ad hoc and caseload consultation wednesday, november 12, 2014 jürgen unützer, md, mph, ma...
TRANSCRIPT
Ad Hoc and Caseload Consultation
Wednesday, November 12, 2014
Jürgen Unützer, MD, MPH, MAProfessor and Chair, Psychiatry and Behavioral SciencesUniversity of Washington
Marc Avery, MDCIBHS CCC Faculty Co-Chair
Gail Bataille, MSWCIBHS CCC Faculty Co-Chair
2
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.
Collaborative Care Model Consutation
PCP
Patient BH CareManager
Psychiatric Consultant
CoreProgram
New Roles
Collaborative Team Model: Two Types of Consultation – Caseload and Ad Hoc
Patient
Psychiatrist
Substance Use
Counselor
Case Manager
Primary Care
Population Consultants
Care Coordination Team
Care Plan
Care Coordinato
r
Peer Counselor
Other
Psychiatrist
Mental Health Substance Use Primary Care
Other Other
PCP
Pay-for-performance cuts median time to depression treatment response in half.
0.0
00.2
50.5
00.7
51.0
0
Estim
ate
d C
um
ula
tive P
rob
ab
lility
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
6Whitebird, et al. Am J Manag Care. 2014;20(9):699-707
7
Engagement/Activation and Remission: Key Factors
Whitebird, et al. Am J Manag Care. 2014;20(9):699-707
Common Consultation Questions
• Consider re-screening patient • Patient may need additional assessment
Clarification of diagnosis
• Make sure patient has adequate dose for adequate duration• Provide multiple additional treatment options
Address treatment resistant disorders
• 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
Recommendations for managing difficult patients
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
9
Uncertainty:Requests for More Information
Complete informatio
n
Sufficient informatio
n
- Tension between complete and sufficient information to make a recommendation
- Often use risk benefit analysis of the intervention you are proposing
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: Positive screen; May be more consistent with substance use Anxiety symptoms: 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 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 Other: 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
Sample Case Review NoteConcise Summary
ASSESSMENT: Depression NOS , most likely MDD but cannot r/o bipolar disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission; r/o ADHD
RECOMMENDATIONS:1) Continue to target sleep hygiene2) Options for antidepressant augmentation. Engage patient in decision
making about which ONE option to pursue:a. 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
b. 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.
c. 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
3) Continue close contact with care coordinator, supporting substance use treatment and behavioral activation.
4) Can consider Strattera in the future if poor concentration persists; Would stay on 40 mg qday as combination with Wellbutrin can increase drug level.
12
Brief & Focused
‘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’ barriers– substance abuse– other psychiatric problems
• Initial treatment not effective?
Sample Consultations ~ 30 min
REASON FOR CONSULT
DIAGNOSIS
RECOMMENDATION
Side effects from lithium BP 1 Switch to valproic acid
SE from lisdexamfetamine
ADHD Try another per protocol
Lithium level is 1.2 BP 1 Cont unless having side effects
Inc depression symptoms
MDNOS TSH, if normal start lamotrigine
Poss SE from quetiapine BP 1/PD Decrease Seroquel to 100 mg
Paroxetine not effective MDD Add bupropion
Regular lamotrigine or XR?
BP 2 No difference
Side effects with citalopram
MDD Switch to bupropion
Depression symptoms increase
BP1 Check lithium level first, maximize if low, may need to add lamotrigine
Suicidal, acute distress PD Safety plan, DBT referral
High doses of meds, confused
MDD Stop hydroxyzine, reduce lorazepam, call collateral
Anxious, wants alprazolam, nipple pain
GAD No alprazolam, increase sertraline, coping skills
ROLE: Direct ConsultantSeeing 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
INFORMALCONSULTATIVECurbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP
COLLABORATIVECurbside with BHP, document recommendations in chart and paid
FORMALDirect with patient after other steps unsuccessful, written opinion SUPERVISORYPsychiatric provider administrative and clinical supervisor of BHP ultimately responsible
• 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
Consultation ranges from
informal to formal.
Is there a doctor-patient
relationship? 18
Collaborative care should reduce risk:
-Care manager supports the PCP -Use of evidence-based tools -Systematic, measurement-based follow-up-Psychiatric consultant
PCP: Oversees overall care and retains overall liability AND prescribes all medications/additional studiesCM/BHP: Responsible for the care they provide within their scope of practice / license
19
AD HOC Consultation
Collaborative Care Model Consutation
PCP
Patient BH CareManager
Psychiatric Consultant
CoreProgram
New Roles
Collaborative Team Model
Patient
Psychiatrist
Substance Use
Counselor
Case Manager
Primary Care
Population Consultants
Care Coordination Team
Care Plan
Care Coordinato
r
Peer Counselor
Other
Psychiatrist
Mental Health Substance Use Primary Care
Other Other
PCP
22
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.”
23
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?