Models and Process of Psychosomatic Medicine

1. Models and Process of Psychosomatic Medicine APM Resident Education Curriculum Revised 2017: Jeanne Lackamp, MD Revised 2013: Robert Joseph, MD, MS, R. Brett Lloyd, MD, PhD Original version 2011: Robert Joseph, MD, MS Version of March 15, 2019

2. Learning Objectives Describe different models of CL Psychiatry and differentiate from traditional office-based psychiatric care Identify essential tasks of the CL psychiatrist List the steps on a psychiatric consultation and the elements of the consult note Review different methods and structure of integrated mental health care programs

3. Introduction • “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features • Goals? • Assist patients with mental health concerns within a medical context • Make mental health concerns relatable and understandable for medical colleagues • Improve patient lives via collaboration with medical colleagues

4. Psychosomatic Medicine • Subspecialty at the interface of Medicine and Psychiatry • Clinical service • Research • Training • Consultation Liaison (CL) Psychiatry is the current name of the accredited subspecialty • Feb 2017: American Board of Psychiatry and Neurology petitioned American Board of Medical Specialties (on behalf of Academy of Psychosomatic Medicine) to change the name back to “Consultation-Liaison Psychiatry”- granted • Nov 2017: APM voted to change its name to ACLP

5. Models of CL Psychiatry • Traditional/Conventional • Hospital- or ambulatory-based • “Consultation upon request” (reactive) • Liaison psychiatry • Mental Health Integration • Hospital- or ambulatory-based • Case finding/screening • Proactive/systemic mental health involvement • Population-based programs • Disorder-specific programs • Hybrid Models

6. Traditional Models • “Consultation upon request” • Reactive • Patient- and consultee-specific • Primary responsibility for patient remains with consultee • Liaison psychiatry components • Support • Service, ward, nursing staff • Can be specialty specific (OB, Oncology, Neurology etc.) • Education • Formal and informal education

7. Types of Patients Complex, co-morbid psychiatric and medical conditions Neurocognitive disorders Somatic symptom and functional disorders Psychiatric disorders secondary to medical conditions or treatments

8. Distinctions from Office-Based Psychiatry • Services are requested by consultee • Rare “self referral” by the patient • Obligations to consultee as well as patient • Patient is often unaware of referral • Participation may be limited • Patient may be ill, uncomfortable, or in pain • Patient motivation is often compromised • Privacy issues abound on inpatient med/surg wards • Visits are not scheduled nor time based

9. Function of Psychiatric Consultation • Doctor-to-doctor communication designed to address the mental health needs of the patient and improve patient care • The over-riding concern is the patient’s well-being

10. Essential Tasks Complete a comprehensive psychiatric assessment and develop a reasonable management plan Remove impediments to medical care Bring a fresh perspective to the clinical dilemma Facilitate a mutual understanding between patient, doctor, and treatment team Educate the consultee about the emotional and neuropsychological needs of the patient

11. Steps in the Consultation (1) • Review chart and identify consult question • Discuss case with consultee • To help delineate the manifest question and help identify any latent question(s) • To help consultee reformulate their question, in a manner which addresses underlying issues and allows the consultant to be most helpful • To help consultee with appropriate expectations of the consultant (what can/cannot be gained by consultation)

12. Steps in the Consultation (2) • Determine urgency • Routine versus urgent versus emergent • Patient interaction • Introduce self and sit down • Share your reason for being there • Address patient’s surprise at the arrival of a psychiatrist (if present) and diffuse tension (as needed) • Attend to any physical discomfort • Perform thorough interview • Answer patient questions as able

13. Steps in the Consultation (3) • Mental status exam • Includes bedside cognitive testing • Targeted physical exam (if appropriate) • Ancillary history gathering is often appropriate • Family • Additional caregivers • PCP • Pharmacy • Other

14. Steps in the Consultation (4) • Written note • Verbal communication (feedback) with consultee, regarding your opinion • Follow-up visits as appropriate • Range from none to daily

15. The Written Note (1) • Formally addressed to the physician requesting the consultation • Designed to be used by other members of the treatment team(s) who are treating the patient • May be read by a variety of hospital personnel • Consider the audience • Consider confidentiality • Consider medico-legal implications

16. The Written Note (2) • Title • “Psychosomatic Medicine” or “Psychiatry CL Service” • Author(s) • Attending • Resident/fellow • Other • Nature of the note • Initial Consultation Note • Follow-up Consultation Note

17. The Written Note (3) • Date and Time • Particularly important when dealing with fluctuating mental status • Source(s) • Patient, family, medical record, other • Identifying statement • This lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note

18. The Written Note (4) • Reason for consultation • Why did the primary treatment team request a psychiatric evaluation? • There is often a difference between what the primary team requests and what they actually want from the psychiatrist • Manifest request: R/O depression • Latent request: There is nothing actually wrong with this patient. She is manipulative and difficult. Please make her behave!

