pc/pcp role session objectives -...
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Primary Care Provider & Psychiatric Consultant Roles
Joseph CerimeleAnna Ratzliff
PC/PCP Role Session Objectives
By the end of the session, participants will:
1. Understand the role of the psychiatric consultant and PCP to support care in a IMPACT care workflow
2. Practice team communication required to provide team-based care
3. Develop a plan to champion PCP engagement and share information from the training
Working as a TeamRole of the PCP and Psychiatric Consultant
Joseph CerimeleAnna Ratzliff
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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Primary Care Provider
PCP oversees all aspects of patient’s care.Introduces collaborative care teamDiagnoses common mental disordersStarts & prescribes pharmacotherapyMakes treatment adjustment in consultation with team
PCP
Patient CareManager
PsychiatricConsultant
Psychotherapist
CoreProgram
Additional ClinicResources
Psychiatric Consultant
Supports care managers and PCPs through caseload consultation.Provides regular (weekly) and as needed consultation on a caseload of patients followed in primary careFocus on patients who are not improving clinically+/- In person or telemedicine consultation Provides education for team
PCP
Patient CareManager
PsychiatricConsultant
Psychotherapist
CoreProgram
Additional ClinicResources
Behavioral Health Care Manager
Owns the caseload of patient and coordinates integrated treatment plans. Either BH CM or psychotherapist delivers brief behavioral interventions.
Facilitates patient engagement and behavioral health educationPerforms systematic initial and follow-up assessments; Systematically tracks treatment response;Supports treatment plan with PCPs; Reviews challenging patients with the consulting psychiatrist weekly
PCP
Patient CareManager
PsychiatricConsultant
Psychotherapist
CoreProgram
Additional ClinicResources
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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PC/PCP Role
Identify & Engage
Establish a Diagnosis
InitiateTreatment
Follow-upCare & Treat to Target
CompleteTreatment & Relapse Prevention
System Level Supports
Behavioral Health Measures as “Vital Signs”• Behavioral health measures are
like monitoring blood pressure!– Identify that there is a problem– Need further assessment to understand
the cause of the “abnormality”– Help with ongoing monitoring to measure
response to treatment
PC/PCP Role
Identify & Engage
Establish a Diagnosis
InitiateTreatment
Follow-upCare & Treat to Target
CompleteTreatment & Relapse Prevention
System Level Supports
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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Weekly Caseload ConsultationCare Manager Psychiatric Consultant
Model Consultation Hour• Brief check in
– Changes in the clinic– Systems questions
• Identify patients and conduct reviews– Requested by CM– Not improved w/o note– Severity of presentation– Disengaged from care
• Wrap up– Confirm next consultation hour– Send any educational resources discussed
Prioritizing Cases for ReviewCare Manager Psychiatric Consultant
CM will flag patient for next call with psychiatric consultant
Can sort to identify patients
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Psychiatric Consultation
CM will flag patientfor next call withpsychiatricconsultant
Easily identify patients not improved with no prior psychiatric consultation
Common Consultation Questions
• Consider re-screening patient • Patient may need additional assessment
Clarification of diagnosis
• Make sure patient has adequate dose for adequate duration• Provide multiple additional treatment options
Address treatment resistant disorders
• Help differentiate crisis from distress• Support development of treatment plans/team approach for patients
with behavioral dyscontrol• Support protocols to meet demands for opioids, benzodiazepines etc…• Support the providers managing THEIR distress
Recommendations for managing difficult patients
Assessment and Diagnosis in the Primary Care Clinic
Functioning as a “back seat driver”• DDevelop an understanding of
the relative strengths and limitations of the providers on your team
• RRelying on other providers (PCP and BHP/Care Manager) to gather history
How do you “steer”?• SStructure your information
gathering (Structured Assessment)
• IInclude assessment of functional impairment
• PPay attention to mental status exam
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Clinical Dashboard: Shared Patient Summary
Uncertainty:Requests for More Information
Complete information
Sufficient information
• Tension between complete and sufficientinformation to make a recommendation
• Often use risk benefit analysis of the intervention you are proposing
Provisional Diagnosis
Provisional diagnosis
and treatment
plan
Screeners filled out by
patient
Assessment by BHP and
PCPConsulting Psychiatrist
Case Review or Direct
Evaluation
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Assessment and Diagnosis in the Primary Care Clinic
Gather information
Exchange information
Generate a treatment
plan
Provide intervention
• Diagnosis can require multiple iterations of assessment and intervention
• Advantage of population based care is longitudinal observation and objective data
• Start with diagnosis that is your ‘best understanding’
PC/PCP Role
Identify & Engage
Establish a Diagnosis
InitiateTreatment
Follow-upCare & Treat to Target
CompleteTreatment & Relapse Prevention
System Level Supports
Recommendations: Medication Treatment
Focus on evidence-based treatments and
treatment algorithms
Brief medication instructions
Details about titrating and monitoring
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Recommendations: Other Interventions
Support managing difficult patients• Working with demanding
patients• Protocols for managing
suicidal ideation• Working with patients with
chronic pain
More recommendations “Beyond Medications”• Behavioral Medicine and
Brief Psychotherapy• Referrals and Community
Resources
Why Brief Behavioral Interventions?
