Serving the Needs of the Many: Identifying Strategies for Better Care

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CONFERENCE REPORTER

“There simply aren’t enough of us,” said Lori Raney, MD, in a scientific session, titled “Unprecedented Access to Psychiatry: Expand Your Impact to Infinity and Beyond! Collaborative Care, eConsults, and ECHO Models,” at the 2021 American Psychiatric Association (APA) Annual Meeting. The session addressed the vast shortage of psychiatrists and proposed alternative models of care to improve outcomes for more patients.

Speakers discussed the ever-widening gap between the shortage of psychiatrists and the overflowing flood of patients needing care. Shannon Kinnan, MD, a member of the APA Integrated Care Committee, spoke about the gravity of the problem of access to psychiatry. “The severity and the incidence of psychiatric illness continues to climb, which has only been magnified by the pandemic,” said Kinnan, assistant professor at Creighton University School of Medicine, Omaha, Nebraska. She worked in psychiatric services that had a wait list of 350 patients.

Moderated by Ron M. Winchel, MD, assistant clinical professor at Columbia University School of Medicine, Department of Psychiatry, presentations centered around 4 main themes: collaborative/integrated care, psychiatric consults, ECHO models, and eConsults.

Essentials of Collaborative Care

Collaborative care, also known as integrated care, is ever evolving, informed by decades of research conducted by the APA, Academy of Psychosomatic Medicine, and other organizations. Kinnan directed participants to APA’s Learn About the Collaborative Care Model to explore current evidence-base for the model, elements of implementation with detailed examples, lessons learned by those in the trenches, as well as recommendations on how to advance the use of the collaborative care model.

According to Kinnan, the collaborative care model is made up of a patient-centered team that targets the special needs of each patient, looks for solutions, and lays out piece by piece ways to educate primary care physicians (PCP). One core feature of the collaborative model includes encouraging PCPs to use measurement-based care with tools such as Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7).

“The patient’s main points of contact are their PCP and a care manager,” she explained. “The psychiatric consultant then reviews cases in a registry with a care manager and offer guidance to the team on the case.”

The integrated psychiatry model attends to the needs of patients with team-based care and systematic regular caseload reviews, which involves psychiatrists, case managers, PCPs, social workers, and other health care providers. It enables delivery of services to patients at most dire need of psychiatric services.

“It is better than traditional care in the primary care setting,” Kinnan told attendees. “Patients get better, faster. And there’s cost savings as well.”

What Makes a Good Psychiatric Consult?

A consult enables those involved in behavioral health to manage multiple cases and communicate with different allied health professionals, with the goal of extending psychiatric services.

According to Lori Raney, MD, a practicing psychiatrist in Colorado and principal consultant with Health Management Associates, curbside consultation educates PCPs about diagnostic dilemmas and medications, helping them with complex patients.

A consult is an opportunity for psychiatrists to educate and collaborate with the general practitioner, especially important since medical training often involves only 2 weeks of psychiatric training. The consult enables the PCP to understand specific needs of patients and provides diagnostic clarification.

“There are definite approaches you can take,” Raney told attendees. “You want to build the PCP’s confidence in prescribing psychotropic medications and diagnosing behavioral health conditions.”

Psychiatrists can get calls for consults on a variety of issues, Raney explained. “The most prevalent, most common behavioral health conditions we are getting called about often involve anxiety disorders, depression, and substance use disorders . . . And then you’ll see other things, patients with multiple somatic symptom personality disorder traits and pain that play out in the clinic,” said Raney.

eConsult: Endless Possibilities

Another item on the menu of integrated behavioral health is the electronic mental health consultation (eConsult).

Christopher T. Benetez, MD, associate medical director of the Los Angeles County Department of Mental Health and assistant clinical professor at UCLA David Geffen School of Medicine, has conducted more than 5000 eConsults in the LA County project over the past 5 years.

“An eConsult is an asynchronous consultative, provider-to-provider communication within a shared electronic health record [EHR] or web-based program,” Benetez explained.

The eConsult approach enables PCPs to have remote access to psychiatrists, entering questions into an EHR for quicker response than the bottleneck often found in traditional models of care.

As the second largest health system, LA County occupies more than 4000 square miles with 10.5 million residents, and it is both rural and urban. Psychiatrists are also involved in an array of community partnerships, jails, and courts.

The eConsult in LA County and other community health hubs are intended for the Safety Net population, defined by the Institute of Medicine (IOM) as “those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients.”1

The eConsult system has optimized health equity by filtering psychiatric expertise to geographically challenged regions and a greater number of residents. “Our Safety Net takes care of over half a million patients a year with > 400 distinct sites; 4000 submitters; 500 specialty reviewers; and > 65 specialty portals,” said Benetez.

The advantages of the system set in place is centralized and coordinated systems and greater access to routine care, as well as patient-centered care and patient education. Limitations include measuring data, reimbursement, and concerns over liability.

Hello, Hello? The ECHO Model

Another way to improve access to psychiatric expertise has been through a learning community. Mark Duncan, MD, spoke about one alternative model at the University of Washington (UW).

Duncan is assistant professor at the Department of Psychiatry and director, UW Psychiatry and Addictions Case Conference (UW PACC), a Project ECHO initiative. ECHO stands for Extension for Community Healthcare Outcomes.

Project ECHO at UW PACC is made up of a didactic and case presentations. “The goal is to increase patient access across the state to effective and evidence based psychiatric, psychological, and addiction care through increasing the knowledge and self-efficacy of all interested health providers within an intentionally supportive virtual community,” said Duncan.

Using a collaborative/educational model, UW PACC is in a position to help guide care across disciplines, including psychology, psychiatry, and primary care. The net result has been to help change practice, build community, and identify providers needing the most assistance.

“It’s a great service because we’re interacting with the provider and asking for quick follow-up questions across many other specialties, so we can get a well-rounded summary of recommendations for people.”

Reference

1. Lewin ME, Altman S, eds. America’s Health Care Safety Net: Intact But Endangered. Washington, DC: National Academy Press; 2000.