Transcript Ad Hoc and Caseload Consultation

Ad Hoc and Caseload Consultation
Wednesday, November 12, 2014
Jürgen Unützer, MD, MPH, MA
Professor and Chair, Psychiatry and Behavioral Sciences
University of Washington
Marc Avery, MD
CIBHS CCC Faculty Co-Chair
Gail Bataille, MSW
CIBHS CCC Faculty Co-Chair
Objectives:
1. Understand the different types of consultation
that are necessary in coordinated care.
2. Learn what elements of consultation are
most effective.
3. (During breakout) Explore ways for
testing/implementing ad hoc and caseload
consultation in your location.
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Collaborative Care Model
Consutation
PCP
Core
Program
New Roles
Patient
BH Care
Manager
Psychiatric
Consultant
Collaborative Team Model: Two Types of
Consultation – Caseload and Ad Hoc
Care Coordination Team
Psychiatrist
Patient
Care
Coordinator
Primary Care
Population
Consultants
Care Plan
Case
Manager
Peer
Counselor
Psychiatrist
Substance
Use
Counselor
PCP
Other
Other
Other
Substance Use
Primary Care
Mental Health
0.00
0.25
0.50
0.75
1.00
Pay-for-performance cuts median time to
depression treatment response in half.
0
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16 24 32 40 48 56 64 72 80 88 96 104 112 120 128 136
Weeks
Before P4P
Unützer et al. 2012.
After P4P
Effective Implementation: 9 Factors
Whitebird, et al. Am J Manag Care. 2014;20(9):699-707
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Engagement/Activation and
Remission: Key Factors
Whitebird, et al. Am J Manag Care. 2014;20(9):699-707
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Common Consultation Questions
Clarification of diagnosis
• Consider re-screening patient
• Patient may need additional assessment
Address treatment resistant disorders
• Make sure patient has adequate dose for adequate duration
• Provide multiple additional treatment options
Recommendations for managing difficult patients
• 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
Key Elements of an Informal
Consultation
• Readily Accessible
• Establish rapport and welcoming
stance
• Concise feedback – pharmacologic and
nonpharmacologic
• If-then scenarios and next steps
• Educational component
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Uncertainty:
Requests for More Information
Complete
information
Sufficient
information
- Tension between
complete and
sufficient
information to
make a
recommendation
- Often use risk
benefit analysis of
the intervention
you are proposing
Sample Case Review Note
SUMMARY: Pt is a 28yo male presenting with depression and anxiety. Pt having trouble
falling asleep (plays with laptop or phone in bed), sleeping 4-7 hrs/night.
Depressive symptoms: Moderate depression; PHQ-9: 18 Bipolar Screen: Positive
screen; May be more consistent with substance use Anxiety symptoms: Moderate to
severe; GAD-7: 18 Past Treatment: Currently taking Bupropion and Citalopram (since
1/31) feels more in control, able to think before reacting, less irritable; Took Zoloft, Prozac,
Wellbutrin at different times during teenage yrs. Doesn't recall effect Suicidality: Denies
Psychotic symptoms: Denies Substance use: History of substance use/alcohol;
Engaged in treatment Psychosocial factors: Completed court appointed time in clean
and sober housing; Now living back with parents in Carnation; Attending community
college; Continues to stay connected to clean and sober housing; Attends Mars Hill Church
Other: ADHD: ASRS-v1.1 screening – positive; Not diagnosed as a child; Now getting B’s
at community college
Medical Problems: hx of frequent migraines
Current medications: Bupropion HCl (Wellbutrin SR)(Daily Dose: 450mg) †Citalopram
Hydrobromide (Celexa) (Daily Dose: 40mg)
Goals: Improve school functioning; Long term goal employment
ASSESSMENT: Depression NOS , most likely MDD but cannot r/o bipolar
disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission;
r/o ADHD
RECOMMENDATIONS:
1)
Continue to target sleep hygiene
2)
Options for antidepressant augmentation. Engage patient in decision
making about which ONE option to pursue:
a.
Option 1: Continue Celexa to 20mg as reported sedation on higher
dose; Make sure he is taking dose at night and allow for longer
period of observation to evaluate efficacy
b.
Option 2: Increase Celexa back to 40mg to target anxiety as did not
notice a change in sedation but noted increased anxiety when
lowered dose.
c.
Option 3: Cross taper to fluoxetine; Week 1: Baseline
weight. Consider BMP for baseline sodium in older adults. Start 10
mg qday. Continue Celexa20mg Week 2: Increase dose to 20 mg
qday, if tolerated, and stop Celexa Week 4 and beyond: Consider
further titration in 10-20 mg qday increments. Typically need higher
doses for anxiety Typical target dosage: 20 mg qday
3)
Continue close contact with care coordinator, supporting substance use
treatment and behavioral activation.
4)
Can consider Strattera in the future if poor concentration
persists; Would stay on 40 mg qday as combination with Wellbutrin can
increase drug level.
