Effects of Telephone Counseling on Antipsychotic Adherence and Emergency Department Utilization

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The American Journal of Managed Care, December 2008, Volume 14, Issue 12

A telehealth nursing program used psychological counseling techniques to improve antipsychotic medication adherence, leading to reduced emergency department utilization in a managed Medicaid population.


: To determine whether ScriptAssist, a telehealth nursing program using psychological techniques, reduced emergency department (ED) utilization and improved adherence among Medicaid health plan members with serious and persistent mental illness (SPMI).

Study Design

: Nonrandomized controlled trial.


: Of 210 eligible Medicaid health plan members with SPMI, 59 (28%) were contacted by phone and 51 (86%) participated. Participants received an average of 3.5 calls over 9 months, with 2.1 attempts per completed call. Participants had clinically significant levels of impairment; medication switching, polypharmacy, and medical comorbidities were common. Intervention group participants’ results were compared with those of nonparticipants to rule out regression to the mean, history, and maturation effects. Intervention group participants’ results also were compared with baseline data to rule out selection bias.


: Program participants had fewer ED visits during the intervention than a comparison group, and reduced their ED use and hospitalization rate compared with the previous year. Participants also had better medication adherence based on pharmacy and interview data.


: Cognitive-behavioral and motivational- interviewing techniques can improve antipsychotic medication adherence. Telehealth may be a useful strategy for disseminating these evidence-based techniques. Lessons learned included the importance of real-time referral data, a need to address polypharmacy, and a need to overcome contact difficulties resulting from disease processes and “unknown caller” IDs. Despite these difficulties, using a disease management model, the program was feasible, and the reduced number of ED visits indicated potential cost-effectiveness.

(Am J Manag Care. 2008;14(12):841-846)

Telephone counseling improved antipsychotic medication adherence and reduced emergency department utilization in a managed Medicaid population.

  • Telehealth nursing is an effective method for delivering evidence-based adherence counseling approaches in community settings.

Program participants had severe impairment, including a high prevalence of bipolar disorder and other mood disorders, complex treatments, and comorbid conditions; contacting and retaining these high-risk members required extra effort.


Three RNs made multiple attempts to reach members (mean of 2.1 attempts per completed call), and each patient worked with the same RN over time. In initial calls the RN administered a proprietary screening tool, originally developed in an outpatient psychiatric population, to predict members’ nonadherence risk27; 90% of participants were screened “at risk” for nonadherence. At-risk participants received followup calls (mean of 7.2 call attempts; mean of 3.5 calls completed) over an average of 4.4 months, with an average call length of 11 minutes (average total contact per participant was 38.5 minutes). Low-risk participants received a toll-free number plus 1 follow-up call at 6 months. During each call, the RN offered cognitive-behavioral counseling or motivationalinterviewing interventions based on the participant’s readiness for change and individual barriers to adherence. RNs mailed follow-up written materials to 45 participants (88%). A written progress note was sent to the participant’s health plan case manager after each call. Four participants reported potential serious adverse drug events; these persons were referred to their primary care providers. Participants did not receive incentives. Data analysis was approved by the Colorado Multiple Institutional Review Board.


All analyses were conducted using SPSS 15.0 (SPSS Inc, Chicago, IL). ED utilization was defined as the number of ED visits by eligible members, divided by months of eligibility. Rates were multiplied by 12 to calculate per member per year (PMPY) ED rates. There were no missing observations in the administrative data set, and a conservative intent-totreat analysis was used.

For pharmacy-based adherence, members were considered adherent if they had no more than a 14-day gap between the end of one SGA prescription (previous fill date plus days supply) and the next fill date for the same or any other SGA. Complete pharmacy records were available, and an intent-to-treat analysis was used. Prescriptions for non-SGA medications were not included, so members who switched to older-generation antipsychotics were counted as “nonadherent.” For self-reported adherence, participants were considered adherent if they reported taking medication as prescribed at least 80% of the time. Self-reported adherence rates were analyzed using all available data for each month of treatment; participants who could not be recontacted were excluded from subsequent analyses. However, participants who indicated at any point that they had stopped treatment were retained in subsequent analyses.


