Medication Management Visits Research Articles

The Tell on Telehealth.

Telehealth in epilepsy care is not new. During the COVID-19 public health emergency, telehealth became more readily used to deliver epilepsy care. However, a summarized guidance of use in caring for people with epilepsy utilizing telehealth is needed. Existing literature was reviewed to provide guidance on various aspects of telehealth. Billing aspects are reviewed. Recommendations and considerations along with benefits and barriers to telehealth are provided. Telehealth can be a preferred delivery route of care for people with epilepsy in specific situations. Examples include psychiatric complaints, medication management, and follow-up visits for noncomplicated epilepsy care. In addition, telehealth is useful for patients who need postoperative visits, are not able to travel, or live in residential facilities. In-person care may be more suitable for patients who are medically complex, have language barriers or difficulty with resource access, hearing impaired, or have neurostimulation devices where remote monitoring or programming options are infeasible. Telehealth care for people with epilepsy can be a useful and important method of care delivery. It should remain an option for providers to use in epilepsy clinical care. It is important for the neurology provider to understand the benefits, billing, and barriers to providing telehealth.

Abstract 13892: Enhancing Guideline-Directed Medical Therapy in Post-Discharge Heart Failure Patients Through Comprehensive Medication Management Visits With Virtual Clinical Pharmacists

Introduction: According to national registries, the adoption and effective titration of GDMT for patients with HFrEF remains notably inadequate. Utilizing virtual clinical pharmacists (VCPs) to identify deficiencies in medication therapy presents a flexible and efficient approach for thorough and immediate interventions following discharge. Methods: A single-center retrospective analysis from May 2022-April 2023 examined post-discharge HF patients who participated in a comprehensive medication management (CMM) visit conducted by a VCP within 72 hours of their discharge. Results: Of 116 participants, 108 (93%) had a discharge diagnosis of HFrEF, and 8 (6.8%) with HFimpEF. During the VCP visit, 27 (23.3%) presented with active HF exacerbation symptoms including SOB (33%), fatigue (22%), weakness (19%), lower extremity swelling (11%), weight gain (11%), and tachycardia (4%). The percentages of the total population currently prescribed GDMT for HRrEF and HFimpEF classes are as follows: Beta Blocker (89.7%), ARNI (47.4%), MRA (33.6%), SGLT2i (25.9%), and ACEI/ARB (22.4%). Up-titrating of dosage was recommended for 75% of patients currently prescribed ARNI, 64% for Beta Blockers, and 51% for MRAs. Additionally, VCPs recommended adding the following drug classes to those not prescribed, despite being indicated: SGLT2i (45%), ARNI (30%), MRA (29%), Beta Blocker (25%), and ACEI/ARB (24%). Comprehensive counseling on HF self-care practices was delivered to the entire cohort (100%). Furthermore, support was extended to facilitate the management of comorbid conditions for 105 patients (91%), and social assistance was provided to 7 patients (6%). Conclusions: The utilization of VCPs played a crucial role in identifying care gaps, including but not limited to patient symptoms, suboptimal medication therapy, insufficient disease education, social assistance, and comorbidity management, which collectively contributed to initiating and up-titrating GDMT.

Pharmacist-provider collaborative visits after hospital discharge in a comprehensive acute kidney injury survivor model

BackgroundPostdischarge follow-up in primary care is an opportunity for pharmacists to re-evaluate medication use in acute kidney injury (AKI) survivors. Of the emerging AKI survivor care models described in literature, only one involved a pharmacist with limited detail about the direct impact. ObjectiveThis study aimed to describe pharmacist contributions to a comprehensive postdischarge AKI survivorship program in primary care (the AKI in Care Transitions [ACT] program). MethodsThe ACT program was piloted from May to December of 2021 at Mayo Clinic as a bundled care strategy for patients who survived an episode of AKI and were discharged home without the need for hemodialysis. Patients received education and care coordination from nurses before discharge and later completed postdischarge laboratory assessment and clinician follow-up in primary care. During the follow-up encounter, patients completed a 30-minute comprehensive medication management visit with a pharmacist focusing on AKI survivorship considerations. Medication therapy recommendations were communicated to a collaborating primary care provider (PCP) before a separate 30-minute visit with the patient. PCPs had access to clinical decision support with evidence-based post-AKI care recommendations. Medication-related issues were summarized descriptively. ResultsPharmacists made 28 medication therapy recommendations (median 3 per patient, interquartile range 2-3) and identified 14 medication discrepancies for the 11 patients who completed the pilot program, and 86% of the medication therapy recommendations were acted on by the PCP within 7 days. Six recommendations were made to initiate renoprotective medications, and 5 were acted on (83%). ConclusionDuring the pilot phase of a multifaceted transitional care program for AKI survivors, pharmacists’ successfully identified and addressed multiple medication therapy problems, including for renally active drugs. These results demonstrate the potential for pharmacist-provider collaborative visits in primary care to improve safe and effective medication use in AKI survivors.

