Team Based Care
in Psychiatry
“Medical Leadership of Psychiatric Teams:
Role of Extenders in Psychiatric Practice”
Michael M. Miller, MD
Wisconsin Psychiatric Association
Kohler, Wisconsin
December 5, 2014
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org
Medical Director, Herrington Recovery Center
Rogers Memorial Hospital, Oconomowoc, Wisconsin
Clinical Adjunct Professor
University of Wisconsin School of Medicine and Public Health
Assistant Clinical Professor
Medical College of Wisconsin
Past President, American Society of Addiction Medicine
At-Large Director, American Board of Addiction Medicine
Delegate, AMA House of Delegates (Wisconsin)
Member, AMA Council on Science and Public Health
Psychiatrists are used to practicing as a
member of a TEAM
• Psychiatrists are trained in clinical care as members of
clinical teams.
• The foundation of the public sector care system is the
multidisciplinary team.
• The standard structure of the inpatient psychiatric unit is
the multidisciplinary team.
• In addiction care, at all levels of care, care is delivered in
private and public sector via multidisciplinary teams.
Who is on the team?
• Psychiatrist
• Nurse
• Psychologist
• Clinical Social Worker
• Occupational Therapist
• Bachelor’s level workers
Who else may be on the team?
• General Medical Consultant
• Pharmacist
• Art Therapist
• Music Therapist
• Movement/Dance Therapist
• Recreation Therapist
• Exercise Instructor
• Yoga Instructor
The Addiction Care Team
• Addiction Counselor
• Physician
• Psychiatrist/Psychologist
• Nurse
• Family Therapist
• Social Worker
• Discharge Planner
• Experiential Therapist (OT, MT, DT, Equine Tx)
Who else may be on the Addiction
Care Team?
• Addiction Specialist Physician
– Addiction Psychiatrist
– Addiction Medicine Physician
• Mental Health Therapist
• Spiritual Counselor/Chaplain
• Vocational Counselor
• Parenting Skills Trainer
• Financial Skills Counselor
What About Non-MH Teams?
• Primary Care Teams
• Patient Centered Health Care Homes
• Medical Teams
– Hospice/Palliative Care Teams
– Oncology Teams
– Dialysis Teams
– Diabetes Teams
– Multidisciplinary Pain Clinics
And SAMHSA and others address another
potential member of the TEAM—the PATIENT!
Check out the SAMHSA-HRSA Center for Integrated
Health Solutions
“Shared Decision-Making” is the lingo:
• http://www.integration.samhsa.gov/clinical-practice/shareddecision-making
There is a free monograph on the topic:
• http://store.samhsa.gov/product/Shared-Decision-Makingin-Mental-Health-Care/SMA09-4371
Mental Health America (formerly the National Mental
Health Association) is also supportive of this path
The patient as a participant in the Health Care Team:
“You’re on the Team.”
http://www.mentalhealthamerica.net/working-provider
Psychiatrists
• Leader of the Team (MH teams)
• Member of the Team (General Medical teams)
Integrating Psychiatry into
General Medical Teams
• Community Health Centers
– http://www.nachc.com/
• Federally Qualified Health Centers
– www.hrsa.gov
– Health centers are community-based and patient-directed
organizations that serve populations with limited access to
health care.
SAMHSA and HRSA collaborating:
The SAMHSA-HRSA Center for Integrated Health Solutions
• http://www.integration.samhsa.gov/
• http://www.integration.samhsa.gov/integrated-care-models
– Integrating Behavioral Health into Primary Care
– Primary Care in Behavioral Health (“reverse integration”)
See also: Pating DR, Miller MM, Goplerud E, Martin J, and Ziedonis DM. “New
Systems of Care for Substance Use Disorders: Treatment, Finance and
Technology under Health Care Reform.” Psychiatric Clinics of North America
35(2): 327-356. 2012.
FQHC’s and the ACA
Major expansion of CHC’s
• Theory: medical education to occur in CHCs.
• Theory: MH care and SA care to be delivered in
integrated fashion via CHCs.
• Theory: health professionals education in behavioral
health to occur in CHCs.
