“Fast Track”: Psychiatrist as Consultant Has Triple Impact on Patient-Centered Medical Home

1. Session # B5b • October 18, 2014 “Fast Track”: Psychiatrist as Consultant Has Triple Impact onPatient-Centered Medical Home 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 Conference • October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • I have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • 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.

4. Bibliography / Reference Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. GoldnerEM; 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 [ClinPediatr (Phila)] 2012 Oct; Vol. 51 (10), pp. 978-82.

5. Bibliography / References 4. In need of psychiatric help--leave a message after the beep. Bridler R; r.bridler@sanatorium-kilchberg.ch Psychopathology [Psychopathology] 2013; Vol. 46 (3), pp. 201-5. 5. Primary care physicians' and psychiatrists' approaches to treating mild depression. Lawrence RE; rlawrence@uchicago.edu; ActaPsychiatricaScandinavica [ActaPsychiatrScand] 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.

6. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

7. The Nature of the Problem • 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.

8. 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.

9. The Size 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

10. Primary Psychiatry • 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.

11. 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

12. Appropriate Referrals • 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

13. “Fast Track” • 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

14. What Fast Track is NOT 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.

15. How “Fast Track” Works • 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.

16. Key Elements for Effective Collaboration: Trust • 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

17. Key Elements for Effective Collaboration: Communication • 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

18. 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…”

19. Patient as Collaborator • 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

20. Shared Electronic Medical Record • 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

21. Privacy Challenges: • 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

22. Role of Behavioral Health Specialist • 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

23. On-Going Education to Support Fast Track Model • 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…”

24. How to Get Started • 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

25. Monitoring • 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

26. Monitoring Tool • 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

27. Case Study • 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

28. Diagnosis Axis I: Major Depression Recurrent, Moderate Generalized Anxiety Disorder Axis II: None Axis III: Degenerative Disc Disease, Chronic Low Back Pain, Hypertension, Hyperlipidemia, Erectile Dysfunction, Vitamin D. Deficiency Axis IV: Wife’s dx of Stage 4 Lung Cancer, Son’s severe disability, Financial strain, Phase of Life issues Axis V: 50

29. Treatment Plan • 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

30. Outcomes of Pilot • # 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%

31. Obstacles & Challenges • 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

32. Conclusion • 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.

33. Questions? Susan D. Wiley, MD Vice Chairman, Dept. Psychiatry Lehigh Valley Health Network Susan.Wiley@LVHN.ORG 610-402-5900

34. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!