Primary Care Provider & Psychiatric Consultant Roles. PC/PCP Role Session Objectives. Working as a Team. Joseph Cerimele Anna Ratzliff

Transcription

1 Primary Care Provider & Psychiatric Consultant Roles Joseph Cerimele Anna Ratzliff PC/PCP Role Session Objectives By the end of the session, participants will: 1. Understand the role of the psychiatric consultant and PCP to support care in a IMPACT care workflow 2. Practice team communication required to provide team-based care 3. Develop a plan to champion PCP engagement and share information from the training Working as a Team Role of the PCP and Psychiatric Consultant Joseph Cerimele Anna Ratzliff 1

2 Primary Care Provider & Psychiatric Consultant Roles 9/27/14 Primary Care Provider PCP Core Program Care Manager Patient Psychiatric Consultant Additional Clinic Resources Psychotherapist PCP oversees all aspects of patient s care. Introduces collaborative care team Diagnoses common mental disorders Starts & prescribes pharmacotherapy Makes treatment adjustment in consultation with team Psychiatric Consultant PCP Core Program Care Manager Patient Psychiatric Consultant Additional Clinic Resources Psychotherapist Supports care managers and PCPs through caseload consultation. Provides regular (weekly) and as needed consultation on a caseload of patients followed in primary care Focus on patients who are not improving clinically +/- In person or telemedicine consultation Provides education for team Behavioral Health Care Manager PCP Core Program Care Manager Patient Psychotherapist Psychiatric Consultant Additional Clinic Resources Owns the caseload of patient and coordinates integrated treatment plans. Either BH CM or psychotherapist delivers brief behavioral interventions. Facilitates patient engagement and behavioral health education Performs systematic initial and follow-up assessments; Systematically tracks treatment response; Supports treatment plan with PCPs; Reviews challenging patients with the consulting psychiatrist weekly 2

3 PC/PCP Role Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention System Level Supports Behavioral Health Measures as Vital Signs Behavioral health measures are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment PC/PCP Role Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention System Level Supports 3

4 Primary Care Provider & Psychiatric Consultant Roles 9/27/14 Weekly Caseload Consultation Care Manager Psychiatric Consultant Model Consultation Hour Brief check in Changes in the clinic Systems questions Identify patients and conduct reviews Requested by CM Not improved w/o note Severity of presentation Disengaged from care Wrap up Confirm next consultation hour Send any educational resources discussed Prioritizing Cases for Review Care Manager Psychiatric Consultant Can sort to identify patients CM will flag patient for next call with psychiatric consultant 4

5 Psychiatric Consultation Easily identify patients not improved with no prior psychiatric consultation CM will flag patient for next call with psychiatric consultant 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 Assessment and Diagnosis in the Primary Care Clinic Functioning as a back seat driver Develop an understanding of the relative strengths and limitations of the providers on your team Relying on other providers (PCP and BHP/Care Manager) to gather history How do you steer? Structure your information gathering (Structured Assessment) Include assessment of functional impairment Pay attention to mental status exam 5

6 Primary Care Provider & Psychiatric Consultant Roles 9/27/14 Clinical Dashboard: Shared Patient Summary Uncertainty: Requests for More Information Complete information Sufficient information Tension between complete and sufficient information to make a recommendation Often use risk benefit analysis of the intervention you are proposing Provisional Diagnosis Assessment by BHP and PCP Consulting Psychiatrist Case Review or Direct Evaluation Screeners filled out by patient Provisional diagnosis and treatment plan 6

7 Assessment and Diagnosis in the Primary Care Clinic Provide intervention Gather information Generate a treatment plan Exchange information Diagnosis can require multiple iterations of assessment and intervention Advantage of population based care is longitudinal observation and objective data Start with diagnosis that is your best understanding PC/PCP Role Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention System Level Supports Recommendations: Medication Focus on evidence-based treatments and treatment algorithms Details about titrating and monitoring Brief medication instructions 7

8 Primary Care Provider & Psychiatric Consultant Roles 9/27/14 Recommendations: Other Interventions Support managing difficult patients Working with demanding patients Protocols for managing suicidal ideation Working with patients with chronic pain More recommendations Beyond Medications Behavioral Medicine and Brief Psychotherapy Referrals and Community Resources Why Brief Behavioral Interventions? Medications Feel Bad Do Less Brief Behavioral Interventions 8

9 Role for PCPs in Behavioral Opportunity Sell Explain WHY recommending engagement in Collaborative Care Relationship Engage patients and strengthen commitment Integrate with medication treatment Approach: Outside In Typically we think of acting from the inside out (e.g., we wait to feel motivated before completing tasks) In BA, we ask people to act according to a plan or goal rather than a feeling or internal state PC/PCP Role Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention System Level Supports 9

10 Track Outcome Over Time A Different Kind of Note Traditional Consult Note Integrated Care Case Reviews Note 1: January Side effects One consult note Note 2: March Pt still has high PHQ Note 3 May: Pt improved! Disclaimer on Psychiatric Case Review 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 # 10