The intervention and control groups were not significantly different in terms of age, sex, or baseline adherence (P >.24 for all comparisons). Intervention group participants had fewer previous ED visits (t = 9.29; P <.001) but more prior hospitalizations (t = 16.2; P <.001), and their recorded diagnoses were more likely to include bipolar disorder or psychosis (77% [14/18] vs 30% [12/40] in the control group). In general, results do not suggest that the intervention group was less impaired or more adherent at baseline. Intervention group attrition was 29% (15/51), and was unrelated to age, baseline adherence, or diagnosis (P >.05 for all correlations). Men were less likely to leave the intervention group.

Emergency Department Utilization


Data for both adherence measures are summarized in the . Baseline adherence for both groups was lower than that observed in some studies,1,2,5 but similar to that observed in a recent Medicaid study.6

Pharmacy Fill Measure

. Among intervention-group participants, 59% (n = 29) received at least 3 consecutive months of medication, and 48% were adherent for 6 months, a significantly higher adherence rate than that in the comparison group (&#967; 2 = 8.01; P = .004).

Self-Report Measure

. Five participants (9.8%) did not fill an initial prescription, and 18 (35.3%) stopped treatment at some point. Three participants who did not start (60.0%) and 7 of those who stopped (38.9%) agreed to resume treatment after speaking with a ScriptAssist nurse. Six-month adherence was 50%, which was higher than the comparison rate (&#967; 2 = 9.47; P = .002).


Although participants received an adequate level of intervention, they were difficult to contact by phone. Staff reported incomplete or inaccurate contact information. Duplicate data were sometimes received, and health plan eligibility frequently expired. However, staff believed the most important barrier was a 2-month average delay from the time members started a new SGA to the time they were identified for the program. Staff said these delays caused them to miss the &#8220;window of opportunity&#8221; when members had questions; by the time enrollment was attempted, the member&#8217;s decision to stop taking medication had already been made. Additional barriers to enrollment included active disease processes that interfered with a working relationship (eg, delusions of persecution) and caller ID features showing &#8220;unknown&#8221; numbers due to Health Insurance Portability and Accountability Act constraints.

Limitations and Directions for Further Research

This study tested adherence counseling for persons with SPMI, using a disease management model in a managed Medicaid plan. Telephonic implementation was feasible and effective in reducing ED rates and improving adherence. Because the program can be implemented in community settings, and because costs were largely offset by reduced ED visits, this program has the potential to be cost-effective and may be appropriate for high-risk Medicaid members with SPMI.

Author Affiliations: From the College of Nursing (PFC, DE), University of Colorado Denver, Aurora, CO; the Medication Adherence Programs, ScriptAssist (SE), St. Louis, MO; and Centene Corporation (CW), St. Louis, MO.

Funding Source: This study was supported by contract 0506-010-PC with Centene Corporation/ScriptAssist Medication Adherence Programs. The contract specifically states that the University of Colorado Denver does not guarantee specific results of the research evaluation, and every effort was made to perform the research in a scientifically valid manner.

Author Disclosure: Ms Emiliozzi is an employee of ScriptAssist Medication Adherence Programs, which provided the telehealth nursing intervention described in this manuscript. Mr Waters is an employee of Centene Corporation, the parent company of the organization that provided the medication adherence program described in the manuscript. Dr Cook and Ms El Hajjj report receiving payment from Centene Corporation for their involvement in the preparation of this manuscript.

Authorship Information: Concept and design (PFC, SE); acquisition of data (SE, CW); analysis and interpretation of data (PFC, SE, CW, DE); drafting of the manuscript (PFC, DE); critical revision of the manuscript for important intellectual content (SE, DE); statistical analysis (PFC, CW); obtaining funding (PFC); administrative, technical, or logistic support (PFC, SE, CW, DE); and supervision (PFC, SE).

Address correspondence to: Paul F. Cook, PhD, College of Nursing, University of Colorado Denver, 13120 E 19th Ave, Campus Box C288-04, Aurora, CO 80045. E-mail: paul.cook@ucdenver.edu.

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