Ad Hoc and Caseload Consultation

Wednesday, November 12, 2014

Jürgen Unützer, MD, MPH, MAProfessor and Chair, Psychiatry and Behavioral SciencesUniversity of Washington

Marc Avery, MDCIBHS CCC Faculty Co-Chair

Gail Bataille, MSWCIBHS CCC Faculty Co-Chair

2

Objectives:1.Understand the different types of consultation

that are necessary in coordinated care.2.Learn what elements of consultation are

most effective.3. (During breakout) Explore ways for

testing/implementing ad hoc and caseload consultation in your location.

Collaborative Care Model Consutation

PCP

Patient BH CareManager

Psychiatric Consultant

CoreProgram

New Roles

Collaborative Team Model: Two Types of Consultation – Caseload and Ad Hoc

Patient

Psychiatrist

Substance Use

Counselor

Case Manager

Primary Care

Population Consultants

Care Coordination Team

Care Plan

Care Coordinato

r

Peer Counselor

Other

Psychiatrist

Mental Health Substance Use Primary Care

Other Other

PCP

Pay-for-performance cuts median time to depression treatment response in half.

0.0

00.2

50.5

00.7

51.0

0

Estim

ate

d C

um

ula

tive P

rob

ab

lility

0 8 16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136

Weeks

Before P4P After P4P

Unützer et al. 2012.

Effective Implementation: 9 Factors

6Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

7

Engagement/Activation and Remission: Key Factors

Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

Common Consultation Questions

• Consider re-screening patient • Patient may need additional assessment

Clarification of diagnosis

• Make sure patient has adequate dose for adequate duration• Provide multiple additional treatment options

Address treatment resistant disorders

• 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

Recommendations for managing difficult patients

Key Elements of an Informal Consultation• Readily Accessible• Establish rapport and welcoming

stance• Concise feedback –

pharmacologic and nonpharmacologic

• If-then scenarios and next steps• Educational component

9

Uncertainty:Requests for More Information

Complete informatio

n

Sufficient informatio

n

- Tension between complete and sufficient information to make a recommendation

- Often use risk benefit analysis of the intervention you are proposing

SUMMARY:  Pt is a 28yo male presenting with depression and anxiety.  Pt having trouble falling asleep (plays with laptop or phone in bed), sleeping 4-7 hrs/night. Depressive symptoms: Moderate depression; PHQ-9: 18 Bipolar Screen:  Positive screen; May be more consistent with substance use Anxiety symptoms:  Moderate to severe; GAD-7: 18 Past Treatment: Currently taking Bupropion and Citalopram (since 1/31) feels more in control, able to think before reacting, less irritable; Took Zoloft, Prozac, Wellbutrin at different times during teenage yrs. Doesn't recall effect Suicidality:   Denies Psychotic symptoms:  Denies Substance use: History of substance use/alcohol; Engaged in treatment Psychosocial factors:  Completed court appointed time in clean and sober housing; Now living back with parents in Carnation; Attending community college; Continues to stay connected to clean and sober housing; Attends Mars Hill Church Other: ADHD: ASRS-v1.1 screening – positive; Not diagnosed as a child; Now getting B’s at community college Medical Problems:  hx of frequent migraines

Current medications: Bupropion HCl (Wellbutrin SR)(Daily Dose: 450mg) †Citalopram Hydrobromide (Celexa) (Daily Dose: 40mg) Goals: Improve school functioning; Long term goal employment 

Sample Case Review NoteConcise Summary

ASSESSMENT:  Depression NOS , most likely MDD but cannot r/o bipolar disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission; r/o ADHD

RECOMMENDATIONS:1)       Continue to target sleep hygiene2)       Options for antidepressant augmentation.  Engage patient in decision

making about which ONE option to pursue:a.       Option 1: Continue Celexa to 20mg as reported sedation on higher

dose;  Make sure he is taking dose at night and allow for longer period of observation to evaluate efficacy 

b.      Option 2: Increase Celexa back to 40mg to target anxiety as did not notice a change in sedation but noted increased anxiety when lowered dose.

c.       Option 3: Cross taper to fluoxetine;  Week 1:  Baseline weight.  Consider BMP for baseline sodium in older adults.  Start 10 mg qday. Continue Celexa20mg  Week 2:  Increase dose to 20 mg qday, if tolerated, and stop Celexa   Week 4 and beyond: Consider further titration in 10-20 mg qday increments. Typically need higher doses for anxiety Typical target dosage: 20 mg qday

3)       Continue close contact with care coordinator, supporting substance use treatment and behavioral activation. 

4)       Can consider Strattera in the future if poor concentration persists;   Would stay on 40 mg qday as combination with Wellbutrin can increase drug level.