PSUN172 Prescribing SGLT-2 Inhibitors and GLP-1 Agonists in Primary Care: Improving Rates of Guideline-Concordant Practice

Abstract Background In practice, prescribing of a GLP-1 agonist (GLP-1a) or SGLT-2 inhibitor (SGLT-2i) for patients with type 2 diabetes mellitus (T2DM) and multiple risk factors for atherosclerotic cardiovascular disease (ASCVD) may be lagging behind the guidelines that recommend it. We aim to increase the prescribing rates of GLP-1as and SGLT-2is in a primary care resident clinic. Methods Eligible patients included adults with T2DM in an internal medicine primary care resident practice at the University of Vermont who were not already taking a SGLT-2i or GLP-1a. These patients were offered a diabetes medication management (DMM) visit with their PCP. The residents participated in a 30-minute educational intervention on: prescribing guidelines, medication risks and side effects, counseling patients, dose titration, and current Medicaid and Medicare insurance coverage estimates. This information was summarized in two tables that were included in a templated progress note to be used for DMM visits. DMM visits took place over a six month period. Chart review was conducted to determine patient co-morbidities and outcomes of the initial and follow-up DMM visits. Additional data was gathered from a post-visit survey completed by resident PCPs. Data was analyzed using descriptive methods. Results One hundred sixteen patients with T2DM were eligible. Sixty-five patients either declined, could not be reached, or did not present for their scheduled appointment. Fifty-one patients (44% of those eligible) completed a DMM visit. Of these 51, 18 (35%) were started on a SGLT-2i, either at the initial visit or at a follow-up visit. A GLP-1a was started for 14 (27%) patients. Nearly all who completed a DMM visit had at least one risk factor for ASCVD, and most had multiple risk factors. Problem lists for these patients showed that 40 (78%) had hypertension, 33 (65%) had hyperlipidemia, 12 (24%) had coronary artery disease, and 5 (10%) were current smokers. Two (4%) had a diagnosis of CHF, and 12 (24%) had CKD. Forty (out of 46) (87%) survey respondents reported that they were "more likely" to prescribe SGLT-2is and GLP-1as after participating in the intervention. The two most common reasons that these medications were not prescribed were the presence of competing visit priorities and co-management of diabetes medications by an endocrinologist. Conclusions Most patients with T2DM also have risk factors for ASCVD and would benefit from a GLP-1a or SGLT-2i. Prescriber education is an effective way to expand prescribing of these medications. Primary care providers are well-positioned to consider patients’ cardiovascular co-morbidities when prescribing diabetes medications, but may also be burdened by other visit priorities taking precedence. This study highlights the importance of a team-based approach to diabetes management and demonstrates a role for enhanced communication between primary care and specialties such as endocrinology and cardiology. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Mental health treatment utilization and relationship functioning among male and female OEF/OIF veterans.

This study examined whether romantic relationship functioning was associated with mental health treatment utilization in male and female veterans. Veterans (N = 760) enrolled in a longitudinal registry completed self-report measures and a diagnostic interview for posttraumatic stress disorder (PTSD). Mental health treatment utilization data procured from Veterans Affairs administrative records were analyzed over 12 months. For men with PTSD, greater romantic relationship dysfunction was associated with more total mental health visits, medication management visits, and group psychotherapy visits. For women with PTSD, romantic relationship dysfunction was negatively associated with total mental health, individual psychotherapy, and group therapy visits. For women without PTSD, greater relationship dysfunction was associated with fewer total mental health visits and group therapy visits. For men, relationship difficulties appear to be positively related to mental health service use; however, for women, relationship difficulties appear to have no relation or a negative relation to mental health service use. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic

Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown. To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes. This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022. Receipt of a video-enabled tablet. Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs). The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide. This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

Effects of Gabapentin on Dorsal Anterior Cingulate Cortex GABA and Glutamate Levels and Their Associations With Abstinence in Alcohol Use Disorder: A Randomized Clinical Trial.

