1. Team Based Care in Psychiatry
“Medical Leadership of Psychiatric Teams: Role of Extenders in Psychiatric Practice”
Michael M. Miller, MD Wisconsin Psychiatric Association Kohler, Wisconsin December 5, 2014

2. Michael M. Miller, MD, FASAM, FAPA mmiller@rogershospital.org
Medical Director, Herrington Recovery Center Rogers Memorial Hospital, Oconomowoc, Wisconsin Clinical Adjunct Professor University of Wisconsin School of Medicine and Public Health Assistant Clinical Professor Medical College of Wisconsin Past President, American Society of Addiction Medicine At-Large Director, American Board of Addiction Medicine Delegate, AMA House of Delegates (Wisconsin) Member, AMA Council on Science and Public Health

3. Psychiatrists are used to practicing as a member of a TEAM
Psychiatrists are trained in clinical care as members of clinical teams.
The foundation of the public sector care system is the multidisciplinary team.
The standard structure of the inpatient psychiatric unit is the multidisciplinary team.
In addiction care, at all levels of care, care is delivered in private and public sector via multidisciplinary teams.

4. Who is on the team? Psychiatrist Nurse Psychologist
Clinical Social Worker
Occupational Therapist
Bachelor’s level workers

5. Who else may be on the team?
General Medical Consultant
Pharmacist
Art Therapist
Music Therapist
Movement/Dance Therapist
Recreation Therapist
Exercise Instructor
Yoga Instructor

6. The Addiction Care Team
Addiction Counselor
Physician
Psychiatrist/Psychologist
Nurse
Family Therapist
Social Worker
Discharge Planner
Experiential Therapist (OT, MT, DT, Equine Tx)

7. Who else may be on the Addiction Care Team?
Addiction Specialist Physician
Addiction Psychiatrist
Addiction Medicine Physician
Mental Health Therapist
Spiritual Counselor/Chaplain
Vocational Counselor
Parenting Skills Trainer
Financial Skills Counselor

8. What About Non-MH Teams?
Primary Care Teams
Patient Centered Health Care Homes
Medical Teams
Hospice/Palliative Care Teams
Oncology Teams
Dialysis Teams
Diabetes Teams
Multidisciplinary Pain Clinics

9. And SAMHSA and others address another potential member of the TEAM—the PATIENT!
Check out the SAMHSA-HRSA Center for Integrated Health Solutions
“Shared Decision-Making” is the lingo:
decision-making
There is a free monograph on the topic:
in-Mental-Health-Care/SMA

10. Mental Health America (formerly the National Mental Health Association) is also supportive of this path
The patient as a participant in the Health Care Team: “You’re on the Team.”

11. Psychiatrists Leader of the Team (MH teams)
Member of the Team (General Medical teams)

12. Integrating Psychiatry into General Medical Teams
Community Health Centers
Federally Qualified Health Centers
Health centers are community-based and patient-directed organizations that serve populations with limited access to health care. 

13. SAMHSA and HRSA collaborating: The SAMHSA-HRSA Center for Integrated Health Solutions
Integrating Behavioral Health into Primary Care
Primary Care in Behavioral Health (“reverse integration”)
See also: Pating DR, Miller MM, Goplerud E, Martin J, and Ziedonis DM. “New Systems of Care for Substance Use Disorders: Treatment, Finance and Technology under Health Care Reform.” Psychiatric Clinics of North America 35(2):

14. FQHC’s and the ACA Major expansion of CHC’s
Theory: medical education to occur in CHCs.
Theory: MH care and SA care to be delivered in integrated fashion via CHCs.
Theory: health professionals education in behavioral health to occur in CHCs.

15. The Affordable Care Act: The Essential Role of Community Health Centers
Health centers are poised to play an essential role in the implementation of the Affordable Care Act.
In particular, health centers emphasize coordinated primary and preventive services or a “medical home” that promotes reductions in health disparities for low‐income individuals, racial and ethnic minorities, rural communities and other underserved populations.

16. The Affordable Care Act: The Essential Role of Community Health Centers
Health centers place emphasis on the coordination and comprehensiveness of care, the ability to manage patients with multiple health care needs, and the use of key quality improvement practices, including health information technology.
The health center model [utilizes] a team‐based approach to care that includes physicians, nurse practitioners, physician assistants, nurses, dental providers, midwives, behavioral health care providers, social workers, health educators, and many others.

17. The Affordable Care Act: The Essential Role of Community Health Centers
The Affordable Care Act established the Community Health Center Fund that provides $11 billion over a 5 year period for the operation, expansion, and construction of health centers throughout the Nation.
$9.5 billion is targeted to:
Support ongoing health center operations.
Create new health center sites in medically underserved areas.
Expand preventive and primary health care services, including oral health, behavioral health, pharmacy, and/or enabling services, at existing health center sites.

