Enhancing Your Own Care

INTRODUCTION

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In this chapter, we consider 3 issues that can improve your conduct of mental health care: working as a team, referral, and personal awareness. The first 2 issues consider how best to get help from others by enlarging your care team, while the latter addresses what you can do to enhance your own success in conducting effective mental health care.

WORKING AS A TEAM

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In this section, we explore ways in which primary care health providers can incorporate other team members to maximize mental health care in primary care settings. As we discuss the benefits of collaborative care models (CCMs), we’ll focus on how you can extend this care beyond the boundaries of a single practice and what an individual practice can do, based on principles developed in patient-centered medical homes.

Working As a Team Within the Primary Care Office

Some practices have formal CCMs. CCMs include mental health specialists (usually a psychiatrist) embedded within or external to the practice. Although there are many models of CCM,¹ in the generic one, the psychiatrist, usually off-site, supervises mental health care by consulting with the second component of a CCM, an onsite (full-time or part-time) care manger, hopefully with some mental health care training. Guided by the psychiatrist on a weekly or biweekly basis, typically by telephone, the care manager provides day-to-day mental health care in consultation with the primary care provider who largely functions to write prescriptions advised by the psychiatrist.^2,3 Studies have found that these models improve outcomes for depression as well as chronic medical conditions like diabetes mellitus.^3-8 Unfortunately, reflecting the dearth of psychiatrists, there has been little widescale penetration into US care when viewed from a population perspective. If you are among those fortunate to have a CCM team available, make use of them not only for your patients, but also as an educational resource.

Nevertheless, because most practitioners to not have access to a CCM team, we need to think about ways that you can construct and mobilize your own core teams based on the chronic care model that guides collaborative care.⁹ This means enlisting your partners and staff in your own offices to fulfill at least some of the functions of CCM team members. After all, these are the people interacting with your patients at check-in, by phone, during visits, and when you are out of town. The skills and roles will vary among different practices, from highly developed patient-centered medical homes to traditional primary care offices.

Identifying core team members can help in several ways with the ongoing care of your patients with mental health disorders. These benefits include:

Identifying high-risk patients
Identifying problematic and/or positive behaviors
Reinforcing care plans
Coordinating care outside of office visits
Facilitating contact with community resources

Doing so requires shared vision and strong leadership backed by open communication, clearly defined roles, and common processes.^10,11 For example, if you are caring for a group of patients with chronic pain, your goals might be to: (1) decrease utilization of the emergency department; (2) decrease diagnostic testing; and (3) decrease specialist referrals. To replace this, your strategy would be to: (1) promote continuity by regularly scheduled, frequent office visits with the provider and/or other skilled office staff; (2) emphasize coping skills and symptom management at these visits; and (3) ensure that calls outside of office hours do not result in emergency department visits. To be successful, you will need the support of your scheduling staff, nurse, a social worker (if available), and partners who share call. Patients with chronic pain (or other medically unexplained symptom problems like irritable bowel syndrome and chronic fatigue or other mental health problems) will need to be clearly identified and general management protocols agreed upon—and the roles of different team members identified. For example, the scheduling staff would ensure open slots in your schedule so that a chronic pain patient can be seen on a regular basis, and they would work with you (and the patient) to avoid nonscheduled visits. A skilled nurse or medical assistant might engage in a 5-minute phone check-in each week with the patient, at the same time helping out with any necessary community resources and doing simple problem-solving. You are thus establishing not just a strong clinician-patient relationship but also a therapeutic relationship for the patient with your office staff. Your on-call physician colleague is also included and would know not to fill opioid or benzodiazepine prescriptions, except with your advance approval, when they were covering your patients in your absence. As part of forming your office team, you will need to meet regularly with office staff, encourage them in what can be a new but exciting role, and do some training such as teaching them to use NURS in their patient interactions. They can also be helpful in identifying problem patients who will benefit from a systematic team approach, and they should be encouraged to be proactive and engaged contributors to the team. You will find that this team effort greatly lessens your own burden and enhances office esprit. Staff like to be involved and feel like they have an important role in patient care.

To guide you, the functions and actions described in Table 11-1 come from studies of CCMs.^3,5-8,10,11 Organizations have implemented the changes as sets, either all at once or incrementally. Activities range from simple interventions such as distributing screening instruments to patients as part of the check-in process, to more labor-intensive endeavors such as creating patient registries. Every team member can—and should—have a role to play, perhaps an area where they are primarily responsible, depending on their skills and interest.

