Best practice model for outpatient psychiatric pharmacy practice, part 2: Confirmation of the attribute statements.

Introduction: The American Association of Psychiatric Pharmacists (AAPP) used multiple modalities to develop and refine 28 attribute statements to describe a best practice model for outpatient psychiatric pharmacists. Before addressing implementation, assessment, and field testing, it was necessary to finalize and confirm the statements and their supporting narratives among stakeholders. The objective of this project was to confirm the attribute statements and supporting justifications for a best practice model for outpatient psychiatric pharmacists providing direct patient care.
Methods: The 4 phases that resulted in the 28 attribute statements and supporting narratives have been described and published elsewhere. As part of phase 5, the confirmation survey was distributed to pharmacists and resident members of AAPP in November 2021 for 3 weeks.
Results: The survey respondents (n = 74; 6.1%) were licensed pharmacists for an average of 15.6 years (SD = 12.0) and had been practicing as psychiatric pharmacists for an average of 11.3 years (SD = 10.4). Slightly more than half (54.2%) of the respondents reported practicing in the outpatient setting and three-fourths (74.3%) were Board Certified Psychiatric Pharmacists. For each of the 28 statements, more than 90% of respondents either agreed or agreed with minimal reservations. Discussion: Given the high degree of agreement on the proposed practice model statements, they will be used as the basis for the outpatient psychiatric pharmacist best practice model. Next steps in developing this model include establishing implementation guidance, determining appropriate metrics for evaluation of these statements in practice, and establishing appropriate field-testing methods.

Introduction

In 2019, a survey conducted by the Professional Affairs Committee of the American Association of Psychiatric Pharmacists (AAPP) to characterize the current state of psychiatric pharmacy in the United States showed that pharmacists provide care to persons with mental illness in a multitude of settings using a wide variety of methods.1 Approximately half of the respondents reported practicing in outpatient settings, with variations in their scope of practice and delivery. Some used prescriptive authority, whereas others only provided care in consultative roles. Tracking of practice outcomes also varied, with small numbers of pharmacists actively tracking the impact of their practice on patient care.1

Based on the results of this survey, the Best Practice Model Subcommittee (BPMS) of the AAPP Professional Affairs Committee initiated work on a best practice model for outpatient psychiatric pharmacy practice between June 2, 2020 and November 22, 2021. The goal was to promote a standardized model that allows outpatient psychiatric pharmacists (OPPs) to maximize their impact on the care of patients with mental illness and work collaboratively with the other members of the health care team. The process of developing these statements involved a series of broad surveys and summit meetings of psychiatric pharmacists providing patient care in outpatient settings. The perspective used in developing these statements was to reflect the future of outpatient psychiatric pharmacy practice that pharmacists should endeavor to meet. Although the current status of practice is quite varied, the goal of the best practice model project is to improve the overall quality of care provided to patients by promoting a standardized model that provides consistent, effective care.

Methods

The first 4 phases of the project resulted in the development of 28 statements with supporting narratives and references that will serve as the basis for the model (Appendix). The methods and results of the first 4 phases (initial membership survey, summit meetings, follow-up membership survey, and summit review meeting) and other project activities have been described and published elsewhere.2 In the fifth and final phase, the goal was to measure overall agreement and obtain consensus on what core attributes and qualities should be incorporated within the best practice model among AAPP members.

An electronic survey using Qualtrics was administered to pharmacist and resident members of AAPP between November 1 and November 22, 2021. Participants were emailed 2 times and were sent 4 reminders during weekly organization emails during the 3-week period. The survey contained 8 demographic questions regarding licensure, board certifications, region of practice, and practice types. Those who indicated they practiced in outpatient settings received 3 questions for each of the 28 statements. They were asked to indicate their level of agreement to each statement (agree, agree with minimal reservations, disagree), how much each statement characterized their outpatient practice (scale from 0 [not at all] to 10 [completely]), and how likely they would be able to implement the statement in their practice (scale from 0 [extremely unlikely] to 10 [extremely likely]). They were also asked whether they were willing to serve as a field tester for the model at their outpatient clinical practice site in the future if resources were available.

