Treating Serious Mental Illness in Rural Areas

Troy Trygstad, PharmD, MBA, PhD: Now Tripp, you work in a community pharmacy in small town America. Do you want to describe your practice and what it feels and looks like, and how you might be a little different than the average pharmacy? But then, also, how do you interface with patients with severe mental illness?

Tripp Logan, PharmD: I took my first steps in my father’s family’s local community pharmacy. And so, I’m a second-generation community pharmacy owner, and community pharmacist in rural southeast Missouri and the Mississippi River Delta—a lot of catfish, fried chicken, sweet tea, and a lot of undiagnosed mental illness. And it’s something that we’ve seen in our practice, especially since we’re very rural. The clinics where most of our patients are treated, they’re not even in our county. And so, we were noticing, years ago, issues with transportation and with even just getting the patient to the visit so they could continue on therapy. Every time I think of this, I think of this story, and I’m going to pull it out right now because I think it kind of tells my area. We had a gentleman who I actually went to high school with. He was a couple of years younger than me, and he’d always suffered from mental illness, and it’s something we all knew. I knew his family very well. And he came in the pharmacy agitated really bad one day. We called his mental health provider, and they said he had missed his last few appointments. And so, he had fallen off of all treatment, all therapy. I worked with him trying to get him an appointment. We got him an appointment scheduled the next day, but he was very, very agitated. He left. I walked him out to the front of the pharmacy, and he was going to walk home. And within probably 4 minutes, we heard gunshots, and he had assaulted a police officer, with a sword, and he was killed. That resonated with me. We looked at this internally. We’re like, how can we better engage these people in our community who need help? There’s nothing in our county for them. And so, we started engaging our local providers. We started doing screenings. We’ve done a lot of depression screenings, and programs with that. We’ve engaged our local mental behavior health center, and they have satellite clinics—none in my county, but trying to figure out ways that we can help. And the barriers... like we don’t know if they even pick up their prescriptions or we send people to their homes but they move a lot. Well, those are things that typically we could help with in a small town, in a small area. We got some staff who know somebody’s cousin or somebody so that we can find that person. And so, there are ways that we can engage. That one incident was the gateway for us to get into this space. But the deeper we’ve gotten, the more we’ve realized, wow, there’s a lot of help that’s needed, and we can’t fulfill all of it, so we’ve got to pull as many folks in as we possibly can.

Troy Trygstad, PharmD, MBA, PhD: Yes. So, one of the themes is that there are persons with severe mental illnesses who don’t just live in urban areas, right?

Tripp Logan, PharmD: Right.

Troy Trygstad, PharmD, MBA, PhD: But yet, most of our specialist providers are in urban areas. So, we’ve got rural Missouri, rural Montana. Tell me about Beaver, Pennsylvania, and your practice, and how you interface with severe mental illness, and what you’re doing about it.

Adrienne Cervone, PharmD: Well, I have a small pharmacy in Beaver. It’s about an hour north of Pittsburgh, and it’s a very small town. And we’re fortunate. We do have several mental health providers in the area, but everybody knows it’s not enough. And we saw a lot of barriers also. We see a lot of barriers. Our biggest is getting the medication covered, and how do we get it covered. How can we work with the physicians to work on prior authorizations, and can we get coupons for patients? And really, our local physicians turn to us. If there’s any question, even if they’re not our patient, about co-pay or coverage, they’re calling my pharmacy because we will do our best to get it covered, and get it in the hands of the patient. There’s just this comfort level of a small pharmacy, compared to maybe sitting down with the doctor. It’s almost like we’re kind of a confessional. They tell us the truth.

Troy Trygstad, PharmD, MBA, PhD: Right. So, the guard’s down, and they’re willing to talk. It has always been remarkable, for me working on nights and weekends in a pharmacy, what folks are willing to share, because you’re another person in the community to them often. So, again, a great thought. What innovative programs do you have going on with patients with severe mental illness?

