Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic.

BACKGROUND: Behavioral health medication nonadherence is associated with poor health outcomes and increased healthcare costs. Little is known about reasons for nonadherence with behavioral health medications among homeless people. OBJECTIVES: To identify reasons for medication nonadherence including the sociodemographic, health-related factors, and behavioral health conditions associated with medication nonadherence among behavioral health patients served by a Health Care for the Homeless center (HCH) in Virginia. METHODS: The study sample was selected from an existing database that included sociodemographic, health-related information, and medication-related problems identified during a pharmacist-provided medication review conducted during October 2008-September 2009. Patients experiencing or at risk of homelessness who were ≥18 years old with at least one behavioral health condition who had a medication review were eligible for the study. A qualitative content analysis of the pharmacist documentation describing the patient's reason(s) for medication nonadherence was conducted. The Behavioral Model for Vulnerable Populations was the theoretical framework. The outcome variable was self-reported medication nonadherence. Descriptive and multivariate (logistic regression) statistics were used. RESULTS: A total of 426 individuals met study criteria. The mean age was 44.7 ± 10.2 years. Most patients were African-American (60.5%) and female (51.6%). The content analysis identified patient-related factors (74.8%), therapy-related factors (11.8%), and social or economic factors (8.8%) as the most common reasons for patients' medication nonadherence. Patients with post-traumatic stress disorder (PTSD) (adjusted odds ratio: 0.4; 95% CI: 0.19-0.87) were less likely to have a medication adherence problem identified during the medication review. CONCLUSIONS: The content analysis identified patient-related factors as the most common reason for nonadherence with behavioral health medications. In the quantitative analysis, patients with a PTSD diagnosis were less likely to have nonadherence identified which may be related to their reluctance to self-report nonadherence and their diagnosis, which warrants further study.

Utilization of behavioral health outpatient therapy and psychiatry services among homeless people recently hospitalized for a psychiatric condition.

A database (n = 1698) at a homeless health care center was used to assess factors associated with a psychiatric hospitalization and subsequent behavioral health outpatient therapy and psychiatry visit adherence. Blacks and those recently incarcerated were less likely to report a psychiatric hospitalization and those with a co-occurring disorder or disability were more likely to report a hospitalization. Of those hospitalized, blacks and those with bipolar disorder were less likely to be high adherers to behavioral health outpatient therapy and those incarcerated 4 to 6 months prior to intake were more likely not to attend behavioral health outpatient therapy. Men were at risk for not keeping psychiatry visits.

Adherence to behavioral therapy and psychiatry visits in a safety-net setting in Virginia, USA.

Little is known about predictors of adherence to outpatient behavioural therapy and psychiatry visits in those who experience homelessness. Yet, consistent receipt of services in the community is critical to preventing use of acute care psychiatric services, which cause a significant cost burden to the mental health system. This retrospective study examined sociodemographic, housing instability and health-related factors associated with adherence to behavioural therapy and psychiatry appointments among 1711 clients served by an urban healthcare for the homeless centre in Virginia, USA. Clients ≥18 years old with a behavioural health condition who had an intake assessment and at least one behavioural therapy or psychiatry appointment scheduled during October 2005-September 2009 were eligible for the study. Of those with scheduled behavioural therapy visits, 27.7% were high adherers and 19.3% did not attend any appointments, whereas of those with scheduled psychiatry visits, 13.6% were high adherers and 22.1% did not attend any appointments. African Americans, when compared with whites, and those with a primary diagnosis of bipolar disorder were less likely to be high adherers to behavioural therapy. Women and being ≥35 years old were associated with a decreased likelihood of failing to attend psychiatry appointments, whereas African Americans, when compared with whites, and those with co-occurring disorders were more likely to not attend any psychiatry appointments. Understanding factors related to adherence to behavioural health services can help homeless care providers tailor strategies for improving visit adherence.

Integration of collaborative medication therapy management in a safety net patient-centered medical home.

OBJECTIVE: To describe the integration of collaborative medication therapy management (CMTM) into a safety net patient-centered medical home (PCMH). SETTING: Federally qualified Health Care for the Homeless clinic in Richmond, VA, from October 2008 to June 2010. PRACTICE DESCRIPTION: A CMTM model was developed by pharmacists, physicians, nurse practitioners, and social workers and integrated with a PCMH. CMTM, as delivered, consisted of (1) medication assessment, (2) development of care plan, and (3) follow-up. PRACTICE INNOVATION: CMTM is integrated with the medical and mental health clinics of PCMH in a safety net setting that serves homeless individuals. MAIN OUTCOME MEASURES: Number of patients having a CMTM encounter, number and type of medication-related problems identified for a subset of patients in the mental health and medical clinics, pharmacist recommendations, and acceptance rate of pharmacist recommendations. RESULTS: Since October 2008, 695 patients have had a CMTM encounter. An analysis of 209 patients in the mental health clinic indicated that 425 medication-related problems were identified (2.0/patient). Pharmacists made 452 recommendations to resolve problems, and 384 (85%) pharmacist recommendations were accepted by providers and/or patients. For 40 patients in the medical clinic, 205 medication-related problems were identified (5.1/patient). Pharmacists made 217 recommendations to resolve the problems, and 194 (89%) recommendations were accepted. CONCLUSION: Integrating CMTM with a safety net PCMH was a valuable patient-centered strategy for addressing medication-related problems among homeless individuals. The high acceptance rate of pharmacist recommendations demonstrates the successful integration of pharmacist services.

Development and Implementation of an Academic-Community Partnership to Enhance Care among Homeless Persons.

An academic-community partnership between a Health Care for the Homeless (HCH) clinic and a school of pharmacy was created in 2005 to provide medication education and identify medication related problems. The urban community based HCH clinic in the Richmond, VA area provides primary health care to the homeless, uninsured and underinsured. The center also offers eye care, dental care, mental health and psychiatric care, substance abuse services, case management, laundry and shower facilities, and mail services at no charge to those in need. Pharmacist services are provided in the mental health and medical clinics. A satisfaction survey showed that the providers and staff (n = 13) in the clinic were very satisfied with the integration of pharmacist services. The quality and safety of medication use has improved as a result of the academic-community collaborative. Education and research initiatives have also resulted from the collaborative. This manuscript describes the implementation, outcomes and benefits of the partnership for both the HCH clinic and the school of pharmacy.