxiety and depression at baseline to experience anxiety and depression symptoms six weeks after discharge (OR = 4.27; 95% CI: 1.38-13.20) (OR = 4.04; 95% CI: 1.25-13.05). Those with poor baseline well-being were almost 12 times more likely to experience poor well-being six weeks after discharge (OR = 11.75; 95% CI: 3.21-42.99). (4) Conclusions: Study results found no significant change in mental health conditions in the short term following hospital discharge. It is essential that researchers and policymakers collaborate in order to implement effective interventions to support and maintain the mental health conditions of patients following discharge.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers

OBJECTIVE

Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States.

METHODS

The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing.

RESULTS

Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming.

CONCLUSIONS

Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

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.

Systematic review of community pharmacist administration of long-acting injectable antipsychotic medications

BACKGROUND

Long-acting injectable antipsychotic (LAIA) medications offer an effective treatment option for patients with serious mental illness. Despite demonstrated clinical safety and efficacy as well as increased adherence and less frequent administration compared with daily oral regimens, LAIAs remain underutilized in clinical practice. With legislation allowing pharmacists to administer injectable medications in 48 U.S. states, community pharmacies are uniquely positioned to serve as an access point for patients with serious mental illnesses to receive LAIA injections.

OBJECTIVE

This study aimed to conduct a systematic review of the health and economic benefits and costs of community pharmacist administration of LAIA medications.

METHODS

A systematic search of the literature published from January 1996 to April 2022 was conducted across 3 databases (Embase, PubMed, and Scopus Plus). Publications describing pharmacist administration of LAIA medications in outpatient settings were included. Publications that examined the use of LAIAs but did not involve a pharmacist administering the medication were excluded.

RESULTS

Of 2261 publications reviewed, we identified 8 publications (4 articles and 4 abstracts) that met our inclusion criteria, of which only 7 included results. Four studies reported high medication adherence achieved by patients receiving pharmacist-administered LAIAs. Two publications surveyed patient satisfaction with pharmacist administration of LAIAs in community pharmacy settings. One study found pharmacists' mixed attitudes regarding LAIA administration and time and safety barriers to offering the service.

CONCLUSION

We found very little evidence on the impact of pharmacist administration of LAIAs on patient outcomes. This review highlights the need to generate greater evidence on the health and economic benefits as well as financial models for pharmacists to administer LAIA medications in outpatient and community pharmacy settings. Such evidence could support more community pharmacists to offer LAIA medications and contribute to the shift toward value-based care.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Improving mental health care transitions through information capture during admission to inpatient mental health services: a quality improvement study

Background

Many interventions aim to improve the transition from ward to community at the time of discharge, with varying success. Guidelines suggest that discharge planning should begin at admission, but in reality this is ideal rather than standard practice. We aimed to develop a novel information capture tool during admission that facilitates and accelerates discharge.

Methods

A quality improvement study to develop, implement and evaluate a novel tool that improves information capture upon admission to acute mental health wards within a single English National Health Service (NHS) trust. We developed the tool by synthesising existing evidence and working with multi-agency and multi-disciplinary professionals in two co-design workshops. During implementation the tool was piloted on three wards. Ethnographic observations (145 h) and interviews (45) were used to evaluate the implementation of the tool across the three wards. Thematic synthesis was used to consolidate the findings.

Results

The tool developed considerably as the process evolved. The finished product is a list of 10 information categories that should be captured from external agencies upon admission to hospital to facilitate discharge planning to community settings. Reported advantages of the tool were: (1) facilitating confidence in junior staff to legitimately question the suitability of a patient for an acute ward (2) collecting and storing essential information in a single accessible place that can be used throughout the care pathway and (3) collecting information from the services/agencies to which patients will eventually be discharged.

Conclusions

Improving the quality of information at admission has the potential to facilitate and accelerate discharge. The novel tool provides a framework for capturing this information that can be incorporated into existing information systems. However, the introduction of the tool exacerbated complex, fragile distributed team dynamics, highlighting the importance of sociocultural context in information flow transitional interventions within distributed teams.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07136-2.

