Consult Liaison Psychiatry Questions?

[prominence]

I work at a VA.

Our C/L psychiatrist recently left on short notice.

Is anyone aware of facilities, especially other VAs, where psychiatry consults from medical floors are managed by mental health staff that are non-psychiatrists (i.e. psychiatric NP, psychiatric physician assistant, mental health pharmacist, mental health social worker, psychiatric nurse, etc.)?

Also, if a psychiatrist is not available on weekends and holidays, are there any facilities with setups that utilize mental health staff that are non-psychiatrists?

I would love to hear any specific examples. Thank you in advance.

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[Stagg737]

I rotated at 3 VAs in residency. At our main VA residents saw consults and staffed with one of the inpatient psychiatrists, they hired a FT C/L psychiatrists during my final year. At another (<40 beds) the outpatient docs covered the rare consults. At the third, the inpatient attendings saw them. None of them had anyone other than psychiatrists (attendings/residents) seeing consults.

 

[Jules A]

In civilian hospitals there are some PsychNPs and PAs doing CL. Due to the medical complexity ideally they have been trained and supervised by a psychiatrist. Call on weekends is generally via phone curbside only unless the unusual well staffed service. Social workers are utilized for dispo but since the majority of CL is med recs the ability to prescribe is necessary.

 

[Celexa]

I know of plenty of places where psych consults are handled only by NPs or (dispo only) by social workers. In my still fairly short career I have seen that result in so many disasters I can't possibly recommend it.

I do think dispo only (patient is evaluated and med cleared by a medical physician, and the only psych question is if they need inpatient or not) is the type of narrow and appropriately targeted scope where APP coverage can work decently well. But medical CL questions, of the type that straddle the differential and management of psych and medicine? It goes poorly.

 

[Sushirolls]

@Celexa
Concur.

But then again I've seen ARNPs in any setting and any specialty fun things up. Chances are they'll still plug an ARNP/PA into the role and be happy. They won't know that their "specialist" is anything but. Conversely, primary services never follow recs from C/L anyways. So maybe it'll all work out in the end?

 

[Celexa]

@Celexa
Concur.

But then again I've seen ARNPs in any setting and any specialty fun things up. Chances are they'll still plug an ARNP/PA into the role and be happy. They won't know that their "specialist" is anything but. Conversely, primary services never follow recs from C/L anyways. So maybe it'll all work out in the end?

Pfffff teams follow my recs at *least* half the time, but that's also because I have a certification in being charmingly but annoyingly persistent. Like a mosquito.

 

[comp1]

The absolute BEST use of PMHNPs is overnight and on weekends. Yes, it is almost VA standard to have those hours handled by NPs because of the complexity in residency work hours that has developed and how limited physicians are in terms of pay differential for weekend/night hours. I've never seen a mental health PA (or even a functional statement for one), but I have heard they exist and can probably play a similar role. Of course NPs are LIPs and PAs are by definition not, so it might be more complicated. Definitely second that most "consults" on the weekend should be curbsides anyways. There are very few psychiatric emergencies in patients who are already admitted to the hospital. As much as I love VA clinical pharmacists, they aren't quite setup for this role as they aren't allowed to diagnose. Similarly, social workers aren't appropriate for a med floor consult service by themselves because generally the primary team is looking for meds. I do think there should be at least one psychiatrist available during business hours for complex cases. This could potentially be an inpatient psychiatrist, but I don't know the specifics of your VA facility. Staffing an ED consult service is different, although NPs can also play a role. Social workers and even clinical pharmacists can potentially play a bigger role in the ED. If your system does end up requiring a psychiatrist, you'll probably have to go virtual to recruit one.

 

[Stagg737]

The absolute BEST use of PMHNPs is overnight and on weekends. Yes, it is almost VA standard to have those hours handled by NPs because of the complexity in residency work hours that has developed and how limited physicians are in terms of pay differential for weekend/night hours. I've never seen a mental health PA (or even a functional statement for one), but I have heard they exist and can probably play a similar role. Of course NPs are LIPs and PAs are by definition not, so it might be more complicated. Definitely second that most "consults" on the weekend should be curbsides anyways. There are very few psychiatric emergencies in patients who are already admitted to the hospital. As much as I love VA clinical pharmacists, they aren't quite setup for this role as they aren't allowed to diagnose. Similarly, social workers aren't appropriate for a med floor consult service by themselves because generally the primary team is looking for meds. I do think there should be at least one psychiatrist available during business hours for complex cases. This could potentially be an inpatient psychiatrist, but I don't know the specifics of your VA facility. Staffing an ED consult service is different, although NPs can also play a role. Social workers and even clinical pharmacists can potentially play a bigger role in the ED. If your system does end up requiring a psychiatrist, you'll probably have to go virtual to recruit one.

