Susan D. Wiley, MD Vice Chairman, Dept. Psychiatry, Lehigh Valley Health Network

Clinical Associate Professor Morsani School of Medicine, University of South Florida

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # B5bOctober 18, 2014

“Fast Track”: Psychiatrist as Consultant Has Triple Impact on

Patient-Centered Medical Home

Faculty Disclosure

• I have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

1. List the key elements of this program.

2. Identify the challenges of implementing “Fast Track.”

3. Discuss the value that “Fast Track” offers to patients and their PCPs.

Bibliography / Reference

1. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Goldner EM; egoldner@sfu.ca ; Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie [Can J Psychiatry] 2011 ; Vol. 56 (8), pp. 474-80.

2. Consultant caseload management. Mathai J; john.mathai@rch.org.au; Australasian Psychiatry: Bulletin Of Royal Australian And New Zealand College Of Psychiatrists [Australas Psychiatry] 2007 Feb; Vol.15 (1), pp. 49-51.

3. Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models. Davis DW; deborah.davis@louisville.edu ;Clinical Pediatrics [Clin Pediatr (Phila)] 2012 Oct; Vol. 51 (10), pp. 978-82.

Bibliography / References

4. In need of psychiatric help--leave a message after the beep.Bridler R; r.bridler@sanatorium-kilchberg.chPsychopathology [Psychopathology] 2013; Vol. 46 (3), pp. 201-5.

5. Primary care physicians' and psychiatrists' approaches to treating mild depression. Lawrence RE; rlawrence@uchicago.edu; Acta Psychiatrica Scandinavica [Acta Psychiatr Scand] 2012 Nov; Vol. 126 (5), pp. 385-92.

6. Telepsychiatry: videoconferencing in the delivery of psychiatric care.Shore JH; Department of Psychiatry, University of Colorado Denver, Aurora, USA. jay.shore@ucdenver.edu; The American Journal Of Psychiatry [Am J Psychiatry] 2013 Mar 1; Vol. 170 (3), pp. 256-62.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Existing models of delivering psychiatric care are unable to meet the volume of community needs.

PCPs are de-facto providers of Mental Health treatment in most communities.

The Nature of the Problem

Many PCPs find themselves untrained, uncomfortable or ill-equipped to manage straightforward psychiatric & behavioral health issues.

PCPs are reluctant to “ask the questions” or screen for MH disorders for fear that they will not be able to manage or refer the patients.

The Nature of the Problem

Unacceptable waiting periods for access:◦Waits range from 2-6 months

Costly delays in diagnosis and treatment◦Assessment late in course◦Often takes place in Emergency

Department◦May lead to avoidable hospitalization◦Greater morbidity and mortality

The Size of the Problem

Uncomplicated History: Straightforward, points to a single diagnosis.

Mild to moderate symptoms

Mild to moderate Behavioral abnormalities: school avoidance, eating problems, sleeping issues, spending or gambling, promiscuity

Course is acute or sub-acute.

Primary Psychiatry

Uncomplicated Anxiety disorders Uncomplicated Depression Uncomplicated Attention Disorders Psychological Affects of Physical Illness Psychological Factors of Physical Illness Uncomplicated Dementia Somatoform disorders Minor Behavioral issues

Primary Psychiatry

33 year old married mother with mild obsessive and compulsive symptoms, responded well to medication adjustment & supportive counseling from the BHS;

55 year old man with diabetes, impotence, job loss and marital strain, cc irritability responded well to new antidepressant & counseling

72 year old man with Parkinson’s Disease and Anxiety, offered anxiolytic medication

Appropriate Referrals

Built upon a platform of shared electronic medical record & shared liability

Effective Collaboration requires trust & communication

Based upon Psychiatric Consultation model Facilitated by the presence of Behavioral

Health Specialists Confidence that an educated & supported

PCP can manage Primary Psychiatric issues effectively, efficiently & at lower cost

“Fast Track”

NOT designed for patients requiring long term comprehensive care: Severe symptoms: Mania Serious behavioral dysfunction: Suicidal Complex co-morbidities: Substance abuse Chronic, persistent or relapsing Mental

Illness Requiring three or more concurrent

psychotropic agents

NOT a “Back Door” into a psychiatrist’s office.

What Fast Track is NOT

BHS evaluates the patient. PCP or BHS identifies need for psychiatric

consultation and discusses it with patient. PCP or BHS initiates referral to psychiatry

consultant through EMR, identifies question. Psychiatrist reviews the record for appropriateness. If possible, curbside consultation is offered. Approved patients are scheduled for appointment

within 2 weeks; Diagnosis & Treatment plan are returned to PCP

day of service. Patients inappropriate for Fast Track may be offered

routine evaluations.

