Access Community Health Centers Integrated Primary Care Consulting Psychiatry Toolkit

Access Community Health Centers Integrated Primary Care Consulting Psychiatry Toolkit

Contents Background...2 Why a Toolkit?...2 Who Should Use this Toolkit?...2 Development of this Toolkit...2 Contact Us...2 Flow: Integrated Primary Care Consulting Psychiatry...3 References...4 Copyright Use The Access Community Health Centers Integrated Primary Care Consulting Psychiatry Toolkit exists for the benefit of the health care community. These materials are available free of charge and can be used without permission; however, we ask that you register with HIPxChange prior to using the toolkit so that we may provide information on usage to our funders. It is acceptable to link to this Web site without express permission. If you decide to use these materials, we ask that you please credit Access Community Health Centers and the UW Health Innovation Program. 1

BACKGROUND An ever-increasing number of patients with mental health needs has resulted in primary care being referred to as the de facto mental health system in the United States. 1-3 In instances where patients are referred elsewhere for mental health treatment, less than one-third of the referrals are actually completed. 3 In addition, the stigma involved with receiving mental health care is a proven barrier to patients seeking care. 4-6 These issues, combined with lack and cost of transportation, distance from service providers, limited clinic hours, and lack of available appointments or insurance coverage, 7-10 have resulted in an uptick of primary care clinicians 2, 11, 12 taking on prescribing authority for patients with complex mental health issues. Increased access to consulting psychiatry allows for potentially better management of patients receiving psychiatric care within the primary care system through a number of mechanisms. It provides more convenient access for patients in an environment that they find familiar and acceptable. 13 It also supports and encourages a collaborative effort between psychiatrists, behavioral health consultants (other mental health providers), and primary care clinicians to provide efficient, whole-person care. Further information regarding the development and role of the psychiatric consultation service, as well as characteristics of the patients and clinics using this model, can be found in the following article: Zeidler Schreiter EA, Pandhi N, Fondow MDM, Thomas C, Vonk J, Reardon CL, Serrano N. Consulting psychiatry within an integrated primary care model. J Health Care Poor Underserved (in press). Why a Toolkit? This toolkit provided detailed information for those thinking about developing an integrated model with consulting psychiatry within primary care in order to allow for a population health focus for the patient population. This toolkit includes: Detailed flow diagram showing how the primary care physicians, behavioral health consultant, and consulting psychiatrist work together within a clinic. The key elements of communication during interactions between these entities. Who Should Use this Toolkit? This toolkit is intended for clinic directors, managers, primary care, behavioral health consultants, and psychiatrists, and provides a framework for a team approach to addressing patients behavioral and mental health needs. Development of this Toolkit This toolkit was developed by Elizabeth Zeidler Schreiter, PsyD, Nancy Pandhi, MD PhD, and Meghan Fondow, PhD (all affiliated with Access Community Health Centers and the University of Wisconsin-Madison Department of Family Medicine) and Lauren Fahey (affiliated with the Health Innovation Program and the University of Wisconsin-Madison School of Social Work). Additional support was provided by the University of Wisconsin School of Medicine and Public Health s Health Innovation Program (HIP), and the Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR), grant UL1 TR000427 from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health. Contact Us Please send questions, comments and suggestions to HIPxChange@hip.wisc.edu 2

