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
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.
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.
|Identifying high-risk patients|
Creating registries of patients with chronic diseases
|Identifying problematic and/or positive behaviors|
Monitoring controlled substance prescriptions
Observing patient behaviors
|Reinforcing care plans|
Maintaining consistent interactions and expectations
Following policies or protocols on medication prescribing and refills
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
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).
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).