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Prescriber Fidelity to a Medication Management Evidence-Based Practice in the Treatment of Schizophrenia

Dr. Howard and Dr. Rayens are affiliated with the College of Nursing, University of Kentucky, Chandler Medical Center, 760 Rose St., Lexington, KY 40536-0232 (e-mail: pbhowa00{at}uky.edu). Dr. El-Mallakh is with the School of Nursing, University of Louisville, Louisville, Kentucky. Dr. Miller is with the Department of Psychiatry, University of Texas Health Science Center at San Antonio. Dr. Bond is with the Department of Psychology, Indiana University-Purdue University Indianapolis. At the time of the study, Ms. Henderson was the Best Practices Administrator at Central State Hospital, Louisville, Kentucky. She is currently with Jewish Hospital and St. Mary's Healthcare, St. Mary's and Elizabeth Hospital, Louisville, Kentucky. Dr. Cooley was principal investigator of the MedMAP study in Kentucky. He is with the Department of Mental Health Developmental Disabilities, and Addiction Services, Kentucky Correctional Psychiatric Center, LaGrange.

OBJECTIVE: Medication Management Approaches in Psychiatry (MedMAP) is an evidence-based practice developed to guide the management and monitoring of psychotropic medications for individuals with schizophrenia. This article reports prescriber fidelity to MedMAP principles in a public mental health service system. METHODS: This three-year longitudinal intervention study implemented MedMAP in six community mental health centers in Kentucky. Nine psychiatrists and five advanced practice psychiatric nurses with prescriptive authority participated in the study. Prescribers were trained in the use of MedMAP about one month before implementation, and MedMAP principles were reinforced throughout the study. Four posttraining assessments were conducted at each site at approximately four-month intervals over a period of 30 months. An 18-item scale was used to assess baseline and posttraining prescriber fidelity over a period of 30 months in 900 randomly selected medical records. RESULTS: Average fidelity scores improved significantly over baseline at each of the four postimplementation fidelity assessments. Training effects were most evident at the second posttraining fidelity assessment, but effects persisted over the course of the study. There was considerable variability in scores across items both at baseline and subsequently. Posttraining improvement was greatest in patient education, documentation of illness and medication history, and simplification of medication regimen. CONCLUSIONS: Implementation and monitoring of MedMAP were feasible in these community mental health settings. Additional implementation projects are crucial for advancing evidence-based practice in clinical settings.

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