Nathan Smith Clinic:Collaborative Care ModelLuming Li, MDAssistant Professor in PsychiatrySeptember 15, 2020

Learning Objectives

− Introduce the collaborative care model with practical description of the model, its importance, the aims and objectives

− Discuss the structure of our collaborative program, including the members and roles

Intro of the collaborative care modelPractical description of the importance, aims, objectives, and model

SBAR for NSC Collaborative Care

Assessment

There is a growing need to systematically screen, diagnose, and treat depression at the NSC.

Recommendation

We propose and recommend the development and implementation of a collaborative care model in treating HIV population of patients.

Background

MDD is a highly treatable psychiatric condition with significant morbidity and mortality consequences worldwide. In the Nathan Smith Clinic (NSC) with its population of HIV+ and PrEP patients, depression treatment is screened through a PHQ-2 at annual screenings and currently managed by primary care residents and HIV attendings. Data suggests many patients have co-morbid depression. The process for screening, diagnosis, and treatment has not been rigorously tracked for consistent and systematic treatment of MDD. One model of care that has been developed (and used nationwide), is the collaborative care model for depression management. The collaborative care model restructures the role of the psychiatrist and primary care provider to more efficiently treat depression at population-health level, and tracks management of depression symptoms through the role of a care manager. .

Situation

Major depressive disorder (MDD) continues to be an under-detected, and under-treated condition. Under-detection can result from lack of structured depression screening. Under-treatment results from lack of adequate and consistent monitoring of symptoms and treatment progress.

At Nathan Smith

45%

28%

8%

5%

2%

3%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

MOOD DISORDERS

ANXIETY DISORDERS

PSYCHOTIC DISORDERS

COGNITIVE DISORDERS

DEVELOPMENTAL DISORDERS

PERSONALITY DISORDERS

Psychiatric Conditions

Depression and HIV

− Depression treatment and HIV outcomes− Comparative effectiveness of dual vs single action

antidepressant − Viral suppression VL<200− PHQ 9− Results:

−Viral suppression increased 16% after antidepressants

−Elevation of 39 CD T cells −No differences in comparative effectiveness (Mills 2017)

NSC Collaborative Care Model

Patient

Primary Care HIV Resident & HIV

Attending

Psychiatrists as Consultants

Care Manager: LCSW to manage

therapy and Pharmacist to

manage medication titration

https://aims.uw.edu/sites/default/files/PCP_role_handout.pdfhttp://depts.washington.edu/aimstrng/pcp/

Care Management and Care Coordination

− Care manager responsibilities include: − Initial evaluation and assessment of depression and other

common mental disorders, or for medical conditions in patients with serious mental illnesses

− Patient engagement and education− Close and proactive follow-up focusing on treatment

adherence, treatment effectiveness, and treatment side effects− Brief counseling using established and evidence-based

techniques: − Motivational Interviewing− Behavioral Activation− Problem-Solving Treatment in Primary Care

Care Management in NSC

Pharmacist: • Track Med Management• Titrate Antidepressants• Discuss with Team• Document Findings• Advise on Medication

Strategy and Safety for antidepressants in (conjunction with HIV medications and other meds)

LCSW• Administer and track

scales (PHQ-9, MDQ, etc.)• Initiate & Monitor

Registry• Deliver Brief Therapy, (or

Online CBT)• Check-in with patients &• Communicate with NSC

residents, pharmacist, and psychiatrists

Psychiatric Consultant

− Supports care managers and PCPs − Provides regular (weekly) and as needed consultation on a

caseload of patients followed in primary care − Approximately 3 hours per week for 50-100 patients− Focus on patients who are not improving clinically

− In-person or telemedicine consultation or referral for complex patients (direct consultation)

− Provides education and training for primary care-based providers − Weekly caseload consultation with care manager (indirect

consultation)− Assessment and diagnosis in collaborative care − Creating treatment recommendations − Psychiatric consultant as educator

Algorithm 1

Algorithm 2

Algorithm 3

Patient Registry: Example

NSC Registry: Work in Progress

Thank You!

Discussion and Questions

Appendix Slides

Care Management and Care Coordination

− Regular (usually weekly) review of all patient who are not improving as expected with a psychiatric consultant

− Facilitation of communication between the PCP and the psychiatric consultant

− Facilitation of referrals to and coordination with outside mental health specialty care or medical specialty care, substance abuse services, and social services. Once patients have shown improvement, the care manager meets with the patient to establish a relapse prevention plan

− In collaborative care programs, the typical patient load for care managers is between 50 and 100 patients.

Psychiatric Consultant

− Notes about Direct Psychiatric Consultation: − In the original IMPACT trial, only 5%−7% of patients required

direct evaluation by the psychiatrist − Direct evaluations usually involve 1-2 visits with the

psychiatrist, who provides a written summary of suggestions for the primary care provider and behavioral health provider to consider.

− Overall responsibility for the care of the patient remains with the primary care provider

− The consultant psychiatric provider does not order medications or additional tests and typically does not build a caseload of patients to follow on a routine basis

Psychiatric Consultant

− Notes about Indirect Psychiatric Consultation: − Much more frequent than Direct Consultation− Provide advice without directly evaluating patients− Critical to the extension of psychiatric expertise to more people in need− Provide information immediately, so that the treatment can move forward

at the time of the primary care appointment− May require willingness to be interrupted or return a call (or text or e-

mail)− Ideally within an hour or at specified times during the day

− Consultation requests are about: 1. Pharmacologic recommendations2. Diagnostic clarification3. Recommendations for other forms of treatment

− Consultations typically take 3–5 minutes and cover a broad range of topics− Common questions are about mood, anxiety, and substance use

disorders

Additional Information

− Important Statistics− 20% of patients started on antidepressant medications in usual

primary care show substantial clinical improvements− 30-50% of patients have a full response to the first treatment

plan− 50-70% of patients need at least one change in treatment