The Affordable Care Act:
The Essential Role of Community Health Centers
• Health centers are poised to play an essential role in the
implementation of the Affordable Care Act.
• In particular, health centers emphasize coordinated
primary and preventive services or a “medical home” that
promotes reductions in health disparities for low‐income
individuals, racial and ethnic minorities, rural
communities and other underserved populations.
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf
The Affordable Care Act:
The Essential Role of Community Health Centers
• Health centers place emphasis on the coordination and
comprehensiveness of care, the ability to manage patients
with multiple health care needs, and the use of key quality
improvement practices, including health information
technology.
• The health center model [utilizes] a team‐based approach to
care that includes physicians, nurse practitioners, physician
assistants, nurses, dental providers, midwives, behavioral
health care providers, social workers, health educators, and
many others.
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf
The Affordable Care Act:
The Essential Role of Community Health Centers
The Affordable Care Act established the Community Health Center Fund
that provides $11 billion over a 5 year period for the operation, expansion,
and construction of health centers throughout the Nation.
$9.5 billion is targeted to:
 Support ongoing health center operations.
 Create new health center sites in medically underserved areas.
 Expand preventive and primary health care services, including oral
health, behavioral health, pharmacy, and/or enabling services, at
existing health center sites.
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf
The Affordable Care Act:
The Essential Role of Community Health Centers
To date in FY 2014, through the Affordable Care Act, the Health Center
Program awarded or announced the following new funding:
Health Center Patient‐Centered Medical Home Capital funding opportunity: In August 2014,
HRSA awarded $35.7 million in Affordable Care Act funding to 147 health centers in 44 states, the
District of Columbia, and Puerto Rico to support patient-centered medical homes through new
construction and facility renovations.
Health Center Mental Health Service Expansion ‐ Behavioral Health Integration Awards: In July
2014, HRSA awarded $54.6 million in Affordable Care Act funding to support 221 health centers in 46
states, the District of Columbia and Puerto Rico to establish or expand behavioral health services for
over 450,000 people nationwide. Health centers will use these funds for efforts such as hiring new
mental health professionals, adding mental health and substance use disorder health services, and
employing integrated models of primary care.
http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf
From the website of the AMA
Physician-Led Team Based Care
• As millions obtain health insurance and can access ongoing
health care, the American Medical Association supports
physician-led health care teams that ensure health care
professionals work together to meet the surge in demand. The
AMA is working to ensure sustainable physician practices that
result in better health outcomes for patients, and having more
physician-led health care teams will help us achieve these goals.
From the website of the AMA
Physician-Led Team Based Care
• New health care delivery system reforms hinge on a teambased approach to care. In the physician-led team approach,
each member of the team plays a critical role in delivering
efficient, accurate, and cost-effective care to patients. With
seven years or more of postgraduate education and thousands
of hours of clinical experience, physicians are uniquely qualified
to lead the health care team. Physicians, physician assistants,
nurses, and other health care professionals have long worked
together to meet patient needs for a reason: the physician-led
team approach to care works.
Think Tanks are “all over” this topic
e.g., a spin-off of the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care
Core Principles & Values of Effective Team-Based Health Care
October 2012
Pamela Mitchell, Matthew Wynia, Robyn Golden, Bob McNellis, Sally Okun, C. Edwin Webb, Valerie Rohrbach, and Isabelle Von
Kohorn*
*Participants drawn from the Best Practices Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care
Copyright 2012 by the National Academy of Sciences. All rights reserved.
https://www.nationalahec.org/pdfs/VSRT-Team-Based-Care-Principles-values.pdf
2013 National AHEC Organization | 7044 S. 13th Street | Oak Creek, WI 53154
Core Principles & Values of Effective
Team-Based Health Care, October, 2012
• Health care has not always been recognized as a team
sport, as we have recently come to think of it. In the “good
old days,” people were cared for by one all-knowing doctor
who lived in the community, visited the home, and was
available to attend to needs at any time of day or night. If
nursing care was needed, it was often provided by family
members, or in the case of a family of means, by a privateduty nurse who “lived in.” Although this conveyed elements
of teamwork, health care has changed enormously since
then and the pace has quickened even more dramatically in
the past 20 years.