Those who indicated that they do not practice in an outpatient setting were also asked to indicate their level of agreement to each of the 28 statements (agree, agree with minimal reservations, disagree), but they were not asked about characterization or implementation. All respondents were provided the opportunity to provide comments and feedback on any of the statements or supporting narratives. The survey items were developed by the BPMS to obtain respondents' confirmation for each statement and identify gaps in current practice and likelihood of implementation for future practice. Statements meeting an a priori cutoff score of 25% disagreement among outpatient providers or 50% disagreement among all respondents were to be eliminated.

Descriptive statistics (mean, SD, percentages) were used to describe the characteristics of the respondents as well as the level of agreement for the 28 statements for best practice. Chi-square/Fisher exact tests were used to compare the level of agreement between certain demographic characteristics. Spearman rank correlations were conducted between the number of years of licensure, number of years of practice as a psychiatric pharmacist, their characterization of their outpatient practice to each statement, and the likelihood of implementing each statement in their practice. Data analysis was completed using IBM SPSS version 28.0.

All responses were maintained confidential and de-identified to protect participant anonymity. IRB exemption approval was received from the Massachusetts College of Pharmacy and Health Sciences and University of California, San Diego, IRBs, and approval of the project was received from the AAPP Board of Directors prior to survey distribution.

Results

Of 1206 pharmacist and resident members who received the survey invitation, 74 individuals (6.1%) consented and responded to the survey. Respondents reported being a licensed pharmacist for an average of 15.6 years (SD, 12.0 years) and practicing as a psychiatric pharmacist (defined as 50% of clinical practice devoted to mental health and/or substance use disorders) for an average of 11.3 years (SD, 10.4 years; Table). Approximately three-fourths of the respondents reported being a Board Certified Psychiatric Pharmacist (BCPP), and 54% of pharmacists reported practicing in an outpatient setting.

TABLE

Demographics of the phase 5 respondents (n = 74)a

Characteristic	Value
Licensed pharmacist, average (SD), y	15.6 (12.0)
Psychiatric pharmacist, average (SD), y	11.3 (10.4)
Region of practice, No. (%)
Northeast	14 (19.7)
Midwest	17 (23.9)
South	19 (26.8)
West	21 (29.6)
Residencies/fellowships completed, No. (%)
PGY1	38 (51.4)
PGY2 neurology	1 (1.4)
PGY2 psychiatry	41 (55.4)
Fellowship	6 (8.1)
None	14 (18.9)
Otherb	3 (4.1)
Board certifications, No. (%)
BCPP	55 (74.3)
BCACP	2 (2.7)
BCPS	15 (20.3)
BCGP	1 (1.4)
None	13 (17.6)
Otherc	1 (1.4)
Primary clinical site: federal agency, No. (%)
Yes	24 (33.8)
No	47 (66.2)
Primary clinical practice setting, No. (%)
Inpatient	25 (34.7)
Outpatient	39 (54.2)
Administration	1 (1.4)
Otherd	7 (9.7)
Primary clinical practice locale, No. (%)
Academic medical center	11 (15.5)
Behavioral health clinic	15 (21.1)
Community hospital	11 (15.5)
Correctional facility	1 (1.4)
Government hospital–state	4 (5.6)
Government hospital–VA	20 (28.2)
Government–othere	1 (1.4)
Home health care	0
Hospice	0
Long term care	0
Managed care	0
Pharmaceutical industry	0
Primary care clinic	4 (5.6)
Nongovernment–othere	4 (5.6)
No clinical practice	0

BCACP = Board Certified Ambulatory Care Pharmacist; BCGP = Board Certified Geriatric Pharmacist; BCPP = Board Certified Psychiatric Pharmacist; BCPS = Board Certified Pharmacotherapy Specialist; PGY = postgraduate year; VA = Veterans Affairs.

