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Janice Berry Edwards, PhD, LICSW, LCSW-C, BCD, ACSW

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1 Janice Berry Edwards, PhD, LICSW, LCSW-C, BCD, ACSW
Enhancing Diagnostic Accuracy In Assessment, Intervention and Advocacy New Directions in Clinical Practice Guided by Integration and Clinical Sensibility Janice Berry Edwards, PhD, LICSW, LCSW-C, BCD, ACSW

2 Mental Health and Wellness
Integration of mental health services into the primary care setting, will lead to improved access to mental health services and communication with providers of health care. Integration of care allows for the promotion of optimal social and emotional wellness, because the whole person is being treated and not just a part. Safe and effective mental and physical health care requires collaboration and communication between all providers of health care. Simply put, it’s a coordinated system that combines medical and behavioral services to address the whole person, not just one aspect of his or her condition. Medical and mental health providers partner to coordinate the detection, treatment, and follow-up of both mental and physical conditions. Combining this care allows consumers to feel that, for almost any problem, they’ve come to the right place.*

3 Health care visits often have underlying psychosocial influences.
HERE’S WHAT WE KNOW Health care visits often have underlying psychosocial influences. 70% of all health care visits are generated by psychosocial factors. (Fries et al., 1993; Shapiro et al., 1985). Mental Health problems can arise from physical problems. The majority of visits in primary care are related to behavioral needs but not to identified mental health disorders. Many patients respond to psychosocial stress by developing vaguely defined, distressing physical symptoms that have no organic cause. (Kroenke et al., 1989) The most frequent psychosocial drivers of medical utilization are mental disorders, alcoholism and drug addiction, deficient social support, lack of coping skills and stressful home/work environment. (Friedman et al., 1995)

4 Mental Health and Wellness
An estimated 75% of patients with depression present physical complaints as the reason they seek health care. (Unutzer et al., 2006). Medical outcome studies reveal that depression results in more functional impairment than chronic diseases such as diabetes, arthritis and angina. (Wells et al., 1989).

5 HERE’S WHAT WE KNOW A national survey found that 32% of undiagnosed, asymptomatic adults would likely turn to their primary care physician to help with mental health issues; only 4% would approach a mental health professional. (National Mental Health Association, 2000).

6 Collaborative Mental Health Care Partnerships What this looks like
Will allow for the early identification of mental health problems and interventions. Improved care coordination among, all providers of health care and especially patients, families, among community mental health clinicians.

7 Collaborative Mental Health Care Partnerships What this looks like
Increased knowledge, and enhanced abilities in diagnosing and responding to presenting and underlying mental health problems. Enhanced abilities in diagnosing and responding to both physical and mental health problems.

8 Collaborative Mental Health Care Partnerships What this looks like
Implementation and discussion of therapeutic and psychopharmacologic services. Development of a means for the collaborative measurement of treatment outcomes. Integration of culturally sensitive and evidence‐based mental health services.  

9 What Practitioners Are Saying

10 COLLABORATIVE CARE We are at a time where there is a critical public health need for evidence‐based mental health services. Improved and better working relationships between all providers of care can significantly enhance mental health services outcomes across populations.  Successful collaborations can lead to significantly influencing the psychiatric care of larger numbers of patients. Collaborative care will also allow for advocacy, the promotion of prevention, early identification, timely intervention, and treatment of psychiatric illness. Preventive interventions can have a major impact on the rate of recidivism, and possibly unnecessary visits to emergency care clinics or emergency room hospital visits.


12 Timely Access to Consultation
“Real time” communication is important to collaborative mental health care partnerships this requires availability. Answers to clinical questions ideally are provided to Primary Care Clinicians (PCCs) within a time frame that allows them to respond in a timely way to patients and their families. PCCs see a higher volume of patients and as such, their workflow requires efficient use of their decision‐making and time. Timely access to consultation can provide practical and understandable advice.

