Models and Process of Psychosomatic Medicine APM Resident

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, Ph. D Original version 2011: Robert Joseph, MD, MS Version of March 15, 2019 ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health

Learning Objectives § Describe different models of CL Psychiatry and differentiate from traditional officebased 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 Academy of Consultation-Liaison Psychiatry 2

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 Academy of Consultation-Liaison Psychiatry 3

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 Academy of Consultation-Liaison Psychiatry 4

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 Academy of Consultation-Liaison Psychiatry 5

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 Academy of Consultation-Liaison Psychiatry 6

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 Academy of Consultation-Liaison Psychiatry 7

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 Academy of Consultation-Liaison Psychiatry 8

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 Academy of Consultation-Liaison Psychiatry 9

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 Academy of Consultation-Liaison Psychiatry 10

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) Academy of Consultation-Liaison Psychiatry 11

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 Academy of Consultation-Liaison Psychiatry 12

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 Academy of Consultation-Liaison Psychiatry 13

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 Academy of Consultation-Liaison Psychiatry 14

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 Academy of Consultation-Liaison Psychiatry 15

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 Academy of Consultation-Liaison Psychiatry 16

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 Academy of Consultation-Liaison Psychiatry 17

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! Academy of Consultation-Liaison Psychiatry 18

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 Academy of Consultation-Liaison Psychiatry 19

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 – – – Special events of the patient’s life (e. g. , losses, illnesses) Precipitants of the current psychological and physical difficulties Nature of the patient’s reaction to these precipitants Usual coping mechanisms and ability to implement them Availability of support systems (e. g. , family/friends) Academy of Consultation-Liaison Psychiatry 20

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 Academy of Consultation-Liaison Psychiatry 21

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 Academy of Consultation-Liaison Psychiatry 22

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 Academy of Consultation-Liaison Psychiatry 23

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 Academy of Consultation-Liaison Psychiatry 24

WHODAS: World Health Organization Disability Assessment Schedule 2. 0 § Axis V (GAF) was dropped from DSM-5 • 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 § 36 -item, self-administered measure used to assess disability in adults (age 18+) § WHODAS is included for further study as an assessment tool for functioning Academy of Consultation-Liaison Psychiatry 25

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 Academy of Consultation-Liaison Psychiatry 26

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 Academy of Consultation-Liaison Psychiatry 27

Mental Health Integration (2) § Collaboration within multidisciplinary team framework – Mental Health (MH) + non-Mental Health (non-MH) providers – Psychiatrist, other MDs, Ph. Ds, 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 Academy of Consultation-Liaison Psychiatry 28

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. Academy of Consultation-Liaison Psychiatry 29

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 Academy of Consultation-Liaison Psychiatry 30

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) Academy of Consultation-Liaison Psychiatry 31

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 Academy of Consultation-Liaison Psychiatry 32

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 Academy of Consultation-Liaison Psychiatry 33

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 Academy of Consultation-Liaison Psychiatry 34

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! Academy of Consultation-Liaison Psychiatry 35

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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. Academy of Consultation-Liaison Psychiatry 37

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. Academy of Consultation-Liaison Psychiatry 38

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