Adrienne Cervone, PharmD: Well, we found out that, in the beginning of treatment mostly, the patients sometimes don’t know what day it is or what date it is, so they can’t follow a calendar and know what day it is. So, we started some compliance packaging. And the particular one that we found that we really like has the day and the date on it, and it also has the time of day. So, if somebody really remembers breakfast time, if they remember to eat breakfast every day, we’ll put as many of medicines in their breakfast spot as we can. Or if they can watch a clock and they can see 9 AM, and that’s a special time to them, well that’s where we’re going to put their medicine. So, we’ve got compliance packaging that we offer for our patients. And for patients who seemed to remember 1 medicine over another—like some reason people remember to take the medicines with food, it just sticks out in their mind—if we can get them on some kind of a long-acting medicine and put everything in that 1 blister spot so that they get all of the medicines at once, it seems to really help with adherence. And we’ve really focused on getting all of their medicines filled on the same day so that they do come to us once a month. We really try to push for that sinking of medications. And that’s made a huge difference, too, because they realize, 'OK, it’s getting low. I’m getting low,' and if they’re not packaged, and they’re just going from bottles, all of their bottles get low at the same time. And that has made a huge difference with them as well.

Troy Trygstad, PharmD, MBA, PhD: Yes. So, Tripp, you told us the story about this tragic event, and clearly the tragic event involved EMS, and local law enforcement, so on and so forth. So, I guess I would ask you the leading question, does your care stop at the walls of the pharmacy at LNS in Charleston, Missouri? And if not, what are you doing to engage, or who should be engaged, beyond the 4 walls of that pharmacy?

Tripp Logan, PharmD: That’s a loaded question, because you can ask that same question of any healthcare provider. Anybody who has a patient should be asked that same question, and the answer should always be the same: 'Absolutely not, my care follows them home.' And luckily, or conveniently for us, in the community space, we have the ability to say, 'Yes, we actually do follow them into the home because we’ve got delivery drivers, and we’ve got pharmacists who can go to their house. And we’ve got people who can check in with them.' So, those additional touch points are why we felt like we were such a benefit to these local prescribers. Like, 'Look, here we are, we’re here. We’re seeing these people a lot more often than you are.' And at 1 of our early meetings we had with this clinic, we had a resident, and we had one of our pharmacists who’s a go-getter, and he was in charge of our packaging because we were going to go in and show that. And we were detailing their social workers, and their psychiatrists, and administrators, and there were about 60 people in this room. And so, before we walked in, I told my colleagues, “Look, these guys are used to nothing. They are used to absolutely nothing. When a prescription is written, they don’t even know if it gets filled. So, I know we’ve got all of these things in our back pocket, all of these services that we want to tell them about, but let’s go in there, and let’s see what’s important to them.” So, we did a few minutes’ presentation on, 'This is packaging. We think this can help in this way. Can anybody tell us how this can help you, and what are your other pressure points?' And we found out the biggest pressure point was that prescriptions are written, but they don’t know if they’re filled. We have to send care managers, and social workers out to their house to look around, and see if they had medication piled up, if it was even filled. Why 1 prescription, the bottle was almost empty while the other one was full. And so, we said, 'Hey, we can help with that because you’re spending all this money to send people to homes. We’re going to the same neighborhood, if not the same person’s house, every week.' We’re trying to break down those walls because to us, I see these people at the grocery store. I see these people walking down the street, and these are my neighbors. These are family members’ friends, and friend’s family members. So, it’s one of those things that when you look at it that way, it only makes sense to include the community pharmacy practice in this equation. Because what better support system for a very vulnerable population could you have than that? So, I think in the scheme of problems, you look at national problems—you know, cost—and you look at substance abuse—which I assume we’ll talk about at some point. All of these things factor in together. Huge cost centers for everybody is a big concern for our society as a whole. We’ve got community pharmacies located in these areas where these people are. They can provide access to so many wonderful programs like we’re talking about.