Psychiatric Consultant Role in Collaborative Care Sept 12, 2013
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1 New York State Collaborative Care Initiative Psychiatric Consultant Role in Collaborative Care Sept 12, 2013
2 Presenter Building on 25 years of Research and Practice in Integrated Mental Health Care Anna Ratzliff, MD, PhD Associate Director of Education Division of Integrated Care and Public Health University of Washington
3 Traditional Consultation Limited access Limited feedback Expensive One Pass There will never be enough psychiatrists to refer all patients for consultation. PCPs experience psychiatry consultation as a black box. All MH referrals require full intakes, often leaving little time and energy for follow up or curbside consultation. Works best for one time or acute issues that don t need follow up.
4 Co Location Psychiatrist comes to primary care. Opportunity for interaction / curbside consultations Better communication (often same chart) and coordination / transfers back to primary care. BUT: Not available in many settings (e.g., rural). Access still problematic: new slots fill up quickly; no shows; little capacity for followup. Limited ability to make sure recommendations are carried out.
5 Collaborative Care Caseload focused psychiatric consultation supported by a care manager Better access PCPs get frequent input Focuses in person visits on the most challenging patients. Regular Communication Psychiatrist has regular (weekly) meetings with a care manager Reviews all patients who are not improving and makes treatment recommendations More patients covered by one psychiatrist Psychiatrist provides input on >10 patients in a half day as opposed to 3 4 patients. Shaping over time Multiple brief consultations More opportunity to correct the course if patients are not improving
6 Collaborative Team Approach PCP New Roles Core Program Patient Care Manager Psychiatric Consultant Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources
7 Collaborative Team Approach PCP Core Program Patient Care Manager Psychiatric Consultant Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources
8 Collaborative Team Approach PCP Core Program Patient Care Manager Psychiatric Consultant Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources
9 Collaborative Team Approach PCP Core Program Patient Care Manager Psychiatric Consultant Other Behavioral Health Clinicians Additional Clinic Resources Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Outside Resources
10 Weekly Caseload Consultation Things are as busy as ever! How are things in the clinic this week? Care Manager Psychiatric Consultant
11 Prioritizing Cases for Review Together I ve marked a few cases for us! Great! I notice that there are a few high PHQ 9 scores too, let s add those to the list for today. Care Manager Psychiatric Consultant
12 Reviewing a Case Can we start with Ms. H? I m really worried about her. Her PHQ 9 is 20. Sure! Any specific questions? Why don t you start with the case overview? I m looking at your notes. Care Manager Psychiatric Consultant
13 Clinical Dashboard: Shared Patient Summary
14 Example: Structured Assessment Brief report on each of the following areas: Depressive symptoms Bipolar Screen Anxiety symptoms Psychotic symptoms Substance use Other (Cognitive, Eating Disorder, Personality traits): Past Treatment Safety/Suicidality Psychosocial factors Medical Problems Current medications Functional Impairments Goals
15 Screening Tools as Vital Signs Behavioral health screeners 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
16 Commonly Used Screeners Mood Disorders Anxiety Disorders Psychotic Disorders Substance Use Disorders Cognitive Disorders PHQ 9: Depression GAD 7: Anxiety, GAD Brief Psychiatric Rating Scale CAGE AID Mini Cog PCL C: PTSD MDQ: Bipolar disorder CIDI: Bipolar disorder OCD: Young Brown Social Phobia: Mini social phobia Positive and Negative Syndrome Scale AUDIT Montreal Cognitive Assessment
17 Making a Provisional Diagnosis I think this is major depression but I wanted to make sure we are not missing bipolar disorder or something else. OK. I agree with you. The CIDI 3 is negative and there is no family history or other concerning symptoms. Do you have any real concerns about alcohol use? Care Manager Psychiatric Consultant
18 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
19 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
20 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
21 Provisional Diagnosis Screeners filled out by patient Assessment by BHP and PCP Provisional diagnosis and treatment plan Consulting Psychiatrist Case Review or Direct Evaluation
22 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
23 Making a Treatment Plan I am not sure the patient is interested in medications, but I have introduced PST. Ok. Since the depression appears moderate let s respect the patient. I will put in a just in case med recommendation. Care Manager Psychiatric Consultant
24 A Different Kind of Note Traditional Consult Note Integrated Care Case Reviews Note 1: January Pt still has high PHQ One consult note Note 2: August Side effects Note 3 Pt improved!
25 Example: Psychiatric Recommendations Concise Summary Brief & Focused
26 Recommendations: Medication Treatment Focus on evidencebased treatments and treatment algorithms Details about titrating and monitoring Brief medication instructions
27
28 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
29 Follow Up Reviews I wanted to update you on Ms. H, She is a little better but still struggling PHQ 9 is 14. I have been talking to her about medications and she is now interested. I agree that we need to adjust treatment. Let s try that med recommendation and I will update my note. Care Manager Psychiatric Consultant
30 Track Treatment Outcome Over Time
31 Most Patients Need Treatment 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
32 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
33 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 about the care of this patient. Dr. x, Consulting Psychiatrist Phone #. Pager #. E mail
34 In Person Assessment Seeing patients directly in collaborative care is different than traditional consultation. Patients pre screened from care manager population Already familiar with patient history and symptoms Typically more focused assessment Common indications for direct assessment Diagnostic dilemmas Treatment resistance Education about diagnosis or medications Complex patients, such as pregnant or medical complicated
35 Roles for Psychiatrists in Collaborative Care Leader Caseload Consultant Direct Consultant Clinical Educator Shape behavioral healthcare for a defined population of patients in primary care Consult indirectly through care team on a defined caseload of patients in primary care Consult directly by seeing selected patients Train BHPs and PCPs Both directly and indirectly
36 Questions?
37 Want more training? We have detailed modules on many of the common collaborative care topics for consulting psychiatrists available through the AIMS Center:
38 Major Depression Medication Treatment 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)
39 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
40 Stepped Depression Treatment SSRI, SNRI, Bupropion Switch Medication, Switch Class, Augment with Bupropion, Mirtazapine Antipsychotic, TCA Other
41 Common Side Effects Short term: GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 10%)
42 Managing Side Effects Discuss with psychiatric consultant Change to or add Behavioral Treatment Short term strategies Change to a different antidepressant
43 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)
44 Sexual Dysfunction (anorgasmia) 25 33% of SSRI treated patients: Change to: Bupropion Mirtazapine Augment Bupropion SR 100mg PO BID Buspirone 15mg 30mg PO BID
45 Weight Gain 5 10% of SSRI treated patients Change to Bupropion Fluoxetine Physical exercise
46 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
47 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
48 Questions?
49 Want more training? We have detailed modules on many of the common collaborative care topics for consulting psychiatrists available through the AIMS Center:
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