Ad Hoc and Caseload Consultation

Wednesday, November 12, 2014

Jürgen Unützer, MD, MPH, MA

Professor and Chair, Psychiatry and Behavioral Sciences University of Washington

Marc Avery, MD

CIBHS CCC Faculty Co-Chair

Gail Bataille, MSW

CIBHS CCC Faculty Co-Chair

Objectives:

1. Understand the different types of consultation that are necessary in coordinated care.

2. Learn what elements of consultation are most effective.

3. (During breakout) Explore ways for testing/implementing ad hoc and caseload consultation in your location.

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Collaborative Care Model Consutation

Patient PCP BH Care Manager New Roles Core Program Psychiatric Consultant

Collaborative Team Model: Two Types of Consultation – Caseload and Ad Hoc

Care Coordination Team

Patient

Care Plan

Care Coordinator Psychiatrist Primary Care

Population Consultants

Case Manager Psychiatrist Peer Counselor

Mental Health

Other Substance Use Counselor

Other Substance Use

PCP Other

Primary Care

Pay-for-performance cuts median time to depression treatment response in half.

0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136 Weeks Before P4P After P4P

Unützer et al. 2012.

Effective Implementation: 9 Factors

Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

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Engagement/Activation and Remission: Key Factors

Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

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Common Consultation Questions

Clarification of diagnosis • Consider re-screening patient • Patient may need additional assessment Address treatment resistant disorders • Make sure patient has adequate dose for adequate duration • Provide multiple additional treatment options Recommendations for managing difficult patients • Help differentiate crisis from distress • Support development of treatment plans/team approach for patients with behavioral dyscontrol • Support protocols to meet demands for opioids, benzodiazepines etc… • Support the providers managing THEIR distress

• • • • •

Key Elements of an Informal Consultation Readily Accessible Establish rapport and welcoming stance Concise feedback – pharmacologic and nonpharmacologic If-then scenarios and next steps Educational component

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Uncertainty: Requests for More Information

Sufficient information Complete information

-

Tension between complete and sufficient information to make a recommendation Often use risk benefit analysis of the intervention you are proposing

Sample Case Review Note

SUMMARY:

Pt is a 28yo male presenting with depression and anxiety. Pt having trouble falling asleep (plays with laptop or phone in bed), sleeping 4-7 hrs/night.

Depressive symptoms:

Moderate depression; PHQ-9: 18

Bipolar Screen:

screen; May be more consistent with substance use

Anxiety symptoms:

Positive Moderate to severe; GAD-7: 18

Past Treatment:

Currently taking Bupropion and Citalopram (since 1/31) feels more in control, able to think before reacting, less irritable; Took Zoloft, Prozac, Wellbutrin at different times during teenage yrs. Doesn't recall effect

Suicidality:

Denies

Psychotic symptoms:

Denies

Substance use:

History of substance use/alcohol; Engaged in treatment

Other: Psychosocial factors:

Completed court appointed time in clean and sober housing; Now living back with parents in Carnation; Attending community college; Continues to stay connected to clean and sober housing; Attends Mars Hill Church ADHD: ASRS-v1.1 screening – positive; Not diagnosed as a child; Now getting B’s at community college

Medical Problems:

hx of frequent migraines

Current medications:

Bupropion HCl (Wellbutrin SR)(Daily Dose: 450mg) †Citalopram Hydrobromide (Celexa) (Daily Dose: 40mg)

Goals:

Improve school functioning; Long term goal employment

ASSESSMENT:

disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission; r/o ADHD Depression NOS , most likely MDD but cannot r/o bipolar

RECOMMENDATIONS:

1) Continue to target sleep hygiene 2) making about which ONE option to pursue: a.

Options for antidepressant augmentation. Engage patient in decision Option 1: Continue Celexa to 20mg as reported sedation on higher dose; Make sure he is taking dose at night and allow for longer period of observation to evaluate efficacy 3) 4) b.

c.

Option 2: Increase Celexa back to 40mg to target anxiety as did not notice a change in sedation but noted increased anxiety when lowered dose.

Option 3: Cross taper to fluoxetine; Week 1: Baseline weight. Consider BMP for baseline sodium in older adults. Start 10 mg qday. Continue Celexa20mg Week 2: Increase dose to 20 mg qday, if tolerated, and stop Celexa Week 4 and beyond: Consider further titration in 10-20 mg qday increments. Typically need higher doses for anxiety Typical target dosage: 20 mg qday Continue close contact with care coordinator, supporting substance use treatment and behavioral activation.

Can consider Strattera in the future if poor concentration persists; Would stay on 40 mg qday as combination with Wellbutrin can increase drug level.

