Presentation on theme: "Ad Hoc and Caseload Consultation"— Presentation transcript
Slide1
Ad Hoc and Caseload ConsultationWednesday, 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-ChairSlide2
2Objectives:Understand the different types of consultation that are necessary in coordinated care.Learn what elements of consultation are most effective.
(During breakout) Explore ways for testing/implementing ad hoc and caseload consultation in your location.Slide3
Collaborative Care Model Consutation
PCP
Patient
BH Care
Manager
Psychiatric Consultant
Core
Program
New RolesSlide4
Collaborative Team
Model: Two Types of Consultation – Caseload and Ad Hoc
Patient
Psychiatrist
Substance Use Counselor
Case Manager
Primary Care
Population Consultants
Care Coordination Team
Care Plan
Care Coordinator
Peer Counselor
Other
Psychiatrist
Mental Health
Substance Use
Primary Care
Other
Other
PCPSlide5
Pay-for-performance cuts median time to depression treatment response in half.
Unützer
et al. 2012.Slide6
Effective Implementation: 9 Factors6
Whitebird
, et al. Am
J
Manag
Care. 2014;20(9):699-707Slide7
7Engagement/Activation and Remission: Key Factors
Whitebird
, et al. Am
J
Manag
Care. 2014;20(9):699-707Slide8
Common Consultation QuestionsSlide9
Key Elements of an Informal ConsultationReadily AccessibleEstablish rapport and welcoming stanceConcise feedback – pharmacologic and nonpharmacologicIf-then scenarios and next stepsEducational component9Slide10
Uncertainty:Requests for More Information
Tension between complete and sufficient information to make a recommendation
Often use risk benefit analysis of the intervention you are proposingSlide11
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 migrainesCurrent medications: Bupropion HCl (Wellbutrin SR)(Daily Dose: 450mg) †Citalopram Hydrobromide (Celexa) (Daily Dose: 40mg)
Goals: Improve school functioning; Long term goal employment
Sample Case Review NoteConcise SummarySlide12
ASSESSMENT: Depression NOS , most likely MDD but cannot r/o bipolar disorder; Anxiety NOS,; Alcohol dependence, in early sustained remission; r/o ADHDRECOMMENDATIONS:1) Continue to target sleep hygiene2) 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.12
Brief & FocusedSlide13
‘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 Slide14
ROLE: Caseload ConsultantSlide15
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 abuseother psychiatric problemsInitial treatment not effective?Slide16
Sample Consultations ~ 30 minREASON FOR CONSULT
DIAGNOSIS
RECOMMENDATION
Side effects
from lithium
BP 1
Switch to
valproic acid
SE from lisdexamfetamineADHDTry another per protocol
Lithium level is 1.2BP 1 Cont unless having side effects
Inc depression symptomsMDNOS TSH, if normal start lamotrigine
Poss SE from quetiapineBP 1/PDDecrease Seroquel to 100 mg
Paroxetine not effectiveMDDAdd bupropionRegular lamotrigine
or XR?BP 2No differenceSide effects with citalopram
MDDSwitch to bupropionDepression symptoms increaseBP1Check lithium level first, maximize if low, may need to add lamotrigineSuicidal, acute distressPDSafety plan, DBT referralHigh doses of meds, confusedMDDStop hydroxyzine, reduce lorazepam, call collateralAnxious, wants alprazolam, nipple painGADNo alprazolam, increase sertraline, coping skillsSlide17
ROLE: Direct ConsultantSeeing patients directly in collaborative care is different than traditional consultation. Approximately 5 – 7 % may need this.
**Utilize
televideo
if warrantedSlide18
Liability
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
Consultation ranges from informal to formal.
Is there a doctor-patient relationship?18
Collaborative care should reduce risk:
Care manager supports the PCP
Use of evidence-based tools
Systematic, measurement-based follow-upPsychiatric consultantPCP: Oversees overall care and retains overall liability AND prescribes all medications/additional studiesCM/BHP: Responsible for the care they provide within their scope of practice / license Slide19
19AD HOC ConsultationSlide20
Collaborative Care Model Consutation
PCP
Patient
BH Care
Manager
Psychiatric Consultant
Core
Program
New RolesSlide21
Collaborative Team Model
Patient
Psychiatrist
Substance Use Counselor
Case Manager
Primary Care
Population Consultants
Care Coordination Team
Care Plan
Care Coordinator
Peer Counselor
Other
Psychiatrist
Mental Health
Substance Use
Primary Care
Other
Other
PCPSlide22
22Example 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.” Slide23
23Bi-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?