18. The Affordable Care Act: The Essential Role of Community Health Centers
To date in FY 2014, through the Affordable Care Act, the Health Center Program awarded or announced the following new funding:
Health Center Patient‐Centered Medical Home Capital funding opportunity: In August 2014, HRSA awarded $35.7 million in Affordable Care Act funding to 147 health centers in 44 states, the District of Columbia, and Puerto Rico to support patient-centered medical homes through new construction and facility renovations.  
Health Center Mental Health Service Expansion ‐ Behavioral Health Integration Awards: In July 2014, HRSA awarded $54.6 million in Affordable Care Act funding to support 221 health centers in 46 states, the District of Columbia and Puerto Rico to establish or expand behavioral health services for over 450,000 people nationwide. Health centers will use these funds for efforts such as hiring new mental health professionals, adding mental health and substance use disorder health services, and employing integrated models of primary care.

19. From the website of the AMA
Physician-Led Team Based Care
As millions obtain health insurance and can access ongoing health care, the American Medical Association supports physician-led health care teams that ensure health care professionals work together to meet the surge in demand. The AMA is working to ensure sustainable physician practices that result in better health outcomes for patients, and having more physician-led health care teams will help us achieve these goals.

20. From the website of the AMA
Physician-Led Team Based Care
New health care delivery system reforms hinge on a team- based approach to care. In the physician-led team approach, each member of the team plays a critical role in delivering efficient, accurate, and cost-effective care to patients. With seven years or more of postgraduate education and thousands of hours of clinical experience, physicians are uniquely qualified to lead the health care team. Physicians, physician assistants, nurses, and other health care professionals have long worked together to meet patient needs for a reason: the physician-led team approach to care works.

21. Think Tanks are “all over” this topic
e.g., a spin-off of the Institute of Medicine’s Roundtable on Value & Science-Driven Health Care
Core Principles & Values of Effective Team-Based Health Care
October 2012
Pamela Mitchell, Matthew Wynia, Robyn Golden, Bob McNellis, Sally Okun, C. Edwin Webb, Valerie Rohrbach, and Isabelle Von Kohorn*
*Participants drawn from the Best Practices Innovation Collaborative of the IOM Roundtable on Value & Science-Driven Health Care
Copyright 2012 by the National Academy of Sciences. All rights reserved.
2013 National AHEC Organization | 7044 S. 13th Street | Oak Creek, WI 53154

22. Core Principles & Values of Effective Team-Based Health Care, October, 2012
Health care has not always been recognized as a team sport, as we have recently come to think of it. In the “good old days,” people were cared for by one all-knowing doctor who lived in the community, visited the home, and was available to attend to needs at any time of day or night. If nursing care was needed, it was often provided by family members, or in the case of a family of means, by a private- duty nurse who “lived in.” Although this conveyed elements of teamwork, health care has changed enormously since then and the pace has quickened even more dramatically in the past 20 years.

23. Core Principles & Values of Effective Team-Based Health Care, October, 2012
“Teams in health care take many forms, for example, there are disaster response teams; teams that perform emergency operations; hospital teams caring for acutely ill patients; teams that care for people at home; office-based care teams; geographically disparate teams that care for ambulatory patients; teams limited to one clinician and patient; and teams that include the patient and loved ones, as well as a number of supporting health professionals. Teams in health care can therefore be large or small, centralized or dispersed, virtual or face-to-face—while their tasks can be focused and brief or broad and lengthy. This extreme heterogeneity in tasks, patient types, and settings is a challenge to defining optimal team-based health care, including specific guidance on the best structure and functions for teams.”

24. Core Principles & Values of Effective Team-Based Health Care, October, 2012
A driving force behind health care practitioners’ transition from being soloists to members of an orchestra is the complexity of modern health care, which is evolving at a breakneck pace. The U.S. National Guideline Clearinghouse now lists over 2,700 clinical practice guide- lines, and, each year, the results of more than 25,000 new clinical trials are published. No single person can absorb and use all this information.
Given this complexity of information and interpersonal connections, it is not only difficult for one clinician to provide care in isolation but also potentially harmful. As multiple clinicians provide care to the same patient or family, clinicians become a team—a group working with at least one common aim: the best possible care—whether or not they acknowledge this fact (emphasis added).
Each clinician relies upon information and action from other members of the team.

25. A Proposed Definition of Team-Based Health Care:
Core Principles & Values of Effective Team-Based Health Care, October, 2012
A Proposed Definition of Team-Based Health Care:
Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.
[To inform a proposed definition of team-based care, we reviewed the literature and reflected on the definitions and factors identified in prior work. Elements found across the definitions we reviewed include the patient and family as team members, more than one clinician, mutual identification of the preferred goal, close coordination across settings, and clear communication and feedback channels.]

