Board-Certified Psychiatric Pharmacists Have a Significant Role, Experts Say

In an interview with Pharmacy Times^®, Jolene Bostwick, PharmD, BCPS, BCPP and Brenda Schimenti from the American Association of Psychiatric Pharmacists (AAPP) discuss the vital role of board-certified psychiatric pharmacists (BCPPs) in integrated care teams, highlighting their expertise in comprehensive medication management, collaborative practice agreements, psychotropic stewardship, and improving outcomes for patients with psychiatric disorders. They emphasize the many ways in which BCPPs optimize safety and efficacy in medication therapy—such as monitoring for adverse effects (AEs), conducting suicide risk assessments, and using pharmacogenetics—while also addressing significant policy barriers, including lack of reimbursement and federal recognition, that limit broader implementation and growth of the profession.

Pharmacy Times: Can you introduce yourselves?

Jolene Bostwick, PharmD, BCPS, BCPP: My name is Jolene Bostwick. I'm a board-certified psychiatric pharmacist and the president of the American Association of Psychiatric Pharmacists (AAPP). And I'm employed by the University of Michigan College of Pharmacy as a clinical professor.

Brenda Schimenti: And I'm Brenda Schimenti, I'm executive director of AAPP. And not a pharmacist, but I've been on staff for over 20 years with AAPP.

Pharmacy Times: Board-certified psychiatric pharmacists (BCPPs) work as part of an integrated health care team. Can you describe how a BCPP collaborates with other health care professionals to provide comprehensive medication management for patients with psychiatric disorders?

Bostwick: Yeah, we see pharmacists in our role as the medication expert on these teams, thanks to our extensive training and education along with board credentials. And when it comes to the integration on the health care team, I want to first highlight collaborative practice agreements (CPAs), since this allows a BCPP to manage medications under a prescriber and can increase the capacity to serve more patients. Depending on the agreement, this may include prescribing medications and allows pharmacists to make changes at the point of care versus having the prescriber to make these changes later, which can significantly reduce prescriber burden and minimize delays and needed adjustments. Some states even allow pharmacists to hold Drug Enforcement Administration licenses to prescribe medications for opioid use disorder, and this impact could be absolutely incredible considering only about 11% of the 2.5 million Americans with opioid use disorder receive medication treatment.

And further, I want to highlight an important model for the practice of collaboration and comprehensive medication management, which is psychotropic stewardship. This is based on the concept of antimicrobial stewardship programs, which, of course, many of us are familiar with. And we've developed the concept of psychotropic stewardship, which promotes a safe and appropriate use of psychotropic medications. AAPP, our organization, envisions that every patient with a psychiatric diagnosis will have their medication treatment plan reviewed, optimized, and managed by a psychotropic stewardship team with a psychiatric pharmacist as a coleader.

And then finally, as part of this team, BCPPs are often referred patients with complex comorbidities, treatment nonresponse, or those experiencing AEs from their medication regimen. We, of course, have the knowledge, experience, and understanding of other disease states to help support the whole patient and deliver care through various mechanisms across a variety of settings. You can find diverse delivery of care models and their impact on our website at AAPP.org, which highlights practice profiles of BCPPs who are supporting providers in primary care, reaching patients through rural areas through telehealth or in clinics managing medications for opioid use disorder, among many others.

Pharmacy Times: Can you provide examples of how a BCPP optimizes medication outcomes and enhances medication safety in a clinical setting?

Bostwick: Absolutely. Yeah, like you said, I shared briefly about some of these practice areas, and the breadth and impact of pharmacists in clinical settings is immense, so I'm just going to scratch the surface here. Some examples would include monitoring for medication effectiveness and toxicity, ensuring appropriate timing and ordering of laboratory tests, assessing for any symptoms or AEs that may be medication-induced, such as metabolic side effects of antipsychotic medications, evaluating the safety of medications and pregnancy and lactation, deprescribing to reduce polypharmacy or unnecessary medications, and drug interaction screenings.

We use pharmacogenetic testing to guide treatment selection to minimize AEs, we work with teams to develop protocols to enhance the safety of high-risk medications, we work to reduce medication errors through developing clinical decision support through electronic prescribing tools, we lead patient medication education groups to help increase patient comfort with taking their medications and to encourage patient self-management, and we complete suicide risk assessments.

And it goes on and on, but taken together, these clinical, educational, and administrative activities in which a BCPP is well-trained all support improved quality of care, patient outcomes, patient satisfaction, access to care, and reduced costs.

Pharmacy Times: In your article published in Psychiatric Services, you highlight current policies that limit BCPP involvement in behavioral health care. What are some of these policies, and what are their limitations?

Schimenti: Yeah, certainly. I think foremost, and a big umbrella-type issue, is payment for patient care services is a problem. It has been a problem for decades, and it's just really inconsistent, or we have a lack of it. So, that really limits the number of practices that can always absorb or employ a psychiatric pharmacist because they obviously have to pay for that psychiatric pharmacist and see some financial value along with the patient outcomes that they were, so it does constrain our growth. That's certainly something that we advocate for them as payment for services, either through governmental entities or private payers, so health care plans [and so on]. And so, we really encourage and would love to see the adoption of value-based payment models; those have been slow to grow. But that is one way through the private sector that we could see more uptake of psychiatric pharmacists because of the value they bring to patient care.

We certainly also have restrictions on the public level. The Centers for Medicaid and Management Services (CMS) does not include BCPPs on their list of qualified health care professionals, so we can't be paid similarly to other health care professionals, according to the physician fee schedules. So, there are some exceptions to that in the states where they've passed some Medicaid expansions, but it is a real challenge then for us to be considered at that same level.

Another area, there's a collaborative care model that has been adopted in some settings and tested. It has a little bit of a limited uptake, but in a similar vein, psychiatric pharmacists have not been listed as the psychiatric professional. They have not been listed like nurses, nurse practitioners, and others within that model, and so, that prevents us from participating fully in some of those models.

So, a couple of other things that are, I think, being explored in our unique environment today would be making changes to the incident-to-billing. Right now, again, pharmacists, it's been ruled by CMS that we can't bill those higher evaluation and management codes, so there's some thought that that might be an additional area that CMS could clarify to allow pharmacists to bill at that higher code level. That would also, of course, require some legislation, but working in tandem with regulatory agencies and having legislative asks could be a solution there as well.

But overall, that is really rate-limiting for us to really grow the profession and really make the kind of impact we'd like to. It’s just that global payment issue.