Three respondents declined to answer region of practice, 2 declined to answer primary clinical practice setting, and 4 declined to answer primary clinical practice locale. Respondents could have selected more than 1 option for residencies/fellowships completed and board certifications.

Other residencies/fellowships: clinical pharmacy practice at psychiatric hospital, psychopharmacology research, emergency medicine, ambulatory care.

Other board certifications: CSP (specialty pharmacy).

Other clinical practice setting: inpatient and outpatient setting, consultant practice, correctional psychiatry.

Other clinical practice locale: county public health department, community care, hospital affiliated outpatient pain management clinic.

Of the 28 statements, those practicing in the outpatient setting had 100% agreement to 9 statements (1, 4, 5, 21, 23-24, 26-28; Figure 1a). There were no significant differences for any of the statements when compared between those who held BCPP versus those who did not. Those who indicated that the statement characterizes their outpatient practice were also significantly correlated with the likelihood of being able to implement the statement in their practice. Despite the high level of agreement with the statements, none of the statements received a perfect rating for characterizing the respondents' outpatient practices, with average ratings ranging 5.74 to 9.90 of 10 (Figure 2).

FIGURE 1

(a) Percent agreement of outpatient respondents for each statement; (b) percent agreement of nonoutpatient respondents for each statement

FIGURE 2

Characterization of current outpatient practice and likelihood of future implementation of each statement in practice (mean score for current characterization represents average ratings of respondents to the question, “How much does this statement currently characterize your outpatient practice” using the scale from 0 [not at all] to 10 [completely]; mean score for future implementation represents average ratings of respondents to the question, “How likely would you be able to implement this statement in your practice” using the scale from 0 [extremely unlikely] to 10 [extremely likely])

Of the respondents, 66% reported that they would be somewhat likely or extremely likely to serve as a field tester for the model at their outpatient clinical practice in the future if resources were available. Among those not practicing in the outpatient setting, respondents reported 100% agreement to 8 statements (4, 6, 21-24, 27-28; Figure 1b).

When the level of agreement was compared between those practicing in the outpatient setting versus those not practicing in the outpatient setting, there was no significant difference for any of the 28 statements. There were 2 statements (2, 11) that had >5% of outpatient or nonoutpatient respondents who disagreed. There were 3 statements among outpatient respondents whose ratings of their ability to implement the statement in practice were less than 7.50 (16, 26, 27).

Statement 2 regarding the requirement of a PharmD and BCPP had a 9.4% disagreement rate among outpatient respondents and a 6.5% disagreement rate among nonoutpatient respondents (along with a 56.3% and 71.0% full agreement rate for each group, respectively; Figure 1a, b). Despite this, both current characterization and future implementation had average scores of 8.25 among outpatient respondents (Figure 2). Some comments regarding this statement mentioned that many current OPPs are not PharmDs or BCPPs and provide high-quality care, that years of experience should also be considered, or that this could limit the number of OPPs available to provide care to patients.

Statement 11 regarding the administration and interpretation of rating scales had some disagreement among outpatient respondents (6.7%) but no disagreement among nonoutpatient respondents (Figure 1a, b). Both groups, however, did have full agreement above 80%. The outpatient current characterization score was 7.91 and future implementation score was 8.48, indicating a potential for growth in this area among OPPs (Figure 2). Comments for this statement included that rating scales should not replace subjective symptom and illness assessment, that the time required to administer some scales is cumbersome, and that there is need for training on the various rating scales.

There were 2 statements (26 and 27) regarding reimbursement and clinical site support for pharmacist activities, respectively, that had future implementation scores under 7.50 (5.57 and 7.16, respectively) and current characterization scores under 7.50 (5.74 and 7.29, respectively), among outpatient providers (Figure 2). There was 100% agreement among both outpatient and nonoutpatient providers (Figure 1a, b). Respondents did not comment on these statements other than to say that reimbursement concerns are “currently the largest barrier to care.”

