Training the 21st Century Psychiatrist for the Patient

Centered Medical HomeJeralyn Jones, MD

Alex J. Reed, PsyD, MPH

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session # FB5October 6, 2012

Faculty Disclosure

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

How are people integrating family medicine and psychiatry?

How are people integrating family medicine and psychiatry training?

Objectives

• Participants will understand the rationale and forces driving integrated health care.

• Participants will be able to describe different models of psychiatric collaboration with primary care providers.

• Participants will explore the challenges and benefits of educating today’s trainees for the integrated care practice of tomorrow.

Boun

Bonner

Kootenai

BenewahBenewah Shoshone

LatahLatah

ClearwaterClearwater

Nez Perce

Lewis

Idaho

Adams

ValleyValley

Washington

Payette

Canyon

Boise

Ada

Owyhee

Twin Falls

Jerome

Blaine

Lincoln

Minidoka

Cassia

Power

OneidaFranklin

Bear Lake

Bannock

Caribou

Bingham

Lemhi

CusterClark Fremont

TetonJefferson Madison

Bonneville

Butte

Gooding

CamasElmore

Gem

Idaho Mental Health Professional Shortage AreaService Areas

Geographic HPSA

State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 4/07 – please contact (208) 334-5993 for updates

Facility

Idaho Primary Care Health Professional Shortage AreaService Areas

Geographic HPSA

Population Group HPSA

State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 5/12 – please contact (208) 334-5993 for updates

Bonner

Kootenai

BenewahBenewah Shoshone

Latah

Clearwater

Idaho

Adams

Washington

Payette

Canyon

Ada

Owyhee

Twin Falls

Jerome

Blaine

Lincoln

Minidoka

CassiaBear Lake

CusterClark Fremont

Gooding

CamasElmore

Gem

Bannock

Valley

Lewis

Nez Perce

Lemhi

Power

FranklinOneida

Boise

Butte

Bingham

JeffersonMadison Teton

Caribou

Boundary

Bonneville

Patient Centered Medical Home

AAFPAAPACPAOA

?APA

Elements of PCMH

Personal Physician

Physician directed medical practice

Whole Person Orientation

Integrated/Coordinated Care

Enhanced Access to care

Quality and Safety

Payment Reform

Psychiatry

Accountable Care Organization (ACO)

An ACO is an entity that will be “held accountable” for providing comprehensive health services to a defined population

Cost HMO in Drag? Accountability

Primary Care focus

University of Washington Idaho Advanced Clinician Track/

Primary Care Psychiatry Training or…

EXTREME INTEGRATED PRIMARY CARE!!!!

Somewhat Censored !!!

Mental Illness in Primary Care

• Most patients with mental health disorders initially present to their PCP.

• Primary care is the “de facto” mental health system for 70% of the population.

• 80% of all psychotropic medications are prescribed by nonpsychiatric medical providers*

*Katon, W., Reis, R.K., Kleinman, A. (1984). The prevalence of somatization in primary care. Compr Psychiatry, 25 (2)., 208-215

Chronic Conditions and MH

Cost w/o Mental Health Condition

Cost w/Mental Health Condition

All Adults $1,913 $3,545

Heart Condition $4,697 $6,919

High Blood Pressure $3,481 $5,492

Asthma $2,908 $4,028

Diabetes $4,172 $5,559

Agency for Healthcare Research and Quality (2003). Medical Expenditure Panel Survey, Rockville, MD.

Depression in Patients with Comorbid Medical Illness

Comorbid Medical Illness Prevalence Rate (%)Cardiac Disease 17-27

Cerebrovascular Disease 14-19

Alzheimer’s Disease 4-75

Epilepsy – Recurrent 20-55

Epilepsy – Controlled 3-9

Diabetes – Self-reported 26

Diagnostic interview 9

Cancer 22-29

HIV-AIDS 5-20

Pain 30-54

Obesity 20-30

General Population 10.3

Evans et al. (2005). Mood Disorders in the Medically Ill: Scientific Review and Recommendations. Biol Psychiatry, 58, 175-189

Traditional Mental Health

Primary Care

Typical Morning in FM Practice

56 y.o. diabetic w/ poor control19 y.o. smoker for annual exam33 y.o. w/ multiple somatic issues7 y.o. with otitis media67 y.o. with insomnia70 y.o. with sinusitis52 y.o. with HTN28 y.o with chest pain & SOB

Anxious

Smoking CessationDepressionEnuresis

Alcohol Abuse

Family Violence

PTSD

Panic DisorderGunn, W. B. & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psycholog, 65 (3), 235-252.

Tell me and I forget, Show me, and I may remember

Involve me, and I will understandConfuscius

Patient Centered Medical Home

One Day per week PGY3 and PGY4

Psychiatrist

Continuity clinic PAC Precepting

with FM

Psychologist

WBC-Brief Behavioral

FM Didactics

Psychiatry Resident

FQHC—Federally qualified health center

Safety Net Clinic

Patients with complex medical/psychiatric illness, few resources

Sawtooth Model

PAC/WBC

Attending Room

Evolution of the 21st Century Psychiatrist

Sawtooth Model

• Recognition illness• Access care• Comprehensive

model

• Help!!!• Education psych• Learn new model

• Measurement driven referrals

• Teach/Expert• Understand/access FM

• Direct OP observation patient care/teach

• Learn new model• Collaborate FM/Psych

Patient FM Resident

Psychiatry ResidentSupervisor

Determinants of Health

Schroeder, Steven A., We Can Do Better -- Improving the Health of the American People, N Engl J Med 2007 357: 1221-1228

Wellness Behavior Clinic

• Opportunity to see patients for behavioral health visits using specific assessment and intervention techniques

• Can use these techniques to provide behavioral health interventions on the fly

• Residents rotate into the clinic and learn these techniques while being observed by the “team” in another room

Let’s Play…Program:

Support top downUW PsychFM

Funders interested

Faculty comfortable FM

Evolving model

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!