Although gabapentin has demonstrated efficacy in mitigating alcohol withdrawal symptoms and preventing relapse drinking in individuals with alcohol use disorder (AUD), the neurobiological mechanisms of action underlying these therapeutic effects remain unknown. The present study evaluated changes in GABA and glutamate levels in the dorsal anterior cingulate cortex (dACC) as candidate mechanisms of action. In a 16-week randomized clinical trial, 68 adults with AUD, including a history of alcohol withdrawal syndrome, received 1,200 mg/day of gabapentin (N=37) or placebo (N=31) and nine medical management visits after ≥72 hours of abstinence. Proton MR spectroscopy (1H-MRS) estimates of dACC levels of GABA (N=67) and glutamate (N=64) were acquired before start of treatment and again approximately 14 days after randomization. Percent days abstinent was reported via timeline followback interview. The effects of gabapentin on GABA and glutamate levels were significantly associated with participants' percent days abstinent during early treatment. Specifically, gabapentin was associated with greater increases in glutamate and greater decreases in GABA levels in participants who remained mostly or entirely abstinent, and yet the opposite in participants who drank on more than half of the days preceding the second scan. Furthermore, gabapentin-treated participants with greater increases in glutamate levels during early treatment had significantly more percent days abstinent across the remainder of the study, relative to placebo-treated participants. In addition to providing insight into the mechanisms through which gabapentin may promote abstinence in individuals with AUD, this study also provides evidence for a biomarker of efficacious treatment that may be used to evaluate other glutamatergic or GABAergic medications for AUD and related conditions.

Impact analysis of virtual ambulatory transplant pharmacists during COVID-19.

IntroductionDuring the coronavirus disease 2019 (COVID‐19) pandemic, transplant centers were challenged to meet the demand for new telemedicine strategies. The ability of lung transplant providers (LTP) to conduct face‐to‐face clinic visits for high‐risk immunocompromised patients, such as lung transplant recipients (LTR), was limited. Through the implementation of comprehensive medication management visits, pharmacists were able to assist LTP in the transition to telemedicine.MethodsA retrospective chart review of telephone encounters from cardiothoracic (CT) transplant pharmacists at our center from March to September 2020 was completed. LTR scheduled for clinic visits with LTP were called prior to the visit by CT transplant pharmacists who conducted medication list reviews, adherence assessments, and medication access assistance. Clinical recommendations were communicated directly to the LTP and documented in patient electronic medical records. The primary outcome was the number of pharmacist‐driven clinical interventions. Secondary endpoints included the clinical severity and value of service of each intervention, percentage of accepted recommendations, patient cost savings interventions, prevention of adverse events, and avoidance of inappropriate doses.ResultsFrom March to September 2020, the CT transplant pharmacists conducted 385 virtual visits on 157 LTR with a median of 20 minutes spent per visit. There were 891 total interventions made by CT transplant pharmacists, including 778 medication discrepancies identified. Over 60% of encounters demonstrated some form of medication error and over 55% of encounters exhibited value of pharmacy services.ConclusionImplementation of CT transplant pharmacist telehealth visits has potential for increased patient access to pharmacy care and improved accuracy of medication lists. When focusing on the severity of errors and value of services, most demonstrated a level of significance. Further investigation is needed to analyze the impact of this service on patient outcomes as well as cost‐effectiveness.

Faculty and Resident Engagement With a Workplace-Based Assessment Tool: Use of Implementation Science to Explore Enablers and Barriers.

