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Susan D. Wiley, MD Vice Chairman, Dept. Psychiatry, Lehigh Valley Health Network
Clinical Associate Professor Morsani School of Medicine, University of South Florida
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # B5bOctober 18, 2014
“Fast Track”: Psychiatrist as Consultant Has Triple Impact on
Patient-Centered Medical Home
Faculty Disclosure
• I have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
1. List the key elements of this program.
2. Identify the challenges of implementing “Fast Track.”
3. Discuss the value that “Fast Track” offers to patients and their PCPs.
Bibliography / Reference
1. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Goldner EM; egoldner@sfu.ca ; Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatrie [Can J Psychiatry] 2011 ; Vol. 56 (8), pp. 474-80.
2. Consultant caseload management. Mathai J; john.mathai@rch.org.au; Australasian Psychiatry: Bulletin Of Royal Australian And New Zealand College Of Psychiatrists [Australas Psychiatry] 2007 Feb; Vol.15 (1), pp. 49-51.
3. Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models. Davis DW; deborah.davis@louisville.edu ;Clinical Pediatrics [Clin Pediatr (Phila)] 2012 Oct; Vol. 51 (10), pp. 978-82.
Bibliography / References
4. In need of psychiatric help--leave a message after the beep.Bridler R; r.bridler@sanatorium-kilchberg.chPsychopathology [Psychopathology] 2013; Vol. 46 (3), pp. 201-5.
5. Primary care physicians' and psychiatrists' approaches to treating mild depression. Lawrence RE; rlawrence@uchicago.edu; Acta Psychiatrica Scandinavica [Acta Psychiatr Scand] 2012 Nov; Vol. 126 (5), pp. 385-92.
6. Telepsychiatry: videoconferencing in the delivery of psychiatric care.Shore JH; Department of Psychiatry, University of Colorado Denver, Aurora, USA. jay.shore@ucdenver.edu; The American Journal Of Psychiatry [Am J Psychiatry] 2013 Mar 1; Vol. 170 (3), pp. 256-62.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
Existing models of delivering psychiatric care are unable to meet the volume of community needs.
PCPs are de-facto providers of Mental Health treatment in most communities.
The Nature of the Problem
Many PCPs find themselves untrained, uncomfortable or ill-equipped to manage straightforward psychiatric & behavioral health issues.
PCPs are reluctant to “ask the questions” or screen for MH disorders for fear that they will not be able to manage or refer the patients.
The Nature of the Problem
Unacceptable waiting periods for access:◦Waits range from 2-6 months
Costly delays in diagnosis and treatment◦Assessment late in course◦Often takes place in Emergency
Department◦May lead to avoidable hospitalization◦Greater morbidity and mortality
The Size of the Problem
Uncomplicated History: Straightforward, points to a single diagnosis.
Mild to moderate symptoms
Mild to moderate Behavioral abnormalities: school avoidance, eating problems, sleeping issues, spending or gambling, promiscuity
Course is acute or sub-acute.
Primary Psychiatry
Uncomplicated Anxiety disorders Uncomplicated Depression Uncomplicated Attention Disorders Psychological Affects of Physical Illness Psychological Factors of Physical Illness Uncomplicated Dementia Somatoform disorders Minor Behavioral issues
Primary Psychiatry
33 year old married mother with mild obsessive and compulsive symptoms, responded well to medication adjustment & supportive counseling from the BHS;
55 year old man with diabetes, impotence, job loss and marital strain, cc irritability responded well to new antidepressant & counseling
72 year old man with Parkinson’s Disease and Anxiety, offered anxiolytic medication
Appropriate Referrals
Built upon a platform of shared electronic medical record & shared liability
Effective Collaboration requires trust & communication
Based upon Psychiatric Consultation model Facilitated by the presence of Behavioral
Health Specialists Confidence that an educated & supported
PCP can manage Primary Psychiatric issues effectively, efficiently & at lower cost
“Fast Track”
NOT designed for patients requiring long term comprehensive care: Severe symptoms: Mania Serious behavioral dysfunction: Suicidal Complex co-morbidities: Substance abuse Chronic, persistent or relapsing Mental
Illness Requiring three or more concurrent
psychotropic agents
NOT a “Back Door” into a psychiatrist’s office.
What Fast Track is NOT
BHS evaluates the patient. PCP or BHS identifies need for psychiatric
consultation and discusses it with patient. PCP or BHS initiates referral to psychiatry
consultant through EMR, identifies question. Psychiatrist reviews the record for appropriateness. If possible, curbside consultation is offered. Approved patients are scheduled for appointment
within 2 weeks; Diagnosis & Treatment plan are returned to PCP
day of service. Patients inappropriate for Fast Track may be offered
routine evaluations.