Core Principles & Values of Effective
Team-Based Health Care, October, 2012
“Teams in health care take many forms, for example, there are
disaster response teams; teams that perform emergency
operations; hospital teams caring for acutely ill patients; teams that
care for people at home; office-based care teams; geographically
disparate teams that care for ambulatory patients; teams limited to
one clinician and patient; and teams that include the patient and
loved ones, as well as a number of supporting health
professionals. Teams in health care can therefore be large or
small, centralized or dispersed, virtual or face-to-face—while their
tasks can be focused and brief or broad and lengthy. This extreme
heterogeneity in tasks, patient types, and settings is a challenge to
defining optimal team-based health care, including specific
guidance on the best structure and functions for teams.”
Core Principles & Values of Effective
Team-Based Health Care, October, 2012
• A driving force behind health care practitioners’ transition from being
soloists to members of an orchestra is the complexity of modern
health care, which is evolving at a breakneck pace. The U.S. National
Guideline Clearinghouse now lists over 2,700 clinical practice guidelines, and, each year, the results of more than 25,000 new clinical
trials are published. No single person can absorb and use all this
information.
• Given this complexity of information and interpersonal connections, it
is not only difficult for one clinician to provide care in isolation but also
potentially harmful. As multiple clinicians provide care to the same
patient or family, clinicians become a team—a group working
with at least one common aim: the best possible care—whether or
not they acknowledge this fact (emphasis added).
• Each clinician relies upon information and action from other
members of the team.
Core Principles & Values of Effective
Team-Based Health Care, October, 2012
A Proposed Definition of Team-Based Health Care:
Team-based health care is the provision of health services to
individuals, families, and/or their communities by at least two
health providers who work collaboratively with patients and
their caregivers—to the extent preferred by each patient—to
accomplish shared goals within and across settings to achieve
coordinated, high-quality care.
[To inform a proposed definition of team-based care, we reviewed the literature and reflected on the
definitions and factors identified in prior work. Elements found across the definitions we reviewed include the
patient and family as team members, more than one clinician, mutual identification of the preferred goal,
close coordination across settings, and clear communication and feedback channels.]
Newly Emerging Team Members
• Nurse Practitioners
• Physician Assistants
Physicians Assistants in Mental Health
“According to a 2009 study, over three quarters of the
United States (US) have a severe shortage of mental
health prescribers and non-prescribers. The lack of mental
healthcare providers has led to prolonged wait times for
mental healthcare services, increased crime related to
mental health issues, and homelessness.
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J
2011Feb; 104 (2):87-8.
Physicians Assistants in Mental Health
“A safe and cost-effective solution to the problem is to employ
the use of midlevel practitioners such as physician assistants
who are adequately trained to practice psychiatry. Physician
assistants have been working in mental health since 1975;
however, the American Academy of Physician Assistants
found psychiatry physician assistants only represent 1.1% of
the total number of practicing physician assistants.”
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J
2011Feb; 104 (2):87-8.
Physicians Assistants in Mental Health
“A physician assistant has the ability to effectively increase
the patient load with significantly less cost as compared to
hiring a psychiatrist for a practice, inpatient ward, or
community mental health center. Physician assistants have
extensive training in primary medical screening techniques.
Not only will a physician assistant be able to provide mental
healthcare, but also a well-rounded medical care for patients.”
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J
2011Feb; 104 (2):87-8.
Terminology
• APRNs are not “extenders.” They are licensed professionals with
advanced degrees who have passed a certification examination,
have completed supervised practice hours, have a defined scope
of practice, and have prescriptive authority. Some states require
them to have a collaborative relationship with a physician for
certain functions (like prescribing). Unlike PAs, they do not work
in a directed relationship with a physician.
• Certainly, as in all professions, APRNs have different levels of
experience and skill which need to be taken into account in their
functioning within the interdisciplinary team.
– Kathleen McCann, RN, PhD, the director of quality and regulatory affairs
for the National Association of Psychiatric Health Systems (NAPHS).