How “Fast Track” Works

◦Mutual respect between PCP & Psychiatrist

◦Referred patients meet agreed upon criteria

◦Psychiatrist responds promptly, offers a clear, coherent treatment plan & supports ongoing care

◦PCP accepts the primary responsibility of patient management

Key Elements for Effective Collaboration: Trust

◦Behavioral Health Specialist assesses the patient and documents findings in EMR

◦Purpose of consultation is clear & appropriate

◦Psychiatrist makes the results of evaluation available to PCP on day of service

◦Follow up is arranged by the psychiatrist as necessary

◦Revisions to treatment can be made “curbside” or in the psychiatrist office

◦Routine refills are managed by PCP office

Key Elements for Effective Collaboration: Communication

Timely Individualized & accurate Pithy and concise Includes salient positives, negatives that

support decision-making Explicit treatment plan Alternatives: “…if this is ineffective then…”

Key Elements for Effective

Collaboration: Communication

Appreciates the PCP will remain the primary provider of the treatment

Appreciates that mental health history and psychiatric evaluation will be shared with her Primary Care treatment team

Understands the target symptoms that are the focus of treatment

Has a clear understanding of possible side effects, risks, benefits & treatment alternatives

Patient as Collaborator

Transparent medical and psychiatric history, diagnoses, medications◦ Drug & Alcohol, Social, Family History

Real time information sharing Attention to medical and psychiatric co-

morbidities Awareness of drug-drug interactions Legibility

Shared Electronic Medical Record

Privileged information & limits of collaboration

Who sees what? Levels of access Patient education & consent process:

-Types of information collected-Details who can access their information-How the information will be used-How the consent can be revoked/expires

Privacy Challenges:

Identify patients in PCP office through screening

Collect relevant history & document this in shared medical record

Assure appropriate patients are referred through Fast Track

Facilitate monitoring of the patient & treatment plan

Role of Behavioral Health Specialist

Team meetings: Behavioral Health Specialists

On-site education: Primary Care Providers

On-going, patient-specific education: “In a case like this, I would try….”

Grand Rounds presentations, “Current Approaches to the Treatment of…”

On-Going Education to Support Fast Track Model

Shared EMR and Liability insurance are key.

Identify your frequently referring PCPs

Identify a Psychiatrist Consultant

Describe your Fast Track criteria

Get buy-in from your clinical team

Put it in writing for the whole team AND the patient

Establish your outcome measures

Establish office processes for referral & tracking

Track & monitor your outcomes

How to Get Started

Appropriateness of referral

Time to evaluation date from referral compared to TAU

Outcome of referral: ◦Successful hand-back to PCP◦Number of Psychiatric visits

Future Measures: Psych ED visits & hospitalizations, costs of episode of care

Monitoring

Name MR number Referring doctor Referring group Date of referral Date seen Telemedicine or In-

office ( T or O) BHS contact (yes/no)

Appropriate/Not Curbside Consult only Kept/Referred # of psych visits Seen/Refused Txt field for

diagnoses Text field for outcome

Monitoring Tool

E.R. is 67 yr old married father CC: Sadness, low energy, interrupted sleep,

excessive worry, restlessness, weight loss, distractibility, guilt

Past Psych Hx: Previous out-patient psychiatric treatment for impotence in his 20’s; again 18 mos ago,

No in-pt Rx, no suicides; D&A: Hx of alcohol dependency, DUI in

past, now sober; Rx: Currently on Prozac 80 mg daily,

Trazodone 100, Xanax .25 prn

Case Study

Axis I: Major Depression Recurrent, Moderate Generalized Anxiety Disorder

Axis II: NoneAxis III: Degenerative Disc Disease, Chronic Low Back Pain, Hypertension, Hyperlipidemia,Erectile Dysfunction, Vitamin D. DeficiencyAxis IV: Wife’s dx of Stage 4 Lung Cancer, Son’s severe disability, Financial strain, Phase of Life issuesAxis V: 50

Diagnosis

Medication Management:◦ Lower to Prozac to 60 mg daily◦ Increase the Trazodone to 150 mg to improve

sleep density and duration◦ Add Buspirone 30- 45 mg daily for anxiety

Psychotherapy◦ Goals to address negative ruminations and guilt◦ Relaxation strategies, Mindfulness◦ Sleep hygiene

Treatment Coordination◦ PCP, BHS & Psychotherapist

Treatment Plan

# Referrals: 22 # Referring Groups: 5 # Unique Providers: 16 Ave. Interval to appointment: 17 days Ave. TAU: 2-3 mos Appropriate Referrals: 55% Patients seen: 55% Retained as patients: 33%

Outcomes of Pilot

Model does not improve access for patients most in need.

Clinical complexity is frequently not apparent

Buy-in varies among members of a group

Some patients prefer on-going management by specialist

Behavioral Health Specialist needed for screening

Personnel needed to facilitate & track referrals

Capacity may not meet demand for services

Obstacles & Challenges

Fast Track is an effective solution to access challenges.

Successful implementation requires willing partners, a shared EMR, & effective communication.

Behavioral Health Specialists & Care managers stream-line the referral and tracking process.

Conclusion

Susan D. Wiley, MD Vice Chairman, Dept. Psychiatry

Lehigh Valley Health NetworkSusan.Wiley@LVHN.ORG

610-402-5900

Questions?

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!