Feel Bad
Do LessBrief Behavioral Interventions
Medications
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Role for PCPs in Behavioral Treatment
Opportunity• Sell• Explain WHY recommending engagement in
Collaborative Care
Relationship• Engage patients and strengthen
commitment• Integrate with medication treatment
Typically we think of acting from the “inside out”
(e.g., we wait to feel motivated before completing tasks)
In BA, we ask people to act according to a plan or goal rather than a
feeling or internal state
Approach: Outside In
PC/PCP Role
Identify & Engage
Establish a Diagnosis
InitiateTreatment
Follow-upCare & Treat to Target
CompleteTreatment & Relapse Prevention
System Level Supports
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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Track Treatment Outcome Over Time
A Different Kind of NoteTraditional Consult Note
One consult note
Integrated Care Case Reviews
Note 1: January
Side effects
Note 2: March
Pt still has high PHQ
Note 3 – May: Pt improved!
‘Disclaimer’ on Psychiatric Case Review NoteThe above treatment considerations and suggestions are
based on consultations with the patient’s care manager and a review of information available in the care management tracking system. I have not personally examined the patient. All recommendations should be implemented with consideration of the patient s relevant prior history and current clinical status. Please feel free to call me with any questions abut the care of this patient.”
•Dr. X, Consulting Psychiatrist•Phone #•Pager #•E-mail
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In Person AssessmentSeeing patients directly in collaborative care is different than traditional consultation!
Patients pre-screened from care manger population
• Already familiar with patient history and symptoms• Typically more focused assessment
Common indications for direct assessment
• Diagnostic dilemmas• Treatment resistance• Education about diagnosis or medications• Complex patients, such as pregnant or medical complicated
Psychiatric Consultant Offer
“You can do this, I’m here for you.”“I’ve got your back.”
• Maximize ability to provide care without specialty referral to psychiatry prioritize patients for limited resource
• Provide education algorithms, articles• Psychiatric consultant readily accessible to
support this work
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PC/PCP Role
Identify & Engage
Establish a Diagnosis
InitiateTreatment
Follow-upCare & Treat to Target
CompleteTreatment &
RelapsePrevention
System Level Supports
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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Relapse Prevention Plan
Questions?
Team CommunicationFor the PCP and Psychiatric Consultant
Primary Care Provider & Psychiatric Consultant Roles 9/27/14
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Provider to Provider Communication
PCP
Patient CareManager
PsychiatricConsultant
Psychotherapist
CoreProgram
Additional ClinicResources
New Roles
Team Communication Plan
PCP Communication CM Communication Plan
How do you want theCM to communicatewith you?
• Format?• Modality?• Frequency?
Give feedback!• What is working?• What can be
improved?
PC Communication Plan
How do you plan to contact the PC with questions?
• Phone?• E-mail?• Via CM?
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Consulting Psychiatrist Communication
CM Communication Plan
Regular consultation!
How do you want theCM to communicatewith you urgently?
• Format?• Modality?• Frequency?
Give feedback!• What is working?• What can be improved
PC Communication PlanHow do you plan to communicate with the PCP?
• Phone?• E-mail?• Via CM?