– She received the “Excellence in Leadership Award” from the American
Psychiatric Nurses Association.
Advanced Practice Psychiatric Nurses
APPNs are health care professionals licensed to practice as specialists
in psychiatric mental health nursing. The advanced practice psychiatric
nurse is board certified by the American Nurses Credentialing Center
(ANCC) to specialize in one of in several Psychiatric Mental Health
(PMH) advanced practice nursing roles.
• Clinical Nurse Specialist (CNS)
– Child & Adolescent Psychiatric & Mental Health
• Clinical Nurse Specialist (PMHCNS-BC)
– Adult Psychiatric & Mental Health Clinical Nurse Specialist (PMHCNS-BC)
• Nurse Practitioner (NP)
– Family Psychiatric & Mental Health NP (PMHNP-BC)
– Adult Psychiatric & Mental Health NP (PMHNP-BC)
Activities/Scope
• Both Psychiatric NPs and Psychiatric CNSs are
responsible for assessment, diagnosis, treatment, and
evaluation of mental illness.
• In 36 states psychiatric & mental health CNSs also
have prescriptive authority.
• APRN NPs may conduct physical exams, order and
interpret tests, counsel on preventive health care, and
write prescriptions.
Certification and MOC
• APRN-PMHs are educated at the master’s or clinical
doctorate (DNP) level in a holistic biopsychosocial
model of psychiatric & mental health nursing.
• Upon graduation, Advanced Practice Psychiatric
Nurses may take a national certification examination
developed by the American Nurses Credentialing
Center (ANCC).
• MOC is every 5 years: must document 1000 clinical
hours of patient care and 75 hours of CE in PMH
nursing in those 5 years.
Education and Rx Authority
• Advanced Practice Psychiatric Nurses (APPN) are educated in
intensive accredited graduate nursing programs. The average APRNPMH program curriculum runs approximately 16-24 months.
• The first CNS program in PMH nursing was at Rutgers in 1955; by
1965 there were 30.
• APPNs are found in all areas of health care. They practice in primary
care – i.e., family medicine, internal medicine, pediatrics, and obstetrics
and gynecology – as well as in hospitals, home health care,
correctional health care, and in other outpatient settings.
• All 50 states and the District of Columbia authorize APPN prescribing if
they are certified as a Nurse Practitioner.
• A Clinical Nurse Specialist, APRN-PMHs, are authorized to prescribe in
36 states.
Drew B. The Evolution of the Role of the Psychiatric Mental
Health Advanced Practice Registered Nurse in the United
States. Archives of Psychiatric Nursing, 2014;28: 298-300
• [Clinical Nurse Specialist]: Rutgers University in 1954-the
development of skills in psychotherapy. Competencies also
included organizational analysis and consultation service—a
systems understanding of nursing, healthcare delivery and the
change process.
• The American Psychiatric Nurses Association (APNA) and the
International Society of Psychiatric-Mental Health Nurses (ISPN)
convened a joint task force of PMH nursing leaders. The primary
recommendation was that “there will be one entry educational
focus for the future: PMH NP with preparation across the lifespan,
addressing mental health promotion and mental illness diagnosis
and treatment”
Physician Assistants
• A physician assistant (or PA) is a nationally certified
and state-licensed medical professional.
• PAs practice medicine on healthcare teams with
physicians and other providers.
• They practice and prescribe medication in all 50
states, the District of Columbia and all U.S. territories,
with the exception of Puerto Rico.
www.aapa.org
What can a physician assistant do for me?
PAs can:
• Take your medical history
• Conduct physical exams
• Diagnose and treat illnesses
• Order and interpret tests
• Develop treatment plans
• Counsel on preventive care
• Assist in surgery
• Write prescriptions
• Make rounds in hospitals and nursing homes
What Can a Psychiatric PA do?
