Closing the Care Gap for People with Severe and Persistent Mental Illness: Collaborative Care, Telehealth, and Clinical Pharmacy

Esti Iturralde
Lisa Fazzolari
Macy Shia
Natalie Slama
Jessica Leang
Sameer Awsare
Lily T. Nguyen
Case Example
April 2022


Virtual collaborative care intervention demonstrates an approach to improve medication adherence and health outcomes.


Individuals with severe and persistent mental illness (SPMI) can experience poor physical and behavioral health outcomes, leading to higher rates of early mortality. Approximately half of individuals with severe and persistent mental illness do not take psychiatric medications at the prescribed frequency. Kaiser Permanente of Northern California developed SPMI Population Care, a program that draws on telehealth and collaborative care models by having advanced practice clinical pharmacists serve as care continuity navigators for patients with SPMI. This case study provides in-depth descriptions of team roles in this program and patient snapshots as well as evaluation metrics and early results.


This case study details participant needs at intake and reports on how the program has reengaged participants that have been less engaged in their psychiatric care. Program leaders are evaluating program health outcomes and cost-effectiveness, as they anticipate that program costs will be offset by reduced hospitalizations as well as improved medication adherence. Bringing this program to scale will require deeper analysis of whether people with SPMI accept use of telehealth platforms for clinical pharmacist care.


A telehealth collaborative care intervention for people with SPMI may be effective in improving medication adherence. Engaging a clinical pharmacist may help to address the shortage of psychiatrists and allow providers to practice at the top of their respective licenses and reach more patients.

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