Collaborative care

[keifernny2]

So, I been watching some CME lectures about collaborative care, and questions for anyone in the collaborative model - ie you never see the patient, but give official treatment recs to social workers and PCPs with your name in the chart.

I'm seeing stats like - psychiatrist should be reviewing 6-8pts /hr, treating based on phq-9, etc. Does this lead to higher provider burnout?

Also, what are the liability issues? (Do you get called into court In a malpractice suit for a patient you never saw?). When your panel increases from 400 to 2000 in this model , I would assume your number of neg outcomes would increase at least proportionally, and you wouldn't have patient rapport to rely on to prevent being sued.

There seems to be a big push into this in my state.


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[splik]

as you don't actually see any patients (except in some circumstances - for example you're just setting up a program) burnout is probably lower! in general this is something that forms part of the psychiatrists work not typically a full time gig.

in terms of malpractice yes you are liable but it's not any different than any other supervisory/consulting relationship. there has not yet been a malpractice case to test this out. you have to remember that the standard of care would not be seeing the person in person as the alternative in cc settings would be the patient gets no psychiatric care at all.

 

[Shikima]

VA has BHIPs. An epic failure. Good in concept.

 

[erg923]

VA has BHIPs. An epic failure. Good in concept.

Yes. I'm in primary care mental health integration, so I have been able to avoid the whole BHIP fad thing here, which is within the general mental health service only.

Other than seeing the NP or psychiatrist same day (which never used to happen when MHC intakes were part 1 and part 2), I am not sure who is benefitting here? When I ask MHC folks at my VA, they only rattle off what BHIP is suppose to do or improve "in theory." Yes, yes, I know you guys get more meeting time gab more about patients, but do patient actually notice, care, or prefer this? Functionally, whats different?

What your experience or exposure like to this?

 

[smalltownpsych]

So, I been watching some CME lectures about collaborative care, and questions for anyone in the collaborative model - ie you never see the patient, but give official treatment recs to social workers and PCPs with your name in the chart.

I'm seeing stats like - psychiatrist should be reviewing 6-8pts /hr, treating based on phq-9, etc. Does this lead to higher provider burnout?

Also, what are the liability issues? (Do you get called into court In a malpractice suit for a patient you never saw?). When your panel increases from 400 to 2000 in this model , I would assume your number of neg outcomes would increase at least proportionally, and you wouldn't have patient rapport to rely on to prevent being sued.

There seems to be a big push into this in my state.


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I would be leery about recommending treatment based on others' diagnoses. Diagnostic reliability is poor even with the best of us and with this you would be one step removed and relying on lesser trained diagnosticians. Especially so when dealing with social workers who typically don't have much emphasis on diagnoses as part of their education and training.

 

[Shikima]

Yes. I'm in primary care mental health integration, so I have been able to avoid the whole BHIP fad thing here, which is within the general mental health service only.

Other than seeing the NP or psychiatrist same day (which never used to happen when MHC intakes were part 1 and part 2), I am not sure who is benefitting here? When I ask MHC folks at my VA, they only rattle off what BHIP is suppose to do or improve "in theory." Yes, yes, I know you guys get more meeting time gab more about patients, but do patient actually notice, care, or prefer this? Functionally, whats different?

What your experience or exposure like to this?

It's typical federal government. That's the problem with these kinds of oversights - politicians are only concerned with metrics that have numerics in it. They don't care about outcomes. The more you see, the happier all are involved and people get bonuses.

My wife's aunt works in Spain at a government facility, similar to a medicare/medicaid clinic - they run people through appointments at 3-4 mins apart. All that is concerned with are numbers - how productive and how is that money being used. Quality of care be damned.

 

[keifernny2]

At the VA, liability is less of an issue, but what I'm seeing is this being pushed into community Medicaid clinics and ACOs, which don't have the same liability protections as the VA.


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[Shikima]

What exactly is an ACO and how does it relate to psychiatry?

 

[keifernny2]

It's when a large hospital system or consortium takes on a contract to basically turn into the sole / self referring provider for a set of Medicaid patients for a capitated fee front the insurance company (or state block grant). It's like a private version of the VA, for non-veterans. There are metrics involved to determine efficacy of treatment.

