| Consultant Pharmacist/Forum | |
In Alvin, Texas, which is located on the Gulf Coast in Brazoria County, a team of mental health professionals takes assertive action in treating a core of individuals who have persistent, long-term mental illnesses. The Assertive Community Treatment (ACT) Team is led by Dawn Petersen, Program Director. In addition to the director, a registered nurse, five clinicians a psychiatrist and consultant pharmacist make up the team. The members are available 24 hours a day, 365 days a year to assist approximately 50 individuals, their families, and significant others.
The ACT Team targets individuals diagnosed with mental illness and an intellectual level in the mild to borderline range. These individuals have at least one previous hospitalization for mental health treatment. Most have a history of aggression, challenging behaviors, criminal activity, and the inability to accommodate change or stress. They require education with daily living skills and close monitoring and assistance. Over half have the additional diagnosis of chemical dependency.
A second target group is adults with chronic serious mental illness who have had one or more readmissions for psychiatric inpatient care during the last two years. Early intervention is critical to improve aftercare services and reduce state and local hospitalizations. Not only does this group present a unique set of circumstances, it also shares the problems encountered by living in small, isolated, rural communities with limited resources. The team is assertive with treatment and pre-crisis management. With this approach, the sense of trust that develops between the staff and consumers allows the staff to be more involved during difficult periods.
Goals of the ACT Team
The goals of the team are to assist the individuals with persistent mental illness to live in the community with increased comfort, independence, and dignity, as well as to avoid hospitalization.
With the team approach, the consumer is seen on an informal, rotating basis by each team member. Visits are made in the community, not in the clinic. They are also made more frequently, sometimes daily. Because of the numerous challenges posed by these individuals, the consumer-to-staff ratio is usually 6:1 and no more than 10:1.
Medication, education, physical health, occupation, habilitation, housing arrangements, and continuity of care are all monitored by team members. Crisis situations can be anticipated, and staff are able to remain aware of these situations as they develop through continuous feedback. Each staff person has knowledge of the individual, present stressors, and situations. The problems are then manageable and hospitalization is limited. The attention paid to consumers’ everyday life allows the team to assist them in taking care of emerging problems such as rent increases, concerns about medications, and conflicts with neighbors. Because of the staff’s accessibility, the consumer does not have to create a crisis to get attention.
The staff work with the individuals, their families, and their significant others to educate them about mental health, precipitating events, and coping skills to help the person live successfully in the community.
Some of the individuals have a history of aggression and violence. However, because of the frequent contacts made by staff, indications of decompensation are more recognizable and precautions can be taken. The team works closely with the mental health deputies to protect the consumer as well as the staff. Local law enforcement agencies are aware of the ACT team and are supportive of their efforts.
How the Team Operates
The staff’s assertive approach with the consumer and the community is ongoing. There is consistent, persistent, and detail-oriented advocacy for the consumer’s needs and services. Staff go to the consumers to find out what is going on. One example is an individual referred to the program who was dual-diagnosed as mentally retarded and a substance abuser. He was noncompliant with psychiatric treatment and services. When the ACT staff first approached him, he refused services. Several more attempts were made throughout the month to develop a relationship, to no avail. The team continued to contact him daily to develop his trust. To achieve this, they would search the entire town, checking the bank, courthouse, and other favorite places. As a result of this approach, the individual did begin to request assistance with obtaining services.
The team has no individual caseloads, and every team member sees every consumer at various points throughout the rotation. As a result, staff can respond with maximum efficiency to all situations. Staff absence is rarely noticed by the consumer, and thus staff are given a periodic respite from the most difficult individuals.
Team reports are held each morning to review the prior day’s experiences, discuss any crises that may have developed overnight, modify treatment plans, and plan the day’s agenda. Each team member participates in all aspects of the consumer’s treatment. The system improves participating consumers’ quality of life, giving them a safer home environment, the ability to participate more effectively in social situations, better medication compliance, and something to do during the day. It also allows them to remain in the most effective and least restrictive environment.
Medications, Administration, Monitoring, Documentation, and Storage
Medications, especially psychoactive ones, are an integral part of the overall treatment of the consumers served by the ACT Team. The administration of medications, monitoring of compliance, documentation of usage, and storage are important issues that must be dealt with.
The psychiatrist assesses each consumer’s mental illness symptoms and behavior and prescribes appropriate medications. All team members assess and document the consumers’ symptoms and behavior in response to medication and monitor for adverse side effects.
Consultant Pharmacist’s Role
During the consultant pharmacist’s initial visit to team headquarters in March 1997, there were several issues and problems noted, including the following:
The consultant pharmacist and the ACT Team worked together to establish medication policies and procedures that identified processes to do the following:
All these problems were addressed, and the solutions identified have made the ACT Team more time-efficient and have assisted in the managed care of the consumers’ mental health program. This process is set up as a continuous quality improvement program. Table 1 shows some of the findings by the consultant pharmacist during the drug utilization review.
Table 1. Results of Drug Utilization Review by the ACT Team Consultant Pharmacist
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The consultant pharmacist’s experience and background in psychoactive medications is extremely valuable in assisting the ACT Team in the management of these consumers’ mental health disorders and medications.
Conclusion
The Brazoria County ACT Team has developed an excellent model for other, similar teams in Texas for providing quality pharmaceutical care in an innovative clinical setting to a group of individuals who have persistent mental illnesses. The consultant pharmacist has an opportunity to use a vast array of knowledge and skills to manage health care in this unique environment. The pharmaceutical systems and procedures implemented have been so successful that the program director has recommended these services to other ACT Teams.
