Session: E5a
October 29, 2011
1:30 PM to 2:15 PM
THE USE OF CONSULTING PSYCHIATRY
WITHIN AN INTEGRATED PRIMARY CARE
MODEL: HOW IT WORKS
Elizabeth Zeidler Schreiter, Psy.D., Psychologist
Meghan Fondow, Ph.D., Psychologist
Jantina Vonk, MD, Psychiatrist
Chantelle Thomas, Ph.D., Psychologist
Access Community Health Centers- Madison, WI
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
FACULTY DISCLOSURE
I/We currently have or have had the following relevant financial
relationships (in any amount) during the past 12 months:
 Fairleigh Dickinson University Certificate Program in Integrated
Primary Care-Dr. Zeidler Schreiter is an expert presenter for this
program.

NEED/PRACTICE GAP & SUPPORTING RESOURCES


Primary care is frequently referred to as the “de
facto” mental health system in the United States
(Cummings et. al., 2001)
Medical clinicians are facing a burden of an ever
increasing number of patients presenting with
major mental illness and/or high risk lifestyle
behaviors, as seen within our Federally Qualified
Health Center (FQHC).
NEED/PRACTICE GAP & SUPPORTING RESOURCES

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Research has shown that in the current treatment model
(clinics that do not have integrated care and refer patients
elsewhere for mental health treatment) less than one-third of
referrals are actually completed (Miranda et. al., 1994).
Primary care physicians prescribe approximately 60% to 70% of
the psychotropic medications prescribed in the United States
(Pirl et. al., 2001).
Given the above issues increased access to consulting
psychiatry is needed to provide optimal management of
increasingly severe patients within the primary care setting.
OBJECTIVES
Upon completion of this presentation, participants will be able
to:
 Identify components of a consulting psychiatry approach
within primary care and potential impact on PCP practice
habits.
 Describe how behavioral health consultation and psychiatry
can work together in a primary care setting to enhance
outcomes.
EXPECTED OUTCOME

Have knowledge to assist with implementing consulting
psychiatry within their practice setting.

List core competencies of a consulting psychiatrist who would
fit well within primary care.

Have knowledge how to utilize BHC to assist with coordination
and access to psychiatry consultation within clinic.
WHO WE ARE:
ACCESS COMMUNITY HEALTH CENTERS
FQHC, Health Care Home
 3 clinic locations in Madison, WI
 Medical, Dental, Behavioral Health Services

 Over
23,000 patients seen in 2010
 Over 105,000 visits for 2010
WHAT WE DO:
BEHAVIORAL HEALTH CONSULTATION
Primary Care Behavioral Health model
(Robinson & Reiter, 2007)
 Fully integrated, fully embedded program
 Mix of scheduled follow ups and warm handoffs
 BHC serves as conduit for referrals to
consulting psychiatry

NEED FOR INTEGRATED SERVICES


Depressive and anxiety disorders in medical patients have
been associated with increased utilization of medical services
leading to increased cost , significant functional impairment,
and sub-optimal adherence rates in patients with chronic
medical issues (Simon et. al., 1995).
Many of these patients can be successfully managed within a
primary care environment as evidenced in recent study by
Serrano & Monden (2011) with assistance from BHC and
access to consulting psychiatry.
POPULATION SERVED
BHC saw about 27% of medical patients in
2010 at 2 sites, about 12% at 3rd site
 Demographics:

 47%
Caucasian
 27% African American
 24% Hispanic

19% Spanish speaking for BHC
REFERRAL REASONS TO BHC


Not just mental health issues. Preventive Health and
Behavioral Health needs also very salient
Depression and Anxiety commonly seen, but also
other mental and behavioral health issues
 Bipolar disorder, psychotic spectrum disorders,
AODA, adjustment, ADHD, smoking cessation, sleep
problems, weight management
ROLE OF CONSULTING PSYCHIATRY

Explanation of consulting psychiatry service


Population based care
Modalities
Chart review
 Face to face
 Verbal recommendations
 Education


Golden Rule: Primary Care Physician retains
prescribing authority
RATIONALE FOR CONSULTING PSYCHIATRY