Psychiatrists may work for the ACO/hospital, or contract with them for care of their patients.


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[Shikima]

I see says the blind man....

 

[VMSmith]

Yes. I'm in primary care mental health integration, so I have been able to avoid the whole BHIP fad thing here, which is within the general mental health service only.

Other than seeing the NP or psychiatrist same day (which never used to happen when MHC intakes were part 1 and part 2), I am not sure who is benefitting here? When I ask MHC folks at my VA, they only rattle off what BHIP is suppose to do or improve "in theory." Yes, yes, I know you guys get more meeting time gab more about patients, but do patient actually notice, care, or prefer this? Functionally, whats different?

What your experience or exposure like to this?

I think BHIPs can only work if they're staffed to the level that they're theoretically supposed to be, which from what I can tell happens very rarely. When I was in a BHIP the wait times were too long to have the luxury of scheduling people for part 1 and part 2 on the same day, so the pt would wait a few months for part 1 and then a few months after part 1 for part 2. We were all too busy doing intakes to have team meetings, and the therapists were all so booked that none of my patients could actually see them, so the whole purpose of the BHIP was defeated.

 

[VMSmith]

Actually now that I think of it, I don't know why we were even called a BHIP. I don't think anything about my experience was what a BHIP was supposed to be like.

 

[Shikima]

The good idea fairy....

 

[birchswing]

If you were to listen in between a primary care doctor consulting with a psychiatrist who does this, what do you think the most common corrections would be to the treatment?

 

[mgdsh]

If our jobs were as simple as PHQ9s or other patient completed questionnaires, we could be replaced by robots.

Let's face it. That's not possible and that's not going to happen. The human mind is the most complex thing Mother Earth has ever seen. Just last week I saw a lady who thought she had ADD because she couldn't concentrate and the therapist referred her to me for that reason. It wasn't until an in depth interview that we discovered she had been through some significant trauma in the past which was repressed and the challenges with her inability to concentrate were actually due to PTSD and not ADD/ADHD.

Had she filled out a questionnaire, she'd be on a stimulant and her anxiety would likely be worse off.

 

[smalltownpsych]

If our jobs were as simple as PHQ9s or other patient completed questionnaires, we could be replaced by robots.

Let's face it. That's not possible and that's not going to happen. The human mind is the most complex thing Mother Earth has ever seen. Just last week I saw a lady who thought she had ADD because she couldn't concentrate and the therapist referred her to me for that reason. It wasn't until an in depth interview that we discovered she had been through some significant trauma in the past which was repressed and the challenges with her inability to concentrate were actually due to PTSD and not ADD/ADHD.

Had she filled out a questionnaire, she'd be on a stimulant and her anxiety would likely be worse off.

I see this one happening all the time. Here was a new one. This was a patient with paranoia and some psychosis and unusual thought patterns, just gets out of three month inpatient stay. The outpatient psychiatrist, inpatient psychiatrists, and myself all have similar dx of various psychotic disorders and now the new provider decided that they can't focus because of "untreated ADHD". Really? Maybe some adderall will help with the paranoid obsessive thought processes and odd interpersonal manner especially the part about telling everyone about unusual methods to kill people. How many people are in inpatient for three months for ADHD? Gosh! attention problems, maybe that's it. Brilliant! How could we have all missed that one? Sometimes I wonder if the robots might do better.

Collaborative care is great in theory, but the other humans we are trying to collaborate with are the problem.

 

[nexus73]

It's a pie in the sky academic idea from the ivory tower. Let's get some articles published and justify our existence.

 

[VMSmith]

If you were to listen in between a primary care doctor consulting with a psychiatrist who does this, what do you think the most common corrections would be to the treatment?

I should clarify though that BHIP has nothing to do with the collaborative care model. I do PCMHI now as a psychiatrist and actually really enjoy it. The discussions I have with PCPs have evolved over time, initially just "yes you can ask about mental health symptoms and this is what you ask" but now it's more helping them with medication choices and recommending next steps in treatment, helping PCPs figure out how to engage with their difficult to treat patients, helping with decisions about transferring difficult pts between PCPs, seeing patients who really do need to see a psychiatrist, deciding who needs to be seen in the mental health clinics, things like that. In a lot of ways it feels more like CL (in a setting where CL isn't just doing reactive consults).