11 In Person Assessment Seeing patients directly in collaborative care is different than traditional consultation! Patients pre-screened from care manger population Already familiar with patient history and symptoms Typically more focused assessment Common indications for direct assessment Diagnostic dilemmas resistance Education about diagnosis or medications Complex patients, such as pregnant or medical complicated Psychiatric Consultant Offer You can do this, I m here for you. I ve got your back. Maximize ability to provide care without specialty referral to psychiatry prioritize patients for limited resource Provide education algorithms, articles Psychiatric consultant readily accessible to support this work 32 PC/PCP Role Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention System Level Supports 11

12 Relapse Prevention Plan Questions? Team Communication For the PCP and Psychiatric Consultant 12

13 Primary Care Provider & Psychiatric Consultant Roles 9/27/14 Provider to Provider Communication PCP Core Program New Roles Care Manager Patient Psychotherapist Psychiatric Consultant Additional Clinic Resources Team Communication Plan PCP Communication CM Communication Plan How do you want the CM to communicate with you? Format? Modality? Frequency? Give feedback! What is working? What can be improved? PC Communication Plan How do you plan to contact the PC with questions? Phone? ? Via CM? 13

14 Consulting Psychiatrist Communication CM Communication Plan Regular consultation! How do you want the CM to communicate with you urgently? Format? Modality? Frequency? Give feedback! What is working? What can be improved PC Communication Plan How do you plan to communicate with the PCP? Phone? ? Via CM? Case Consultation Practice! 1) Role Play Psychiatric Consultant (played by psychiatric consultant) PCP/BHP (played by PCP) 2) BHP/PCP: Read vignette 3) Psychiatric Consultant: Provide consultation Would you make a recommendation based on the info (consider the source phone vs )? If not, what additional information would be required (tension between uncertainty and requests for more information)? 4) Switch PCPs and Repeat 41 Planning to Champion PCP Engagement 14

15 How Can You Engage Your PCPs? Pick a time! Provider meeting? Rolling information session? Determine content! Daniel video PCP role Program specific Reward attention! Depression care update Medication sheet Get organized! Who will present? What resources would help you? Ongoing promotion! Celebrate success SIF IMPACT updates in newsletters and bulletin boards Ongoing education and promotion Planning! Get into your clinic group Brainstorm ideas using worksheet Leave with a plan! 15

16 Medications for Depression Most Patients Need Adjustments 30 50% of patients will have a complete response to initial treatment 50 70% will require at least one change in treatment to get better If Patients Do Not Improve, Consider: Wrong diagnosis? Problems with treatment adherence? Insufficient dose / duration of treatment? Side effects? Initial treatment not effective? Other complicating factors? psychosocial stressors / barriers medical problems / medications psychological barriers substance abuse other psychiatric problems 16

17 Major Depression Medication SSRI Fluoxetine/Prozac Sertraline/Zoloft Citalopram/Celexa Escitalopram/Lexapro Paroxetine/Paxil Fluvoxamine/Luvox SNRI Venlafaxine/ Effexor Duloxetine/Cymblta Other Newer: Bupropion / Wellbutrin / Zyban, Mirtazapine / Remeron Older: TCA (Amitriptyline, Nortriptyline ) MAOI Common Augmentation Buspirone /Buspar Antipsychotic medications (ex. Abilify or Seroquel) Choosing Antidepressants Prior treatment history in patient/family members Patient preferences Expertise of prescribing provider Side effect profile Safety in overdose (TCA) Drug-drug interactions Stepped Depression SSRI, SNRI, Bupropion Switch Medication, Switch Class, Augment with Bupropion, Mirtazapine Antipsychotic, TCA Other 17

18 Common Side Effects Short term: GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 10%) Managing Side Effects Discuss with psychiatric consultant Change to or add Behavioral Short term strategies Change to a different antidepressant Insomnia Treat depression effectively! Sedating antidepressants Mirtazapine (15-45 mg po qhs) Short term Add zolpidem (Ambien; 5-10 mg) or eszopiclone (Lunesta; 1-2 mg) Longer term Add low dose Trazodone ( mg po qhs) 18

19 Sexual Dysfunction (anorgasmia) 25 33% of SSRI-treated patients: Change to: Bupropion Mirtazapine Augment Bupropion SR 100mg PO BID Buspirone 15mg-30mg PO BID Weight Gain 5 10% of SSRI-treated patients Change to Bupropion Fluoxetine Physical exercise Drug-Drug Interactions Antidepressants are metabolized by the P450 isoenzyme system in the liver. They can: Change blood levels of other drugs that are metabolized by the same hepatic enzymes Displace other protein-bound drugs Rule of thumb: if a patient is on a drug with a narrow therapeutic window (e.g., digoxin, warfarin, theophylline, antiarrhythmics, lithium, TCAs, anticonvulsants), check a serum level of that drug when a steady state of the antidepressant is reached or if there are side effects Consult pharmacist 19

20 Good Reasons to Stop a Medication Intolerable side effects Dangerous interactions with necessary medications The medication was not indicated to start with (e.g., bipolar depression) Medication has been at maximum therapeutic dose without improvement for 4-8 weeks 20