26. Newly Emerging Team Members
Nurse Practitioners
Physician Assistants

27. Physicians Assistants in Mental Health
“According to a 2009 study, over three quarters of the United States (US) have a severe shortage of mental health prescribers and non-prescribers. The lack of mental healthcare providers has led to prolonged wait times for mental healthcare services, increased crime related to mental health issues, and homelessness.
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J 2011Feb; 104 (2):87-8.

28. Physicians Assistants in Mental Health
“A safe and cost-effective solution to the problem is to employ the use of midlevel practitioners such as physician assistants who are adequately trained to practice psychiatry. Physician assistants have been working in mental health since 1975; however, the American Academy of Physician Assistants found psychiatry physician assistants only represent 1.1% of the total number of practicing physician assistants.”
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J 2011Feb; 104 (2):87-8.

29. Physicians Assistants in Mental Health
“A physician assistant has the ability to effectively increase the patient load with significantly less cost as compared to hiring a psychiatrist for a practice, inpatient ward, or community mental health center. Physician assistants have extensive training in primary medical screening techniques. Not only will a physician assistant be able to provide mental healthcare, but also a well-rounded medical care for patients.”
Sharma, TR, Nicely MD. Physicians Assistants in Mental Health. South Med J 2011Feb; 104 (2):87-8.

30. Terminology
APRNs are not “extenders.” They are licensed professionals with advanced degrees who have passed a certification examination, have completed supervised practice hours, have a defined scope of practice, and have prescriptive authority. Some states require them to have a collaborative relationship with a physician for certain functions (like prescribing). Unlike PAs, they do not work in a directed relationship with a physician. 
Certainly, as in all professions, APRNs have different levels of experience and skill which need to be taken into account in their functioning within the interdisciplinary team.
Kathleen McCann, RN, PhD, the director of quality and regulatory affairs for the National Association of Psychiatric Health Systems (NAPHS).
She received the “Excellence in Leadership Award” from the American Psychiatric Nurses Association.

31. Advanced Practice Psychiatric Nurses
APPNs are health care professionals licensed to practice as specialists in psychiatric mental health nursing. The advanced practice psychiatric nurse is board certified by the American Nurses Credentialing Center (ANCC) to specialize in one of in several Psychiatric Mental Health (PMH) advanced practice nursing roles. 
Clinical Nurse Specialist (CNS)
Child & Adolescent Psychiatric & Mental Health
Clinical Nurse Specialist (PMHCNS-BC)
Adult Psychiatric & Mental Health Clinical Nurse Specialist (PMHCNS-BC)
Nurse Practitioner (NP)
Family Psychiatric & Mental Health NP (PMHNP-BC)
Adult Psychiatric & Mental Health NP (PMHNP-BC)

32. Activities/Scope
Both Psychiatric NPs and Psychiatric CNSs are responsible for assessment, diagnosis, treatment, and evaluation of mental illness.
In 36 states psychiatric & mental health CNSs also have prescriptive authority. 
APRN NPs may conduct physical exams, order and interpret tests, counsel on preventive health care, and write prescriptions.

33. Certification and MOC
APRN-PMHs are educated at the master’s or clinical doctorate (DNP) level in a holistic biopsychosocial model of psychiatric & mental health nursing.  
Upon graduation, Advanced Practice Psychiatric Nurses may take a national certification examination developed by the American Nurses Credentialing Center (ANCC).
MOC is every 5 years: must document 1000 clinical hours of patient care and 75 hours of CE in PMH nursing in those 5 years.

34. Education and Rx Authority
Advanced Practice Psychiatric Nurses (APPN) are educated in intensive accredited graduate nursing programs. The average APRN- PMH program curriculum runs approximately months.
The first CNS program in PMH nursing was at Rutgers in 1955; by there were 30.
APPNs are found in all areas of health care. They practice in primary care – i.e., family medicine, internal medicine, pediatrics, and obstetrics and gynecology – as well as in hospitals, home health care, correctional health care, and in other outpatient settings.
All 50 states and the District of Columbia authorize APPN prescribing if they are certified as a Nurse Practitioner.
A Clinical Nurse Specialist, APRN-PMHs, are authorized to prescribe in 36 states.

35. Drew B. The Evolution of the Role of the Psychiatric Mental Health Advanced Practice Registered Nurse in the United States. Archives of Psychiatric Nursing, 2014;28:
[Clinical Nurse Specialist]: Rutgers University in 1954-the development of skills in psychotherapy. Competencies also included organizational analysis and consultation service—a systems understanding of nursing, healthcare delivery and the change process.
The American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric-Mental Health Nurses (ISPN) convened a joint task force of PMH nursing leaders. The primary recommendation was that “there will be one entry educational focus for the future: PMH NP with preparation across the lifespan, addressing mental health promotion and mental illness diagnosis and treatment”

36. Physician Assistants
A physician assistant (or PA) is a nationally certified and state-licensed medical professional.
PAs practice medicine on healthcare teams with physicians and other providers.
They practice and prescribe medication in all 50 states, the District of Columbia and all U.S. territories, with the exception of Puerto Rico.