What I like about it is that I feel like I have an overview of the mental health needs of the population and can triage who goes where: who stays in primary care, who sees me and the psychologists for brief targeted interventions then returns to primary care, and who actually does need longer term psychiatric follow up. It's not just making decisions based on phq 9 alone (though to be honest I used to be opposed to measurement based care I find it a really helpful tool nowadays) because you have a care manager who is talking to the patient and can give you more of the qualitative info that can help you determine whether this is a pt for whom you can just follow phq over time or someone more complex for whom you may need to see yourself and pay closer attention to.

 

[DD214_DOC]

yes! I frequently get referrals for kids with ADHD who have failed multiple stimulants, only to learn they have a h/o trauma. 😡 I would argue, though, that it doesn't require an in-depth interview to figure this out. It requires someone actually asking.

Also had a kid dx with ADHD, put on concerta, then dx with ASD because of poor socialization and bizarre behavior (which isn't necessarily ASD to begin with). 2 minutes into the intake learned the "ASD symptoms" started when the Concerta was started. Stopped the concerta and, "cured" the kid's ASD. 🙄

Does anyone, you know, actually listen to their patients?

 

[FlowRate]

What exactly is an ACO and how does it relate to psychiatry?

In addition to what @keifernny2 said, ACO's are important because the patients in the ACO are allowed to go outside the ACO, but the ACO is still liable for those charges. This is why very large hospital corporations are doing their best to regionally monopolize -- reduces the chance of paying for the care patients get elsewhere.

In a lot of ways it feels more like CL (in a setting where CL isn't just doing reactive consults).

In some academic places, it's the CL docs who are actually piloting the (outpatient) CC efforts.

 

[rollercoaster]

In addition to what @keifernny2 said, ACO's are important because the patients in the ACO are allowed to go outside the ACO, but the ACO is still liable for those charges. This is why very large hospital corporations are doing their best to regionally monopolize -- reduces the chance of paying for the care patients get elsewhere.



In some academic places, it's the CL docs who are actually piloting the (outpatient) CC efforts.

It seems like an ignorant way to treat patients. Our care depends on interviewing skills. No High tech MRIs CT scans, blood tests, BP instruments unlike other branches of medicine - old school plain old 'talking' to patients gets the diagnosis (and part of treatment).

 

[FlowRate]

It seems like an ignorant way to treat patients. Our care depends on interviewing skills. No High tech MRIs CT scans, blood tests, BP instruments unlike other branches of medicine - old school plain old 'talking' to patients gets the diagnosis (and part of treatment).

It's a different paradigm, for sure. Think about it in a different way: there are two relatively clear buckets: patients who can be managed by a primary care doctor and patients who need a psychiatrist. Collaborative care is about that middle ground, where the primary care doc might be a little out of their depth (what med do I try next?) or uncertain about next steps (psych referral? specific neuropsych testing? etc.) In some places, the collaborating psychiatrist will also see the patients who clearly need a psychiatrist.

 

[keifernny2]

It seems like a good idea, but what I worry about in a CYA sense is that the PCP will pass liability to the psychiatrist "I asked for recommendations from the specialist," however the psychiatrist never saw the patient. The opposing attorney could easily argue that the standard of care is to examine the patient.

If the patient were to not need a psychiatrist, and could be managed by an independent psychologist/sw alone, then the psychiatrist wouldn't necessarily need their name in the chart at all and the current system would be adequate.

If the PCP just wants to know what drug to try next, they can open a book or look at an algorithm.

So, I'm not sure what value the psychiatrist adds other than making everyone else on the team feel better and like they have someone to refer to when things aren't going well, which they already have under the current system on an individual referral basis without the psychiatrist necessarily being liable for large numbers of active patients that they don't see.