How “Fast Track” Works
◦Mutual respect between PCP & Psychiatrist
◦Referred patients meet agreed upon criteria
◦Psychiatrist responds promptly, offers a clear, coherent treatment plan & supports ongoing care
◦PCP accepts the primary responsibility of patient management
Key Elements for Effective Collaboration: Trust
◦Behavioral Health Specialist assesses the patient and documents findings in EMR
◦Purpose of consultation is clear & appropriate
◦Psychiatrist makes the results of evaluation available to PCP on day of service
◦Follow up is arranged by the psychiatrist as necessary
◦Revisions to treatment can be made “curbside” or in the psychiatrist office
◦Routine refills are managed by PCP office
Key Elements for Effective Collaboration: Communication
Timely Individualized & accurate Pithy and concise Includes salient positives, negatives that
support decision-making Explicit treatment plan Alternatives: “…if this is ineffective then…”
Key Elements for Effective
Collaboration: Communication
Appreciates the PCP will remain the primary provider of the treatment
Appreciates that mental health history and psychiatric evaluation will be shared with her Primary Care treatment team
Understands the target symptoms that are the focus of treatment
Has a clear understanding of possible side effects, risks, benefits & treatment alternatives
Patient as Collaborator
Transparent medical and psychiatric history, diagnoses, medications◦ Drug & Alcohol, Social, Family History
Real time information sharing Attention to medical and psychiatric co-
morbidities Awareness of drug-drug interactions Legibility
Shared Electronic Medical Record
Privileged information & limits of collaboration
Who sees what? Levels of access Patient education & consent process:
-Types of information collected-Details who can access their information-How the information will be used-How the consent can be revoked/expires
Privacy Challenges:
Identify patients in PCP office through screening
Collect relevant history & document this in shared medical record
Assure appropriate patients are referred through Fast Track
Facilitate monitoring of the patient & treatment plan
Role of Behavioral Health Specialist
Team meetings: Behavioral Health Specialists
On-site education: Primary Care Providers
On-going, patient-specific education: “In a case like this, I would try….”
Grand Rounds presentations, “Current Approaches to the Treatment of…”
On-Going Education to Support Fast Track Model
Shared EMR and Liability insurance are key.
Identify your frequently referring PCPs
Identify a Psychiatrist Consultant
Describe your Fast Track criteria
Get buy-in from your clinical team
Put it in writing for the whole team AND the patient
Establish your outcome measures
Establish office processes for referral & tracking
Track & monitor your outcomes
How to Get Started
Appropriateness of referral
Time to evaluation date from referral compared to TAU
Outcome of referral: ◦Successful hand-back to PCP◦Number of Psychiatric visits
Future Measures: Psych ED visits & hospitalizations, costs of episode of care
Monitoring
Name MR number Referring doctor Referring group Date of referral Date seen Telemedicine or In-
office ( T or O) BHS contact (yes/no)
Appropriate/Not Curbside Consult only Kept/Referred # of psych visits Seen/Refused Txt field for
diagnoses Text field for outcome
Monitoring Tool
E.R. is 67 yr old married father CC: Sadness, low energy, interrupted sleep,
excessive worry, restlessness, weight loss, distractibility, guilt
Past Psych Hx: Previous out-patient psychiatric treatment for impotence in his 20’s; again 18 mos ago,
No in-pt Rx, no suicides; D&A: Hx of alcohol dependency, DUI in
past, now sober; Rx: Currently on Prozac 80 mg daily,
Trazodone 100, Xanax .25 prn
Case Study
Axis I: Major Depression Recurrent, Moderate Generalized Anxiety Disorder
Axis II: NoneAxis III: Degenerative Disc Disease, Chronic Low Back Pain, Hypertension, Hyperlipidemia,Erectile Dysfunction, Vitamin D. DeficiencyAxis IV: Wife’s dx of Stage 4 Lung Cancer, Son’s severe disability, Financial strain, Phase of Life issuesAxis V: 50
Diagnosis
Medication Management:◦ Lower to Prozac to 60 mg daily◦ Increase the Trazodone to 150 mg to improve
sleep density and duration◦ Add Buspirone 30- 45 mg daily for anxiety
Psychotherapy◦ Goals to address negative ruminations and guilt◦ Relaxation strategies, Mindfulness◦ Sleep hygiene
Treatment Coordination◦ PCP, BHS & Psychotherapist
Treatment Plan
# Referrals: 22 # Referring Groups: 5 # Unique Providers: 16 Ave. Interval to appointment: 17 days Ave. TAU: 2-3 mos Appropriate Referrals: 55% Patients seen: 55% Retained as patients: 33%
Outcomes of Pilot
Model does not improve access for patients most in need.
Clinical complexity is frequently not apparent
Buy-in varies among members of a group
Some patients prefer on-going management by specialist
Behavioral Health Specialist needed for screening
Personnel needed to facilitate & track referrals
Capacity may not meet demand for services
Obstacles & Challenges
Fast Track is an effective solution to access challenges.
Successful implementation requires willing partners, a shared EMR, & effective communication.
Behavioral Health Specialists & Care managers stream-line the referral and tracking process.
Conclusion
Susan D. Wiley, MD Vice Chairman, Dept. Psychiatry
Lehigh Valley Health NetworkSusan.Wiley@LVHN.ORG
610-402-5900
Questions?
Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!