Session # B5b
October 18, 2014
Psychiatrist as Consultant Has Triple Impact on
Patient-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 16 th Annual Conference
October 16-18, 2014 Washington, DC U.S.A.

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

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.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
; 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.

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

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Existing models of delivering psychiatric care are unable to meet the volume of community needs.
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PCPs are de-facto providers of Mental Health treatment in most communities.

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Many PCPs find themselves untrained, uncomfortable or ill-equipped to manage straightforward psychiatric & behavioral health issues.
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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.

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Unacceptable waiting periods for access:
◦ Waits range from 2-6 months
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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

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Uncomplicated History: Straightforward, points to a single diagnosis.
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Mild to moderate symptoms
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Mild to moderate Behavioral abnormalities: school avoidance, eating problems, sleeping issues, spending or gambling, promiscuity
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Course is acute or sub-acute.

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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

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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

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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

NOT designed for patients requiring long term comprehensive care:
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Severe symptoms: Mania
Serious behavioral dysfunction: Suicidal
Complex co-morbidities: Substance abuse
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Chronic, persistent or relapsing Mental Illness
Requiring three or more concurrent psychotropic agents
NOT a “Back Door” into a psychiatrist’s office.

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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.

◦ 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

◦ 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

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Timely
Individualized & accurate
Pithy and concise
Includes salient positives, negatives that support decision-making
Explicit treatment plan
Alternatives: “…if this is ineffective then…”

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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

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Transparent medical and psychiatric history, diagnoses, medications
◦ Drug & Alcohol, Social, Family History
Real time information sharing
Attention to medical and psychiatric comorbidities
Awareness of drug-drug interactions
Legibility

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Privileged information & limits of collaboration
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Who sees what? Levels of access
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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

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Identify patients in PCP office through screening
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Collect relevant history & document this in shared medical record
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Assure appropriate patients are referred through Fast Track
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Facilitate monitoring of the patient & treatment plan

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Team meetings: Behavioral Health Specialists
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On-site education: Primary Care Providers
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On-going, patient-specific education: “In a case like this, I would try….”
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Grand Rounds presentations, “Current
Approaches to the Treatment of…”

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Shared EMR and Liability insurance are key.
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Identify your frequently referring PCPs
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Identify a Psychiatrist Consultant
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Describe your Fast Track criteria
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Get buy-in from your clinical team
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Put it in writing for the whole team AND the patient
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Establish your outcome measures
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Establish office processes for referral & tracking
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Track & monitor your outcomes

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Appropriateness of referral
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Time to evaluation date from referral compared to TAU
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Outcome of referral:
◦ Successful hand-back to PCP
◦ Number of Psychiatric visits
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Future Measures: Psych ED visits & hospitalizations, costs of episode of care

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Name
MR number
Referring doctor
Referring group
Date of referral
Date seen
Telemedicine or Inoffice ( T or O)
BHS contact (yes/no)
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Appropriate/Not
Curbside Consult only
Kept/Referred
# of psych visits
Seen/Refused
Txt field for diagnoses
Text field for outcome

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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

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

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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

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# 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%

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Model does not improve access for patients most in need.
Clinical complexity is frequently not apparent
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Buy-in varies among members of a group
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Some patients prefer on-going management by specialist
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Behavioral Health Specialist needed for screening
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Personnel needed to facilitate & track referrals
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Capacity may not meet demand for services

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Fast Track is an effective solution to access challenges.
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Successful implementation requires willing partners, a shared EMR, & effective communication.
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Behavioral Health Specialists & Care managers stream-line the referral and tracking process.

Session Evaluation