1. 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

2. 2 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.

3. Collaborative Care Model Consutation PCP Patient BH Care Manager BH Care Manager Psychiatric Consultant Core Program New Roles

4. 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 PCP

5. Pay-for-performance cuts median time to depression treatment response in half. Unützer et al. 2012.

6. Effective Implementation: 9 Factors 6 Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

7. 7 Engagement/Activation and Remission: Key Factors Whitebird, et al. Am J Manag Care. 2014;20(9):699-707

8. Common Consultation Questions Consider re-screening patient Patient may need additional assessment Clarification of diagnosis Make sure patient has adequate dose for adequate duration Provide multiple additional treatment options Address treatment resistant disorders 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 Recommendations for managing difficult patients

9. 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 9

10. 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

11. 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 Sample Case Review Note Concise Summary

12. 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. 12 Brief & Focused

13. ‘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

14. 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

15. 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?

16. Sample Consultations ~ 30 min REASON FOR CONSULTDIAGNOSI S RECOMMENDATION Side effects from lithiumBP 1Switch to valproic acid SE from lisdexamfetamineADHDTry another per protocol Lithium level is 1.2BP 1Cont 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 bupropion Regular lamotrigine or XR?BP 2No difference Side effects with citalopramMDDSwitch to bupropion Depression symptoms increase BP1Check lithium level first, maximize if low, may need to add lamotrigine Suicidal, acute distressPDSafety plan, DBT referral High doses of meds, confused MDDStop hydroxyzine, reduce lorazepam, call collateral Anxious, wants alprazolam, nipple pain GADNo alprazolam, increase sertraline, coping skills

17. 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

18. Liability INFORMAL CONSULTATIVE Curbsides, advice to PCP and BHP, no charting, not paid and not supervisor of BHP COLLABORATIVE Curbside with BHP, document recommendations in chart and paid FORMAL Direct with patient after other steps unsuccessful, written opinion SUPERVISORY Psychiatric provider administrative and clinical supervisor of BHP  ultimately responsible 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? 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-up -Psychiatric consultant Collaborative care should reduce risk: -Care manager supports the PCP -Use of evidence- based tools -Systematic, measurement- based follow-up -Psychiatric consultant 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

19. 19 AD HOC Consultation

20. Collaborative Care Model Consutation PCP Patient BH Care Manager BH Care Manager Psychiatric Consultant Core Program New Roles

21. 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 PCP

22. 22 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.”

23. 23 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?