Implementation of workplace-based assessment programs has encountered significant challenges. Faculty and residents alike often have a negative view of these programs as "tick-box" or "jump through the hoops" exercises. A number of recommendations have been made to address these challenges. To understand the experience with a workplace-based assessment tool that follows many of these recommendations, the authors conducted a qualitative study using the Consolidated Framework for Implementation Research (CFIR) to identify enablers and barriers to engagement with the tool. The Psychopharmacotherapy-Structured Clinical Observation (P-SCO) is a direct observation tool designed to assess resident performance during a psychiatric medication management visit. From August 2017 to February 2018, the P-SCO was implemented in the outpatient continuity clinics for second- and third-year residents at Zucker Hillside Hospital/Northwell Health. In February and March 2019, the authors conducted semistructured interviews of participating faculty and residents. Interview guides based on the CFIR were used to capture the enablers and barriers to engagement. Interview transcripts were independently coded. Codes were then organized into themes relevant to the domains of the CFIR. Ten faculty and 10 residents were interviewed. Overall, participants had a positive experience with the P-SCO. Enabling factors for faculty and residents included the ongoing training, design features of the P-SCO, predisposing beliefs, dedicated faculty time, and the perception that the P-SCO improved verbal feedback quality. Barriers for faculty included checklist length and discomfort with feedback that threatens identity, and barriers for residents included faculty variability in timeliness and quality of feedback and minimal review of the feedback after initial receipt. This study demonstrates that the negative experience of faculty and residents with workplace-based assessment tools shown in prior studies can be overcome, at least in part, when specific implementation strategies are pursued. The findings provide guidance for future research and implementation efforts.

Workload evaluation of clinical pharmacists in the ambulatory care setting

AbstractIntroductionInpatient clinical pharmacists' roles and contributions to team‐based care are well established; however, there is limited evidence describing the activities and processes for the delivery of care by ambulatory care clinical pharmacists.ObjectivesThe primary objective was to measure time spent on daily activities that comprise the workload of clinical pharmacists providing direct patient care services in an integrated ambulatory care setting.MethodsA prospective, ethnographic, and observational pilot study was conducted at six pharmacist‐integrated multidisciplinary ambulatory care clinics. Clinical pharmacist participants were observed for up to three nonconsecutive clinic workdays. Participant demographics, site characteristics, and self‐reported engagement in direct patient care activities were collected. Workload was evaluated through direct observation of time spent on daily clinical and administrative activities. Time allocated, visit type, number of disease states assessed, and use of clinical support staff were collected for each visit. Results were stratified based on participant engagement in targeted, dual, or comprehensive medication management (CMM) visits, in which one, two, or three or more disease states were assessed, respectively. The primary outcome was analyzed using descriptive statistics.ResultsTen clinical pharmacists were observed for a total of 26 clinic workdays. Of prespecified activities, clinical pharmacist participants spent the most time documenting care activities, spending a mean (SD) of 6.6 (6.7), 8.0 (8.2), and 7.6 (7.7) minutes after targeted, dual, and CMM visits, respectively. There was a large variation in the distribution of prespecified clinical and administrative activities among participants. Years of practice experience, postgraduate training, board certification(s), duration of practice at the site, and site characteristics did not affect the distribution of time spent on activities (P > .05).ConclusionsThis evaluation articulates the daily activities that contribute to the work of ambulatory care clinical pharmacists and may serve as the foundation to perform more comprehensive evaluations of their contributions to patient outcomes.

Efficacy of Gabapentin for the Treatment of Alcohol Use Disorder in Patients With Alcohol Withdrawal Symptoms

Although an estimated 30 million people meet criteria for alcohol use disorder (AUD), few receive appropriate pharmacotherapy. A more personalized, symptom-specific, approach might improve efficacy and acceptance. To examine whether gabapentin would be useful in the treatment of AUD, especially in those with the most alcohol withdrawal symptoms. This double-blind randomized clinical trial conducted between November 2014 and June 2018 evaluated gabapentin vs placebo in community-recruited participants screened and treated in an academic outpatient setting over a 16-week treatment period. A total of 145 treatment-seeking individuals who met Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria for AUD and were not receiving other AUD intervention were screened, and 96 who also met recent alcohol withdrawal criteria were randomized to treatment after 3 abstinent days. Daily drinking was recorded, and percentage of disialo carbohydrate-deficient transferrin in the blood, a heavy drinking marker, was collected at baseline and monthly during treatment. Gabapentin up to 1200 mg/d, orally, vs placebo along with 9 medical management visits (20 minutes each). The percentage of individuals with no heavy drinking days and those with total abstinence were compared between treatment groups and further evaluated based on prestudy alcohol withdrawal symptoms. Of 96 randomized individuals, 90 were evaluable (44 in the gabapentin arm and 46 in the placebo arm), with a mean (SD) age of 49.6 (10.1) years; 69 were men (77%) and 85 were white (94%). The evaluable participants had 83% baseline heavy drinking days (4 or more drinks/day for women, 5 or more for men) and met 4.5 alcohol withdrawal criteria from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). More gabapentin-treated individuals had no heavy drinking days (12 of 44 participants [27%]) compared with placebo (4 of 46 participants [9%]), a difference of 18.6% (95% CI, 3.1-34.1; P = .02; number needed to treat [NNT], 5.4), and more total abstinence (8 of 44 [18%]) compared with placebo (2 of 46 [4%]), a difference of 13.8% (95% CI, 1.0-26.7; P = .04; NNT, 6.2). The prestudy high-alcohol withdrawal group had positive gabapentin effects on no heavy drinking days (P < .02; NNT, 3.1) and total abstinence (P = .003; NNT, 2.7) compared with placebo, while within the low-alcohol withdrawal group, there were no significant differences. These findings were similar for other drinking variables, where gabapentin was more efficacious than placebo in the high-alcohol withdrawal group only. Gabapentin caused more dizziness, but this did not affect efficacy. These data, combined with others, suggest gabapentin might be most efficacious in people with AUD and a history of alcohol withdrawal symptoms. Future studies should evaluate sleep changes and mood during early recovery as mediators of gabapentin efficacy. ClinicalTrials.gov Identifier: NCT02349477.

