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Title: Free PowerPoint poster templates


1
A Novel Collaborative Practice Model (CPM) for
the Treatment of Mental Illness of the Indigent
and Uninsured Davor N. Zink, Keenan Withers,
Aaron Dedmon, Margie Hernandez, Tara Jackman,
Hannah Lindsey, Lee Wiegand, Heather Hughes,
Ahmed Fasfous, Jennifer Buxton, and Antonio E.
Puente University of North Carolina Wilmington
University of North Carolina Wilmington
University of North Carolina Wilmington
Introduction
Method
Procedure In order to determine the efficacy
of the program, a series of pre-post measures
were administered, including the SF-12, the
PHQ-9, and the AUDIT. Patients were tested prior
to the onset of intervention and approximately
three months after initiation of the
intervention. The patient outcome data collected
for program evaluation is standardized and
offered in both English and Spanish. After
patients give consent to the regulations and
procedures of the clinic regarding patient
conduct, attendance, and testing a psychology
student administers three questionnaires. The
first is the Alcohol Use Disorders Identification
Test (AUDIT), which incorporates questions about
the quantity and frequency of alcohol use in
adults to detect dependence as well as harmful or
hazardous drinking. Scores range from zero to 40
with higher scores displaying increasing quantity
and frequency of alcohol use. The second
questionnaire is the Patient Health Questionnaire
for depression (PHQ-9). The PHQ-9 assesses and
monitors depression severity. Scores range from
zero to 27 with higher scores indicating an
increase in severity of depression. The third
questionnaire is the Short Form-12 (SF-12). This
questionnaire assesses quality of life by
quantifying overall physical and mental health
via two population-based scores the physical
component summary (PCS) and the mental component
summary (MCS). Scores range from 0 to 100, where
a zero score indicates the lowest level of health
measured by the scales and 100 indicates the
highest level of health. Both Physical and
Mental Health Composite Scales can be compared to
a national norm with a mean score of 50.0 and a
standard deviation of 10.0. Inclusion
criteria. All adult patients (18 years of age)
of the mental health clinic who received pre- and
post-testing were eligible for inclusion in the
analysis. These patients received the same
testing, but their data was not included in the
study due to lack of questionnaire validation in
pediatric and adolescent age groups.
Exclusion criteria. Any pre- and post-test sets
with an elapsed time of greater than 12 months
were excluded from the study. Any incomplete
questionnaires (questions unanswered or
ineligible writing) were also excluded. Patient
Demographics. The age and gender of the mental
health clinic patient population based on
pre-testing are displayed in Table 1.
We describe the development, implementation, and
evaluation of an innovative collaborative
practice model (CPM) designed to address the
mental health needs of indigent and uninsured
patients. The practice model consists of a
program, started seven years ago, to provide
comprehensive psychopharmacological and mental
health treatment for individuals with clinically
significant mental disorders as well as limited
economic resources and no insurance coverage at a
free clinic in Wilmington, NC. Three aspects of
the program are novel 1) it is comprehensive in
that all forms of diagnostic and therapeutic
interventions are provided, 2) services are
provided in English and Spanish and 3) no direct
physician involvement is included.
The Collaborative Practice Program
The structure of the CPM includes four
major components an initial evaluation (which
will include an interview and may include
testing), psychotherapy only, medication
management only, and psychotherapy plus
medication management. Once a referral is made
and/or acceptance to the clinic is established,
all patients participate in a comprehensive
initial interview conducted jointly by a
doctorate level clinical neuropsychologist and
the clinical pharmacist. Initial interviews
generally last one hour and conclude with a
suggested diagnosis followed by discussion and
implementation of the most feasible treatment
plan. Patients with difficult diagnoses or
unclear etiologies receive a more comprehensive
evaluation which includes psychological or
neuropsychological testing, as deemed appropriate
by the psychologist who conducts the initial
interview. In 2006, a collaborative practice
agreement was established between the volunteer
pharmacist and the clinics medical director (a
practicing physician). In accordance with state
laws, the pharmacist obtained a Clinical
Pharmacist Practitioner (CPP) license from the
state boards of pharmacy and medicine. This
license allowed the pharmacist to participate in
patient interviews with the clinics psychologist
and prescribe medications based on the
psychologists diagnosis and assessment. Current
evidence suggests that optimal management of many
mental health conditions includes both
psychotherapy and medication management. Most
patients referred to the mental health clinic
receive psychotherapy in conjunction with
pharmacotherapy. Medications are selected based
on American Psychiatric Association (APA)
guidelines for treatment and drug availability.
