TRAINING PSYCHIATRY RESIDENTS IN HOUSING FIRST MALLIKARJUN B. ELLUR, MD HOWARD DICHTER, MD MATTHEW TICE, LCSW

Transcription

1 TRAINING PSYCHIATRY RESIDENTS IN HOUSING FIRST MALLIKARJUN B. ELLUR, MD HOWARD DICHTER, MD MATTHEW TICE, LCSW

2 DISCLOSURES None

3 CONTENT Introduction Goals and objectives Discussion Conclusion

4 INTRODUCTION Psychiatrists- vital for successful implementation of HF program Need for psychiatrists trained in this model Discussants: Mallikarjun B. Ellur, MD : 3 rd year psychiatry resident at EMCP in Philadelphia PA Howard Dichter, MD : Medical Director at Pathways to Housing PA Mathew Tice, LCSW: Director of clinical services at Pathways to Housing PA Discuss clinical aspects of housing first

5 GOALS To introduce a housing first-academic partnership, designed to increase the availability of psychiatrists interested in working with the chronically homeless. To encourage HF models to pursue partnerships with local psychiatry residency programs

6 OBJECTIVES Describe an HF partnership with a psychiatry training program Special training opportunities in a HF program complements traditional psychiatric training program Challenges in developing psychiatric training in a HF program

7 WHO ARE WE? Began in 2008 Followed New York's model, founded in 1992 by Sam Tsemberis, Ph.D. Grown from 125 people from Philadelphia s chronic homeless population to housing more than 400 people Pathways' staff work in multi-disciplinary teams to help each individual that comes to us to move out of homelessness Mission: Transform individual lives by ending homelessness and supporting recovery for people with disabilities

8 CLINICAL CARE AT PTHPA Non-fidelity ACT Team structure MSW Team Leaders, Case Managers (3-4), Certified Peer Specialists, Substance Use Specialist, Registered Nurse Case Manager, Psychiatrist, Program Assistant Case Ratio of about 1:11 with around participants per team 6 Clinical Teams Each with a slightly different focus including Chronic Alcoholism, HIV/AIDS related care, and a graduated lower-level of care team Integrated and multidisciplinary approach Medication Management Money Management and Payeeship Focus is on independent living and community integration with individualized goals and degrees of support

9 HARM REDUCTION APPROACH Pragmatic and compassionate philosophy that acknowledges individuals are at varying degrees of readiness for change and therefore are going to still engage in risky behaviors Practitioners work with participants to mutually develop a set of practical strategies and ideas aimed at reducing negative consequences associated with risky behaviors Educate, offer choices, and support regardless of decisions Application with substance use, medication adherence, and accessing treatment Also useful with housing, hoarding behaviors, social expectations when reintegrating into the community and other areas Recognizes natural consequences of decisions

10 WHO ARE WE? EHN- Not-for-profit organization with 150 years of service to the community Largest independent academic medical center in Philadelphia Trains more than 400 residents, 30 ACGME-accredited residency programs Affiliated with Thomas Jefferson University Department of Psychiatry: 4 yrs. program, 8-10 residents per yr. total of 40 residents Academic scope of the training

11 EMCP PSYCHIATRY RESIDENCY CLINICAL ROTATIONS PGY-1 Inpatient - Internal Medicine Emergency Medicine Geriatrics 2 months - Neurology 5 months - Inpatient Psychiatry 1 month - Emergency Psychiatry at Crisis Response Center ( CRC ) PGY-2 9 months - various inpatient floors 2 months -Child CRC PGY-3 Full year of Outpatient One elective for 2-3 residents at Pathways to Housing PGY-4 Outpatient, on-site electives TBI, C&L Neuroradiology Inpatient junior attending month Away electives- Pathways to Housing Forensic and Methadone clinic Comprehensive Didactic Curriculum: basic and advanced Psychotherapy including CBT, basic and advanced psychopharmacology, psychoanalysis at Center for Psychoanalysis at Einstein ( for first 3 years ); grand rounds

12 CHALLENGES IN TRADITIONAL ACADEMIC TRAINING PROGRAMS Little or no exposure to recovery-oriented, harm reduction model Rarely exposed to public/community psychiatric experience Little exposure to different patient population Lack of exposure to workflow in various public domainsgovernmental and non-governmental agencies