If the system allowed for indemnity (i.e. Eliminating to National practitioner database, for example) for taking on responsibility for large numbers of patients then it seems like it would be worth a try, but under the current system the lawyers will just sue whomever is richest individually (the psychiatrist and hospital system).


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[Salpingo]

VA has BHIPs. An epic failure. Good in concept.

It seems like collaborative care is a lot like DBT. It gets more diluted the further away you go from Seattle, and people like to say it's an evidence based approach without really explaining what the evidence is for. Then it becomes a standard boards question...

 

[Salpingo]

It seems like a good idea, but what I worry about in a CYA sense is that the PCP will pass liability to the psychiatrist "I asked for recommendations from the specialist," however the psychiatrist never saw the patient. The opposing attorney could easily argue that the standard of care is to examine the patient.

If the patient were to not need a psychiatrist, and could be managed by an independent psychologist/sw alone, then the psychiatrist wouldn't necessarily need their name in the chart at all and the current system would be adequate.

If the PCP just wants to know what drug to try next, they can open a book or look at an algorithm.

So, I'm not sure what value the psychiatrist adds other than making everyone else on the team feel better and like they have someone to refer to when things aren't going well, which they already have under the current system on an individual referral basis without the psychiatrist necessarily being liable for large numbers of active patients that they don't see.

If the system allowed for indemnity (i.e. Eliminating to National practitioner database, for example) for taking on responsibility for large numbers of patients then it seems like it would be worth a try, but under the current system the lawyers will just sue whomever is richest individually (the psychiatrist and hospital system).


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I'm not sure how far the standard of care argument goes, since people are actively writing the standard of care as we speak. They might argue tha they are acting like radiologists, albeit with treatment recs.

You can make the argument that if a psychiatrist had to see and examine every patient with a mental health issue, we would have to let tons of people go untreated (not sure if you could present the last bit in court, but it might make you more sympathetic to juries who see you as just trying to help in a system stacked against you).

 

[keifernny2]

I'm not sure how far the standard of care argument goes, since people are actively writing the standard of care as we speak. They might argue tha they are acting like radiologists, albeit with treatment recs.

You can make the argument that if a psychiatrist had to see and examine every patient with a mental health issue, we would have to let tons of people go untreated (not sure if you could present the last bit in court, but it might make you more sympathetic to juries who see you as just trying to help in a system stacked against you).

You could make that same argument wrt telepsychiatry. If we didn't provide telepsychiatry, then many would be left untreated.
The standard of care , however, has been accepted to be the same for telepsychiatry as it is for in-person visits.

If legal exceptions aren't made for telepsychiatry, then it's not clear that they would be made for collaborative psychiatry.

 

[Salpingo]

You could make that same argument wrt telepsychiatry. If we didn't provide telepsychiatry, then many would be left untreated.
The standard of care , however, has been accepted to be the same for telepsychiatry as it is for in-person visits.

If legal exceptions aren't made for telepsychiatry, then it's not clear that they would be made for collaborative psychiatry.

In telepsychiatry you are the provider of care, not a consultant. When patients have abdominal pain, they don't go to a radiologist to get a CT scan, they go to their PMD or ED, who then send out for imaging, give the radiologist the relevant clinical info, and receive a report. A radiologist is liable if they miss something from the information given or if they don't inform the primary team that the data is inadequate to answer their question (hence the "needs MRI to r/o" whatever).

Also, telepsychiatry is an answer for getting care to underserved areas, but is not sufficient to getting who needs care contact with a psychiatrist. I remember seeing the numbers at a talk, but if every patient with mental health needs saw a psychiatrist once a year with no restrictions in travel, they would be seen for something like 2 minutes.

 

[doctorpilgrim]

How does giving primary care more work going to solve the primary care shortage, and how does it save cost as the E&M reimbursement is same. I can see if social workers are seeing patients and then psychiatrist just prescribes over the phone, leading to cost savings.

 

[masterofmonkeys]

yes! I frequently get referrals for kids with ADHD who have failed multiple stimulants, only to learn they have a h/o trauma. 😡 I would argue, though, that it doesn't require an in-depth interview to figure this out. It requires someone actually asking.