13 Consultation and Collaboration
Timely access assures real time discussion of plans in collaboration with the PCCs.  It helps PCCs to support therapeutic goals. Particularly in collaborative consultation timely access can foster the development of a growing sense of trust and confidence develops that encourages PCCs to extend their involvement in mental health care beyond their usual scope of practice. should include:   o Days and hours available.   o Who will be available (i.e., CAPs or other child mental health clinicians working with the CAPs). o Manner of availability (i.e., onsite, telephone, fax, , shared electronic medical record, or telemedicine).   o What the specific consultation will and will not include. o How the recommendations will be communicated (i.e., verbal and/or written). o How the PCCs will document the consultation in the patient record and what will be included in the documentation. o Procedures and criteria for routine, urgent, and emergency requests. o Process to communicate about interim medication follow‐up by PCCs. • CAPs generally need to provide direct psychiatric assessments. In consultation with a PCC, a CAP may determine, based on the description of illness acuity and complexity, that the patient needs to be directly evaluated by the CAP or a child mental health clinician.   Collaborative partnerships are significantly strengthened by the provision of (or at least facilitation of) urgent patient evaluations and treatment recommendations.

14 Consultation and Collaboration
The development of a communication protocol can be helpful to enhance the quality of the consultation and collaboration. Social Workers who are working closely with PCCs can identify their ability to handle psychiatric problems in their practices and when necessary, can help facilitate referrals to other mental health or community agencies.    Social Workers in consultation with PCCs can serve to triage primary care patients, based on acuity and complexity, to the appropriate level of service intensity (e.g., direct evaluation and treatment by the appropriate clinical provider of care, or emergency care and inpatient hospitalization when indicated).

15 Consultation and Collaboration
   Consultation or collaboration can involve scheduling the evaluation in the offices of the PCC and/or mental health clinicians.    The use of telepsychiatry is an option, particularly in rural settings. When used in the context of a collaborative system of care in which both the mental health clinician and the PCC share responsibility for the success of the treatments, telepsychiatry can prove a valuable resource. o Telepsychiatry refers to the use of interactive video conferencing as a substitute for the actual presence of a CAP in a remote location.    o With optimal connection speed, remote control camera, and high definition video and audio quality, the technology has been successful in the provision of remote interactive psychiatric evaluations of children, as well as allowing CAPs to remotely participate in case conferences and staff meetings.   o

16 Direct Psychiatric Service
The psychiatric evaluation or consultation should include biopsychosocial formulation, diagnostic impressions, and treatment/referral recommendations. It is important to have specific recommendations for the PCC that include in the consultation prompt communication of the findings and recommendations. Initial communication regarding urgent findings requiring immediate response by the PCC can occur in real time. (i.e., medication management recommendations). rather than the next business day otherwise a written evaluation summary should be within one to two weeks.  

17 Care Coordination Given the complexity of the nation’s health care system, care coordination (or case management) is essential to helping patients and their families navigate access the appropriate level of psychiatric services (e.g., outpatient, urgent, emergency, inpatient). Care coordination is an important component of effective collaborative partnerships.

18 Care Coordination Care coordination needs to be part of the collaborations. PCCs should consider in the their practices the inclusion of Social Workers who can be responsible for care coordination and case management. Social Workers are well versed in utilizing the available community mental health resources. Social Workers are well trained in both of these roles.

19 Care Coordination Social Workers and other Mental Health clinicians have the opportunity to educate PCCs regarding mental health issues and treatments that allow PCCs to extend their involvement in mental health care beyond their usual scope of practice.   Education opportunities are evident in the case‐based teaching that occurs in the consultations and direct psychiatric services provided to the PCCs patients.   

20 Care Coordination They also have the opportunity to guide PCCs in the education of their patients and their families. Mental Health clinicians working with the PCC can “lunch and learn” in primary care practices about cases, diagnosis, treatment, best practices, therapies, and community resources. 

21 Care Coordination The Benefits
Opportunities to involve mental health providers of care in CME training events, case conferences, and collaborative office rounds can enhance the relationship as well as provide an opportunity to share opinions on the care of selected patients.

22 Advocacy Advocating for collaborative mental health partnerships ranges from simple networking with community PCCs, to implementing a local community program, or to building large‐scale partnerships. Working with PCCs have proven to be a successful combination in building a strong foundation of awareness and concern among the widest array of stakeholders about the problems of access to mental health services.  

23 CONCLUSION “The walls between professions and institutions will crumble, so that your experiences will become seamless. You will never feel lost.’’  Institute of Medicine, Crossing the Quality Chasm. The New Health System for the 21st Century. Washington, DC: National Academy Press; 2001

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