37. www.aapa.org What can a physician assistant do for me? PAs can:
Take your medical history
Conduct physical exams
Diagnose and treat illnesses
Order and interpret tests
Develop treatment plans
Counsel on preventive care
Assist in surgery
Write prescriptions
Make rounds in hospitals and nursing homes

38. What Can a Psychiatric PA do?
PAs can:
Take a psychiatric/addiction history
Conduct physical exams and mental status exams
Diagnose and treat mental illnesses
Order and interpret tests
Develop treatment plans
Counsel on preventive care
Write prescriptions (except for O.B.O.T.—buprenorphine)
Make rounds in hospitals and nursing homes
Handle general medical needs of the psychiatric and addiction care patient

39. Moran M. Physician assistants extend access to psychiatric care
Moran M. Physician assistants extend access to psychiatric care. Psychiatric News 2003:38:5.
"PAs are trained to do things by the book," said Bruce Pfohl, M.D., a professor of psychiatry at the University of Iowa and past director of the university's outpatient clinic, where two PAs are now employed. "They tend to be very systematic and are well trained to practice evidence-based medicine. The majority of the patients we see respond very well to standard treatment, so it's a matter of following things by the book to decide how to treat them. PAs do an excellent job of that."

40. Moran M. Physician assistants extend access to psychiatric care
Moran M. Physician assistants extend access to psychiatric care. Psychiatric News 2003:38:5.
"While they are extenders, they are not replacements," said Bedi. "To use this model correctly, you need to understand the limitations and play to the strengths. I have no problem delegating to a PA who knows how to use the medications and knows that I expect to be called for consultation. And they do extremely well in an inpatient setting because they get supervision almost daily. In this way, the psychiatrist can be in charge of 25 patients instead of 15."

41. For many policymakers, this topic is all about workforce issues
There will never be enough psychiatrists to meet the clinical or public health needs
We can look to non-psychiatric MH providers (PhDs, PsyDs, MSWs, etc)
Or we can look to Physician Assistants and Psychiatric/Mental Health Nurse Practitioners

42. For many policymakers, this topic is all about workforce issues
Not a new topic for SAMHSA
Major conference in Washington, DC
Integrating Substance Use Services into Primary Care: Workforce Issues
August 10-11, 2011

43. How are PA’s Trained?
Greg Thomas, P.A.-C, M.P.H, director of external relations at the National Commission on Certification of Physician Assistants (NCCPA), explained that the typical curriculum for an accredited PA program is a 27-month master’s degree program that is based on a medical- education model consisting of one year of didactics and a second year of clinical rotations—which includes a rotation in psychiatry as an option.
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News 2014:49:15

44. How are PA’s Trained?
Currently, the NCCPA is urging PAs who want to join a collaborative team in psychiatric practices to obtain the Certificate of Added Qualifications (CAQ) in psychiatry, a new specialty credential that is held by about 10 percent of the certified PAs working in psychiatry.
Under CAQ requirements, prospective candidates will have to work 2,000 hours (the equivalent of one year) and earn 150 Category 1 CME credits related to psychiatry within the six years prior to applying for the CAQ exam, in addition to earning 50 CME credits within the two years after taking the exam.
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News 2014:49:15

45. How are PA’s Trained?
“…specially designed PA ‘residency’ program in psychiatry at the Cherokee Mental Health Institute in Cherokee, Iowa-a state in which only 21 of the 99 counties can boast a psychiatrist, and where 80 percent of the state's psychiatrists are in five counties.”
“The institute, a 60-bed state mental health facility, designed the one- year program for individuals already certified as physician assistants with a particular interest in psychiatry.”
“Cherokee's appears to have a precarious future, having stopped and started and stopped again due to lack of money. It's costly and labor intensive, and we haven't found people to fund it."
Moran M. Physician assistants extend access to psychiatric care. Psychiatric News 2003:38:5.

46. Final Comments on PA’s
Greg Thomas, P.A.-C, M.P.H, director of external relations at the National Commission on Certification of Physician Assistants (NCCPA): “There are roughly 100,000 certified practicing PAs in the United States, with approximately 1,500 of them working in psychiatry.”
Thomas stressed that PAs will never be replacements for physicians. “The PA profession was started by physicians and will always be linked to physicians. The doctor is the supervisor.”
Watts V. “Is There a Place for PAs in Psychiatric Practice?” Psychiatric News 2014:49:15

47. Thank you! Herrington Recovery Center
Michael M. Miller, MD, FASAM, FAPA
Herrington Recovery Center
at Rogers Memorial Hospital
For more information, call or visit rogershospital.org