aConsultation-Liaison-Psychiatry-Models-and-Processes-2019.pptx

Consultation Liason Psychiatry

1. Models and Process of Psychosomatic Medicine APM Resident Education Curriculum Revised 2017: Jeanne Lackamp , MD Revised 2013: Robert Joseph, MD, MS, R. Brett Lloyd, MD, PhD Original version 2011: Robert Joseph, MD, MS Version of March 15, 2019

2. Learning Objectives Describe different models of CL Psychiatry and differentiate from traditional office-based psychiatric care Identify essential tasks of the CL psychiatrist List the steps on a psychiatric consultation and the elements of the consult note Review different methods and structure of integrated mental health care programs 2

3. Introduction “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features Goals? Assist patients with mental health concerns within a medical context Make mental health concerns relatable and understandable for medical colleagues Improve patient lives via collaboration with medical colleagues 3

4. Psychosomatic Medicine Subspecialty at the interface of Medicine and Psychiatry Clinical service Research Training Consultation Liaison (CL) Psychiatry is the current name of the accredited subspecialty Feb 2017: American Board of Psychiatry and Neurology petitioned American Board of Medical Specialties (on behalf of Academy of Psychosomatic Medicine) to change the name back to “ Consultation-Liaison Psychiatry ”- granted Nov 2017: APM voted to change its name to ACLP 4

5. Models of CL Psychiatry Traditional/Conventional Hospital- or ambulatory-based “Consultation upon request” (reactive) Liaison psychiatry Mental Health Integration Hospital- or ambulatory-based Case finding/screening Proactive/systemic mental health involvement Population-based programs Disorder-specific programs Hybrid Models 5

6. Traditional Models “Consultation upon request” Reactive Patient- and consultee-specific Primary responsibility for patient remains with consultee Liaison psychiatry components Support Service, ward, nursing staff Can be specialty specific (OB, Oncology, Neurology etc.) Education Formal and informal education 6

7. Types of Patients Complex, co-morbid psychiatric and medical conditions Neurocognitive disorders Somatic symptom and functional disorders Psychiatric disorders secondary to medical conditions or treatments 7

8. Distinctions from Office-Based Psychiatry Services are requested by consultee Rare “self referral” by the patient Obligations to consultee as well as patient Patient is often unaware of referral Participation may be limited Patient may be ill, uncomfortable, or in pain Patient motivation is often compromised Privacy issues abound on inpatient med/surg wards Visits are not scheduled nor time based 8

9. Function of Psychiatric Consultation Doctor-to-doctor communication designed to address the mental health needs of the patient and improve patient care The over-riding concern is the patient’s well-being 9

10. Essential Tasks Complete a comprehensive psychiatric assessment and develop a reasonable management plan Remove impediments to medical care Bring a fresh perspective to the clinical dilemma Facilitate a mutual understanding between patient, doctor, and treatment team Educate the consultee about the emotional and neuropsychological needs of the patient 10

11. Steps in the Consultation (1) Review chart and identify consult question Discuss case with consultee To help delineate the manifest question and help identify any latent question(s) To help consultee reformulate their question, in a manner which addresses underlying issues and allows the consultant to be most helpful To help consultee with appropriate expectations of the consultant (what can/cannot be gained by consultation) 11

12. Steps in the Consultation (2) Determine urgency Routine versus urgent versus emergent Patient interaction Introduce self and sit down Share your reason for being there Address patient’s surprise at the arrival of a psychiatrist (if present) and diffuse tension (as needed) Attend to any physical discomfort Perform thorough interview Answer patient questions as able 12

13. Steps in the Consultation (3) Mental status exam Includes bedside cognitive testing Targeted physical exam (if appropriate) Ancillary history gathering is often appropriate Family Additional caregivers PCP Pharmacy Other 13

14. Steps in the Consultation (4) Written note Verbal communication (feedback) with consultee, regarding your opinion Follow-up visits as appropriate Range from none to daily 14

15. The Written Note (1) Formally addressed to the physician requesting the consultation Designed to be used by other members of the treatment team(s) who are treating the patient May be read by a variety of hospital personnel Consider the audience Consider confidentiality Consider medico-legal implications 15

16. The Written Note (2) Title “Psychosomatic Medicine” or “Psychiatry CL Service” Author(s) Attending Resident/fellow Other Nature of the note Initial Consultation Note Follow-up Consultation Note 16

