The Use of Consulting Psychiatry Within an Integrated Primary Care Model: How it Works

1. Session: E5a October 29, 20111:30 PM to 2:15 PM Elizabeth ZeidlerSchreiter, Psy.D., Psychologist Meghan Fondow, Ph.D., Psychologist JantinaVonk, MD, Psychiatrist Chantelle Thomas, Ph.D., Psychologist Access Community Health Centers- Madison, WI The Use of Consulting Psychiatry Within an Integrated Primary Care Model: How it Works Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. I/We currently have or have had the following relevant financial relationships (in any amount) during the past 12 months: Fairleigh Dickinson University Certificate Program in Integrated Primary Care-Dr. Zeidler Schreiter is an expert presenter for this program. Faculty Disclosure

3. Primary care is frequently referred to as the “de facto” mental health system in the United States (Cummings et. al., 2001) Medical clinicians are facing a burden of an ever increasing number of patients presenting with major mental illness and/or high risk lifestyle behaviors, as seen within our Federally Qualified Health Center (FQHC). Need/Practice Gap & Supporting Resources

4. Research has shown that in the current treatment model (clinics that do not have integrated care and refer patients elsewhere for mental health treatment) less than one-third of referrals are actually completed (Miranda et. al., 1994). Primary care physicians prescribe approximately 60% to 70% of the psychotropic medications prescribed in the United States (Pirl et. al., 2001). Given the above issues increased access to consulting psychiatry is needed to provide optimal management of increasingly severe patients within the primary care setting. Need/Practice Gap & Supporting Resources

5. Upon completion of this presentation, participants will be able to: Identify components of a consulting psychiatry approach within primary care and potential impact on PCP practice habits. Describe how behavioral health consultation and psychiatry can work together in a primary care setting to enhance outcomes. Objectives

6. Have knowledge to assist with implementing consulting psychiatry within their practice setting. List core competencies of a consulting psychiatrist who would fit well within primary care. Have knowledge how to utilize BHC to assist with coordination and access to psychiatry consultation within clinic. Expected Outcome

7. FQHC, Health Care Home • 3 clinic locations in Madison, WI • Medical, Dental, Behavioral Health Services • Over 23,000 patients seen in 2010 • Over 105,000 visits for 2010 Who We Are: Access Community Health Centers

8. Primary Care Behavioral Health model (Robinson & Reiter, 2007) Fully integrated, fully embedded program Mix of scheduled follow ups and warm hand-offs BHC serves as conduit for referrals to consulting psychiatry What We Do:Behavioral Health Consultation

9. Depressive and anxiety disorders in medical patients have been associated with increased utilization of medical services leading to increased cost , significant functional impairment, and sub-optimal adherence rates in patients with chronic medical issues (Simon et. al., 1995). Many of these patients can be successfully managed within a primary care environment as evidenced in recent study by Serrano & Monden (2011) with assistance from BHC and access to consulting psychiatry. Need for Integrated Services

10. BHC saw about 27% of medical patients in 2010 at 2 sites, about 12% at 3rd site • Demographics: • 47% Caucasian • 27% African American • 24% Hispanic • 19% Spanish speaking for BHC Population Served

11. Not just mental health issues. Preventive Health and Behavioral Health needs also very salient • Depression and Anxiety commonly seen, but also other mental and behavioral health issues • Bipolar disorder, psychotic spectrum disorders, AODA, adjustment, ADHD, smoking cessation, sleep problems, weight management Referral Reasons to BHC

12. Explanation of consulting psychiatry service • Population based care • Modalities • Chart review • Face to face • Verbal recommendations • Education • Golden Rule: Primary Care Physician retains prescribing authority Role of Consulting Psychiatry

13. Research has discussed several options to increase collaboration between psychiatry and primary care. • Possible options: • Psychiatrist working as specialists who can be consulted as needed • Increasing referrals from practitioners to psychiatrists • Integrated team model, in which the psychiatrist and other mental health providers work alongside their primary care colleagues in primary care environment (Cowley et. al., 2000). • Integrated consulting psychiatry is highly desirable given volume of patients that receive their psychiatric care within the primary care system and issues with poor follow-up when referred outside of the system. Rationale for Consulting Psychiatry

14. Allows residents exposure to community psychiatry Able to see wide variety of patients Working in collaboration with primary care providers and BHC Prepares resident to work within a medical home Learn to recognize and diagnose psychiatric and/or behavioral conditions common in primary care settings Residency Training

15. Main requests focused on diagnostic clarification, medication recommendations, management of psychiatric issues co-morbid with physical health issues, and guidance regarding needed lab monitoring. • Primary diagnoses seen include: Mood disorders, schizophrenia/psychotic disorders, PTSD/Anxiety disorders. • Many patients also had co-morbid substance abuse issues. Referral Reasons to Consulting Psychiatry

16. Patient numbers as seen face-to-face by Consulting Psychiatry: • 2010: 210 patients • 2009: 170 patients • 2008: 107 patients • 2007: 34 patients • Over 350 verbal or written consultations in 2010 • Resident started 3rd quarter 2010 Population Served

17. Consulting psychiatry started at ACHC in 2007. • Administrative backing. • Needs assessment of clinic is warranted to determine best fit and time needed. • Population care focus thus emphasis on verbal and written consultations in addition to face-to-face encounters. • Psychoeducation for medical providers • Space for consultant to work (e.g. exam room) • Finding a psychiatrist ready, willing, and able to thrive in this environment. • Utilization of Behavioral health consultant to assist with triaging need and appropriate allocation of resources. Steps Toward Implementation

18. Flexible Confident Able to function as part of a team Understanding of context-working within an FQHC and limited patient resources Population based care focus Core Competencies of a consulting psychiatrist who would fit well within primary care

19. Dr. Jantina Vonk, MD • Consulting psychiatrist at Access Community Health Centers • Started in 2007 • Training background and experiences Expert Discussant

20. Comparing and contrasting roles within community mental health center and primary care environment (within an FQHC). Review of structure of initial consultation and brief follow-up consultations as needed. Use of electronic medical record. Educating providers on utilization of medication algorithms for mental health issues. Expert Discussant

21. Questions? Learning Assessment

22. Cowley, D.S., Katon, W., & Veith, R.C. (2000). Training psychiatry residents as consultants in primary care settings. Academic Psychiatry, 24:3, 124-130. Cummings, N.A., O’Donohue, W., Hays, S.C., & Follette, V. (2001). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. San Diego: Academic Press. Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:1026–1031 Miranda, J., Hohnmann A.A., Attikisso, C.A. (1994). Epidemiology of Mental Health Disorders in Primary Care. San Francisco, CA: Jossey-Bass. Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of psychiatric consultations in a community primary care center. Primary Care Companion Journal of Clinical Psychiatry, 3, 190-194. References

23. Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science. Serrano, N and Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110:3, 113-118. Simon GE, Ormel J, Von Korff M, et al: Health care costs associated with depressive and anxiety disorders in primary care. American Journal of Psychiatry 1995; 152:352–357. Slay, J.D., & McCleod, C. (1997). Evolving an integration model: The Healthcare Partners experience.  In N.A. Cummings, J.L. Cummings, and J. Johnson (Eds.) Behavioral health in primary care: A guide for clinical integration (pp 121-144).  New York: International Universities Press. References

24. Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you! Session Evaluation