Session # F6b
October 6, 2012
Psychosis and safety management
in integrated primary care
Verena Roberts, Ph.D., Integrated Primary Care Psychologist
Elizabeth Lowdermilk, M.D., Psychiatrist
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
We have not had any relevant
financial relationships
during the past 12 months.
Objectives
• Attendees will learn how to successfully integrate behavioral
health and psychiatry into primary care
• Attendees will learn innovative approaches to management of
patients with psychosis and high risk behaviors, such as safety
issues
• Attendees will learn key differences and challenges in
management of psychosis and safety concerns within an
integrated primary care setting as compared to traditional
mental health management
• Attendees will learn to pay attention to the fact that no
existing standards and accepted norms of practice exist to
date.
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:
Please incorporate audience interaction through a
brief Question & Answer period during or at the
conclusion of your presentation.
This component MUST be done in lieu of a written
pre- or post-test based on your learning objectives to satisfy
accreditation requirements.
Denver Health – Overview CHS
Eastside Family Health Center
(GIM)
Medical Director/Team Leader (MD)
Program Manager (RN)
6 FT/3 PT MD Attendings
8 Internal Medicine Residents
1 Behavioral Health Consultant (PhD) and 1 BHC resident
1 Psychiatrist and 1 psychiatry resident
2 Social Workers
2 Clinical Pharmacists
2 RNs
1 Patient Navigator
6 Medical Assistants a/k/a Health Care Partners (HCPs)
3 Laboratory Technicians
Clerical Supervisor
5 Clerks
Clinic Make-up
• Eastside Clinic is a federally qualified community
health center which provides primary care medical
services for low income patients in central Denver.
• The patients seen:
– low income (97% are <200% of the federal poverty level),
uninsured or on public insurance (24% Medicare, 31%
Medicaid, 43% uninsured)
– are mostly under-represented racial/ethnic minorities
(41% African American, 34% Hispanic/Latino)
– Denver Health = “safety net”
Mental Health Services in Denver
Current State
• The Mental Health Center of Denver (MHCD) is the
largest provider of services
– Over 5000 patients served at any given time
– Each year, they serve approx. 14,000 patients
– They serve those with medicaid, medicare & the indigent
population (self pay) & have a small insurance based clinic
• Reimbursement is poor for medicare
• Minimal state support for the care of the uninsured
– Much less than the actual cost of care & medications
– The demand for services is much greater then the
number of spots
• 100 pts call every day for 5-7 intake spots
Mental Health Services in Denver
Continued
• Denver Health Medical Center
– Is the primary site for inpatient care in Denver, we work
closely with MHCD to serve patients
– Provides integrated care at the FQHCs (more later)
• smaller integrated care presence in the Women’s clinic & the HIV
primary care clinic
– Multiple specialty outpatient teams
• Child & Adolescent, Substance Use Disorders, Methadone, ID clinic
– Limited outpatient services for general adult population
• Small team - 1.7 FTE prescriber time and 2.0 FTE psychology time
• Severity of illness that can be cared for is limited by the lack of
ancillary services
– No CM support, minimal nursing support
Mental Health Services in Denver
Continued
• The Colorado Coalition for the Homeless
– Serves the homeless population, medical and psychiatrically
– Psychiatric clinic closed to intake due to high demand
– Have incorporated integrated care approach in one of their primary care
locations to help meet the need
• The University of Colorado
– Resident clinic serves some of the medicare/ medicaid population, but they
too are limited in the severity of illnesses that they can accommodate
• There are various other programs that offer sliding scale counseling
(typically training programs) – typically these are small, and not set up to
accommodate the more seriously mentally ill
Mental Health Services in Denver
The Bottom Line
• There are very few agencies capable of handling
those with severe and persistent mental illness
– Significant unmet need
• The Mental Health Center of Denver gets over 100 calls every day
for 5 to 7 intake slots
– There are fewer slots for the uninsured population
– Poor Medicare reimbursement leads to significant access
problems for this group as well
• And the problem is growing
– The impact of the economic downturn
– We are facing a national workforce shortage in psychiatry
So, What Happens to the Patients?