Also had a kid dx with ADHD, put on concerta, then dx with ASD because of poor socialization and bizarre behavior (which isn't necessarily ASD to begin with). 2 minutes into the intake learned the "ASD symptoms" started when the Concerta was started. Stopped the concerta and, "cured" the kid's ASD. 🙄

Does anyone, you know, actually listen to their patients?

That's the real problem here. We're required to do 4 months of primary care in residency even though most of us will enver touch it. They're nto required to get any formalized psych (As direct providers) at all, even though that's 30% of their primary patient presenting problems.B

 

[Shikima]

That's the real problem here. We're required to do 4 months of primary care in residency even though most of us will enver touch it. They're nto required to get any formalized psych (As direct providers) at all, even though that's 30% of their primary patient presenting problems.B

You still need a working knowledge and understand of TSH, Ferritin levels, Infections causing delirium, etc and so forth. Because your colleagues will be dumbfounded on what to do and ask for psych consults on an intubated person.

 

[Ceke2002]

How can it be considered collaborative care if the Psychiatrist doesn't actually see the patient? I mean there's no real collaboration if one part of the collaborative process is kind of missing. When I think of collaborative care I think more in terms of a patient goes to their GP, the GP realises the patients symptoms are outside their scope of diagnostic (and therefore treatment) ability, the GP refers the patient to a Psychiatrist for a full assessment (at least 1 and half - 2 hours), the Psychiatrist then either draws up a recommended treatment plan for the GP to follow (with 3 monthly follow ups to see how the treatment is going, and if adjustments need to be made), or the Psychiatrist recommends that the patient actually be primarily under their care if the case is, say more complex.

 

[masterofmonkeys]

You still need a working knowledge and understand of TSH, Ferritin levels, Infections causing delirium, etc and so forth. Because your colleagues will be dumbfounded on what to do and ask for psych consults on an intubated person.

I think we NEED those 4 months, or maybe even more. I also think that stuff needs to be tested/maintained through boards or CMEs or whatever. My argument was that it makes perfect sense that we're not total disasters outside of psych, and likewise it would make sense they were immersed in a psych environment for 4-6 months of training as well.

 

[notdeadyet]

I think we NEED those 4 months, or maybe even more. I also think that stuff needs to be tested/maintained through boards or CMEs or whatever. My argument was that it makes perfect sense that we're not total disasters outside of psych, and likewise it would make sense they were immersed in a psych environment for 4-6 months of training as well.

Absolutely. We need 6 months of medical rotations to recognize medical illness and not assume everything we see is psych.

That said, the odds of us ever getting IM or family to do more than 1 month rotation for psych is a moonshot. Too many competing priorities. Also, most of the psych issues they manage are going to be at the level of needing about three classes of medications before they will refer them to psychiatry.

 

[nexus73]

It's a curbside on steroids. Without seeing the patient how do you know what you might be missing? A good lawyer should be able to eviscerate a psychiatrist doing this type of work if there was something missed. It's not standard of care. It's just an academic experiment.There is no training for this in residency.

How much time does it save anyways. Can you do more chart review assessments per hour than actual patient consults? Honestly, it makes way more sense from a patient care and liability standpoint to put psychiatrists and Family doctors in the same office. Especially in the community mental health setting.

 

[Salpingo]

How can it be considered collaborative care if the Psychiatrist doesn't actually see the patient? I mean there's no real collaboration if one part of the collaborative process is kind of missing. When I think of collaborative care I think more in terms of a patient goes to their GP, the GP realises the patients symptoms are outside their scope of diagnostic (and therefore treatment) ability, the GP refers the patient to a Psychiatrist for a full assessment (at least 1 and half - 2 hours), the Psychiatrist then either draws up a recommended treatment plan for the GP to follow (with 3 monthly follow ups to see how the treatment is going, and if adjustments need to be made), or the Psychiatrist recommends that the patient actually be primarily under their care if the case is, say more complex.

The model you're describing is the current status quo, and people are arguing that we just don't have the manpower to provide 1-2 hour consultations for all the people who could benefit from mental health care. Very few specialties do provide that intensive level of consultation (maybe academic physicians funded primarily with grants).