17. The Written Note (3) Date and Time Particularly important when dealing with fluctuating mental status Source(s) Patient, family, medical record, other Identifying statement This lays the groundwork for your formulation and recommendations in a way that helps the readers to understand your note 17

18. The Written Note (4) Reason for consultation Why did the primary treatment team request a psychiatric evaluation? There is often a difference between what the primary team requests and what they actually want from the psychiatrist Manifest request : R/O depression Latent request : There is nothing actually wrong with this patient. She is manipulative and difficult. Please make her behave! 18

19. The Written Note (5) Identifying statement Important! “The patient is a 34 year old male admitted for abdominal pain with a history of multiple medical complaints and pain unresponsive to usual interventions. Psychiatry CL team was asked to evaluate him for possible depression.” A reiteration of the manifest question Reminds us to answer the question Respectful to consultee 19

20. The Written Note (6) History of present illness (HPI) Documents the essential positive and negative aspects of the history Provides a historical framework for understanding the patient Must include DSM descriptive characteristics and review of systems relevant to patient diagnosis Consider the following S pecial events of the patient’s life (e.g., losses, illnesses) P recipitants of the current psychological and physical difficulties N ature of the patient’s reaction to these precipitants Usual coping mechanisms and ability to implement them Availability of support systems (e.g., family/friends) 20

21. The Written Note (7) Past Medical/Surgical History Include menstrual and obstetric as applicable Past Psychiatric History Include past diagnoses, treatments, hospitalizations, suicide attempts Medication Prior to admission At time of consultation Recent changes Substance Use History Include history of complicated withdrawal, and MAT details as needed Family History Social History Include upbringing, abuse, legal, military, violence/legal as applicable 21

22. The Written Note (8) Physical Exam (as appropriate) Mental Status Exam Is analogous to the physical examination Reflects one point in time Addresses the question of the consultation and your formulation within the mental status examination Provides an opportunity to teach and to demonstrate how diagnoses are made Helps the clinician gain access to a patient’s mental life Pertinent laboratory and radiologic findings 22

23. The Written Note (9) Assessment/Impression Other than recommendations, the most likely part of the consult to be read Should have the components of a good biopsychosocial formulation, but avoid psychiatric jargon whenever possible Know your audience and what you want to accomplish Include stressors and functional status Differential diagnosis, including personality disorders and medical disorders 23

24. The Written Note (10) Diagnosis DSM-5 is the primary diagnostic framework List ICD-9-CM V codes related to psychosocial and environmental problems WHODAS may be used to demonstrated disability 24

25. WHODAS: World Health Organization Disability Assessment Schedule 2.0 Axis V (GAF) was dropped from DSM-5 WHODAS is included for further study as an assessment tool for functioning 36-item, self-administered measure used to assess disability in adults (age 18+) 25 Included in Section III of the DSM-5 Domains include: Communication, getting around, self-care, relationships, household activities, school and work activities, participation in society

26. The Written Note (11) Plan/Recommendations Most likely part of the consultation to be read! Safety elements (e.g., does patient require 1:1 observation) Further work-up suggested (e.g., labs, EKG, imaging, EEG) Physician management Medication – scheduled and PRNs, with specific indications Behavioral approaches with patient – be clear, avoid jargon Nursing management (e.g., restraint initiation/limitations) Social service needs Legal issues (e.g., legal guardian, involuntary transfer status) Aftercare plans Consultant follow-up Inform treatment team of your availability, whether/when you will return, and the purpose of your return 26

27. Mental Health Integration (1) “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features Goals? Assist patients with mental health concerns within a medical context Make mental health concerns relatable and understandable for medical colleagues Improve patient lives via collaboration with medical colleagues 27

28. Mental Health Integration (2) Collaboration within multidisciplinary team framework Mental Health (MH) + non-Mental Health (non-MH) providers Psychiatrist, other MDs, PhDs, SW, NPs/PAs, RNs, case managers, support staff Elements of integration Mission Optimal care for mental health/behavioral issues in non-MH setting Target population Patients with co-morbid medical and psychiatric problems Patients with MH problem but no other MH care Location Generally involves co-location of MH staff in medical site Communication Team meetings, shared medical records, shared treatment plans Administration Shared or coordinated efforts between MH and non-MH staff Fiscal Integrated budget for MH and medical staff vs. separate 28