• Multiple hospitalizations and ER visits
• Medical Illnesses worsen due to untreated mental
illnesses
• Primary Care Physicians have become the defacto
psychiatric providers for thousands of patients at
Denver Health
This has led to the development of innovative
new approaches to psychiatric treatment
Key Features of Integrated Care
• FT Psychologist and PT psychology student
– 2 scheduled 30 min. behavioral health appointments per
session (for further evals, tx)
• Allows for overbooks for pt. with high follow-up needs
– Scheduled and unscheduled (warm-handoffs) integrated
visits with PCPs
• PT Psychiatrist & PT psychiatry resident
– 1 pm session a week in clinic
– 3-4 40 min. scheduled appointments (3 + 1 OVBK)
– E-mail/phone consults about patients - ongoing
Overview of Integrated Care
• BHC and psychiatrist are “pulled” into care of patients by PCP
on an “as needed” basis (consultant model)
– Since the BHC is on site, and the schedule allows for warm-handoffs,
evaluations (safety, psychosis) can be done during medical visit
– BHC has more time to ask in depth questions
• “Order of tx”: All patients have to have BHC contact to clarify
dx before being seen by or consulted about by psychiatrist
• BHC role: dx clarification, keeping close f/u with “high-risk”
patients, some case management as related to managing such
patients (including 3 phone calls and a letter if patients noshow for f/u), treatment
Overview of Integrated Care cont’d
• Psychiatrist: med evaluations and recommendations,
limited to 1-3 visits with very few exceptions (try to
utilize e-mail consults)
• Treatment length: orig. 4-6 BHS and ICV visits,
referral for long-term tx
• Adjusted TX (current model): patients are seen as
long as needed, making model clear to patients and
continuing to work on LT referrals (applies mostly to
high-risk patients)
• E-mail consults: PCP and BHC always included in email – allows for better communication
Issues in the Management of Active Psychosis
and Safety Issues in Primary Care Psychiatry/
Psychology
• As we mental health providers merged into primary care
clinics, we have increased the recognition of active psychosis
& safety issues
• We have identified:
– issues of acute management
• Here, the behavioral health clinician enhances the
services of the primary care clinic
– Assessing and documenting safety issues
• We use existing resources to manage the cases
– Security, a psychiatric emergency room, etc.
• Our standard of care and liability is the same as an
emergency evaluation anywhere
Issues in the Management of Active Psychosis
and Safety Issues in Primary Care Psychiatry/
Psychology
And we have identified issues of ongoing management:
– Specialty care is always recommended
• We document this
• We document their attempts to access care or refusal
• But as described before, many of our patients have
limited access to specialty care
– Additionally, some are unwilling to go
– Some say they will go but never take the steps to engage in
treatment elsewhere
» From the outpt setting, we can not link the patient
directly to specialty services
Our Evolution Into the Process of Ongoing
Management
• It became quickly apparent as we started our
integrated care program that we needed to address
this group of patients
• As a group of providers – mental health and primary
care - we have decided that some treatment is better
than no treatment
• Thus, we have opted to manage patients with active
psychosis and safety issues with the primary care
physicians in the FQHCs when necessary
• We have had to adjust our practices accordingly
Considerations in the Ongoing
Management of Active Psychosis and
Safety Issues in the Primary Care Settings
• The standards of practice are different for primary
care and specialty mental health care
– Different level of assessment expected
– Different level of follow up expected
• Outreach
• Frequency and type of follow up
• There is no clearly defined standard of practice for this subset
of patients by integrated care clinicians
– No current case law
Considerations in the Ongoing Management of
Active Psychosis and Safety Issues in the Primary
Care Settings – Cont.
• The FQHC clinic infrastructure does not support the
typical management that a mental health center
would provide
– Mental health centers have CMs, therapists, nursing
support, urgent/ emergent resources, etc
• Thus, we have had to develop a “blended
approach” for care of these patients
Integrated Care – Flow Chart
Med
changes
at visit
Pt.
medical
visit
Meet
BHC
E-mail
psychiatry if
med choice
unsure or
has failed
Schedule
psychiatry
visit comprehens
ive cases
Referral to
BHC for
further
eval (OVBK
1-2 wks)
Initial (same) visit
(may be f/u visit if established
patient)
PCP
calls pt.
w/ med
Return
in ICV
(PCP+ BHC)
1-4 wks.
Med
changes
at visit
Return in
BHV
1-4 wks.