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‘Disclaimer’ on Note
•“The 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
ROLE: Caseload Consultant
Caseload Reviews
• Scheduled (ideally
weekly)
• Prioritize patients that are
not improving
Availability to Consult
Urgently
• Diagnostic dilemmas
• Education about
diagnosis or medications
• Complex patients, such
as pregnant or medical
complicated
If patients do not improve,
consider:
•
•
•
•
•
Wrong diagnosis?
Problems with treatment adherence?
Insufficient dose / duration of treatment?
Side effects?
Other complicating factors?
– psychosocial stressors / barriers
– medical problems / medications
– ‘psychological’ barriers
– substance abuse
– other psychiatric problems
• Initial treatment not effective?
Sample Consultations ~ 30 min
REASON FOR CONSULT
DIAGNOSI
S
RECOMMENDATION
Side effects from lithium
BP 1
Switch to valproic acid
SE from lisdexamfetamine
ADHD
Try another per protocol
Lithium level is 1.2
BP 1
Cont unless having side effects
Inc depression symptoms
MDNOS
TSH, if normal start lamotrigine
Poss SE from quetiapine
BP 1/PD
Decrease Seroquel to 100 mg
Paroxetine not effective
MDD
Add bupropion
Regular lamotrigine or XR?
BP 2
No difference
Side effects with citalopram
MDD
Switch to bupropion
Depression symptoms
increase
BP1
Check lithium level first, maximize if low,
may need to add lamotrigine
Suicidal, acute distress
PD
Safety plan, DBT referral
High doses of meds,
confused
MDD
Stop hydroxyzine, reduce lorazepam, call
collateral
Anxious, wants alprazolam,
GAD
No alprazolam, increase sertraline, coping
ROLE: Direct Consultant
Seeing patients directly in collaborative care is different than traditional
consultation. Approximately 5 – 7 % may need this.
Patients pre-screened from care manger population
• Already familiar with patient history and symptoms
• Typically more focused assessment, tele-video OK
Common indications for direct assessment
•
•
•
•
Diagnostic dilemmas
Treatment resistance
Education about diagnosis or medications
Complex patients, such as pregnant or medical
complicated
**Utilize televideo if warranted
Liability
PCP: Oversees overall care and
retains overall liability AND
prescribes all
medications/additional studies
CM/BHP: Responsible for the
care they provide within their
scope of practice / license
COLLABORATIVE
Curbside with BHP,
document
recommendations in
chart and paid
INFORMAL
CONSULTATIVE
Curbsides, advice to
PCP and BHP, no
charting, not paid and
not supervisor of BHP
•Olick et al, Fam Med 2003
•Sederer, et al, 1998
•Sterling v Johns Hopkins Hospital., 145 Md.
App. 161, 169 (Md Ct. Spec. App. 2002
FORMAL
Direct with patient
after other steps
unsuccessful, written
opinion
SUPERVISORY
Psychiatric provider
administrative and
clinical supervisor of
BHP  ultimately
responsible
Consultation ranges
from informal to
formal.
Is there a doctorpatient relationship?
Collaborative
care should
reduce risk:
-Care manager
supports the PCP
-Use of evidencebased tools
-Systematic,
measurementbased follow-up
-Psychiatric
consultant
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AD HOC Consultation
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Collaborative Care Model
Consutation
PCP
Core
Program
New Roles
Patient
BH Care
Manager
Psychiatric
Consultant
Collaborative Team Model
Care Coordination Team
Psychiatrist
Patient
Care
Coordinator
Primary Care
Population
Consultants
Care Plan
Case
Manager
Peer
Counselor
Psychiatrist
Substance
Use
Counselor
PCP
Other
Other
Other
Substance Use
Primary Care
Mental Health
Example Vignettes:
Case #1:
Your patient calls you, the care coordinator, complaining of
feeling extremely anxious. She states that this started
yesterday when the PCP started a new diabetes
medication. She also is a bit dizzy.
Case #2:
Your CC patient sees his PCP complaining of increasingly
intrusive voices. He tells the PCP that he always has more
voices when under stress and he is about to be evicted
from his SRO. He thinks his care coordinator is “working
on it.”
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Bi-Directional Ad Hoc Clinical Consultation – Breakout Session
Case #1: Your patient calls you, the care coordinator, complaining of feeling
extremely anxious. She states that this started yesterday when the PCP started a
new diabetes medication. She also is a bit dizzy. How would you obtain medical
consultation from PC clinic?
Case #2: Your CC patient sees his PCP complaining of increasingly intrusive
voices. He tells the PCP that he always has more voices when under stress and
he is about to be evicted from his SRO. He thinks his care coordinator is
“working on it.” The PCP would like to consult with you and mental health. How
would this happen?
• How have you begun to test/implement population focused clinical care
coordination meetings with your key CCC provider partners?
• How frequently are you meeting to develop/review Integrated Care Plans?
• What criteria have you used for selecting patients for caseload consultation?
• Are you using population-based criteria to select patients for caseload
reviews?
• If so, are there additional population-based criteria that you can
test/implement?
• If not, what criteria can you begin to test/use?
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