Visits occur every two weeks upon initiation of
medication therapy and during the acute phase of
treatment. These visits then decrease in number
when the patient transitions into the maintenance
phase of therapy with follow-up occurring every
three to six months.
Discussion
We present a novel approach to the assessment
and intervention of mental health problems in a
community clinic for indigents. However, the
implementation of an innovative CPM in the mental
health clinic was not associated with significant
improvements in PHQ-9 depression scores, SF-12
quality of life scores, or AUDIT alcohol abuse
scores despite increased access to mental health
care and medications among clinic patients.
Several flaws in study design and data collection
limited the usefulness of the pre-and post-test
data. The lack of statistical differences could
be due to the small sample size, the varied
elapsed time at post testing, and the
instruments themselves. Despite the results,
clinical data illustrates improvement in the
patients symptoms. Clinic patients were
provided access to mental health care and
medications that were previously unavailable
within the community. In 2009 alone, clinic
patients received over 139,000 in free mental
health care and prescription medications. The
most common diagnosis was depression and most
commonly prescribed medications include
citalopram, escitalopram, fluoxetine, buproprion,
venlafaxine, paroxetine, trazodone, and
quetiapine. More importantly, this model
provides a novel approach in that is bilingual,
comprehensive, and does not involve typical
medical intervention for the provision of
psychopharmaceutical intervention. The model is
now being presented as a cost effective way to
provide mental health intervention in free
clinics throughout North Carolina, especially in
a changing demographic environment.
Results
Pre and Post Test Results. Table 1 lists the
pre- and post-testing results for the AUDIT,
PHQ-9, and SF-12. The pre- and post-AUDIT mean
scores were 1.59 and 1.72 respectively. Prior to
receiving treatment, 6.9 of patients had
participated in harmful or hazardous drinking
over the year prior to treatment while 3.4 were
likely alcohol dependent. After receiving
treatment, none of the scores indicated harmful
or hazardous drinking, while 3.4 were likely
alcohol dependent. A paired samples t-test was
conducted to assess if there was a significant
difference between the pre and post AUDIT scores.
Results showed no significant difference, t (28)
-0.190, p 0.851, 95 CI (-1.62, 1.35).
Pre-PHQ-9 testing identified 37.9 patients
as having severe depression. The mean test score
was 15.7 and the mean number of symptoms was 7.3.
Post-testing revealed 34.4 of patients remained
severely depressed. The mean post-test score was
14.4 and the mean number of symptoms was 6.8. A
paired samples t test was conducted to assess if
there was a significant difference between the
pre and post PHQ-9 scores. Results showed no
significant difference, t (28) 0.925, p
0.363, 95 CI (-1.55, 4.1). Pre-SF-12
testing provided a mean and standard deviation
MCS of 30.9 12.1, and a mean and standard
deviation PCS of 35.3 11.7. The mean and
standard deviation post-test MCS was 36.7 37.4.
The mean and standard deviation post-test PCS
was 37.4 12.5. A paired sample t test was
conducted to assess if there was a significant
difference between the pre and post SF-12 scores
(PCS, MCS). Results showed no significant
difference between pre and post PCS scores, t
(19) -0.641, p 0.529, 95 CI (-5.73, 3.04),
and pre and post MCS scores, t (19) -1.75, p
0.95, 95 CI (-14.24, 1.24).


Numerical Transformation Comparison. Patient
demographics for the post-tested population are
listed in Table 1. Table 2 quantifies the amount
of free healthcare provided in 2009 by estimating
the hourly cost of each service provided. A total
of 165 hours of free care were provided by mental
health clinic practitioners with a total
estimated value of 15,580.88. Prescription
data was also collected from the pharmacy
computer system and analyzed for the year 2009.
This data is summarized in Table 3. A total of
775 prescriptions were issued by the CPP and were
associated with a total patient cost savings of
123,699.29.
Acknowledgments
Health professionals and volunteers at the Cape
Fear Community Clinic puente_at_uncw.edu
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