E-mail
psychiatry if
med choice
unsure or
has failed
May utilize
phone call in
between visits
to monitor
safety, med
response
This may be
psychiatry
visit if
overbooked
Phone call/letter
for no shows
according to risk
level
Document efforts
2nd visit
(or f/u visit if previous pt.)
May utilize
phone call in
between visits
to monitor
safety, med
response
PCP
calls
pt. w/
med
Pt.
returned to
PCP/BHC
for f/u visit
Management of Integrated Care
Patients – Data Base
• We use a data base to track patients
– For productivity
– For quick overview
– For risk management
– For follow-up
Management of Integrated Care
Patients – Risk Levels
Level 4 = highest risk
• any patient with active safety issues
• patients just discharging from the hospital
• patients with active/concerning psychosis
• goal contact would be weekly (or at minimum
weekly attempts with documentation of
outreach attempts)
• Psychologist and psychiatrist discuss these
patients weekly
Management of Integrated Care
Patients – Risk Levels Cont’d
Level 3 = patients we are following who are not doing well, would want to
outreach if they do not show, would discuss with PCP/ Psychiatrist as
needed.
• goal contact 1/month,
• List reviewed periodically - looking specifically for those who are not
showing up & need to be outreached
• pts who need to be scheduled with psychiatry & for those who need to be
referred to a higher level of care.
• examples of such pts are:
• patients who are having moderate to severe symptoms but no acute
safety issues
• patients who are not improving as we would expect/ hope (might raise
the question of whether or not diagnosis is accurate and/or treatment is
appropriate)
• those you are actively working with to refer out for more intense mental
health services
Management of Integrated Care
Patients – Risk Levels Cont’d
Level 2 = patients we have no sig. concerns about but
have routine involvement with.
• could be pts we are seeing for a brief course of
therapy, but are overall doing well
• or pts we are seeing as an ICV when they are in clinic
- if possible.
• generally, these pts would have no safety issues, &
no issues related to active psychosis
• these are pts you would likely not outreach if they
did not show for an appt.
Management of Integrated Care
Patients – Risk Levels Cont’d
Level 1 - minimal risk
• the patients seen once, available prn but no
ongoing need/ services provided
– i.e. patients now seen in specialty behavioral
health elsewhere
Case Example I
BB – 45 yr. old African-American
•
•
•
•
•
•
•
depressed, highly irritable, hx of recent fights
SI, HI (hx of plans, duty to warn, current plans)
trauma hx, antisocial PD, unclear psychosis (AH vs. his thoughts “blowing up cops”)
Denied current intent
Perseveration on how to hurt self/others (on train thought of “slitting kids throats”
because they were irritating (when asked if he had a knife – handed over knife)
Met in ICV, PCP started antipsychotic
OVBK w/ psychiatry next week – no-show – called pt., no-showed for ICV, too.
–
•
•
•
•
Another OVBK for psychiatry, now tag-teaming
Safety plan, involving GF, frequent phone calls for monitoring med response and
making sure he started meds
Referral to mental health center – but no efforts from pt. to f/u yet
Managed with monthly visits now
Risk level 4 initially, now 3
Case Example II
LA - 69 yr. old Caucasian female
• Depressed w/ SI (future date –depending on outcome of a certain event,
specific plan, no imminence)
• Guns in home
• Husband – “suicide pact”
• TBI, impulsivity, Obsessive-Compulsive PD, PTSD
• Emotional dysregulation (anger outbursts)
• Met in ICV, OVBK w/ psychiatry next week
• Safety plan, involving husband
• f/u bi-weekly w/BHC
• Sliding fee clinics for LT tx (but unlikely)
• Consider hospitalization around event, but unlikely
• Risk level 4 initially, now 3, around event up to 4
To sum it all up….
• High need for psychosis and safety management in primary care
– Added BHC and PT psychiatrist
• No standards, literature, case law
– Developed our own program fitting our needs, merging approaches
• Managing “high risk” patients is “risky” in primary care due to lack of
resources (no CM…)
–
–
–
–
–
–
Developed database, tracking system, risk levels
BHC does some case management
Excellent communication
Easy access to BHC and psychiatrist
Tag-teaming visits
1x mo. Behavioral Health – mini-psychiatry lectures
• Future: need to develop standards of care
Questions and Answers
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!