Research finds innovative Kaiser Permanente program promotes behaviors that protect health for people with schizophrenia, bipolar disorder
Telehealth visits with a specially trained pharmacist resulted in better medication adherence and diabetes screening for people with serious mental illness who are enrolled in an innovative Kaiser Permanente Northern California (KPNC) program, according to a study published in the Journal of Clinical Psychiatry.
The analysis found patients with severe and persistent mental illness (SPMI) in the collaborative care program filled psychotropic medication prescriptions more regularly and were screened for blood sugar levels more often than SPMI patients who had usual care, without the pharmacist visits.
Program participants did not see any increase in psychiatric emergency department visits or hospitalizations, suggesting that shifting some routine tasks from psychiatrists to trained pharmacists is beneficial and safe, said co-lead author Esti Iturralde, PhD, a research scientist with the Kaiser Permanente Division of Research.
SPMI program pharmacists work closely with the patient’s psychiatrist in a collaborative care model. “The clinical pharmacists are providing important additional support, while the psychiatrist is leader of the team,” explained co-lead author Lisa Fazzolari, DO, a psychiatrist with The Permanente Medical Group and regional medical director of the SPMI program. The collaborative care team also includes other clinicians such as the primary care physician, with the pharmacist acting as care navigator and following the patient with regular video and telephone appointments.
“The feedback we’ve received from both patients and clinicians is that pharmacists are well-integrated with the care team,” Iturralde said. “This collaboration allows psychiatrists to focus on stabilizing patients while pharmacists check in with patients to make adjustments that support treatment success and overall health goals.”
Greater risk of chronic disease
People with SPMI — with conditions such as schizophrenia and bipolar disorder — may have difficulty staying on needed psychiatric medications due to side effects or uncertainty about the necessity of continued treatment. Many patients also are at higher risk for health conditions such as obesity, diabetes, and heart disease, in part because of side effects of medications they take. The addition of a psychiatric clinical pharmacist to their care team is meant to help manage both mental and physical health.
The study compared 968 program enrollees at 6 KPNC demonstration sites with 8,339 similar patients with SPMI, examining several health outcomes for the year before and after the collaborative care program began in 2021.
On average, patients in both groups improved in their psychotropic medication adherence during the study, but those enrolled in the collaborative care group improved more, with 60% versus 50% in the usual care group meeting an optimal threshold at study’s end. The collaborative care group was also more likely to receive glycemic (blood sugar) screening (74% versus 64% at study end).
More than 75% of collaborative care participants attended an initial intake meeting and at least one follow-up visit, suggesting that people with SPMI were open to receiving support through telehealth, possibly on their smartphones or other devices.
“Offering a connection through telehealth may overcome challenges to attending appointments, providing a convenient way to stay in touch with the care team by phone or video visit,” said Fazzolari. “These may be patients who wouldn’t otherwise be seen in person and are now getting important health screenings.”
Building clinical pharmacy expertise
The clinical pharmacists in the program are board-certified or board-eligible in psychiatric pharmacy, having completed a 2-year specialized postgraduate program or equivalent clinical experience. To maintain access to these highly in-demand practitioners, KPNC has established an in-house postgraduate training program, said study co-author and program regional director Macy Shia, PharmD.
The specialized training provides a boost both for the care teams and for the pharmacists, Shia said. “A staff survey found that advanced practitioners who participate in specialized training programs experience an increase in confidence, along with feeling more fulfilled and satisfied in taking on diverse challenges,” she said.
The program, unique to KPNC, was described in greater detail in a 2022 paper in NEJM Catalyst, a publication of the New England Journal of Medicine, and in a previous Research Spotlight story.
The researchers are continuing to expand their evaluation of the program, which is now in 11 KPNC service areas, Iturralde said. They will look at additional health outcomes, preventive care, psychiatric status, and program costs. Estimating what it costs to implement the program will be important for other health systems to consider adopting the model, she said.
“There’s a definite need to study these types of specialized clinical pharmacists and if they should be more integrated into health systems,” Iturralde added.
The study was funded by a grant from The Permanente Medical Group Delivery Science and Applied Research program.
Additional co-authors were Natalie E. Slama, MPH, Stacy E. Alexeeff, PhD, Stacy A. Sterling, MSW, DrPH, of the Division of Research; and Sameer Awsare, MD, and Maria T. Koshy, MD, of The Permanente Medical Group.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.
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