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‘Disclaimer’ on Note

• “ The above treatment considerations and suggestions are based on consultations with the patient ’ s care manager and a review of information available in the care management tracking system. I have not personally examined the patient. All recommendations should be implemented with consideration of the patient ’ s relevant prior history and current clinical status. Please feel free to call me with any questions abut the care of this patient.

“ •Dr. X, Consulting Psychiatrist •Phone #. •Pager #.

•E-mail

ROLE: Caseload Consultant

Caseload Reviews • Scheduled (ideally weekly) • Prioritize patients that are not improving Availability to Consult Urgently • Diagnostic dilemmas • Education about diagnosis or medications • Complex patients, such as pregnant or medical complicated

If patients do not improve, consider:

• Wrong diagnosis?

• Problems with treatment adherence?

• Insufficient dose / duration of treatment?

• Side effects?

• Other complicating factors?

– psychosocial stressors / barriers – medical problems / medications – ‘ psychological ’ – substance abuse barriers – other psychiatric problems • Initial treatment not effective?

Sample Consultations ~ 30 min

REASON FOR CONSULT

Side effects from lithium SE from lisdexamfetamine

DIAGNOSI S

BP 1 ADHD

RECOMMENDATION

Switch to valproic acid Try another per protocol Lithium level is 1.2

Inc depression symptoms Poss SE from quetiapine Paroxetine not effective Regular lamotrigine or XR?

Side effects with citalopram Depression symptoms increase Suicidal, acute distress High doses of meds, confused Anxious, wants alprazolam, nipple pain BP 1 MDNOS BP 1/PD MDD BP 2 MDD BP1 PD MDD GAD Cont unless having side effects TSH, if normal start lamotrigine Decrease Seroquel to 100 mg Add bupropion No difference Switch to bupropion Check lithium level first, maximize if low, may need to add lamotrigine Safety plan, DBT referral Stop hydroxyzine, reduce lorazepam, call collateral No alprazolam, increase sertraline, coping skills

ROLE: Direct Consultant

Seeing patients directly in collaborative care is different than traditional consultation. Approximately 5 – 7 % may need this.

Patients pre-screened from care manger population • Already familiar with patient history and symptoms • Typically more focused assessment, tele-video OK Common indications for direct assessment • Diagnostic dilemmas • Treatment resistance • Education about diagnosis or medications • Complex patients, such as pregnant or medical complicated **Utilize televideo if warranted

Liability

PCP:

Oversees overall care and retains overall liability AND prescribes all medications/additional studies

CM/BHP:

Responsible for the care they provide within their scope of practice / license

COLLABORATIVE

Curbside with BHP, document recommendations in chart and paid

INFORMAL CONSULTATIVE

Curbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP •Olick et al, Fam Med 2003 •Sederer, et al, 1998 •Sterling v Johns Hopkins Hospital., 145 Md. App. 161, 169 (Md Ct. Spec. App. 2002

FORMAL

Direct with patient after other steps unsuccessful, written opinion

SUPERVISORY

Psychiatric provider administrative and clinical supervisor of BHP  ultimately responsible

Consultation ranges from informal to formal. Is there a doctor patient relationship?

Collaborative care should reduce risk:

-Care manager supports the PCP -Use of evidence based tools -Systematic, measurement based follow-up -Psychiatric consultant 18

AD HOC Consultation

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Collaborative Care Model Consutation

Patient PCP BH Care Manager New Roles Core Program Psychiatric Consultant

Collaborative Team Model

Care Coordination Team

Patient

Care Plan

Care Coordinator Psychiatrist Primary Care

Population Consultants

Case Manager Psychiatrist Peer Counselor

Mental Health

Other Substance Use Counselor

Other Substance Use

PCP Other

Primary Care

Example Vignettes: Case #1: Your patient calls you, the care coordinator, complaining of feeling extremely anxious. She states that this started yesterday when the PCP started a new diabetes medication. She also is a bit dizzy.

Case #2: Your CC patient sees his PCP complaining of increasingly intrusive voices. He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.” 22

Bi-Directional Ad Hoc Clinical Consultation – Breakout Session

Case #1:

Your patient calls you, the care coordinator, complaining of feeling extremely anxious. She states that this started yesterday when the PCP started a new diabetes medication. She also is a bit dizzy. How would you obtain medical consultation from PC clinic?

Case #2:

Your CC patient sees his PCP complaining of increasingly intrusive voices. He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.” The PCP would like to consult with you and mental health. How would this happen?

• How have you begun to test/implement population focused clinical care coordination meetings with your key CCC provider partners? • How frequently are you meeting to develop/review Integrated Care Plans?

• What criteria have you used for selecting patients for caseload consultation?

• Are you using population-based criteria to select patients for caseload reviews? • If so, are there additional population-based criteria that you can test/implement?

• If not, what criteria can you begin to test/use?

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