Trajectory classes of opioid use among individuals in a randomized controlled trial comparing extended-release naltrexone and buprenorphine-naloxone

ObjectivesTo advance our understanding of medication treatments for opioid use disorders (OUDs), identification of distinct subgroups and factors associated with differential treatment response is critical. We examined trajectories of opioid use for patients with OUD who were randomized to (but not in all cases inducted onto) buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX), and identified characteristics associated with each trajectory. MethodsGrowth mixture models (GMMs) were run to identify distinct trajectories of days of opioid use among a subsample of 535 individuals with OUD who participated in a 24-week randomized controlled trial (RCT; 2014–2016) of BUP-NX (n = 281) or XR-NTX (n = 254). ResultsFour distinct opioid use trajectory classes were identified for BUP-NX (near abstinent/no use (59%); low use (13.2%); low use, increasing over time (15%); and moderate use, increasing over time (12.8%)). Three distinct opioid use trajectory classes were found for XR-NTX (near abstinent/no use (59.1%); low use (14.6%); and moderate use, increasing over time (26.4%)). Across both BUP-NX and XR-NTX, the near abstinent/no use class had the highest number of medical management visits. Within BUP-NX, the low use class had a greater proportion of individuals with a previous successful treatment history compared with other classes. Within XR-NTX, the moderate use, increasing over time class had the highest proportion of Hispanic participants compared with other classes. ConclusionsFindings highlight the significant heterogeneity of opioid use during a RCT of BUP-NX and XR-NTX and factors associated with opioid use patterns including medical management visits and history of treatment success.

Increasing Mental Health Care Access, Continuity, and Efficiency for Veterans Through Telehealth With Video Tablets.

In 2016, the Veterans Health Administration (VHA) began distributing video-enabled tablets to veterans with access barriers. This study evaluated the implementation of this initiative for veterans with mental health conditions, including the impact of tablet receipt on access to and continuity of mental health care, missed opportunities for care, and use of urgent care. A retrospective matched cohort study was conducted, matching tablet recipients with diagnoses of mental disorders (N=728) to a comparison group (N=1,020) on the basis of sociodemographic characteristics, mental health utilization and diagnoses, and wireless coverage. A difference-in-differences approach was used to compare 6-month pre-post changes in number of psychotherapy and medication management visits, continuity of psychotherapy based on VHA's quality metric for mental health care continuity, missed opportunity rate (i.e., the proportion of mental health appointments that were missed or canceled), and probability of any and number of emergency department (ED) or urgent care visits. Compared with the matched control group, tablet recipients experienced an increase of 1.94 (p<0.001) psychotherapy encounters, an increase of 1.05 (p<0.001) medication management visits, an 18.54 percentage point (p<0.001) increase in their likelihood of receiving recommended mental health care necessary for continuity of care, and a 20.24 percentage point (p<.001) decrease in their missed opportunity rate in the 6-month period following receipt of tablets (or the index date for the matched sample). No significant differences in ED or urgent care use were found. Distributing video-enabled tablets to veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency by decreasing missed opportunities for care.

