Psychosis and safety management in integrated primary care

Verena Roberts, Ph.D., Integrated Primary Care PsychologistElizabeth Lowdermilk, M.D., Psychiatrist

Collaborative Family Healthcare Association 14th Annual ConferenceOctober 4-6, 2012 Austin, Texas U.S.A.

Session # F6bOctober 6, 2012

Faculty Disclosure

We have not had any relevant financial relationships

during the past 12 months.

Objectives

• Attendees will learn how to successfully integrate behavioral health and psychiatry into primary care

• Attendees will learn innovative approaches to management of patients with psychosis and high risk behaviors, such as safety issues

• Attendees will learn key differences and challenges in management of psychosis and safety concerns within an integrated primary care setting as compared to traditional mental health management

• Attendees will learn to pay attention to the fact that no existing standards and accepted norms of practice exist to date.

Learning AssessmentA learning assessment is required for CE credit.

Attention Presenters:Please incorporate audience interaction through a

brief Question & Answer period during or at the conclusion of your presentation.

This component MUST be done in lieu of a written pre- or post-test based on your learning objectives to satisfy

accreditation requirements.

Denver Health – Overview CHS

Eastside Family Health Center(GIM)

Medical Director/Team Leader (MD)Program Manager (RN)6 FT/3 PT MD Attendings8 Internal Medicine Residents1 Behavioral Health Consultant (PhD) and 1 BHC resident 1 Psychiatrist and 1 psychiatry resident2 Social Workers2 Clinical Pharmacists2 RNs1 Patient Navigator6 Medical Assistants a/k/a Health Care Partners (HCPs)3 Laboratory Technicians Clerical Supervisor5 Clerks

Clinic Make-up

• Eastside Clinic is a federally qualified community health center which provides primary care medical services for low income patients in central Denver.

• The patients seen:– low income (97% are <200% of the federal poverty level),

uninsured or on public insurance (24% Medicare, 31% Medicaid, 43% uninsured)

– are mostly under-represented racial/ethnic minorities (41% African American, 34% Hispanic/Latino)

– Denver Health = “safety net”

Mental Health Services in DenverCurrent State

• The Mental Health Center of Denver (MHCD) is the largest provider of services– Over 5000 patients served at any given time– Each year, they serve approx. 14,000 patients– They serve those with medicaid, medicare & the indigent

population (self pay) & have a small insurance based clinic• Reimbursement is poor for medicare• Minimal state support for the care of the uninsured

– Much less than the actual cost of care & medications

– The demand for services is much greater then the number of spots• 100 pts call every day for 5-7 intake spots

Mental Health Services in DenverContinued

• Denver Health Medical Center– Is the primary site for inpatient care in Denver, we work

closely with MHCD to serve patients– Provides integrated care at the FQHCs (more later)

• smaller integrated care presence in the Women’s clinic & the HIV primary care clinic

– Multiple specialty outpatient teams• Child & Adolescent, Substance Use Disorders, Methadone, ID clinic

– Limited outpatient services for general adult population• Small team - 1.7 FTE prescriber time and 2.0 FTE psychology time• Severity of illness that can be cared for is limited by the lack of

ancillary services– No CM support, minimal nursing support

Mental Health Services in DenverContinued

• The Colorado Coalition for the Homeless– Serves the homeless population, medical and psychiatrically– Psychiatric clinic closed to intake due to high demand– Have incorporated integrated care approach in one of their primary care

locations to help meet the need

• The University of Colorado – Resident clinic serves some of the medicare/ medicaid population, but they

too are limited in the severity of illnesses that they can accommodate

• There are various other programs that offer sliding scale counseling (typically training programs) – typically these are small, and not set up to accommodate the more seriously mentally ill

Mental Health Services in DenverThe Bottom Line

• There are very few agencies capable of handling those with severe and persistent mental illness– Significant unmet need

• The Mental Health Center of Denver gets over 100 calls every day for 5 to 7 intake slots

– There are fewer slots for the uninsured population– Poor Medicare reimbursement leads to significant access

problems for this group as well

• And the problem is growing– The impact of the economic downturn– We are facing a national workforce shortage in psychiatry

So, What Happens to the Patients?

