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In the treatment of serious mental illnesses such as schizophrenia and bipolar disorder, adherence to pharmacotherapy is essential in achieving desired outcomes. Poor adherence can result in devastating consequences; yet, the majority of patients with major mental illness have adherence problems. For example, as many as 75% of patients with schizophrenia become non-adherent within 2 years of hospital discharge. The median duration of lithium use from initial prescription to discontinuation without advice was approximately 2 months.
Adherence problems are complex and multi-determined (e.g., poor insight and lack of illness awareness, distress associated with side effects, inadequate efficacy with persistent symptoms, the belief that medications are no longer needed, cognitive impairment, co-occurring substance use, environmental factors including family and social supports, and lack of therapeutic alliance). Therefore, improving adherence requires customized interventions for each client, focusing on the various underlying causes. In the current study, we examine the impact of a system level service delivery reform developed to improve the capacity to provide customized care.
The healthcare home model was implemented in a mid-western state, targeting Medicaid beneficiaries with severe mental illness. Adopting a “whole person” approach, primary medical care was integrated into existing community mental health centers (CMHCs). Clients were served by teams that included a primary nurse care manager, a health coach, case management staff, and provided pharmaceutical detailing. Access to non-medical supports and social services were emphasized. Care provision was supported by a web-based electronic health information accessible to providers, that integrates data from lab procedures, Medicaid paid clinical services and pharmaceutical data. Informatics supports also included real-time notification of hospital admissions to assure continuity of care and clinician alerts for overdue refills.
METHODS
We analyzed Medicaid enrollment and billing data for health service utilization and filled prescriptions. The study population included non elderly adults, enrolled in a health home for at least 9 months during the first year of the implementation, continuously enrolled in Medicaid during the study period, and with poor medication adherence prior to health home enrollment. Using the diagnosis recorded on the billing data, we created two cohorts: people living with schizophrenia (n=1,401) and with bipolar disorder (n=1,736).
RESULTS
Clients living with bipolar disorder had an average medication possession ratio of 43% during the year prior to the implementation of the reform. After 6-9 months of service receipt from the health homes, their annual medication possession ratio increased to 53% (p<0.05). Similar results were observed for clients living with schizophrenia (48% vs. 55%, p<0.05).
CONCLUSIONS and IMPLICATIONS
In this service delivery model, in which the contemporary social work practice is prominent, psychotropic medication adherence is improved for severely mentally ill Medicaid beneficiaries. Findings suggest the need for social workers' critical perspective on psychiatric medication management.