Assessment of a Mental Health Residential Rehabilitation Treatment Program As Needed Medication List
The Mental Health Residential Rehabilitation Treatment Program (MHRRTP) is an essential part of the mental health services offered at the Clement J. Zablocki VAMC (ZVAMC) in Milwaukee, Wisconsin. Across the nation, there are about 250 MHRRTPs, which are designed to provide rehabilitation and treatment services to veterans ranging in age from 18 to 80 years, with medical conditions, mental illness, addiction, or psychosocial deficits.1 About 900 patients were admitted to the ZVAMC MHRRTP in 2013.
Background
Prior to 2010, pharmacy administrators recognized that many MHRRTP patients were inappropriately using emergency care services (ECS) to obtain treatments for simple ailments that often required only the use of over-the-counter medications. This was likely associated with the Safe Medication Management (SMM) Policy as defined in Professional Services Memorandum VII-29.2,3 This policy states that MHRRTP patients are not allowed to bring in any home medications—all medications are reconciled and readministered on admission in an effort to reduce diversion.
A lack of 24-hour-per-day provider availability forced patients to find treatment elsewhere. A 6-month review was completed in 2010, which identified all of the MHRRTP patients who used ECS, their chief medical condition, and the medication(s) that were administered to each patient. This review identified a total of 254 ECS visits made by MHRRTP patients during this period. Twenty percent of these visits resulted in prescriptions for over-the-counter medications. As a result, an as needed (PRN) medication list was created for patients to have medications readily available for simple ailments with nursing oversight (Box). The goal of the PRN medication list is to reduce the amount of unnecessary ECS visits, decrease unnecessary cost, and improve treatment efficiency and overall patient care.
Treatment Programs
The ZVAMC MHRRTP has 189 beds divided among 7 different 6-week treatment programs, including General Men’s Program (GEN), Substance Abuse Rehabilitation (SAR), Posttraumatic Stress Disorder (PTSD), Women’s Program (WOM), Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND), Domiciliary Care for Homeless Veterans (DCHV), and Individualized Addiction Consultation Team (I-ACT).4
The treatment programs within the MHRRTP at the ZVAMC address goals of rehabilitation, recovery, health maintenance, improved quality of life, and community integration in addition to specific treatment of medical conditions, mental illnesses, addictive disorders, and homelessness. Various levels of care are available through the program, based on the needs of each veteran. This care generally provides methods to enhance patients’ functional status and psychosocial rehabilitation.
A SMM program is used to ensure safe and effective medication use for all patients in the MHRRTP.2 As a result, the patients are admitted to the MHRRTP with inpatient status, and the medication delivery procedure varies based on the veteran’s ability to take medication independently. Veterans are assisted in developing self-care skills, which include comprehensive medication education. The goal of the SMM program is to give patients the assistance to eventually manage their medications independently.
MHRRTP Staffing
The MHRRTP must have adequate staffing in order to provide safe and effective patient care. Program staffing patterns are based on workload indicators and a bed-to-staff ratio.4 The MHRRTP is a multidisciplinary program; however, the only providers who can address medication issues are the 1.2 full-time employee equivalent MHRRTP psychiatrists. Unfortunately, the psychiatrists are not available for triage on nights, weekends, or holidays.
The role of the psychiatrist is to focus on the mental health needs of the MHRRTP patients, not the primary care medical concerns, which are the main reason for ECS visits. With the current model, providers are sometimes unavailable to meet the emergent needs of patients in the MHRRTP, and patients may be forced to choose between using ECS or leaving the concern unaddressed. Patients’ needs vary from mild to serious emergent needs but may not necessarily require full emergency assessments. For example, if a patient has a headache and a physician is not available to write an order for acetaminophen, the patient may need to visit the ECS to obtain a medication that otherwise would have been readily available at home. The restrictions are designed to promote medication safety, prevent medication diversion and misuse, and be in compliance with regulatory agencies (eg, The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities).
ECS Use
During fiscal year 2010, pharmacy administrators discovered that many patients were using ECS to obtain medications for nonemergent conditions. Inappropriate and unnecessary use of ECS by MHRRTP patients delayed treatment, increased wait times for veterans in need of emergent care, and increased the cost of caring for simple ailments. To put this into perspective, the average cost of all conditions at the ZVAMC during the 2013 fiscal year was $657 per ECS visit, while the total cost of ECS was about $14 million.