668-P: A Coaching Intervention with Low Literacy Progress Report Improves Glycemic Control

Diabetes imposes a greater burden on minority and disadvantaged populations. Tailored interventions are needed to improve self-management outcomes among these populations. Purpose: To determine a) the effect of tailored coaching on patient knowledge, attitudes, and A1c and b) whether patient age, diabetes duration, or education level moderated intervention effect. Methods: A pre-post efficacy analysis of a randomized patient coaching intervention in an urban diabetes clinic was conducted. Eligibility included diagnosed diabetes, A1c ≥ 7.0%, on insulin or high dose oral agents, at least two clinic visits in the prior year and at least four coaching sessions at ∼6-month intervals. Participants received either standard diabetes handouts (N=192) or one-on-one, low literacy tailored coaching (N=161). Coaching included review of home and clinic blood sugars/A1c using a color coded graphical printed progress report, goal setting and formulation of questions for the provider. Outcomes included A1c/blood sugar target knowledge, measured A1c, Diabetes Empowerment Scale scores, and Patient Activation Measure scores. Results: Most participants were female (64%), black (96%), had household incomes &amp;lt; $15,000/year (83%), and had type 2 diabetes (96%). Mean age was 56.5 years and mean baseline A1c was 8.7%. Coaching increased knowledge of target A1c compared to control (OR 3.2, CI 1.6-6.2) but not knowledge of target blood sugar. Coaching improved measured A1c (-1.0% vs. -0.4% p &amp;lt; 0.05). The magnitude of improvement tended to be somewhat greater at higher educational levels (high school -0.97, p&amp;lt;.01; more than high school -1.19, p&amp;lt;.05). Coaching did not significantly increase diabetes self-efficacy or patient activation. Summary: Personalized, multi-component low literacy coaching significantly improves A1c and knowledge of A1c control targets. Repeated coaching sessions can enhance the effectiveness of medical management visits. Disclosure R. Wolf: None. C.S. Barnes: None. C. Wan: None. J. Caudle: None. D.C. Ziemer: None. Funding American Diabetes Association (7-05-CR-03 to C.S.B.)

Poster Number: NR 25 - The Implementation and Effectiveness of a Higher Level Outpatient Mental Health Care Program for Older Adults

Introduction: Multiple stakeholders are increasing pressure to provide high quality outpatient care for older adults with mood disorders. Inpatient psychiatric care is expensive, and payers are scrutinizing the necessity of each inpatient day. Traditional outpatient programs that cater to people with non-commercial health insurance struggle to stay financially solvent. Unfortunately, the current intermediate levels of care such as intensive outpatient services and partial hospitalization programs present practical barriers for older adults. Those with multiple medical issues struggle to tolerate long, frequent therapy sessions, and the cost of care can be a barrier. To meet the needs of our older adults with significant impairment from mood and anxiety disorders, we designed the Bellefield Enhanced Supportive Team (BEST) in 2014. It is an ambulatory program with biweekly group therapy, weekly individual psychotherapy and frequent medication management visits.

Performance Assessment of Pharmacotherapy: Results from a Content Validity Survey of the Psychopharmacotherapy-Structured Clinical Observation (P-SCO) Tool.

The Psychopharmacotherapy-Structured Clinical Observation (P-SCO) tool is designed to assess performance of a medication management visit and to enhance feedback. Prior research indicated that the P-SCO was feasible to implement in a resident clinic and generated behaviorally specific, high-quality feedback. This research also highlighted problems with some of the instrument's items. This study seeks to improve the items. The authors initially revised the P-SCO items based on the problems identified by a prior study. Next, these items were iteratively modified by experts in clinical pharmacotherapy and educational assessment. Forty-five items emerged. Finally, faculty attending an annual department education retreat rated each item on its relevance (4-point scale) and provided comments on how the item might be revised. For final inclusion, an item must have met a quantitative threshold (i.e., content validity index equal to or greater than 0.8 and the lower end of the asymmetric confidence interval equal to or greater than 3.0) and received comments that were supportive. Forty-one of the 45 items had strong quantitative support. However, the comments endorsed lumping a number of items in order to decrease overlap between items and to shorten the instrument. This process resulted in the further elimination of 15 items. The revised 26-item P-SCO builds upon prior evidence of feasibility and utility and now possesses additional evidence of content validity. The use of the tool should enhance feedback and improve the capacity of educational programs to assess performance.