The Assertive Community Treatment Team and Dawn Petersen may be contacted at 281-585-1087 or by writing to 204 W. Coombs, Alvin, TX 77511.
Larry McClaugherty, RPh, MPH, FASCP
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Consultant Pharmacist
PharMerica
Houston, Texas
There is a great deal in the news these days about the aging baby boomers. No wonder there is so much discussion. The average American life span has increased dramatically this century. In 1900 the average life span was 47, in 1981 it was 73, and by 2010 it is predicted to be approximately 82 years. Current projections are that 20% of the population will be over the age of 65 by 2020. Individuals over the age of 85 are the fastest growing group, and their number is expected to triple over the next 30 years.
Individuals 65 and older comprise about 12% of the U.S. population and consume 33% of all prescription drugs. Obviously, this increasing proportion of elderly has tremendous implications for the health care system and pharmaceutical care.
Recently, the Food and Drug Administration ruled that prescription drug labels will have mandatory "geriatric use" labeling indications by 2003; some drugs will be affected by as early as August 1998. The labeling will be on drugs that are commonly used by the elderly, including anticoagulants, calcium channel blockers, digoxin, and anti-arrhythmics. The labeling will list drug-disease interactions, therapeutic ranges, and adverse drug reactions (ADRs). The labels will focus on the drugs effect on the elderly and will include dose limits, hazards, and monitoring.
Truly the ground is fertile for pharmacists to plant more seeds about how we may contribute to improving therapeutic outcomes because of this increasing awareness of medication-related problems in the elderly. After all, that is what pharmaceutical care is all about.
According to Hepler and Strand (Am J Health-System Pharm 1993;50:1720—3), the goal of pharmaceutical care is "to improve an individual quality of life through achievement of definite medication-related therapeutic outcomes." The outcomes sought in the Hepler and Strand model are curing a disease, eliminating or reducing a patient’s symptomatology, arresting or slowing a disease process, or preventing a disease or symptomatology. Further, we must identify potential or actual medication-related problems, resolve them, and prevent future problems from occurring.
The Problem
We must identify therapeutic duplications and paradoxical drug combinations and altered pharmacokinetics that may predispose the patient to excessive drug accumulation. And in dosing, we must recognize differences among dosing weight, ideal body weight, and actual body weight.
A number of problems in the elderly complicate their therapy. Declining physiological function leads to altered pharmacokinetics and pharmacodynamics and to increased potential for adverse effects. Increased incidence or severity of diseases may also lead to altered pharmacokinetics and pharmacodynamics or to an increase in the number of drugs prescribed. Naturally, the more medications, the greater the potential for drug-drug interactions. Decreased mental acuity or a fixed income may also decrease medication compliance and consequently alter the therapeutic effect of drugs.
Physiological Changes and Polypharmacy
The literature demonstrates that about one-third of all prescriptions and more than 40% of non-prescription medications are consumed by people over 65 years old. In addition, approximately 25% of this group receive inappropriate medications, which places them at risk for ADRs.
Many physiological conditions associated with aging require medications. The age-related pharmacokinetics and pharmacodynamics alter response to the medication. In addition to the usual list of hepatic and renal changes, there are other considerations such as decreased lean body mass, decreased albumin levels, and insufficient homeostatic adjustments.
Chronic illnesses associated with aging include arthritis, congestive heart failure, hypertension, and chronic obstructive pulmonary disease. The drug regimens required to treat these disorders along with acute problems adds to the risk for ADRs and other drug-related problems.
Pharmacokinetics
Age is associated with alterations in distribution, metabolism, and elimination of many drugs. These changes vary among individuals and may be complicated by disease states. They increase the risk of side effects and ADRs in this population.
Absorption is not significantly changed, despite alterations in gastrointestinal function including increased gastric pH, decreased gastric emptying, diminished splanchnic blood flow, and decreased intestinal motility. These have some effect on absorption, but they rarely have a significant effect on the rate or extent of absorption of oral medications.
Metabolism by the liver is dependent on hepatic blood flow and enzyme activity. Between the ages of 25 and 65, it is possible to have a decrease of up to 45% of the hepatic blood flow and hepatic mass.
After age 40, glomerular filtration and tubular secretion decrease, causing a decline in creatinine clearance. There may be a decrease in functioning nephrons and renal perfusion secondary to other pathologic conditions such as decreased cardiac output. Several creatinine clearance nomograms have been published to assist in calculating dosages of medication for the elderly.
Pharmacodynamics
Pharmacodynamic changes have been noted in various body systems– particularly the central nervous system and the cardiovascular system– and in beta-adrenergic, cholinergic, and dopaminergic receptors. Pharmacodynamic responses in the elderly may be exacerbated by existing disease states and altered drug effects. Changes in receptor sensitivity result in altered reactions to normal doses of medications. The anticholinergics may more likely cause urinary retention or dementia, while the beta-adrenergic blockers may require larger doses.
Conclusion
Explosive growth in the numbers of older Americans certainly warns us to sharpen our skills related to geriatric practice. We have a vital role to play in geriatric medicine and psychiatry if our patients are to achieve optimal benefits. We are realizing that many problems in the elderly such as some dementias and other psychiatric disorders are drug-related, and they have frequently been overlooked as we explore outcomes.
While the call for more outcome measures to improve quality of life is important, we can embrace many strategies now to improve care. We must remember that if we do the "right" things by our patients–right diagnosis, right drug, right dose, right delivery system, right instructions, right diet (to avoid drug-nutrient interactions), and right monitoring, we will improve outcomes.
Phyllis M. Parks-Veal, PharmD
Milledgeville, Georgia