Mindoula collaborative care feedback

[willl]

Has anyone been a psychiatrist with Mindoula Health Collaborative Care?

I am considering working for them.

Any feedback would be appreciated.

Best,
Will

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[Jules A]

Is the "Dr" who runs it a social worker? From what I've heard secure your rate prior to investing too much time and energy.

 

[Jules A]

Just saw an ad from them $125-$150 hour weekends in rural Maryland where locums are generally around $200 an hour for weekdays. As with any position be sure to check out their expected patient load to ensure it is realistic also.

 

[Mass Effect]

Just saw an ad from them $125-$150 hour weekends in rural Maryland where locums are generally around $200 an hour for weekdays. As with any position be sure to check out their expected patient load to ensure it is realistic also.

Keep in mind the "patient load" in CC may be different from standard practice as the OP isn't actually seeing the patients.

 

[Jules A]

Keep in mind the "patient load" in CC may be different from standard practice as the OP isn't actually seeing the patients.

Perhaps I'm confused. As far as I know the Mindoula I'm referring to is essentially a hospitalist group that contracts for services on inpatient units and outpatient as well. It would be my understanding the OP would be seeing patients and possibly quite a few from what I have heard.

 

[Mass Effect]

Perhaps I'm confused. As far as I know the Mindoula I'm referring to is essentially a hospitalist group that contracts for services on inpatient units and outpatient as well. It would be my understanding the OP would be seeing patients and possibly quite a few from what I have heard.

If that's the case then it's not collaborative care. CC is consulting to PCPs. Psychiatrists in a CC model generally don't see the patient. OP, can you clarify?

 

[willl]

In this setup, a pcp is treating the patient. A case manager presents the patients to me. It is 5 minutes for follow up patients and 15 minutes for new patients.

Best
Will

 

[aim-agm]

It is 5 minutes for follow up patients and 15 minutes for new patients.

Is this typical of collaborative care? Because that seems a little...short

 

[WisNeuro]

15 minutes for a new psychiatric intake? Maybe I just work with fairly complex people when it comes to MH issues, but that seems like the perfect recipe for a load of misdiagnoses.

 

[Mass Effect]

In this setup, a pcp is treating the patient. A case manager presents the patients to me. It is 5 minutes for follow up patients and 15 minutes for new patients.

Best
Will

Push back on those times. You need longer to appropriately ask questions/discuss. How many patients per day are they presenting? Is this a full-time collaborative care position?

15 minutes for a new psychiatric intake? Maybe I just work with fairly complex people when it comes to MH issues, but that seems like the perfect recipe for a load of misdiagnoses.

This isn't an intake. This is collaborative care. Basically, a primary care case manager will present a patient who is depressed/anxious/adjustment issues and the OP gives recs for the PCP. It's like a formal curbside. More serious psych illness -- suicidality, bipolar symptoms, psychotic symptoms are generally referred to an outpatient psych clinic for formal intake and longitudinal care for meds and/or therapy. The OP's only job is to give recs based on symptoms/GAD7, PHQ9, and other scores. The patients who are not referred to a psych clinic are generally those who generally have no psych hx but are experiencing anxiety related to a new job or those experiencing grief or those with depression that's generally mild. PCPs may start Zoloft 25 mg and then want input from psych regarding up-titrating or it's already been up-titrated with poor response and they want further recs (other med options, how to taper, cross-taper, etc).

A common collaborative care issue is how to taper benzos or how to do proper ADHD evals. These are patients who, if uncomplicated, can be managed by PCP with psych input rather than seeking care at a psych clinic and extending the wait times for those who have more complex histories/presentations.

 

[WisNeuro]

Push back on those times. You need longer to appropriately ask questions/discuss. How many patients per day are they presenting? Is this a full-time collaborative care position?



