Training the 21st Century Psychiatrist for the Patient
Centered Medical HomeJeralyn Jones, MD
Alex J. Reed, PsyD, MPH
Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.
Session # FB5October 6, 2012
Faculty Disclosure
We have not had any relevant financial relationships during the past 12 months.
How are people integrating family medicine and psychiatry?
How are people integrating family medicine and psychiatry training?
Objectives
• Participants will understand the rationale and forces driving integrated health care.
• Participants will be able to describe different models of psychiatric collaboration with primary care providers.
• Participants will explore the challenges and benefits of educating today’s trainees for the integrated care practice of tomorrow.
Boun
Bonner
Kootenai
BenewahBenewah Shoshone
LatahLatah
ClearwaterClearwater
Nez Perce
Lewis
Idaho
Adams
ValleyValley
Washington
Payette
Canyon
Boise
Ada
Owyhee
Twin Falls
Jerome
Blaine
Lincoln
Minidoka
Cassia
Power
OneidaFranklin
Bear Lake
Bannock
Caribou
Bingham
Lemhi
CusterClark Fremont
TetonJefferson Madison
Bonneville
Butte
Gooding
CamasElmore
Gem
Idaho Mental Health Professional Shortage AreaService Areas
Geographic HPSA
State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 4/07 – please contact (208) 334-5993 for updates
Facility
Idaho Primary Care Health Professional Shortage AreaService Areas
Geographic HPSA
Population Group HPSA
State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 5/12 – please contact (208) 334-5993 for updates
Bonner
Kootenai
BenewahBenewah Shoshone
Latah
Clearwater
Idaho
Adams
Washington
Payette
Canyon
Ada
Owyhee
Twin Falls
Jerome
Blaine
Lincoln
Minidoka
CassiaBear Lake
CusterClark Fremont
Gooding
CamasElmore
Gem
Bannock
Valley
Lewis
Nez Perce
Lemhi
Power
FranklinOneida
Boise
Butte
Bingham
JeffersonMadison Teton
Caribou
Boundary
Bonneville
Patient Centered Medical Home
AAFPAAPACPAOA
?APA
Elements of PCMH
Personal Physician
Physician directed medical practice
Whole Person Orientation
Integrated/Coordinated Care
Enhanced Access to care
Quality and Safety
Payment Reform
Psychiatry
Accountable Care Organization (ACO)
An ACO is an entity that will be “held accountable” for providing comprehensive health services to a defined population
Cost HMO in Drag? Accountability
Primary Care focus
University of Washington Idaho Advanced Clinician Track/
Primary Care Psychiatry Training or…
EXTREME INTEGRATED PRIMARY CARE!!!!
Somewhat Censored !!!
Mental Illness in Primary Care
• Most patients with mental health disorders initially present to their PCP.
• Primary care is the “de facto” mental health system for 70% of the population.
• 80% of all psychotropic medications are prescribed by nonpsychiatric medical providers*
*Katon, W., Reis, R.K., Kleinman, A. (1984). The prevalence of somatization in primary care. Compr Psychiatry, 25 (2)., 208-215
Chronic Conditions and MH
Cost w/o Mental Health Condition
Cost w/Mental Health Condition
All Adults $1,913 $3,545
Heart Condition $4,697 $6,919
High Blood Pressure $3,481 $5,492
Asthma $2,908 $4,028
Diabetes $4,172 $5,559
Agency for Healthcare Research and Quality (2003). Medical Expenditure Panel Survey, Rockville, MD.
Depression in Patients with Comorbid Medical Illness
Comorbid Medical Illness Prevalence Rate (%)Cardiac Disease 17-27
Cerebrovascular Disease 14-19
Alzheimer’s Disease 4-75
Epilepsy – Recurrent 20-55
Epilepsy – Controlled 3-9
Diabetes – Self-reported 26
Diagnostic interview 9
Cancer 22-29
HIV-AIDS 5-20
Pain 30-54
Obesity 20-30
General Population 10.3
Evans et al. (2005). Mood Disorders in the Medically Ill: Scientific Review and Recommendations. Biol Psychiatry, 58, 175-189
Traditional Mental Health
Primary Care
Typical Morning in FM Practice
56 y.o. diabetic w/ poor control19 y.o. smoker for annual exam33 y.o. w/ multiple somatic issues7 y.o. with otitis media67 y.o. with insomnia70 y.o. with sinusitis52 y.o. with HTN28 y.o with chest pain & SOB
Anxious
Smoking CessationDepressionEnuresis
Alcohol Abuse
Family Violence
PTSD
Panic DisorderGunn, W. B. & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psycholog, 65 (3), 235-252.
Tell me and I forget, Show me, and I may remember
Involve me, and I will understandConfuscius
Patient Centered Medical Home
One Day per week PGY3 and PGY4
Psychiatrist
Continuity clinic PAC Precepting
with FM
Psychologist
WBC-Brief Behavioral
FM Didactics
Psychiatry Resident
FQHC—Federally qualified health center
Safety Net Clinic
Patients with complex medical/psychiatric illness, few resources
Sawtooth Model
PAC/WBC
Attending Room
Evolution of the 21st Century Psychiatrist
Sawtooth Model
• Recognition illness• Access care• Comprehensive
model
• Help!!!• Education psych• Learn new model
• Measurement driven referrals
• Teach/Expert• Understand/access FM
• Direct OP observation patient care/teach
• Learn new model• Collaborate FM/Psych
Patient FM Resident
Psychiatry ResidentSupervisor
Determinants of Health
Schroeder, Steven A., We Can Do Better -- Improving the Health of the American People, N Engl J Med 2007 357: 1221-1228
Wellness Behavior Clinic
• Opportunity to see patients for behavioral health visits using specific assessment and intervention techniques
• Can use these techniques to provide behavioral health interventions on the fly
• Residents rotate into the clinic and learn these techniques while being observed by the “team” in another room
Let’s Play…Program:
Support top downUW PsychFM
Funders interested
Faculty comfortable FM
Evolving model
Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!