Mental Health Spending and Intensity of Service Use Among Individuals With Diagnoses of Eating Disorders Following Federal Parity.

The Mental Health Parity and Addiction Equity Act (MHPAEA) was intended to eliminate differences in insurance coverage for mental health and substance use disorder services and medical-surgical care. No studies have examined mental health service use after federal parity implementation among individuals with diagnoses of eating disorders, for whom financial access to care has often been limited. This study examined whether MHPAEA implementation was associated with changes in use of mental health services and spending in this population. Using Truven Health MarketScan data from 2007 to 2012, this study examined trends in mental health spending and intensity of use of specific mental health services (inpatient days, total outpatient visits, psychotherapy visits, and medication management visits) among individuals ages 13-64 with a diagnosis of an eating disorder (N=27,594). MHPAEA implementation was associated with a small increase in total mental health spending ($1,271.92; p<.001) and no change in out-of-pocket spending ($112.99; p=.234) in the first year after enforcement of the parity law. The law's implementation was associated with an increased number of outpatient mental health visits among users, corresponding to an additional 5.8 visits on average during the first year (p<.001). This overall increase was driven by an increase in psychotherapy use of 2.9 additional visits annually among users (p<.001). MHPAEA implementation was associated with increased intensity of outpatient mental health service use among individuals with diagnoses of eating disorders but no increase in out-of-pocket expenditures, suggesting improvements in financial protection.

Rethinking the 15-Minute Medication Management Visit: Does it Work?

Rethinking the 15-Minute Medication Management Visit: Does it Work?

First-Person Perspectives on Prescriber-Service User Relationships in Community Mental Health Centers.

Because of changes in health care, there is a greater focus on brief medication management visits as the primary method of providing psychiatric care in community mental health settings. Research on the first-person perspectives of service users and prescribers in these settings is limited. The objective of this study was to describe first-person perspectives on medication management visits and the service user-prescriber relationship. Researchers conducted qualitative interviews as part of a larger comparative effectiveness trial at 15 community mental health centers, researchers interviewed service users (N=44) and prescribers (N=25) about their perspectives on the typical elements of a medication management visit and asked service users about their relationship with their prescriber. Both service users and prescribers described medication management visits as very brief encounters focused on medication and symptoms. Most service users reflected on the service user-prescriber relationship in positive or neutral terms; they did not describe the development of a strong therapeutic relationship or a meaningful clinical encounter with prescribing clinicians. Service users described the service user-prescriber relationship and medication management visit as largely transactional. Despite the transactional nature of these encounters, most service users described relationships with prescribing clinicians in positive or neutral terms. Their satisfaction with the visit did not necessarily mean that they were receiving high-quality care. Satisfaction may instead suggest service users' disengagement from care. They may need more support to fully participate in their own care.

Drug Therapy Problems Identified by Pharmacists Through Comprehensive Medication Management Following Hospital Discharge

Background: Pharmacists influence health care outcomes through the identification and resolution of drug therapy problems (DTPs). Objective: The objectives of this study were to describe number, type, and severity of DTPs based on clinical significance and likelihood of harm in patients transitioning from hospital to home as assessed during a comprehensive medication management (CMM) visit with a pharmacist. Secondary objectives were to assess intrarater reliability in severity ratings and assess likelihood of harm for adverse drug reactions (ADR) by drug classes. Methods: Retrospective review of 408 patients having a face-to-face, telephonic, or virtual CMM visit within the Fairview Health System. Teams of 3 investigators reviewed each DTP from the electronic medical record for each of the 408 patients and assigned a severity score (0-10) for clinical significance and likelihood of harm. Main Results: The highest severity DTP classes were adherence and ADR. The lowest severity DTP class was unnecessary drug therapy. An average of 2.5 DTPs was found per patient at the index CMM visit following hospital discharge. The most common DTP classes were needs additional therapy and dose too low. There were statistically significant differences in DTP severity scoring between reviewer types, though differences were &lt;5%. Drug classes with the highest severity ADR included diabetes, cardiovascular, and anticoagulant/antiplatelet agents. Conclusions: The DTP severity ratings indicated that reviewers found ADR and adherence DTPs were potentially the most severe. There were differences in DTP ratings between reviewer types, though clinical significance of these differences is unclear.