Tele-consults and Models of Collaborative Psychiatric Care in Palliative Care William Pirl, MD, MPH Director, Center for Psychiatric Oncology and Behavioral Sciences Past-President, American Psychosocial Oncology Society June 10, 2015
Objectives ➔ Describe at least two different models of collaborative psychiatric care ➔ List the steps needed to implement a collaborative psychiatric care model ➔ Analyze the feasibility and appropriateness of implementing a collaborative psychiatric care model at their own site 2
Psychiatric Care in the U.S. ➔ 319 million people in U.S. ➔ 25,000 psychiatrists ➔ > 50% of psychiatric care provided by non- psychiatrists 3
Lessons from Primary Care ➔ Novel models of care ➔ Collaborative with non-mental health providers ➔ Decreased barriers for patients 4
Extension Models and Palliative Care ➔ Palliative care clinicians assess psychosocial well-being in all patients (screening) ➔ Higher level of psychiatric skills in palliative care ➔ Experienced in working closely with other services 5
Psychiatry Expertise ➔ Diagnosis of psychiatric disorders ➔ Psychopharmacology ➔ Mental health treatment planning ➔ Neuropsychiatry ➔ Recognizing limitations ➔ Being suspicious 6
Psychiatry Models Integrated Separate Collaborative 7
Patient Needs and Models 8
Patient Needs and Models Primary care 9
Patient Needs and Models Specialty psychiatry: Bipolar disorder Psychotic disorders’ Suicidal patients 10
Patient Needs and Models Palliative care with extension of specialty psychiatry: Depression Anxiety Sleep problems 11
Patient Needs and Models Palliative care with extension of specialty psychiatry: Can the patient be managed by palliative care? Treatment resistant disorders 12
Extension Models ➔ Remote visits ➔ Supervision ➔ Tele-consults ➔ Integrated consults 13
Remote Visits ➔ Psychiatrist provides evaluations and treatment directly to patient via video or telephone 14
Remote Visits ➔ Pros – May be best option in rural settings – More thorough evaluation by psychiatrist – Billing – Convenient for patients ➔ Cons – Same amount of psychiatrist time – Need for local responsible clinician (safety issues) – Patients’ ability to operate technology – Equipment and space 15
Supervision ➔ Regular meeting, in person or over phone, to discuss cases with psychiatrist and get recommendations and education 16
Supervision ➔ Pros – Might be easiest way to start – Efficient use of psychiatry time – Lower cost – May facilitate referrals ➔ Cons – Not in real time – Coordinating staff 17
Tele-consults ➔ Direct to patient (remote visits) ➔ Clinician-to-psychiatrist consults in which psychiatrist provides recommendations over phone to patient’s clinician 18
Tele-consults ➔ Pros – In real time – Efficient use of psychiatry time – No space needs – Value is back up, not number of consults – May be able to bill in rural areas ➔ Cons – Set up – Face time still needed – Costs 19
MGH Psychiatry Tele-consults for Primary Care Providers ➔ Psychiatrist available by phone in real time during clinic hours ➔ Assist with diagnosis ➔ Recommend treatments and referrals ➔ Brief consult note Stern and Worth, 2000 20
MGH Psychiatric Oncology Tele-consult Service ➔ Psychiatrist available by phone in real time during clinic hours ➔ Assist with diagnosis ➔ Recommend treatments and referrals ➔ Brief consult note 21
MGH Psychiatric Oncology Tele-consult Service (cont.) ➔ E-mail consults ➔ Site visits ➔ Psychosocial rounds ➔ Educational programs 22
Integrated Consults ➔ Psychiatrist provides consults within the palliative care clinic with goal of palliative care clinicians managing ongoing psychiatric care 23
Integrated Consults ➔ Pros – Face-to-face psychiatric evaluations – Clinician interactions with psychiatrist outside of appointments – Normalizes psychiatric care ➔ Cons – Same amount of psychiatrist time – Space – No shows – Insurance issues – Costs 24
Alternatives ➔ One prescriber on team gets more training – CME courses: MGH annual psychopharm update, etc. ➔ Case manager to develop a local network of providers 25
Getting Started ➔ Supervision – Team buy in – Finding someone • Your institution first • Psychiatrist who treated your patients • Hook – Payment • $150-300/hr – Mode 26
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