This isn't an intake. This is collaborative care. Basically, a primary care case manager will present a patient who is depressed/anxious/adjustment issues and the OP gives recs for the PCP. It's like a formal curbside. More serious psych illness -- suicidality, bipolar symptoms, psychotic symptoms are generally referred to an outpatient psych clinic for formal intake and longitudinal care for meds and/or therapy. The OP's only job is to give recs based on symptoms/GAD7, PHQ9, and other scores. The patients who are not referred to a psych clinic are generally those who generally have no psych hx but are experiencing anxiety related to a new job or those experiencing grief or those with depression that's generally mild. PCPs may start Zoloft 25 mg and then want input from psych regarding up-titrating or it's already been up-titrated with poor response and they want further recs (other med options, how to taper, cross-taper, etc).

In this case, totally appropriate. I just hope these aren't relatively new patients, presenting with psych problems from the get go. PCPs generally aren't that great at teasing out complex psych and/or axis II IMO.

 

[Jules A]

In this case, totally appropriate. I just hope these aren't relatively new patients, presenting with psych problems from the get go. PCPs generally aren't that great at teasing out complex psych and/or axis II IMO.

I have to wonder why if they are so uncomplicated the PCP can't manage the Zoloft? In my experience they are only simple until they aren't and if there is an adverse event it will be the psychiatrist sitting behind the TV screen who saw a patient for 5 minutes, relied on a case manager's input who will be left holding the bag.

 

[Mass Effect]

I have to wonder why if they are so uncomplicated the PCP can't manage the Zoloft? In my experience they are only simple until they aren't and if there is an adverse event it will be the psychiatrist sitting behind the TV screen who saw a patient for 5 minutes, relied on a case manager's input who will be left holding the bag.

You'd be surprised. I'm in an integrated care clinic and have experience with collaborative care in residency. Some PCPs think keeping a patient on Zoloft 25 mg for 4 months is appropriate. Some say that Zoloft 50 mg is all they're comfortable with. Never mind trying to switch to a different SSRI or SNRI. A lot of them also aren't comfortable with stimulants or benzos and want to take everyone off these meds right away no matter the circumstances.

I can't speak for collab care practices in general, but in residency, we documented exactly what the CM or SW said and had a disclaimer on our notes that stated we did not see the patient and that this is a consultation to the PCP answering a specific question so that he/she can manage the patient's psychiatric symptoms. There's still some risk, but it's no different than a curbside.

 

[Jules A]

I can't speak for collab care practices in general, but in residency, we documented exactly what the CM or SW said and had a disclaimer on our notes that stated we did not see the patient and that this is a consultation to the PCP answering a specific question so that he/she can manage the patient's psychiatric symptoms. There's still some risk, but it's no different than a curbside.

Interesting and I've always felt, perhaps wrongly, that curbsides are risky as I imagine the patient's and PCP's lawyers would both argue they looked to my expertise for advice and then XYZ happened.

 

[Mass Effect]

Interesting and I've always felt, perhaps wrongly, that curbsides are risky as I imagine the patient's and PCP's lawyers would both argue they looked to my expertise for advice and then XYZ happened.

Not to say they're not risky, but we still do them. I also think that if you act in good faith with the information you have in the chart and given to you, you're doing all you can. Could it still go all wrong? Sure. But the guy I have 25 mg of Zoloft too can also sue me for a bad outcome.

 

[sighchiatry]

Not to say they're not risky, but we still do them. I also think that if you act in good faith with the information you have in the chart and given to you, you're doing all you can. Could it still go all wrong? Sure. But the guy I have 25 mg of Zoloft too can also sue me for a bad outcome.

Some relevant, recent case law:

Warren v. Dinter

The Supreme Court reversed the judgments of the lower courts that, as a matter of law, a hospitalist owed no duty of care to a patient seeking to be admitted because no physician-patient relationship had been established, holding that there was sufficient evidence in the record to survive a...

law.justia.com

 

[Mass Effect]

Some relevant, recent case law:

Warren v. Dinter

The Supreme Court reversed the judgments of the lower courts that, as a matter of law, a hospitalist owed no duty of care to a patient seeking to be admitted because no physician-patient relationship had been established, holding that there was sufficient evidence in the record to survive a...

law.justia.com

Yup, I'm aware. That's why I said it could still all go wrong.