Research has discussed several options to increase collaboration between
psychiatry and primary care.
 Possible options:
1.
Psychiatrist working as specialists who can be consulted as needed
2.
Increasing referrals from practitioners to psychiatrists
3.
Integrated team model, in which the psychiatrist and other mental health
providers work alongside their primary care colleagues in primary care
environment (Cowley et. al., 2000).
Integrated consulting psychiatry is highly desirable given volume of patients that
receive their psychiatric care within the primary care system and issues with poor
follow-up when referred outside of the system.
RESIDENCY TRAINING

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Allows residents exposure to community psychiatry
Able to see wide variety of patients
Working in collaboration with primary care providers and BHC
Prepares resident to work within a medical home
Learn to recognize and diagnose psychiatric and/or behavioral
conditions common in primary care settings
REFERRAL REASONS TO CONSULTING
PSYCHIATRY



Main requests focused on diagnostic clarification,
medication recommendations, management of
psychiatric issues co-morbid with physical health
issues, and guidance regarding needed lab
monitoring.
Primary diagnoses seen include: Mood disorders,
schizophrenia/psychotic disorders, PTSD/Anxiety
disorders.
Many patients also had co-morbid substance abuse
issues.
POPULATION SERVED

Patient numbers as seen face-to-face by
Consulting Psychiatry:
 2010:
210 patients
 2009: 170 patients
 2008: 107 patients
 2007: 34 patients
Over 350 verbal or written consultations in
2010
 Resident started 3rd quarter 2010

STEPS TOWARD IMPLEMENTATION

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Consulting psychiatry started at ACHC in 2007.
Administrative backing.
Needs assessment of clinic is warranted to determine best fit and
time needed.
Population care focus thus emphasis on verbal and written
consultations in addition to face-to-face encounters.
Psychoeducation for medical providers
Space for consultant to work (e.g. exam room)
Finding a psychiatrist ready, willing, and able to thrive in this
environment.
Utilization of Behavioral health consultant to assist with triaging need
and appropriate allocation of resources.
CORE COMPETENCIES OF A CONSULTING
PSYCHIATRIST WHO WOULD FIT WELL WITHIN
PRIMARY CARE
Flexible
 Confident
 Able to function as part of a team
 Understanding of context-working within an
FQHC and limited patient resources
 Population based care focus

EXPERT DISCUSSANT

Dr. Jantina Vonk, MD
 Consulting
psychiatrist at Access Community Health
Centers
 Started in 2007
 Training background and experiences
EXPERT DISCUSSANT




Comparing and contrasting roles within community
mental health center and primary care environment
(within an FQHC).
Review of structure of initial consultation and brief
follow-up consultations as needed.
Use of electronic medical record.
Educating providers on utilization of medication
algorithms for mental health issues.
LEARNING ASSESSMENT

Questions?
REFERENCES
Cowley, D.S., Katon, W., & Veith, R.C. (2000). Training psychiatry residents
as consultants in primary care settings. Academic Psychiatry, 24:3,
124-130.
Cummings, N.A., O’Donohue, W., Hays, S.C., & Follette, V. (2001).
Integrated behavioral healthcare: Positioning mental health practice
with medical/surgical practice. San Diego: Academic Press.
Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve
treatment guidelines: impact on depression in primary care. JAMA
1995; 273:1026–1031
Miranda, J., Hohnmann A.A., Attikisso, C.A. (1994). Epidemiology of Mental
Health Disorders in Primary Care. San Francisco, CA: Jossey-Bass.
Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of
psychiatric consultations in a community primary care center. Primary
Care Companion Journal of Clinical Psychiatry, 3, 190-194.
REFERENCES
Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and
Primary Care (pp 1-16). N.Y.: Springer Science.
Serrano, N and Monden, K. (2011). The effect of behavioral health
consultation on the care of depression by primary care clinicians.
Wisconsin Medical Journal, 110:3, 113-118.
Simon GE, Ormel J, Von Korff M, et al: Health care costs
associated with depressive and anxiety disorders in primary
care. American Journal of Psychiatry 1995; 152:352–357.
Slay, J.D., & McCleod, C. (1997). Evolving an integration model: The
Healthcare Partners experience. In N.A. Cummings, J.L.
Cummings, and J. Johnson (Eds.) Behavioral health in primary
care: A guide for clinical integration (pp 121-144). New York:
International Universities Press.
SESSION EVALUATION
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!