Team Based Tele-Psychiatry in Family Medicine. Collaborative Learning Session October 26th SIM/TCPi

Team Based Tele-Psychiatry in Family Medicine Collaborative Learning Session October 26th SIM/TCPi

Have you been infected with stigma? Please access your smart phones, we are taking the stigma quiz Go to site: PollEv.com/bh931

If you answered C B D Congratulations!!! Your results show that you are #StigmaFree Thank you for being an ally to people with mental health conditions. We hope you will continue to be an ally to people with mental health conditions. Together, we can #CureStigma. https://www.curestigma.org

Collaborative care models Population Centered Models IMPACT (Washington State) Patient-Centered, Population-Based, Measurement-Based, Evidence-Based CMS supported Specialized (eg. TOPS,) Comprehensive Models (Cherokee) Colorado Models (Deep end of the pool)

ECHO Style Grand Rounds E-Consultation Store and Forward Telepsychiatry Virtual Integrated Care Shared EMR/Tracking Virtual Teaming E-Consult Store and Forward Direct Patient Care Supervision Education Telepsychiatry Supervision Telepsychiatry Consultation

Credentialing & Liability Licensure is needed in the state where the patient is located Unless you are working in a federal system Credentialing is largely dependent on the organization. Credentialing by proxy JACHO Define liability within contractual agreements Check in with malpractice providers Create good clinical protocols Work on consistent and clear communication 12

Technology Need HIPPA compliant technology Journey not a destination Flexibility to meet needs of patients, providers, and organization. Build in time and resources for troubleshooting 13

Program Design: Blending Telepsychiatry into Integrated Care Blended Model of Tele-Health Services and In-Person behavioral services for increased access Nursing PCP Psychiatry Technology: Cloud-based virtual telemedicine platform, real-time, video-based (Vidyo/Zoom platforms) Pharmacy Patient Psychology Stepped Model of Available Services: 1) E-consults: Staff message through EPIC EMR for brief questions/chart review 2) Provider-to-Provider Consultations: Scheduled or brief curbsides with PCP and/or BHP Social Work MODE OF CONSULT DELIVERY 3) Co-Consultations: Provide Consultations with PCP, Patient, and sometimes BHP to develop a plan together 4) Psychiatric Evaluation: Initiate plan, document recommendations for continued management 5) Interdisciplinary Team Meetings: Discuss patients with high medical complexity 6) Didactic Education Care Management Structure and Flexibility: Time is scheduled for consultations, meetings, and didactics & unscheduled time for curbside questions, warm-hand-offs, and supervision Coordinate with Behavioral Health Team: Psychologists, Social Workers, Health Coaches, Care Managers

Scheduling Add in as provider to your system PARs and MAs support technology and workflow Attach to other provider visits for co-consults Build in precepting time for scheduled and unscheduled consultation No 1:1 psychiatry visits Good communication with PCP and BHP Help increase PCP comfort with prescribing Pass patient back to PCP 15

Introducing Tele-behavioral health services to a Patient Appropriate for telehealth? Discuss with team Primary Care Provider a provider to provider consult may suffice Behavioral Health Provider can help with diagnostic clarification and treatment options Not for acutely suicidal or homicidal patients Can use in person behavioral health provider for support No patients with immediate hospitalization needs Can use in person behavioral health provider for support Consent before first session A few minute introduction and discussion to orient patient 16

Documentation Shared EMR with all team members and patient Not behind the glass or wall Open note system with patients Create referral structures for tracking of all behavioral health services Standard notes for shared system No process or psychotherapy notes No unnecessary details 17

Service Utilization Early Findings Mode of Consult Delivery Mental Health Diagnoses 18

Lessons Learned 19

More Lessons Learned Have Patience Organizational and change management takes time and ongoing education. Become Part of the Team While in many instances, providers must operate independently, successful integration requires A Beginner s Mind or a humility-based mindset with an ongoing learning orientation as providers on each side adjust to a different medical culture and learn how to be useful to each other. This mindset may require a shift from a hierarchical orientation to a team-based practice and is intrinsically linked to relationships. Relationships Matter Relationships with other providers will impact patient care. We need to be aware of different personalities and priorities, build trust and navigate new technology.