19. The Written Note (5) • Identifying statement • Important! • “The patient is a 34 year old male admitted for abdominal pain with a history of multiple medical complaints and pain unresponsive to usual interventions. Psychiatry CL team was asked to evaluate him for possible depression.” • A reiteration of the manifest question • Reminds us to answer the question • Respectful to consultee

20. The Written Note (6) • History of present illness (HPI) • Documents the essential positive and negative aspects of the history • Provides a historical framework for understanding the patient • Must include DSM descriptive characteristics and review of systems relevant to patient diagnosis • Consider the following • Special events of the patient’s life (e.g., losses, illnesses) • Precipitants of the current psychological and physical difficulties • Nature of the patient’s reaction to these precipitants • Usual coping mechanisms and ability to implement them • Availability of support systems (e.g., family/friends)

21. The Written Note (7) • Past Medical/Surgical History • Include menstrual and obstetric as applicable • Past Psychiatric History • Include past diagnoses, treatments, hospitalizations, suicide attempts • Medication • Prior to admission • At time of consultation • Recent changes • Substance Use History • Include history of complicated withdrawal, and MAT details as needed • Family History • Social History • Include upbringing, abuse, legal, military, violence/legal as applicable

22. The Written Note (8) • Physical Exam (as appropriate) • Mental Status Exam • Is analogous to the physical examination • Reflects one point in time • Addresses the question of the consultation and your formulation within the mental status examination • Provides an opportunity to teach and to demonstrate how diagnoses are made • Helps the clinician gain access to a patient’s mental life • Pertinent laboratory and radiologic findings

23. The Written Note (9) • Assessment/Impression • Other than recommendations, the most likely part of the consult to be read • Should have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possible • Know your audience and what you want to accomplish • Include stressors and functional status • Differential diagnosis, including personality disorders and medical disorders

24. The Written Note (10) • Diagnosis • DSM-5 is the primary diagnostic framework • List ICD-9-CM V codes related to psychosocial and environmental problems • WHODAS may be used to demonstrated disability

25. WHODAS: World Health Organization Disability Assessment Schedule 2.0 • Included in Section III of the DSM-5 • Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society Axis V (GAF) was dropped from DSM-5 WHODAS is included for further study as an assessment tool for functioning 36-item, self-administered measure used to assess disability in adults (age 18+)

26. The Written Note (11) • Plan/Recommendations • Most likely part of the consultation to be read! • Safety elements (e.g., does patient require 1:1 observation) • Further work-up suggested (e.g., labs, EKG, imaging, EEG) • Physician management • Medication – scheduled and PRNs, with specific indications • Behavioral approaches with patient – be clear, avoid jargon • Nursing management (e.g., restraint initiation/limitations) • Social service needs • Legal issues (e.g., legal guardian, involuntary transfer status) • Aftercare plans • Consultant follow-up • Inform treatment team of your availability, whether/when you will return, and the purpose of your return

27. Mental Health Integration (1) • “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features • Goals? • Assist patients with mental health concerns within a medical context • Make mental health concerns relatable and understandable for medical colleagues • Improve patient lives via collaboration with medical colleagues

28. Mental Health Integration (2) • Collaboration within multidisciplinary team framework • Mental Health (MH) + non-Mental Health (non-MH) providers • Psychiatrist, other MDs, PhDs, SW, NPs/PAs, RNs, case managers, support staff • Elements of integration • Mission • Optimal care for mental health/behavioral issues in non-MH setting • Target population • Patients with co-morbid medical and psychiatric problems • Patients with MH problem but no other MH care • Location • Generally involves co-location of MH staff in medical site • Communication • Team meetings, shared medical records, shared treatment plans • Administration • Shared or coordinated efforts between MH and non-MH staff • Fiscal • Integrated budget for MH and medical staff vs. separate

29. Mental Health Integration (3) • General hospital-based • Tends to be disorder specific • E.g., delirium, transplant, or substance use disorder teams in the general hospital setting • Ambulatory • Primary care clinics • Medical/Surgical specialty clinics • OB, Oncology, Neurology, Transplant etc.