Treatment of other medical illnesses (Statement 16) also had a low outpatient future implementation score of 7.48, with a current characterization score of 7.40 (Figure 2). Although both outpatients and nonoutpatients had low disagreement rates (3.1% and 3.2%, respectively), they also had low full agreement rates (71.9% and 74.2%, respectively; Figure 1a, b). Respondents discussed the need for OPPs to focus on mental health care and concerns about site support and liability. There were also comments that supported OPPs working collaboratively with medical providers to assist in treating medical illnesses in patients with mental illness.

Discussion

This survey confirmed that a high level of consensus exists around the attributes and qualities that are the basis for the OPP best practice model. The appropriateness of the statements is further confirmed by a cursory examination of similarities to current practice within the Department of Veterans Affairs, where the psychiatric pharmacist is a core team member in the advanced practice provider role.3 Despite consensus, there is room for improvement with most of the attributes. Some statements can be implemented directly by the pharmacist, such as “Outpatient psychiatric pharmacists should be able to communicate with empathy, respect, assertiveness, confidence, and cultural awareness (Statement 5).” Other statements can only be implemented with the support of the health system, such as “Outpatient psychiatric pharmacists should have full electronic health record (EHR) access and should document services within the EHR (Statement 28).” Although the feasibility of implementation was generally high, it was notably lower when the statement required action by the health system or payer, such as “Outpatient psychiatric pharmacists should be able to receive reimbursement for clinical services (Statement 26).” Additional implementation concerns were raised through respondents' comments where additional training was needed for the statements, such as those regarding measurement-based care (Statements 11-13), suicide assessment and prevention (Statement 3), and comprehensive medication management (Statements 9 and 10). Future development of the model will need to address these implementation concerns through training and advocacy efforts. The model could also be used by OPPs to gain support from practice administration because it provides guidance regarding ideal practice conditions.

One item of particular interest was Statement 2 regarding the PharmD degree and BCPP certification as the credentials for OPPs to maintain. This statement had higher rates of disagreement and lower rates of full agreement among both outpatient and non-outpatient respondents. The concerns raised about potentially losing existing OPPs not meeting these credentials or decreasing future expansion of OPPs are worth considering. However, this model is not intended to exclude any existing OPPs or prevent future OPPs from entering the workforce. It is intended to help standardize the quality of care provided by OPPs that is achievable in all outpatient settings.

One limitation of the survey was the low response rate, but current findings aligned with results of previous phases of this project.2 Throughout phases 1 through 5, there was a wide representation of AAPP members who contributed to the development and confirmation of the statements. Although earlier project phases allowed participants to suggest additional attributes, the design of this survey did not validate whether the attributes represented a complete description of the ideal model. Therefore, it is possible that some attributes for the model may be missing. This concern was mitigated somewhat because respondents could have commented on the survey about any missing attributes. In fact, there were some comments recommending minor word revisions to the statements' supporting narratives that will be considered by the BPMS. The consensus-building process was important for developing a durable best practice model, but it is noteworthy that previous informal efforts yielded many of the same attributes as described here.4,5 These statements also align with the vision of the psychiatric pharmacy specialty in order to best position psychiatric pharmacists to positively impact patient care.6

There was a high degree of agreement on the proposed practice model statements that will serve as the basis for the OPP best practice model. Psychiatric pharmacists are uniquely poised to serve as medication experts and provide comprehensive medication management to patients. Current assessment of practice by psychiatric pharmacists in the outpatient setting reveals a high degree of variability, in both attributes of the practitioner and the practice model. Reports of practice models share some similarities, but there is no standardized best practice model. The next steps in developing the OPP best practice model include establishing implementation guidance, determining any needed training, and developing appropriate metrics for the assessment of these statements.