12

Brief & Focused

‘Disclaimer’ on 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 abut the care of this patient.“

•Dr. X, Consulting Psychiatrist•Phone #. •Pager #.•E-mail

ROLE: Caseload Consultant

Caseload Reviews

• Scheduled (ideally weekly)

• Prioritize patients that are not improving

Availability to Consult Urgently

• Diagnostic dilemmas• Education about

diagnosis or medications

• Complex patients, such as pregnant or medical complicated

If patients do not improve, consider:• Wrong diagnosis?• Problems with treatment adherence?• Insufficient dose / duration of treatment?• Side effects?• Other complicating factors?

– psychosocial stressors / barriers– medical problems / medications– ‘psychological’ barriers– substance abuse– other psychiatric problems

• Initial treatment not effective?

Sample Consultations ~ 30 min

REASON FOR CONSULT

DIAGNOSIS

RECOMMENDATION

Side effects from lithium BP 1 Switch to valproic acid

SE from lisdexamfetamine

ADHD Try another per protocol

Lithium level is 1.2 BP 1 Cont unless having side effects

Inc depression symptoms

MDNOS TSH, if normal start lamotrigine

Poss SE from quetiapine BP 1/PD Decrease Seroquel to 100 mg

Paroxetine not effective MDD Add bupropion

Regular lamotrigine or XR?

BP 2 No difference

Side effects with citalopram

MDD Switch to bupropion

Depression symptoms increase

BP1 Check lithium level first, maximize if low, may need to add lamotrigine

Suicidal, acute distress PD Safety plan, DBT referral

High doses of meds, confused

MDD Stop hydroxyzine, reduce lorazepam, call collateral

Anxious, wants alprazolam, nipple pain

GAD No alprazolam, increase sertraline, coping skills

ROLE: Direct ConsultantSeeing patients directly in collaborative care is different than traditional consultation. Approximately 5 – 7 % may need this.

Patients pre-screened from care manger population

• Already familiar with patient history and symptoms• Typically more focused assessment, tele-video OK

Common indications for direct assessment

• Diagnostic dilemmas• Treatment resistance• Education about diagnosis or medications• Complex patients, such as pregnant or medical

complicated **Utilize televideo if warranted

Liability

INFORMALCONSULTATIVECurbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP

COLLABORATIVECurbside with BHP, document recommendations in chart and paid

FORMALDirect with patient after other steps unsuccessful, written opinion SUPERVISORYPsychiatric provider administrative and clinical supervisor of BHP ultimately responsible

• Olick et al, Fam Med 2003 • Sederer, et al, 1998• Sterling v Johns Hopkins Hospital.,

145 Md. App. 161, 169 (Md Ct. Spec. App. 2002

Consultation ranges from

informal to formal.

Is there a doctor-patient

relationship? 18

Collaborative care should reduce risk:

-Care manager supports the PCP -Use of evidence-based tools -Systematic, measurement-based follow-up-Psychiatric consultant

PCP: Oversees overall care and retains overall liability AND prescribes all medications/additional studiesCM/BHP: Responsible for the care they provide within their scope of practice / license

19

AD HOC Consultation

Collaborative Care Model Consutation

PCP

Patient BH CareManager

Psychiatric Consultant

CoreProgram

New Roles

Collaborative Team Model

Patient

Psychiatrist

Substance Use

Counselor

Case Manager

Primary Care

Population Consultants

Care Coordination Team

Care Plan

Care Coordinato

r

Peer Counselor

Other

Psychiatrist

Mental Health Substance Use Primary Care

Other Other

PCP

22

Example Vignettes:

Case #1:Your patient calls you, the care coordinator, complaining of feeling extremely anxious.  She states that this started yesterday when the PCP started a new diabetes medication.  She also is a bit dizzy.     Case #2:Your CC patient sees his PCP complaining of increasingly intrusive voices.  He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.” 

23

Bi-Directional Ad Hoc Clinical Consultation – Breakout Session Case #1: Your patient calls you, the care coordinator, complaining of feeling extremely anxious.  She states that this started yesterday when the PCP started a new diabetes medication.  She also is a bit dizzy.  How would you obtain medical consultation from PC clinic? Case #2: Your CC patient sees his PCP complaining of increasingly intrusive voices.  He tells the PCP that he always has more voices when under stress and he is about to be evicted from his SRO. He thinks his care coordinator is “working on it.”  The PCP would like to consult with you and mental health.  How would this happen?

• How have you begun to test/implement population focused clinical care coordination meetings with your key CCC provider partners?

• How frequently are you meeting to develop/review Integrated Care Plans?• What criteria have you used for selecting patients for caseload consultation?    • Are you using population-based criteria to select patients for caseload

reviews? • If so, are there additional population-based criteria that you can

test/implement?• If not, what criteria can you begin to test/use?