Table 11-1.Key Functions and Actions to Provide Team-Based Care for Patients

Functions	Actions	Examples
Identifying high-risk patients	Screening for: Depression (eg, Patient Health Questionnaire-9^a) Anxiety (eg, Generalized Anxiety Disorders 7-item) Bipolar disorder (eg, The Mood Disorder Questionnaire) Drug and alcohol misuse (eg, CAGE, CAGE-AID) Risk of substance misuse (eg, Opioid Risk Tool) Social determinants of health Creating registries of patients with chronic diseases	Front office staff distributes screening forms at check-in.^a Medical assistant administers screening forms as part of intake for visit.^a Nurse or social worker screens patients with depression for comorbidities. Nurse creates and maintains registries.
Identifying problematic and/or positive behaviors	Reconciling medications Monitoring controlled substance prescriptions Observing patient behaviors	Medical assistant or Nurse completes medication reconciliation and updates medical record.^a Nurse maintains registry of patients on controlled substances and runs reports from prescription monitoring system. Nurse maintains registry of patients being treated for depressive disorders and monitors for remission.^a Team members participate in huddles to discuss patient care. Team members report concerns based on interactions at check-in, during telephone conversations, and other interactions
Reinforcing care plans	Maintaining consistent interactions and expectations Following policies or protocols on medication prescribing and refills	Front office staff schedule patient with primary care provider to facilitate continuity. Nurse (as care manager), physician, and patient meet together during visits. Team members give patients a team business card to reinforce roles and available resources. Nurse or social worker reinforces treatment plans with patients outside of formal visits. Physician and physician extender use evidence-based protocols for patient management (ie, psychotropic medication prescribing, follow up for chronic pain, minimizing serial testing for medically unexplained symptoms).
Coordinating care	Educating patients Administering medications in the office Monitoring adherence and effectiveness of therapy Scheduling appointments with primary team, diagnostic services, or consultants Communicating with consultants Providing or identifying resources (eg, for medications, transportation, housing, exercise) Performing handovers for complicated patients	Physician extender, Nurse, or social worker teaches patient about self-care practices. Nurse or social worker calls to ensure patient is taking medication. Nurse or social worker conduct in-person visits. Social worker provides contacts for counselors. Social worker provides brief counseling directly. Team members participate in huddles to discuss goals for specific visits or chronic disease management. Medical Assistants use pre-visit planning sheets or templates to prepare for visits or obtain data during visits. Physicians or other team members perform structured handovers for patients in case of contact outside business hours or during absences. Nurse manages patient portal to facilitate between-visit care and to engage patients in self-management. Team members work from buckets or electronic “to do” lists.

All teams need clearly defined roles and expectations to be successful. One way to support this objective in a primary care office is to create small “pods” that include some combination of physician, physician assistant or nurse practitioner, nurse, medical assistant, and front office staff. Pod members should be working in the same space to enhance real-time communication.^10,11 Additional strategies like daily huddles and white boards at staff stations help. Pods can come together in weekly staff meetings to share best practices and problem-solve.

Huddles are structured activities to support the vision and goals of team-based care. Pod members meet briefly, say, at the beginning of a clinic session, to review the patients scheduled, the care to be provided, and any outstanding concerns.^10,11 Huddles also can be used to review patient registries and determine next steps. For example, the nurse and practice physicians might review a registry of patients with major depressive disorder and determine who needs lab tests ordered or an assessment for remission of symptoms on a Patient Health Questionnaire-9 (PHQ-9).

Collaborating Outside the Core Office Team

CCM is a wonderful opportunity to provide mental health care within primary care practices if it’s available. Most of us, however, rely on collaborating with consultants external to our practices. This is especially important for complex patients and for specialized services, like counseling or psychotherapy. When should we refer? Who is the “right” professional to add to the patient’s team? And how do we communicate effectively and coordinate care?

Table 11-2 summarizes the many indications for referral but they generally fall into 3 categories:

Emergency care, such as suicidal ideation or psychosis;
Failure to respond to first- and second-line therapies for conditions otherwise within your scope of practice;
To receive care that is outside your scope of practice, such as counseling for mood disorders, pharmacological treatment of complex mental health disorders (eg, bipolar disorder, schizophrenia, substance abuse), electroconvulsive therapy, or diagnostic testing (eg, neuropsychiatric testing).

Table 11-2.Indications for Referral

Suicidal or homicidal ideation
Psychosis, whether due to schizophrenia, bipolar I disorder, or other causes
Other indications for inpatient management, such as substance abuse
Failure of your primary care treatment, eg, for depression or anxiety
Worsening of dysfunctional behaviors, irrespective of other indications
Resistance of the patient to becoming engaged in your treatment
The patient requests a referral
Multiple and/or severe stressors
When your treatment has been successful in identifying a need for and a patient’s desire for counseling