30. Mental Health Integration (4) • Rationale • Improved access • Need for improved access to MH services • Patient reluctance to go to MH clinic • Patient-centered care • Prevalence of mental health (MH) issues in medical settings • Improved medical and psychiatric clinical outcomes • Extensive co-morbidity of medical and MH disorders • Bidirectional adverse effect of co-morbid disorders • Associated morbidity and cost of disorders

31. Mental Health Integration (5) • Method/structure • Reactive programs • Mimic traditional consult services, except perhaps for co-location • Planned programs • Highly structured, oriented toward “Disease Management” • Value added • Delirium prevention programs • Anxiety, depression, bipolar disorder, schizophrenia, and substance use disorder management in primary care • Co-morbid MH and medical disorders • Depression, diabetes, cardiac disorders • Medically Unexplained Physical Symptoms (MUPS)

32. Mental Health Integration (6) • Planned care framework • Addressing behavioral health disorders in medical clinics • Derivative of chronic disease management programs • Over 70 randomized control trials have established value of collaborative care for patients with mental health issues

33. Mental Health Integration (7) • Methods • Proactive screening/case identification by designated team members • Patient-centered care • Co-location does not equal collaboration • Population-based care • Create patient registries and tracking methods to monitor progress • Algorithm- or otherwise evidence-based treatments • Measurements • Based on tracking results, changes are made until treatment is effective • Team management and case management • Accountable care • Providers are held accountable (and reimbursed) based on quality of patient care and outcomes, not merely the volume of patients

34. Mental Health Integration (8) • Psychiatrist role as a collaborative care team member? • Receive referrals and “warm hand-offs” from primary care colleagues • Consult and provide supervision on a scheduled and PRN basis, for an identified caseload of patients followed in the medical clinic • Function as the team expert • Support the team as they engage with the patient • Give mental health input and suggestions for evidence-based care • Function as an educator • Teach medical colleagues clinically-relevant and evidence-based information, with relevance for the patient cohort in question

35. Conclusions • “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features • Goals? • Assist patients with mental health concerns within a medical context • Make mental health concerns relatable and understandable for medical colleagues • Improve patient lives via collaboration with medical colleagues THANK YOU!

36. REFERENCES • Alexander T, Bloch S. 2002. The written report in consultation-liaison psychiatry: A proposed schema. Australian and New Zealand Journal of Psychiatry 36:251-258. • Ash JS, Berg M, Coiera E. 2004. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. JAMIA 11:104-112. • Campbell EM, Sittig DF, Ash JS et al. 2006. Types of unintended consequences related to computerized order entry. JAMIA 13(5):547-556. • Garrick TR, & Stotland NL. 1982. How to write a psychiatric consultation. Am J Psychiatry 139(7):849-855. • Gilbody S et al. 2006. Collaborative care for depression, accumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 166:2314-2321. • Goldman L, Lee T, Rudd R. 1983. Ten commandments for effective consultations. Arch Intern Med 143:1753-1755. • Kathol R et al. 2009. Psychiatrists for medically complex patients: Bringing value at the physical health and mental health/substance-use disorder interface. Psychosomatics 50(2):93-107.

37. REFERENCES • Katon W et al. 2010. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 363:2611-2620. • Kontos N; Querques J. Psychiatric consultation to medical and surgical patients. 2008. In: Stern TA, Rosenbaum JF, Fava M, et al. eds: Massachusetts General Hospital Comprehensive Clinical Psychiatry. Philadelphia: Mosby-Elsevier. 749-760. • Meyer F, Joseph RC, Peteet JR. 2009. Models of Care for Co-occurring Mental and Medical Disorders. Harvard Review of Psychiatry 17(6):353-60. • Press MJ et al. 2017. Medicare payment for behavioral health integration. N Engl J Med 376(5):405-407. • Salerno, SM et al. 2007. Principles of effective consultation: An update for the 21st-century consultant. Arch Intern Med 167:271-275. • Shannon D. 2012. Effective physician-to-physician communication: an essential ingredient for care coordination. Physician Exec 38(1):16-21.

38. REFERENCES • Smith G; Clarke D. 2006. Assessing the Effectiveness of Integrated Interventions: Terminology and Approach. Med Clin N Am 90:533-548. • Sola CL, Bostwick JM, Sampson S. 2007. Benefits of an Electronic Consultation-Liaison Note System: Better Notes Faster. Academic Psychiatry 31(1):61-63. • Venkat KK. 2015. Short and sweet: Writing better consult notes in the era of the electronic medical record. Cleveland Clinic Journal of Medicine 82(1):13-17. • Weiner, JP et al. 2007. e-Iatrogenesis: The Most Critical Unintended Consequence of CPOE and other HIT. JAMIA 14(3):387-388. • Williams J et al. 2007. Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry 29:91-116.

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