Case Consultation Practice!1) Role Play
– Psychiatric Consultant (played by psychiatric consultant)– PCP/BHP (played by PCP)
2) BHP/PCP: Read vignette
3) Psychiatric Consultant: Provide consultation– Would you make a recommendation based on the info
(consider the source – phone vs e-mail)?– If not, what additional information would be required
(tension between uncertainty and requests for more information)?
4) Switch PCPs and Repeat41
Planning to Champion PCP Engagement
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How Can You Engage Your PCPs?• Pick a time!
– Provider meeting?– Rolling information session?
• Determine content!– Daniel video– PCP role– Program specific
• Reward attention!– Depression care update– Medication sheet
• Get organized!– Who will present? – What resources would help you?
• Ongoing promotion!– Celebrate success – SIF IMPACT updates in newsletters and bulletin boards– Ongoing education and promotion
Planning!
• Get into your clinic group• Brainstorm ideas using worksheet• Leave with a plan!
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Medications for Depression
Most Patients NeedTreatment Adjustments
30 – 50% of patients will
have a complete
response to initial
treatment
50 – 70% will require at least one change in
treatment to get better
If Patients Do Not Improve, Consider:Wrong diagnosis?
Problems with treatment adherence?
Insufficient dose / duration of treatment?
Side effects?
Initial treatment not effective?
Other complicating factors?• psychosocial stressors / barriers• medical problems / medications• ‘psychological’ barriers• substance abuse• other psychiatric problems
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Major Depression Medication Treatment
SSRI•Fluoxetine/Prozac•Sertraline/Zoloft•Citalopram/Celexa•Escitalopram/Lexapro•Paroxetine/Paxil•Fluvoxamine/Luvox
SNRI•Venlafaxine/ Effexor•Duloxetine/Cymblta
Other•Newer:
•Bupropion / Wellbutrin / Zyban,•Mirtazapine / Remeron
•Older:•TCA (Amitriptyline, Nortriptyline )•MAOI
Common Augmentation•Buspirone /Buspar•Antipsychotic medications (ex. Abilify
or Seroquel)
Choosing Antidepressants
Prior treatment history in patient/family members
Patient preferences
Expertise of prescribing provider
Side effect profile
Safety in overdose (TCA)
Drug-drug interactions
Stepped Depression Treatment
SSRI, SNRI, Bupropion
Switch Medication, Switch Class, Augment with
Bupropion, Mirtazapine
Antipsychotic, TCA
Other
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Common Side Effects
Short term:• GI upset / nausea• Jitteriness / restlessness
/ insomnia• Sedation / fatigue
Long term:• Sexual dysfunction (up
to 33%)• Weight gain (5 – 10%)
Managing Side Effects
Discuss with psychiatric consultant
Short term strategies
Change to a different antidepressant
Change to or add
Behavioral Treatment
InsomniaTreat depression
effectively!– Sedating
antidepressants• Mirtazapine (15-45 mg po
qhs)– Short term
• Add zolpidem (Ambien; 5-10 mg) or eszopiclone(Lunesta; 1-2 mg)
– Longer term• Add low dose Trazodone
(25-100 mg po qhs)
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Sexual Dysfunction (anorgasmia)25 – 33% of SSRI-treated
patients:– Change to:
• Bupropion• Mirtazapine
– Augment• Bupropion SR 100mg PO
BID• Buspirone 15mg-30mg PO
BID
Weight Gain5 – 10% of SSRI-treated
patients• Change to
– Bupropion– Fluoxetine
• Physical exercise
Drug-Drug InteractionsAntidepressants are metabolized by the P450
isoenzyme system in the liver. They can:– Change blood levels of other drugs that are metabolized
by the same hepatic enzymes– Displace other protein-bound drugs
Rule of thumb: if a patient is on a drug with a narrow therapeutic window (e.g., digoxin, warfarin, theophylline, antiarrhythmics, lithium, TCAs, anticonvulsants), check a serum level of that drug when a steady state of the antidepressant is reached or if there are side effects
Consult pharmacist
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Good Reasons to Stop a Medication
Intolerable side effects
Dangerous interactions with necessary medications
The medication was not indicated to start with (e.g., bipolar depression)
Medication has been at maximum therapeutic dose without improvement for 4-8 weeks
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