PAs can:
• Take a psychiatric/addiction history
• Conduct physical exams and mental status exams
• Diagnose and treat mental illnesses
• Order and interpret tests
• Develop treatment plans
• Counsel on preventive care
• Write prescriptions (except for O.B.O.T.—buprenorphine)
• Make rounds in hospitals and nursing homes
• Handle general medical needs of the psychiatric and addiction care
patient
Moran M. Physician assistants extend access to
psychiatric care. Psychiatric News 2003:38:5.
"PAs are trained to do things by the book," said Bruce Pfohl,
M.D., a professor of psychiatry at the University of Iowa and
past director of the university's outpatient clinic, where two PAs
are now employed. "They tend to be very systematic and are
well trained to practice evidence-based medicine. The majority
of the patients we see respond very well to standard treatment,
so it's a matter of following things by the book to decide how to
treat them. PAs do an excellent job of that."
Moran M. Physician assistants extend access to
psychiatric care. Psychiatric News 2003:38:5.
"While they are extenders, they are not replacements," said
Bedi. "To use this model correctly, you need to understand the
limitations and play to the strengths. I have no problem
delegating to a PA who knows how to use the medications and
knows that I expect to be called for consultation. And they do
extremely well in an inpatient setting because they get
supervision almost daily. In this way, the psychiatrist can be in
charge of 25 patients instead of 15."
For many policymakers, this topic
is all about workforce issues
• There will never be enough psychiatrists to meet the clinical
or public health needs
• We can look to non-psychiatric MH providers (PhDs, PsyDs,
MSWs, etc)
• Or we can look to Physician Assistants and
Psychiatric/Mental Health Nurse Practitioners
http://www.integration.samhsa.gov/images/res/Workforce,%204.22.pdf
For many policymakers, this topic is all
about workforce issues
• Not a new topic for SAMHSA
• Major conference in Washington, DC
• Integrating Substance Use Services into Primary Care:
Workforce Issues
• August 10-11, 2011
How are PA’s Trained?
Greg Thomas, P.A.-C, M.P.H, director of external
relations at the National Commission on Certification of
Physician Assistants (NCCPA), explained that the typical
curriculum for an accredited PA program is a 27-month
master’s degree program that is based on a medicaleducation model consisting of one year of didactics and a
second year of clinical rotations—which includes a
rotation in psychiatry as an option.
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News
2014:49:15
How are PA’s Trained?
• Currently, the NCCPA is urging PAs who want to join a collaborative
team in psychiatric practices to obtain the Certificate of Added
Qualifications (CAQ) in psychiatry, a new specialty credential that is
held by about 10 percent of the certified PAs working in psychiatry.
• Under CAQ requirements, prospective candidates will have to work
2,000 hours (the equivalent of one year) and earn 150 Category 1
CME credits related to psychiatry within the six years prior to applying
for the CAQ exam, in addition to earning 50 CME credits within the
two years after taking the exam.
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News
2014:49:15
How are PA’s Trained?
• “…specially designed PA ‘residency’ program in psychiatry at the
Cherokee Mental Health Institute in Cherokee, Iowa-a state in which
only 21 of the 99 counties can boast a psychiatrist, and where 80
percent of the state's psychiatrists are in five counties.”
• “The institute, a 60-bed state mental health facility, designed the oneyear program for individuals already certified as physician assistants
with a particular interest in psychiatry.”
• “Cherokee's appears to have a precarious future, having stopped and
started and stopped again due to lack of money. It's costly and labor
intensive, and we haven't found people to fund it."
Moran M. Physician assistants extend access to psychiatric care. Psychiatric News
2003:38:5.
Final Comments on PA’s
• Greg Thomas, P.A.-C, M.P.H, director of external relations
at the National Commission on Certification of Physician
Assistants (NCCPA): “There are roughly 100,000 certified
practicing PAs in the United States, with approximately
1,500 of them working in psychiatry.”
• Thomas stressed that PAs will never be replacements for
physicians. “The PA profession was started by physicians
and will always be linked to physicians. The doctor is the
supervisor.”
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News
2014:49:15
Thank you!
Michael M. Miller, MD, FASAM, FAPA
mmiller@rogershospital.org
Herrington Recovery Center
at Rogers Memorial Hospital
For more information, call
800-767-4411
or visit
rogershospital.org