Literature Collection

BACKGROUND: Community pharmacists frequently care for patients with complex medical and social needs; however, specific evidence on pharmacist perceptions of what makes a patient encounter complex has not been clearly characterized. There is a need to better understand specific factors that contribute to patient encounter complexity and demonstrate how pharmacists in community settings care for these individuals. OBJECTIVES: The objectives of this programmatic case study were to: (1) elucidate factors that contributed to patient encounter complexity as a part of a Medicaid Managed Care Organization comprehensive medication management payer program in community pharmacies and (2) curate a series of patient case vignettes that provide evidence of pharmacists care for patients with complex medical and social needs within community pharmacies. METHODS: This qualitative programmatic case study utilized data from semi-structured interviews with community pharmacists who provided comprehensive medication management services to Medicaid patients in Pennsylvania. Pharmacists described their most complex patient encounter. Interviews were transcribed and independently coded by 2 investigators. The coded texts were grouped into categories, and a cross-case inductive thematic analysis was performed to identify complexity factors. RESULTS: Thirty pharmacists provided 48 patient case vignettes and 3 complexity factors emerged: (1) care coordination; (2) behavioral health support; and (3) social determinants of health. Representative patient case vignettes were selected to illustrate these factors. CONCLUSION: Pharmacists, who participated in a community pharmacy Medicaid Managed Care Organization payer program, provided care to patients with complex health needs. In addition to medication-related problems, specific factors that increased pharmacist perception of encounter complexity were care coordination with other health care providers, behavioral health support, and addressing social determinants of health.

BACKGROUND: With the onset of the COVID-19 crisis, many federal agencies relaxed policies regulating opioid use disorder treatment. The impact of these changes has been minimally documented. The abrupt nature of these shifts provides a naturalistic opportunity to examine adaptations for opioid use disorder treatment in primary care. OBJECTIVE: To examine change in medical and behavioral health appointment frequency, visit type, and management of patients with opioid use disorder in response to COVID-19. DESIGN: A 14-item survey queried primary care practices that were enrolled in a medications for opioid use disorder statewide expansion project. Survey content focused on changes in service delivery because of COVID-19. The survey was open for 18 days. PARTICIPANTS: We surveyed 338 clinicians from 57 primary care clinics located in California, including federally qualified health centers and look-alikes. A representative from all 57 clinics (100%) and 118 staff (34.8% of all staff clinicians) participated in the survey. MAIN MEASURES: The survey consisted of seven dimensions of practice: medical visits, behavioral health visits, medication management, urine drug screenings, workflow, perceived patient demand, and staff experience. KEY RESULTS: A total of 52 of 57 (91.2%) primary care clinics reported practice adaptations in response to COVID-19 regulatory changes. Many clinics indicated that both medical (40.4%) and behavioral health visits (53.8%) were now exclusively virtual. Two-thirds (65.4%) of clinics reported increased duration of buprenorphine prescriptions and reduced urine drug screenings (67.3%). The majority (56.1%) of clinics experienced an increase in patient demand for behavioral health services. Over half (56.2%) of clinics described having an easier or unchanged experience retaining patients in care. CONCLUSIONS: Many adaptations in the primary care approach to patients with opioid use disorder may be temporary reactions to COVID-19. Further evaluation of the impact of these adaptations on patient outcomes is needed to determine whether changes should be maintained post-COVID-19.

IntroductionIndividuals with serious mental illness (SMI), including major depression, schizophrenia, and bipolar disorder, experience disproportionately high rates of cardiovascular (CV) risk and disease. Despite this well-established connection, it remains unclear how professional society guidelines across cardiology and psychiatry address this relationship.MethodsMajor American and European CV and psychiatric society guidelines published from 2013-2023 were reviewed. Included were guidelines on primary and secondary CV disease prevention, and disease-specific guidelines for schizophrenia, bipolar disorder, and major depressive disorder. Relevant text was extracted and classified as recommendations or supporting text.ResultsTwenty-six guidelines were included (13 CV; 13 psychiatric). Psychiatric considerations appeared in 5 CV guidelines (38%), most commonly addressing mental illness treatment to improve CV outcomes (n = 5), pharmacological considerations (n = 2), and recognition of mental illness as a CV risk factor (n = 2). Only 13% of American CV guidelines included psychiatric content, compared to 80% of European CV guidelines. In contrast, 10 psychiatric guidelines (77%) included CV-related recommendations, including CV screening (n = 16), pharmacological considerations (n = 8), and risk factor control (n = 7). Among psychiatric guidelines, 40% of U.S. and 100% of European documents included CV content.ConclusionsCV considerations are more frequently addressed in psychiatric than psychiatric considerations in CV guidelines. European guidelines showed greater cross-disciplinary integration. These findings highlight the need for more unified, interdisciplinary guidance to reduce CV risk in individuals with SMI.