Session: E5a October 29, 2011 1:30 PM to 2:15 PM

THE USE OF CONSULTING PSYCHIATRY WITHIN AN INTEGRATED PRIMARY CARE MODEL: HOW IT WORKS

Elizabeth Zeidler Schreiter, Psy.D., Psychologist Meghan Fondow, Ph.D., Psychologist Jantina Vonk, MD, Psychiatrist Chantelle Thomas, Ph.D., Psychologist Access Community Health Centers- Madison, WI Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

FACULTY DISCLOSURE

 I/We currently have or have had the following relevant financial relationships (in any amount) during the past 12 months:  Fairleigh Dickinson University Certificate Program in Integrated Primary Care-Dr. Zeidler Schreiter is an expert presenter for this program.

NEED/PRACTICE GAP & SUPPORTING RESOURCES  Primary care is frequently referred to as the “de facto” mental health system in the United States (Cummings et. al., 2001)  Medical clinicians are facing a burden of an ever increasing number of patients presenting with major mental illness and/or high risk lifestyle behaviors, as seen within our Federally Qualified Health Center (FQHC).

NEED/PRACTICE GAP & SUPPORTING RESOURCES    Research has shown that in the current treatment model (clinics that do not have integrated care and refer patients elsewhere for mental health treatment) less than one-third of referrals are actually completed (Miranda et. al., 1994). Primary care physicians prescribe approximately 60% to 70% of the psychotropic medications prescribed in the United States (Pirl et. al., 2001). Given the above issues increased access to consulting psychiatry is needed to provide optimal management of increasingly severe patients within the primary care setting.

OBJECTIVES

Upon completion of this presentation, participants will be able to:  Identify components of a consulting psychiatry approach within primary care and potential impact on PCP practice habits.

 Describe how behavioral health consultation and psychiatry can work together in a primary care setting to enhance outcomes.

EXPECTED OUTCOME

 Have knowledge to assist with implementing consulting psychiatry within their practice setting.

 List core competencies of a consulting psychiatrist who would fit well within primary care.

 Have knowledge how to utilize BHC to assist with coordination and access to psychiatry consultation within clinic.

WHO WE ARE: ACCESS COMMUNITY HEALTH CENTERS

 FQHC, Health Care Home  3 clinic locations in Madison, WI  Medical, Dental, Behavioral Health Services  Over 23,000 patients seen in 2010  Over 105,000 visits for 2010

WHAT WE DO: BEHAVIORAL HEALTH CONSULTATION

 Primary Care Behavioral Health model (Robinson & Reiter, 2007)  Fully integrated, fully embedded program  Mix of scheduled follow ups and warm hand offs  BHC serves as conduit for referrals to consulting psychiatry

NEED FOR INTEGRATED SERVICES

  Depressive and anxiety disorders in medical patients have been associated with increased utilization of medical services leading to increased cost , significant functional impairment, and sub-optimal adherence rates in patients with chronic medical issues (Simon et. al., 1995). Many of these patients can be successfully managed within a primary care environment as evidenced in recent study by Serrano & Monden (2011) with assistance from BHC and access to consulting psychiatry.

POPULATION SERVED

 BHC saw about 27% of medical patients in 2010 at 2 sites, about 12% at 3 rd site  Demographics:  47% Caucasian  27% African American  24% Hispanic  19% Spanish speaking for BHC

REFERRAL REASONS TO BHC

 Not just mental health issues. Preventive Health and Behavioral Health needs also very salient  Depression and Anxiety commonly seen, but also other mental and behavioral health issues  Bipolar disorder, psychotic spectrum disorders, AODA, adjustment, ADHD, smoking cessation, sleep problems, weight management

ROLE OF CONSULTING PSYCHIATRY

 Explanation of consulting psychiatry service  Population based care  Modalities  Chart review  Face to face  Verbal recommendations  Education  Golden Rule: Primary Care Physician retains prescribing authority

RATIONALE FOR CONSULTING PSYCHIATRY

  Research has discussed several options to increase collaboration between psychiatry and primary care.  Possible options: 1.