29. Mental Health Integration (3) General hospital-based Tends to be disorder specific E.g., delirium, transplant, or substance use disorder teams in the general hospital setting Ambulatory Primary care clinics Medical/Surgical specialty clinics OB, Oncology, Neurology, Transplant etc. 29

30. Mental Health Integration (4) Rationale Improved access Need for improved access to MH services Patient reluctance to go to MH clinic Patient-centered care Prevalence of mental health (MH) issues in medical settings Improved medical and psychiatric clinical outcomes Extensive co-morbidity of medical and MH disorders Bidirectional adverse effect of co-morbid disorders Associated morbidity and cost of disorders 30

31. Mental Health Integration (5) Method/structure Reactive programs Mimic traditional consult services, except perhaps for co-location Planned programs Highly structured, oriented toward “Disease Management” Value added Delirium prevention programs Anxiety, depression, bipolar disorder, schizophrenia, and substance use disorder management in primary care Co-morbid MH and medical disorders Depression, diabetes, cardiac disorders Medically Unexplained Physical Symptoms (MUPS) 31

32. Mental Health Integration (6) Planned care framework Addressing behavioral health disorders in medical clinics Derivative of chronic disease management programs Over 70 randomized control trials have established value of collaborative care for patients with mental health issues 32

33. Mental Health Integration (7) Methods Proactive screening/case identification by designated team members Patient-centered care Co-location does not equal collaboration Population-based care Create patient registries and tracking methods to monitor progress Algorithm- or otherwise evidence-based treatments Measurements Based on tracking results, changes are made until treatment is effective Team management and case management Accountable care Providers are held accountable (and reimbursed) based on quality of patient care and outcomes, not merely the volume of patients 33

34. Mental Health Integration (8) Psychiatrist role as a collaborative care team member? Receive referrals and “warm hand-offs” from primary care colleagues Consult and provide supervision on a scheduled and PRN basis, for an identified caseload of patients followed in the medical clinic Function as the team expert Support the team as they engage with the patient Give mental health input and suggestions for evidence-based care Function as an educator Teach medical colleagues clinically-relevant and evidence-based information, with relevance for the patient cohort in question 34

35. Conclusions “Psychosomatic Medicine” + “Consultation-Liaison Psychiatry” + “Integrated Care” + “Collaborative Care” share core features Goals? Assist patients with mental health concerns within a medical context Make mental health concerns relatable and understandable for medical colleagues Improve patient lives via collaboration with medical colleagues THANK YOU! 35

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37. REFERENCES Katon W et al. 2010. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 363:2611-2620. Kontos N; Querques J. Psychiatric consultation to medical and surgical patients. 2008. In: Stern TA, Rosenbaum JF, Fava M, et al. eds : Massachusetts General Hospital Comprehensive Clinical Psychiatry . Philadelphia: Mosby-Elsevier. 749-760. Meyer F, Joseph RC, Peteet JR. 2009. Models of Care for Co-occurring Mental and Medical Disorders. Harvard Review of Psychiatry 17(6):353-60. Press MJ et al. 2017. Medicare payment for behavioral health integration. N Engl J Med 376(5):405-407. Salerno, SM et al. 2007. Principles of effective consultation: An update for the 21 st -century consultant. Arch Intern Med 167:271-275. Shannon D. 2012. Effective physician-to-physician communication: an essential ingredient for care coordination. Physician Exec 38(1):16-21. 37

38. REFERENCES Smith G; Clarke D. 2006. Assessing the Effectiveness of Integrated Interventions: Terminology and Approach. Med Clin N Am 90:533-548. Sola CL, Bostwick JM, Sampson S. 2007. Benefits of an Electronic Consultation-Liaison Note System: Better Notes Faster. Academic Psychiatry 31(1):61-63. Venkat KK. 2015. Short and sweet: Writing better consult notes in the era of the electronic medical record. Cleveland Clinic Journal of Medicine 82(1):13-17. Weiner, JP et al. 2007. e- Iatrogenesis : The Most Critical Unintended Consequence of CPOE and other HIT. JAMIA 14(3):387-388. Williams J et al. 2007. Systematic Review of Multifaceted Interventions to Improve Depression Care. General Hospital Psychiatry 29:91-116. 38

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