• Multiple hospitalizations and ER visits• Medical Illnesses worsen due to untreated mental

illnesses• Primary Care Physicians have become the defacto

psychiatric providers for thousands of patients at Denver Health

This has led to the development of innovative new approaches to psychiatric treatment

Key Features of Integrated Care

• FT Psychologist and PT psychology student– 2 scheduled 30 min. behavioral health appointments per

session (for further evals, tx)• Allows for overbooks for pt. with high follow-up needs

– Scheduled and unscheduled (warm-handoffs) integrated visits with PCPs

• PT Psychiatrist & PT psychiatry resident– 1 pm session a week in clinic– 3-4 40 min. scheduled appointments (3 + 1 OVBK)– E-mail/phone consults about patients - ongoing

Overview of Integrated Care

• BHC and psychiatrist are “pulled” into care of patients by PCP on an “as needed” basis (consultant model)– Since the BHC is on site, and the schedule allows for warm-handoffs,

evaluations (safety, psychosis) can be done during medical visit– BHC has more time to ask in depth questions

• “Order of tx”: All patients have to have BHC contact to clarify dx before being seen by or consulted about by psychiatrist

• BHC role: dx clarification, keeping close f/u with “high-risk” patients, some case management as related to managing such patients (including 3 phone calls and a letter if patients no-show for f/u), treatment

Overview of Integrated Care cont’d

• Psychiatrist: med evaluations and recommendations, limited to 1-3 visits with very few exceptions (try to utilize e-mail consults)

• Treatment length: orig. 4-6 BHS and ICV visits, referral for long-term tx

• Adjusted TX (current model): patients are seen as long as needed, making model clear to patients and continuing to work on LT referrals (applies mostly to high-risk patients)

• E-mail consults: PCP and BHC always included in e-mail – allows for better communication

Issues in the Management of Active Psychosis and Safety Issues in Primary Care Psychiatry/

Psychology• As we mental health providers merged into primary care

clinics, we have increased the recognition of active psychosis & safety issues

• We have identified:– issues of acute management• Here, the behavioral health clinician enhances the

services of the primary care clinic– Assessing and documenting safety issues

• We use existing resources to manage the cases – Security, a psychiatric emergency room, etc.

• Our standard of care and liability is the same as an emergency evaluation anywhere

Issues in the Management of Active Psychosis and Safety Issues in Primary Care Psychiatry/

PsychologyAnd we have identified issues of ongoing management:– Specialty care is always recommended• We document this• We document their attempts to access care or refusal• But as described before, many of our patients have

limited access to specialty care– Additionally, some are unwilling to go– Some say they will go but never take the steps to engage in

treatment elsewhere» From the outpt setting, we can not link the patient

directly to specialty services

• It became quickly apparent as we started our integrated care program that we needed to address this group of patients

• As a group of providers – mental health and primary care - we have decided that some treatment is better than no treatment

• Thus, we have opted to manage patients with active psychosis and safety issues with the primary care physicians in the FQHCs when necessary

• We have had to adjust our practices accordingly

Our Evolution Into the Process of Ongoing Management

Considerations in the Ongoing Management of Active Psychosis and

Safety Issues in the Primary Care Settings

• The standards of practice are different for primary care and specialty mental health care– Different level of assessment expected– Different level of follow up expected

• Outreach• Frequency and type of follow up

• There is no clearly defined standard of practice for this subset of patients by integrated care clinicians– No current case law

Considerations in the Ongoing Management of Active Psychosis and Safety Issues in the Primary

Care Settings – Cont.

• The FQHC clinic infrastructure does not support the typical management that a mental health center would provide– Mental health centers have CMs, therapists, nursing

support, urgent/ emergent resources, etc

• Thus, we have had to develop a “blended approach” for care of these patients

Integrated Care – Flow Chart

Med changes at visit

E-mail psychiatry if med choice

unsure or has failed

Pt. medical

visit

Meet BHC

Schedule psychiatry

visit - comprehens

ive cases

Referral to BHC for further

eval (OVBK 1-2 wks)

Initial (same) visit(may be f/u visit if established

patient)

Return in ICV

(PCP+ BHC) 1-4 wks.