FLOW: INTEGRATED PRIMARY CARE CONSULTING PSYCHIATRY Legend: PCP = Primary Care Provider; BHC = Behavioral Health Consultant; EHR = Electronic Health Record PCP identifies patient with mental health issues or symptoms and completes a warm hand-off to the BHC team. EHR Referral BHC determines if psychiatry consult would be beneficial in collaboration with PCP. Patients are seen by BHC prior to referral to consulting psychiatrist. Potential reasons for a written consult Additional follow-up questions regarding next steps Patient seen by consulting psychiatrist in the past Patient access barriers PCP request is a medical management issue and doesn t require a face-toface visit BHC determines whether a written or oral psychiatry consult will suffice or if a face-to-face appointment is more appropriate. The lead BHC triages patients & schedules appointments with the consulting psychiatrist. Important considerations for face-to-face visits Never schedule visits more than 2 weeks in advance to limit potential no-shows If a face-to-face consult is necessary and the wait is longer than 2 weeks, the psychiatrist will provide a written consult until patient can be seen in person Have patients bring in all medications to visit to get sense of current adherence After completing a chart review and reading the referral submitted via EHR, the psychiatrist provides written recommendations. Written/Oral Consult Only Face-to- Face Visit Patient is contacted by the BHC team to schedule an appointment. Lead BHC meets with psychiatrist and PCPs at outset of clinic to review schedule of the day, reviews reason for referral, insurance status and history. After completing a chart review, the psychiatrist sees patient in-person (~45 minutes), formally assesses the patient s mental health history, past medication trials and completes diagnostic interview. Recommendations can include: Medication: Indication, monitoring needs, dosing and titration, patient education needs, etc. Recommendations are algorithmic and provide stepwise options for pharmacologic interventions, taking into account possible failed trials. Behavioral: Continue engagement with BHC team, receive psychiatric care in the community, etc. Psychiatrist formally documents recommendations to be implemented by PCP. If necessary, sends an EHR email to the PCP (not formally attached to patient s chart). PCP is always the main point of contact and maintains prescriptive authority. Psychiatrist encourages patient- PCP follow-up to discuss implementation options based on psychiatrist recommendations. Reasons for EHR Email Message: Allows for informal dialogue between PCP and psychiatrist Ability to include stronger opinions Reminders to check labs/ other quality of care issues 3

REFERENCES 1. Cummings NA, O'Donohue W, Hays SC, et al. Integrated Behavioral Healthcare: Positioning Mental Health Practice with Medical/Surgical Practice. San Diego: Academic Press, 2001. 2. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry. 1978 Jun;35(6):685-93. 3. Mechanic D, Bilder S. Treatment of people with mental illness: a decade-long perspective. Health Aff (Millwood). 2004 Jul-Aug;23(4):84-95. 4. Pietrzak RH, Johnson DC, Goldstein MB, et al. Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr Serv. 2009 Aug;60(8):1118-22. 5. Kim PY, Thomas JL, Wilk JE, et al. Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat. Psychiatric Services. 2010 Jun;61(6):582-8. 6. Pailler ME, Cronholm PF, Barg FK, et al. Patients' and caregivers' beliefs about depression screening and referral in the emergency department. Pediatr Emerg Care. 2009 Nov;25(11):721-7. 7. Goldner EM, Jones W, Fang ML. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Can J Psychiatry. 2011 Aug;56(8):474-80. 8. Kruzich JM, Jivanjee P, Robinson A, et al. Family caregivers' perceptions of barriers to and supports of participation in their children's out-of-home treatment. Psychiatr Serv. 2003 Nov;54(11):1513-8. 9. Mechanic D. Removing barriers to care among persons with psychiatric symptoms. Health Aff (Millwood). 2002 May-Jun;21(3):137-47. 10. Pieh-Holder KL, Callahan C, Young P. Qualitative needs assessment: healthcare experiences of underserved populations in Montgomery County, Virginia, USA. Rural Remote Health. 2012 Jul;12(3):1816. 11. Pirl WF, Beck BJ, Safren SA, et al. A Descriptive Study of Psychiatric Consultations in a Community Primary Care Center. Prim Care Companion J Clin Psychiatry. 2001 Oct;3(5):190-4. 12. Norquist GS, Regier DA. The epidemiology of psychiatric disorders and the de facto mental health care system. Annual Review of Medicine. 1996;47:473-9. 13. Lang AJ. Mental health treatment preferences of primary care patients. J Behav Med. 2005 Dec;28(6):581-6. 4