Unsustainable compensation impacts comprehensive medication management services in community mental health clinic

The state of mental health care for U.S. residents, particularly nonmetropolitans, is rather bleak. About one in five U.S. adults live with a mental illness, though roughly half that population receives treatment.¹ Despite the 7.7 million nonmetropolitan residents who reported having a mental illness and more than 16% of U.S. adults who reported taking prescription medication to help with mental health in 2023,² access to medical and mental health services remains significantly limited.³ This is the backdrop to the recent pause in the College of Pharmacy’s longstanding partnership with the Human Development Center (HDC), a certified community behavioral health clinic serving northern Minnesota and Wisconsin.

Based out of Duluth but with services reaching across four northern counties, the HDC is a “hub for everything that is rural,” said their medical director Sarah McIsaac, a psychiatric mental health nurse practitioner. Their providers and visiting trainees go out into the local and rural community and underserved clinics as part of assertive community treatment teams, but the organization’s overall services are driven by the needs of the community, said McIsaac. Sometimes the demand is for mental health crisis care, other times it’s for substance-use programming. In 2024, the HDC served well over 6,000 people and their crisis response team fielded 1,389 calls, according to their health records department. As one of the largest mental health centers in the state, they have the capacity to offer more “wraparound” services. 

“I always think of ourselves almost as the internal psychiatric medicine of Duluth,” McIsaac said. “We really try to flex ourselves into areas of the community where things are needed. Part of that is being involved with people diagnosed with a Severe and Persistent Mental Illness (SPMI)... due to strict attendance policies at private practices and severity of symptoms, there's really no place else for many people with an SPMI to go. And that's where we hope to fill the gap.”

At the heart of the college’s collaboration with HDC is psychiatric pharmacist Dr. Mark Schneiderhan, an associate professor in the college’s Pharmacy Practice and Pharmaceutical Sciences department. Attracted by the HDC’s “team-based approach to care,” he established a Comprehensive Medication Management (CMM) service for patients there that operates in collaboration with the HDC psychiatry department while also leading experiential training opportunities for pharmacy students. Schneiderhan conducts a “deep dive” to create a complete medication history of a patient, including over-the-counter medications and any other consumption (nutrients, caffeine, nicotine, etc.) that can affect biological systems. He also uses laboratory testing to monitor side effects, analyze drug blood levels to ensure safe dosing, and apply pharmacogenetic testing to understand how a patient's system may be metabolizing medications. If a patient permits it, he will also coordinate care with the patient’s primary care providers and other non-HDC providers as needed.  

“A complete medication and health history is crucial for assessing current meds and future treatment strategies,” Schneiderhan said. “It might not predict whether the medication will work or not, but at least we can maybe make some guesstimations and more educated inferences about dosing.” 

Schneiderhan serves as a critical resource for the HDC team, who consult him on complex cases. McIsaac would refer clients with unusual medication reactions to Schneiderhan, who would identify any genetic incompatibilities or similar conflicts with their prescriptions. This optimization process often validates people who have endured several medication trials. Particularly when patients have bounced between different providers or specialists, the HDC team checks if they take an abundance of medications simultaneously— called “polypharmacy.” As clients age, their list of medications often grows, too, and McIsaac said the current health care system leaves scarce opportunity to talk directly with colleagues in primary care. 

“With polypharmacy, you've got too many cooks in the kitchen… nobody's really paying attention to how these medications are interacting with each other and how that can create this medication stew,” said McIsaac. “We take the opportunity to plug Mark into most of our programs because the perspective he has is so unique to our medications that it's nice to get that pharmacy lens that the rest of us don't have on some of our particularly complicated patients.”

As of this past August, however, Schneiderhan’s position at HDC will drop down to a purely consultative role a few hours per week and he will no longer have a patient-facing role at HDC, an element that is critical to his work. Due to structural and systemic barriers— stagnant billing rates and “non-billable” services that compose the majority of patient care appointments— the partnership is no longer financially sustainable for the clinic. Psychiatric pharmacists aren’t classified as mental health providers for certified community behavioral health clinics and other mental health services in Minnesota, preventing them from generating sufficient revenue to support operational costs for their services.

“I'm already hearing about it from my patients— I've started to tell people I'm going to go— I had one patient, I told her and she started to cry. It just kind of broke my heart that I wouldn't be able to follow her,” Schneiderhan said. “But I told her that we're going to work on getting her followup [care] and I'll be still around to consult.”  

Schneiderhan trained 89 pharmacy students in patient care over the past 15 years at HDC, but in light of funding cuts, the clinic will no longer be a training site for future pharmacists in the area of mental health. The students contribute fresh perspectives, McIsaac noted, helping the providers educate themselves and stay up to date on new medications. Through rotations at HDC, students had the opportunity to accompany staff to patients’ homes in the community and review any over-the-counter medications or duplicates that may be left off medication lists.  

“A number of my students have gone on to do psych rotations and psych residencies,” Schneiderhan said. “A lot of them choose my site because of their interest in mental health to begin with but I also get really excited when they actually want to go into the field of mental health because we do need to continue to grow this area.”

Further complicating matters for the clinic, UCare announced plans to withdraw Medicaid coverage from St. Louis County— home to the HDC—along with ten other Minnesotan counties, leaving many of the clinic’s clientele scrambling to find new coverage. Even before recent federal and state cuts, the HDC had to advocate for the continuation of critical funds, Schneiderhan said. McIsaac said that funding always plays a large role in the services they’re capable of providing, so if the general public isn’t aware of that, the work remains undervalued. Factor in the cost of billing services plus a reimbursement rate that has hardly budged for over a dozen years and it’s clear why the HDC is almost always calculating a cost-benefit analysis.

“It's such an amazing thing that we’re able to do— this collaboration in this field. To have that is very special and needed. This is such a unique model of care that is superior to any other I've worked with,” McIsaac said. “It's not just the direct patient contact, it's the efforts we were making to help show how this kind of [work] should be a standard of care— and it's not.” 

For a while, momentum was building in terms of advocacy for mental health services, proper compensation for pharmacists, and the need for psychiatric pharmacists positions like Schneiderhan’s, McIsaac said. Realistically, she now anticipates at least another two years and a political shift before being able to “continue the progress [they] were just starting to really make.” Schneiderhan believes that while funding cuts force a big change, if the HDC and mental health care advocates can weather the storm it will make a big difference. He and McIsaac are still pushing forward, consulting neighboring clinics, attending a conference on advocacy for pharmacists, and planning to publish a case report on a patient success story using genetic testing for medication optimization. 

“Our hope is that this is just a pause in our relationship. Like many other mental health care clinics, or even more broadly, in all of healthcare, everyone is feeling the pinch of the loss of federal and state funding,” McIsaac said. “There is a lot of fear of what’s next and of the unknowns with funding. This is just one of many examples of the loss of direct client services and support that we are seeing at every level and scope of care resulting from cuts and what-ifs. What we do know is that this isn’t the end of it— we are actively looking to figure out what other routes we can take.”

1. “Mental Illness.” National Institute of Mental Health, September 2024. 

2. ^"Results from the 2023 National Survey on Drug Use and Health.” Substance Abuse and Mental Health Services Administration, February 13, 2025. 

3. “Rural Mental Health Resources.” Mental Health America, July 16, 2025.