2.

Psychiatrist working as specialists who can be consulted as needed Increasing referrals from practitioners to psychiatrists 3.

Integrated team model, in which the psychiatrist and other mental health providers work alongside their primary care colleagues in primary care environment (Cowley et. al., 2000). Integrated consulting psychiatry is highly desirable given volume of patients that receive their psychiatric care within the primary care system and issues with poor follow-up when referred outside of the system.

RESIDENCY TRAINING

     Allows residents exposure to community psychiatry Able to see wide variety of patients Working in collaboration with primary care providers and BHC Prepares resident to work within a medical home Learn to recognize and diagnose psychiatric and/or behavioral conditions common in primary care settings

REFERRAL REASONS TO CONSULTING PSYCHIATRY

   Main requests focused on diagnostic clarification, medication recommendations, management of psychiatric issues co-morbid with physical health issues, and guidance regarding needed lab monitoring.

Primary diagnoses seen include: Mood disorders, schizophrenia/psychotic disorders, PTSD/Anxiety disorders.

Many patients also had co-morbid substance abuse issues.

POPULATION SERVED

 Patient numbers as seen face-to-face by Consulting Psychiatry:  2010: 210 patients  2009: 170 patients  2008: 107 patients  2007: 34 patients  Over 350 verbal or written consultations in 2010  Resident started 3 rd quarter 2010

STEPS TOWARD IMPLEMENTATION

        Consulting psychiatry started at ACHC in 2007.

Administrative backing. Needs assessment of clinic is warranted to determine best fit and time needed.

Population care focus thus emphasis on verbal and written consultations in addition to face-to-face encounters.

Psychoeducation for medical providers Space for consultant to work (e.g. exam room) Finding a psychiatrist ready, willing, and able to thrive in this environment.

Utilization of Behavioral health consultant to assist with triaging need and appropriate allocation of resources.

CORE COMPETENCIES OF A CONSULTING PSYCHIATRIST WHO WOULD FIT WELL WITHIN PRIMARY CARE  Flexible  Confident  Able to function as part of a team  Understanding of context-working within an FQHC and limited patient resources  Population based care focus

EXPERT DISCUSSANT

 Dr. Jantina Vonk, MD  Consulting psychiatrist at Access Community Health Centers  Started in 2007  Training background and experiences

EXPERT DISCUSSANT

 Comparing and contrasting roles within community mental health center and primary care environment (within an FQHC).  Review of structure of initial consultation and brief follow-up consultations as needed.  Use of electronic medical record.

 Educating providers on utilization of medication algorithms for mental health issues.

LEARNING ASSESSMENT

 Questions?

REFERENCES

Cowley, D.S., Katon, W., & Veith, R.C. (2000). Training psychiatry residents as consultants in primary care settings. Academic Psychiatry, 24:3, 124-130. Cummings, N.A., O’Donohue, W., Hays, S.C., & Follette, V. (2001). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. San Diego: Academic Press.

Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:1026–1031 Miranda, J., Hohnmann A.A., Attikisso, C.A. (1994). Epidemiology of Mental Health Disorders in Primary Care. San Francisco, CA: Jossey-Bass.

Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of psychiatric consultations in a community primary care center. Primary Care Companion Journal of Clinical Psychiatry, 3, 190-194.

REFERENCES

Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science.

Serrano, N and Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110:3, 113-118.

Simon GE, Ormel J, Von Korff M, et al: Health care costs associated with depressive and anxiety disorders in primary care. American Journal of Psychiatry 1995; 152:352–357.

Slay, J.D., & McCleod, C. (1997). Evolving an integration model: The Healthcare Partners experience. In N.A. Cummings, J.L. Cummings, and J. Johnson (Eds.) Behavioral health in primary care: A guide for clinical integration (pp 121-144). New York: International Universities Press.

SESSION EVALUATION

Please complete and return the evaluation form to the classroom monitor before leaving this session.

Thank you!