Sample cases Patient 1 Severe depression, renal failure, hypertension, CHF, morbid obesity, insulin-dependent diabetes, sleep apnea Patient 2 Bipolar, hypothyroidism, migraines, severe premenstrual syndrome including suicidality Patient 3 Bipolar, diabetes, history of substance use disorder, chronic back pain, cardiomyopathy, pulmonary hypertension, and suicide ideation Patient 4 Joint degeneration muscular atrophy, social anxiety, Munchausen disorder, chronic pain, phobias Patient 5 Perinatal depression, grief, anxiety, insomnia, psychosocial stress Patient 6 Depression, anxiety, PTSD, end stage renal disease, on dialysis, refusal to continue behavioral care with community mental health center

Story 1 Ms. B was in her late 20s and presented with a complex eating disorder hx and high degree of emotional distress. On the day of her first visit, the clinic administrators informed me Ms. B contacted the clinic multiple times throughout the day to demand immediate medical services. She was highly distressed and tangential during her first visit, but her PCP and I were able to help her reduce her distress and identify specific needs. The initial presentation suggested that she required a referral for eating disorder treatment. The behavioral health model at AFW gave me the time and flexibility to align with the patient and understand she did not want or need additional treatment for her eating disorder. Instead, she described a long history of systemic problems related to inattention and concentration. Through additional assessment, and consultation with our telepsychiatry team, we were able determine she had untreated ADHD, which greatly impaired daily functioning and interfered with her ability to successfully manage her eating disorder. Our telepsychiatrist was able to prescribe an appropriate medication, and we helped the patient establish long term care with a therapist in the community. During my last visit with Ms. B she told me that she was enrolled in community college courses, and, for the first time in years, was hopeful about her future.

Story 2 PCP requested a warm hand off with behavioral health for a 9-year-old, cisgender, Hispanic female, presenting with suicidal ideation. The BHP worked with the child to help her manage her anxious distress and suicidal thoughts. After the second visit, the patient reported feeling "safe" at A.F. Williams. She would invite her father and siblings in to each visit at the end to teach them what she had learned to help the family develop strategies to support healthy forms of distress management at home. After three visits, the patient disclosed she was hearing voices and seeing shadows. Telepsychiatry was brought into the patient s care as a bridge for support with psychiatric medications until she was able to establish with a community psychiatrist. Ultimately, we were able to connect the patient to Children's Hospital for psychiatry. Because of team based care available at A.F. Williams, we were able to meet the child and her family's immediate and remote needs.

Story 3 A single woman in her early 40s presented with fibromyalgia, obesity, history of depression, delayed-sleep phase syndrome, sleep apnea. She was also grieving her father s death, recently lost her job, reported her chronic pain and sleep difficulties were making it very challenging to maintain a job, and as a result was feeling worthless and hopeless. We provided therapy and helped her identify values and goals, discussed how social relationships were an important values to the patient and how pain, fatigue, and depression were perceived barriers to developing and maintaining meaningful relationships. With the support of telepsychiatry the PCP made adjustments to antidepressant medications. BHP presented her case at an integrated care team meeting and received suggestions from physicians, pharmacists and social workers about considerations for whole person care. As a result of our team based care approach, the patient is reporting progress, applied for jobs, successfully completed several interviews, and began a new job, started selling her crafts on Etsy, and intentionally increased socialization. She still struggles with chronic pain and sleep and we are introducing CBT and acceptancebased approaches to chronic pain.

How has telepsychiatry impacted patient care? With telepsychiatry you can teach an old dog new tricks. - This provides an opportunity for primary care providers to get a glimpse into what happens in a psychiatry visit. - Often times, after training we don t get to see how others practice. We have many patients who will never go outside of primary care for their health needs. - Now we can do more to help them in our own practice where they feel most comfortable and are more likely to follow up. 25

Next Steps Expansion of telepsychiatry as we expand in person behavioral health integration with the hiring of new psychologists Westminster Boulder Lone Tree Collaborating with the Department of Psychiatry for resident training Planning to provide 5 psychiatry residents clinical experience in the 2018-2019 year Planning didactics for psychiatry residents as well as some combined didactics for psychiatry residents, family medicine residents, and psychology interns/externs

Discussion and Questions 27