The Role of Board-Certified Psychiatric Pharmacists in Expanding Access to Care and Improving Patient Outcomes

Although approximately 20% of adults in the United States experience a mental health condition annually, there continues to be a gap in the provision of care because of a shortage of behavioral health providers. The National Council for Behavioral Health Medical Director Institute has recommended that the number of board-certified psychiatric pharmacists (BCPPs), who are clinical pharmacists with advanced specialized training and experience in the treatment of patients with psychiatric and substance use disorders, be expanded to help meet this need. Although BCPPs currently assist in expanding care access, improving medication-related outcomes, and reducing health care costs by working collaboratively with physicians and other health care providers, BCPPs are often underutilized. This lack of utilization results in lost opportunity to better address the needs of persons with psychiatric or substance use disorders and to meet these needs in a timely manner. Here, the authors bring attention to five key areas-opioid use disorder, antipsychotic use among children, long-acting injectable antipsychotics, clozapine use, and transitions of care and care coordination-in which BCPPs, along with other pharmacists, provide evidence-based care and could be more extensively used as a collaborative solution to the mental health and substance use disorder crisis in the United States.

Human factors/ergonomics work system analysis of patient work: state of the science and future directions

PURPOSE

To demonstrate the use and value of the Human Factors/Ergonomics-based Systems Engineering Initiative for Patient Safety (SEIPS) family of work system models for studying and improving patient work.

DATA SOURCES

We conducted a review of the published empirical literature applying the SEIPS family of work system models for patient work.

STUDY SELECTION

Included studies had to apply one of the SEIPS family of work system models to study patient work; be published in a peer-reviewed journal in English and include analysis of data. We identified 16 articles that met our inclusion criteria.

DATA EXTRACTION

For each study, we extracted settings and situations in which models were applied; research design; study methods; model(s) used; type and number of study participants; study objective(s); whether the study included an intervention; specific aspects of the model used; knowledge generated about patient work and benefits of using the models.

RESULTS OF DATA SYNTHESIS

Our analysis revealed that a majority of studies were conducted in the United States, used qualitative or mixed methods and employed a variety of data collection techniques to study adult patient populations with chronic illness and their informal caregivers and healthcare providers performing patient work in the home and clinical setting. The studies resulted in a variety of useful products, demonstrating several benefits of using the models.

CONCLUSION

Our review has demonstrated the value of using the SEIPS family of work systems models to study and improve patient and family contributions to health-related work.

Pharmacist-led telemental health transitions of care clinic improves antidepressant medication continuity posthospitalization

A pharmacist-led telemental health transitions of care clinic was created at a Veterans Affairs Medical Center to improve continuity of psychiatric medication therapy following discharge from an acute psychiatric hospitalization. This was a single-center, multi-site, retrospective cohort study (historical cohort). The primary study objective was to determine the impact of a post-discharge pharmacist-led telemental health transitions of care clinic on improving antidepressant adherence rates after an acute psychiatric hospitalization. Secondary objectives included evaluation of rates of readmission to psychiatric hospitals, time to first mental health provider follow-up, and characterization of various pharmacist interventions made during the clinic visit. Pilot study results support that a pharmacist-led telemental health transitions of care clinic can improve antidepressant adherence after psychiatric hospital discharge and reduce time to postdischarge follow-up with a mental health provider. Patients enrolled in the clinic were more likely to maintain a medication possession ratio >0.8 within 90 days of discharge when compared to a historical control (100% vs 43%, P  = .035). The clinic also improved time to first mental health provider follow-up as seen by a statistically significant improvement in the number of patients seen within 14 days of discharge by a mental health provider (100% vs 43%, P = .035). Results highlight the valuable role of psychiatric pharmacists in delivery of transitions of care services and support the expansion of current roles to improve outcomes after psychiatric hospitalizations.

Developing a core outcome set for interventions to improve discharge from mental health inpatient services: a survey, Delphi and consensus meeting with key stakeholder groups

OBJECTIVE

To develop a core set of outcomes to be used in all future studies into discharge from acute mental health services to increase homogeneity of outcome reporting.

DESIGN

We used a cross-sectional online survey with qualitative responses to derive a comprehensive list of outcomes, followed by two online Delphi rounds and a face-to-face consensus meeting.

SETTING

The setting the core outcome set applies to is acute adult mental health.

PARTICIPANTS

Participants were recruited from five stakeholder groups: service users, families and carers, researchers, healthcare professionals and policymakers.

INTERVENTIONS

The core outcome set is intended for all interventions that aim to improve discharge from acute mental health services to the community.

RESULTS

Ninety-three participants in total completed the questionnaire, 69 in Delphi round 1 and 68 in round 2, with relatively even representation of groups. Eleven participants attended the consensus meeting. Service users, healthcare professionals, researchers, carers/families and end-users of research agreed on a four-item core outcome set: readmission, suicide completed, service user-reported psychological distress and quality of life.

CONCLUSION

Implementation of the core outcome set in future trials research will provide a framework to achieve standardisation, facilitate selection of outcome measures, allow between-study comparisons and ultimately enhance the relevance of trial or research findings to healthcare professionals, researchers, policymakers and service users.