When people talk collaborative care, they're thinking of the following scenario: 20% of the patients at a community health clinic have poorly controlled diabetes, and the GP can't figure out why (or doesn't have the time). Each patient is assigned to a case manager, who checks in on the patient, surveys their home environment, assesses their social support (none of which requires an MD). They review the list of patients with a psychiatrist to see who needs further intervention, who may be at risk for severe mental illness that is going undetected, who is over or underutilizing resources. The MD may see a few patients that seem to have increased complexity, but otherwise, points out areas to be further explored or possible interventions (either psychosocial or medical).

 

[Salpingo]

It's a curbside on steroids. Without seeing the patient how do you know what you might be missing? A good lawyer should be able to eviscerate a psychiatrist doing this type of work if there was something missed. It's not standard of care. It's just an academic experiment.There is no training for this in residency.

How much time does it save anyways. Can you do more chart review assessments per hour than actual patient consults? Honestly, it makes way more sense from a patient care and liability standpoint to put psychiatrists and Family doctors in the same office. Especially in the community mental health setting.

We'll see if it ever becomes an issue, legally. But if we only practice the "standared of care" (or what we assume is the standard of care), fearing some vague lawsuit, the field will never advance. And I agree, most residencies don't prepare you for this type of work, but the APA is putting a massive effort to provide that training as part of CME.

And yes, there's no comparison in terms of time saved, not only in terms of physician's time but also scheduling, billing, etc

 

[Ceke2002]

The model you're describing is the current status quo, and people are arguing that we just don't have the manpower to provide 1-2 hour consultations for all the people who could benefit from mental health care. Very few specialties do provide that intensive level of consultation (maybe academic physicians funded primarily with grants).

When people talk collaborative care, they're thinking of the following scenario: 20% of the patients at a community health clinic have poorly controlled diabetes, and the GP can't figure out why (or doesn't have the time). Each patient is assigned to a case manager, who checks in on the patient, surveys their home environment, assesses their social support (none of which requires an MD). They review the list of patients with a psychiatrist to see who needs further intervention, who may be at risk for severe mental illness that is going undetected, who is over or underutilizing resources. The MD may see a few patients that seem to have increased complexity, but otherwise, points out areas to be further explored or possible interventions (either psychosocial or medical).

Thanks for the explanation. That does kinda sound like what we have here in South Australia, but I think we look at it more as two separate things. My understanding is that collaborative care where I am is supposed to help keep people out of the mental health system (particularly the community mental health system), but once a person is referred for potential crisis assessment that's when the initial GP report, and follow up social worker/psych nurse home visit is taken into account and then the patient is sort of triaged as to how long they can wait to be assessed by a Psychiatric registrar, at which point they can either become a patient of the CMHC, get referred back to their GP for care, or be recommended to be referred onto the care of a private psychiatrist. Sorry I'm probably really not explaining that very well, but the second example I wouldn't consider collaborative care...not how I understand it to be here anyway.

edited to add: Somebody feel free to correct me on any of this, I've had my stuck in a toilet for the past few days so I could be a tad bit muddled at the moment.

 

[masterofmonkeys]

Absolutely. We need 6 months of medical rotations to recognize medical illness and not assume everything we see is psych.

That said, the odds of us ever getting IM or family to do more than 1 month rotation for psych is a moonshot. Too many competing priorities. Also, most of the psych issues they manage are going to be at the level of needing about three classes of medications before they will refer them to psychiatry.

Most of the time they spend is based on service and not learning. Chest pain rule out Hypertensive emergency CHF exacerbation Lobar pneumonia C. Diff Renal failure. Hepatic crisis. I may or may not have covered 80% of admissions, but I'm probably close.

And you're correct, they won't need a ton of medications before they refer to us. But things like recognizing cluster B symptomatology, the role of external locus of control and catastrophization in medical symptom presentation, self-efficacy and adherence, motivational enhancement techniques (which CAN be used effectively in 5 minute chunks) and, well, I can go on. But most primary care problems have a HUGE psych component. In some cases you can argue psych plays the largest role.