Return in BHV

1-4 wks.

May utilize phone call in

between visits to monitor safety, med

response

2nd visit (or f/u visit if previous pt.)

Phone call/letter for no shows

according to risk level

Document efforts

This may be psychiatry

visit if overbooked

Pt. returned to

PCP/BHC for f/u visit

PCP calls pt. w/ med

E-mail psychiatry if med choice unsure or has failed

Med changes at visit

PCP calls pt. w/ med

May utilize phone call in

between visits to monitor safety, med

response

Management of Integrated Care Patients – Data Base

• We use a data base to track patients– For productivity– For quick overview– For risk management– For follow-up

Management of Integrated Care Patients – Risk Levels

Level 4 = highest risk•any patient with active safety issues•patients just discharging from the hospital•patients with active/concerning psychosis•goal contact would be weekly (or at minimum weekly attempts with documentation of outreach attempts)•Psychologist and psychiatrist discuss these patients weekly

Management of Integrated Care Patients – Risk Levels Cont’d

Level 3 = patients we are following who are not doing well, would want to outreach if they do not show, would discuss with PCP/ Psychiatrist as needed.•goal contact 1/month, •List reviewed periodically - looking specifically for those who are not showing up & need to be outreached•pts who need to be scheduled with psychiatry & for those who need to be referred to a higher level of care. •examples of such pts are:•patients who are having moderate to severe symptoms but no acute safety issues•patients who are not improving as we would expect/ hope (might raise the question of whether or not diagnosis is accurate and/or treatment is appropriate) •those you are actively working with to refer out for more intense mental health services

Management of Integrated Care Patients – Risk Levels Cont’d

Level 2 = patients we have no sig. concerns about but have routine involvement with.•could be pts we are seeing for a brief course of therapy, but are overall doing well•or pts we are seeing as an ICV when they are in clinic - if possible.•generally, these pts would have no safety issues, & no issues related to active psychosis•these are pts you would likely not outreach if they did not show for an appt.

Management of Integrated Care Patients – Risk Levels Cont’d

Level 1 - minimal risk •the patients seen once, available prn but no ongoing need/ services provided– i.e. patients now seen in specialty behavioral

health elsewhere

Case Example I

BB – 45 yr. old African-American•depressed, highly irritable, hx of recent fights•SI, HI (hx of plans, duty to warn, current plans)•trauma hx, antisocial PD, unclear psychosis (AH vs. his thoughts “blowing up cops”)•Denied current intent•Perseveration on how to hurt self/others (on train thought of “slitting kids throats” because they were irritating (when asked if he had a knife – handed over knife)•Met in ICV, PCP started antipsychotic•OVBK w/ psychiatry next week – no-show – called pt., no-showed for ICV, too.

– Another OVBK for psychiatry, now tag-teaming

•Safety plan, involving GF, frequent phone calls for monitoring med response and making sure he started meds •Referral to mental health center – but no efforts from pt. to f/u yet•Managed with monthly visits now•Risk level 4 initially, now 3

Case Example II

LA - 69 yr. old Caucasian female•Depressed w/ SI (future date –depending on outcome of a certain event, specific plan, no imminence)•Guns in home•Husband – “suicide pact”•TBI, impulsivity, Obsessive-Compulsive PD, PTSD•Emotional dysregulation (anger outbursts)•Met in ICV, OVBK w/ psychiatry next week•Safety plan, involving husband•f/u bi-weekly w/BHC •Sliding fee clinics for LT tx (but unlikely)•Consider hospitalization around event, but unlikely•Risk level 4 initially, now 3, around event up to 4

To sum it all up….• High need for psychosis and safety management in primary care

– Added BHC and PT psychiatrist

• No standards, literature, case law– Developed our own program fitting our needs, merging approaches

• Managing “high risk” patients is “risky” in primary care due to lack of resources (no CM…)– Developed database, tracking system, risk levels– BHC does some case management– Excellent communication– Easy access to BHC and psychiatrist– Tag-teaming visits– 1x mo. Behavioral Health – mini-psychiatry lectures

• Future: need to develop standards of care

Questions and Answers

Session Evaluation

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