Codesigning a Mental Health Discharge and Transitions of Care Intervention: A Modified Nominal Group Technique

BACKGROUND

Discharge from acute mental health services has long been associated with mortality, risk, and related adverse outcomes for patients. Many of the interventions that currently aim to reduce adverse outcomes focus on a single group of healthcare professionals within a single healthcare setting. A recent systematic review highlights very few robust interventions that specifically aim to improve communication across services. However the importance of promoting interagency working and improving information flow between services is continually highlighted as a key priority.

METHODS

Using a novel codesign and experience based approach we worked with a multistakeholder group to develop possible solutions to reduce the adverse outcomes commonly associated with discharge from acute mental health services. This utilized a modified Nominal Group Technique and creative problem solving method to follow a four-stage process: Problem Identification, Solution Generation, Decision-Making, Prioritization and Implementation. Thirty-two healthcare professionals and an expert by lived experienced engaged with the process that took place over two stakeholder events.

RESULTS

Stakeholders at the first event identified and agreed upon 24 potential ideas to improve discharge from acute mental health services. These were refined at the second event to four elements of an interagency intervention: a multiagency 'Discharge Team' (with designated discharge coordinator), inclusive technology enabled team meetings, universal documentation and a patient generated discharge plan.

CONCLUSION

This is the first study to codesign an interagency mental health discharge intervention based around a discharge team. We developed a model for working that places a greater focus on a patient generated discharge plan, interagency working, and information flow. A pilot of the proposed intervention is now needed to test the feasibility and effectiveness in reducing adverse outcomes.

Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework

Objective

To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors.

Materials and Methods

This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework.

Results

Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology.

Discussion

Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging.

Conclusion

Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

Interventions to improve discharge from acute adult mental health inpatient care to the community: systematic review and narrative synthesis

Background

The transition from acute mental health inpatient to community care is often a vulnerable period in the pathway, where people can experience additional risks and anxiety. Researchers globally have developed and tested a number of interventions that aim to improve continuity of care and safety in these transitions. However, there has been little attempt to compare and contrast the interventions and specify the variety of safety threats they attempt to resolve.

Methods

The study aimed to identify the evidence base for interventions to support continuity of care and safety in the transition from acute mental health inpatient to community services at the point of discharge. Electronic Databases including PsycINFO, MEDLINE, Embase, HMIC, CINAHL, IBSS, Cochrane Library Trials, ASSIA, Web of Science and Scopus, were searched between 2000 and May 2018. Peer reviewed papers were eligible for inclusion if they addressed adults admitted to an acute inpatient mental health ward and reported on health interventions relating to discharge from the acute ward to the community. The results were analysed using a narrative synthesis technique.

Results

The total number of papers from which data were extracted was 45. The review found various interventions implemented across continents, addressing problems related to different aspects of discharge. Some interventions followed a distinct named approach (i.e. Critical Time Intervention, Transitional Discharge Model), others were grouped based on key components (i.e. peer support, pharmacist involvement). The primary problems interventions looked to address were reducing readmission, improving wellbeing, reducing homelessness, improving treatment adherence, accelerating discharge, reducing suicide. The 69 outcomes reported across studies were heterogeneous, meaning it was difficult to conduct comparative quantitative meta-analysis or synthesis.

Conclusions

The interventions reviewed are spread across a spectrum ranging from addressing a single problem within a single agency with a single solution, to multiple solutions addressing multi-agency problems. We recommend that future research attempts to improve homogeneity in outcome reporting.

Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

Purpose:

To measure diagnostic imaging safety events reported to an electronic safety reporting system (ESRS) and assess steps where they occurred within the diagnostic imaging workflow and contributing socio-technical factors.

Methods:

We evaluated all ESRS safety reports related to diagnostic imaging during calendar 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and performing 680,000 diagnostic imaging studies annually. Each report was assigned a 0-4 harm score by the reporter; we classified scores of 2 (minor harm) to 4 (death) as “potential harm”. Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and socio-technical factors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Kappa measured inter-reviewer agreement on 10% of reports. The percentage of reports that could cause “potential harm” was compared for each step and socio-technical factor using chi-square analysis.

Results:

Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was Imaging Procedure (54% of reports), potential harm occurred more in Report Communication (Odds Ratio=2.36, p=0.05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to Task compared to Person factors (OR=5.03, p<0.0001). Kappa was 0.79.

Conclusion:

Safety events were related to diagnostic imaging in 7% of reports and potential harm occurred primarily during Imaging Procedure and Report Communication. Safety events were attributed to multifactorial socio-technical factors. Further work is necessary to decrease safety events related to diagnostic imaging.