The transition from inpatient to outpatient care can be a challenging time in any healthcare setting.
In the psychiatric setting, however, this period represents a crucial time that can make the difference between successful outpatient clinical outcome and a relapse and rehospitalization. Continuity of pharmaceutical care is vital to the success of this transition. Having an understanding of this process can allow community pharmacists to better assist patients as they move into the outpatient care setting.
A Word on Communication
The importance of communicating with empathy in a nonjudgmental manner is critical. Because of the stigma that inherently surrounds mental illness, patients may be hesitant to communicate openly with healthcare professionals regarding their care.
A patient’s medication regimen may change dramatically and he or she may be confused, uncertain, or even fearful of managing his or her medications after being discharged from the hospital or inpatient facility. As healthcare professionals, we are well aware of the importance of effective communication with all patients, and mental health patients are no exception to this.
The Discharge Process
Pharmacists in the community setting can play an integral role in addressing issues that may occur as patients make the transition to outpatient care. After an inpatient admission, patients are discharged into a multitude of settings ranging from self-managed home care to intensive outpatient or partial hospitalization programs. Understanding to what setting a patient has been discharged will help identify and address barriers to care and open channels of communication.
Upon discharge from the Barnabas Health Behavioral Health Center (BHBHC), patients are provided with prescriptions for a short-term supply of their current medications that will last approximately 30 days along with instructions for follow-up with aftercare services. Information regarding their medications, including instructions for how and when to take each medication, is also provided.
This short-term supply should be sufficient to allow time for the patient to follow up with his or her aftercare provider. Inpatient facilities, such as BHBHC, cannot refill prescriptions once patients are discharged; these requests should instead be directed to their current outpatient provider.
Reinforcing Patient Education
Even with this information, patients often feel overwhelmed and confused about the changes made during their inpatient stay. It is important to determine what medications they were taking prior to their admission and what changes have been made during their admission to help them understand what their new regimen will be following discharge. Community pharmacists are in an ideal position to provide continuing assistance and reinforcement as patients make the transition into outpatient care, in addition to the patient education provided in the inpatient setting.
Because several medication changes must be made slowly, patients may be discharged before such a change is completed. In these cases, every effort is made to provide both the patient and his or her outpatient provider with clear instructions for the steps needed for completion. This is another opportunity for community pharmacists to assist patients understand and properly adhere to prescriber instructions.
Other Opportunities for Community Pharmacists
During inpatient hospitalization, arrangements are made for continuing psychiatric care after discharge. It is imperative that community pharmacists stress the importance of long-term adherence to prescribed therapy. Similar to other fields of medicine, medication nonadherence is an all too common occurrence among psychiatric patients. As would be expected, nonadherence with treatment has been associated with illness recurrence and rehospitalization among patients with bipolar disorder.1 It has also been shown that patients with psychosis often underestimate the risk of recurrence due to nonadherence or may not even be aware that nonadherence can lead to illness recurrence.2 We have seen, however, that pharmacists can play an important role in improving medication adherence. For example, pharmacist intervention has been shown to improve adherence in patients taking antidepressant medication.3
Tobacco cessation is another area in which community pharmacists can provide intervention in mental health patients. Tobacco use is prevalent among patients with mental illness. In addition to the known risks associated with tobacco, smoking can substantially affect the metabolism of a number of psychiatric medications, which, in turn, may impact efficacy of treatment. In the inpatient setting, we consistently encourage tobacco cessation but patients are only with us for a short time. Community pharmacists can provide continued encouragement and facilitation such as education regarding nicotine replacement products.
Transitioning into outpatient care after psychiatric hospitalization can be a challenging time for patients. Community pharmacists are able to play a vital role in easing this transition.
- Li C, Chen C, Qiu B, Yang G. A 2-year follow-up study of discharged psychiatric patients with bipolar disorder. Psychiatry Res. 2014;218:75-78.
- Chan KW, Wong MH, Hui CL, et al. Perceived risk of relapse and role of medication: comparison between patients with psychosis and their caregivers. Soc Psychiatry Psychiatr Epidemiol. 2014 Jul 24. Epub ahead of print.
- Al-Jumah KA, Qureshi NA. Impact of pharmacist interventions on patients’ adherence to antidepressants and patient-reported outcomes: a systematic review. Patient Prefer Adherence. 2012;6:87-100.