Post really shows the saying of "if you've been to 1 VA, you've been to 1 VA" as my VA experiences in residency were pretty different.

Where I was at the main hospitals did not have psych NPs other than the outpatient clinics. The main VA I rotated at had 2 psych PAs in their clinic, both seemed pretty solid. There was also a psych pharmacist who had her own outpatient clinic and did evaluate/diagnose patients. She also had some of the worst med regimens, which you'd think would at least be a strong point. Where I went the VA leaned pretty heavily on psych residents, but there were a lot of attendings as well and patient loads were (mostly) very reasonable.

We did weekend call for the inpatient unit at that VA and that resident would also cover consults on the medical floors on the weekends. Usually was just 1-3 total and most commonly stat capacity consults to leave AMA and occasionally for severe agitation, aka the kinds of things you absolutely want an actual psychiatrist managing and not midlevels who are just covering extra shifts.

 

[comp1]

VAs definitely vary, but clinical pharmacists cannot diagnose at any VA. It's a national policy. It's a subtle thing for outpatient, but would be very problematic for a consult service.

 

[Stagg737]

VAs definitely vary, but clinical pharmacists cannot diagnose at any VA. It's a national policy. It's a subtle thing for outpatient, but would be very problematic for a consult service.

Interesting. The pharmacist where I was at was definitely diagnosing. Maybe not the initial, but definitely added diagnoses later on without other professionals evaluating further.

 

[docksan]

VAs definitely vary, but clinical pharmacists cannot diagnose at any VA. It's a national policy. It's a subtle thing for outpatient, but would be very problematic for a consult service.

And doctors can't see patients while drunk.

 

[soundnin]

The absolute BEST use of PMHNPs is overnight and on weekends. Yes, it is almost VA standard to have those hours handled by NPs because of the complexity in residency work hours that has developed and how limited physicians are in terms of pay differential for weekend/night hours. I've never seen a mental health PA (or even a functional statement for one), but I have heard they exist and can probably play a similar role. Of course NPs are LIPs and PAs are by definition not, so it might be more complicated. Definitely second that most "consults" on the weekend should be curbsides anyways. There are very few psychiatric emergencies in patients who are already admitted to the hospital. As much as I love VA clinical pharmacists, they aren't quite setup for this role as they aren't allowed to diagnose. Similarly, social workers aren't appropriate for a med floor consult service by themselves because generally the primary team is looking for meds. I do think there should be at least one psychiatrist available during business hours for complex cases. This could potentially be an inpatient psychiatrist, but I don't know the specifics of your VA facility. Staffing an ED consult service is different, although NPs can also play a role. Social workers and even clinical pharmacists can potentially play a bigger role in the ED. If your system does end up requiring a psychiatrist, you'll probably have to go virtual to recruit one.

As a resident that covers weekends at a VA, the majority of "stat" consults I get on the weekend are for psych patients who are medically cleared for transfer to inpatient psychiatry lol.

 

[michaelrack]

And doctors can't see patients while drunk.

A real problem for all of those alcoholic doctors 😉

 

[FlowRate]

I work at a VA.

Our C/L psychiatrist recently left on short notice.

Is anyone aware of facilities, especially other VAs, where psychiatry consults from medical floors are managed by mental health staff that are non-psychiatrists (i.e. psychiatric NP, psychiatric physician assistant, mental health pharmacist, mental health social worker, psychiatric nurse, etc.)?

Also, if a psychiatrist is not available on weekends and holidays, are there any facilities with setups that utilize mental health staff that are non-psychiatrists?

I would love to hear any specific examples. Thank you in advance.

Well I have a negative example for NP's doing consults. The hospital where I did a few of my medicine months in residency was a ****show in general and their "CL" person was an NP. She had a single template note for all presentations where she'd just delete recs that weren't applicable (but not all of them, leading to bloated notes with many recs that were unnecessary.) She said multiple times that patients who were in the ICU for acute severe suicide attempts could leave since they were "no longer suicidal." Most of her recs, regardless of case, were unhelpful.

 

[prominence]

Appreciate everyone’s helpful thoughts and insights on my post.

 

[comp1]

I think there probably are some VAs that allow assessment of drunk patients and it's definitely appropriate to assess drunk patients for some things. What's not appropriate is what's asked for most, ie assessing actively drunk patients for suicidality and subsequent admission to a psych unit.