13 PATIENT RELATIONSHIP WITH PSYCHIATRIST Inpatient and Outpatient setting Crisis/stabilization orientation Disease management HF setting Long term relationship Outpatient clinic Requires appointment adherence No adjunct social supports

14 HOUSING FIRST- ACADEMIC PARTNERSHIP Introduced in 2014 with one psychiatry resident rotating at Pathways 2015: Three 3 rd year residents rotating three months each, three days a week (12 hrs/wk.) Elective

15 How Training in Housing First Program complements traditional Psychiatric experiences? 1. Differences in clinical approaches compared to traditional medical model Team based services Enhanced psychosocial support Supportive housing Recovery based Harm reduction Community based services Population based services Psychiatrist roles as consultant/clinician to teams working with participants

16 HOW TRAINING IN HF PROGRAM COMPLEMENTS TRADITIONAL PSYCHIATRIC EXPERIENCES? 2. Residents exposure to unique clinical circumstances Exposure to recovery oriented psychiatrist role models in community setting Psychopathology not typically seen, i.e., hoarding disorder Engaging symptomatic mentally ill or stable substance abusing participants who live in the community Integrating physical health care in to the model

17 WHAT DOES RESIDENT DO AT PATHWAYS? Clinical Rotation: - 3 months One day total divided among several days - Involve in team meetings and liaises with all teams - Evaluates and treat participants - Home visits with team member - Clinical supervision - Work with family physician at a local FQHC - Additional : Naloxone Training, research and other scholarly activity

18 RECOVERY ORIENTED MODEL Resident assumes all participants potential for recovery regardless of treatment adherence and sobriety Assess them for their mental and physical health care needs both in the office and community Instill hope, and convey true and caring concern Helps participants stay motivated and engaged with the team

19 WHY HAVE PSYCHIATRIC RESIDENTS IN A HF PROGRAM? Community Trains Psychiatrists - population based, recovery and harm reduction Encourages career interest working in community Housing First Program Assists understanding of housing first Creates partnerships with local academic centers Enhances psychiatric services Increases job satisfaction

20 HOW TO GET A PSYCHIATRY RESIDENT ROTATION STARTED Elective Fourth year Resident One month Combine with third year outpatient Longer length Team integration Emphasize community involvement Tailor to Residents interest

21 PTHPA AND EMCP RESIDENCY TRAINING PROGRAM Agreement with PTHPA and EMCP Contracting issues Common occurrence for Residency Residents voluntary Part of outpatient rotation Third year 2 3 Residents per team per year Emphasize new participants, outreach Extended involvement - Identify participants who can be followed in outpatient clinic

22 RESIDENT TESTIMONIALS Pathways exposes residents to participants who are in contemplative or precontemplative stages of change and gives the residents experience of working and engaging them in the treatment. It is the only place I would ever see an active substance abuser who is not in any form of treatment or a participant with schizophrenia, who is living in the community without treatment. Pathways has enhanced my ability to work with the large teams involved in providing the care based on recoveryoriented and harm reduction model. It also helped me to understand how a psychiatrist can be a consultant in the public sector. - MBE, MD -Alexander Heisler, DO

23 RESIDENT TESTIMONIALS When I first learned about Pathways to Housing my immediate association was Maslow s Hierarchy of Needs. How can we expect individuals to engage in treatment if they don t have their fundamental needs addressed? Secure housing, harm reduction, and community integration provide a foundation for the process of recovery and wellness. -Kimia Pourrezaei, DO

24 CONCLUSION Clinical rotation had a large impact on residents-in training in their approach to treating participants with mental illnesses and co-morbid substance use disorders which complements traditional training Enhanced the interest of residents to choose career paths serving public patients Residents as advocates for HF model, serve homeless and help governmental agencies to implement this model in other states

25 Q & A

26 REFERENCES www. einstein.edu Sam T. Housing first- the pathways model to end homelessness for people with mental illness and addiction, 2010

27 ACKNOWLEDGEMENTS Pathways to Housing PA Staff Kimberly Best, MD : Director of Psychiatry Residency Training EMCP David Greenspan, MD : Chairman, Department of Psychiatry EMCP

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