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APNA 29th Annual Conference Session 3012.1: October 30, 2015 Higgins 1

Jesse M. Higgins, PMH‐NP, MSN The Acadia Hospital Bangor, Maine

Conflicts of interest

 The speaker has no conflicts of interest to disclose.

Learning objectives

 Explain how psychiatric mental health nurse practitioners (PMH‐NP’s) are uniquely positioned to identify and resolve existing and variable problems in integrated health care.  Name the 4 guiding principles and structure of consult‐liaison psychiatry.  Consider how the collaborative care model could be adapted to your practice and community, keeping key principles of collaborative, team‐based care intact.

APNA 29th Annual Conference Session 3012.1: October 30, 2015 Higgins 2

Lexicon: Key concepts

 Integrated care: The care that results from a practice team

• f medical and behavioral health clinicians, working

together with patients and families, using a systematic and cost‐effective approach to provide patient‐centered care for a defined population(Peak, 2013).  Consultation‐liaison (CL) psychiatry: Evaluating and treating emotional and behavioral symptoms in medical settings, often addressing co‐occurring psychiatric and medical conditions, or emotional and behavioral problems resulting from a medical illness or as a reaction to the illness and its treatment (Leigh & Streltzer, 2007).

Core principles of collaborative care

 Patient centered: All patients in the practice educated about and included in the model.  Evidence based: Model and interventions supported by evidence.  Measurement‐based: Data‐driven with outcomes measured and assessed.  Population‐based: Adherent to core principles but adaptable to meet each population’s unique needs.  Accountable: Providers and interventions evaluated for cost efficiency as well as quality of care.

(Unützer et al., 2013)

Principles of team‐based care

 Shared goals: Treatment plan is developed with the patient and is simple, time‐based and targeted toward achieving functional improvement.  Clear roles: Differentiate between care manager, behavioral health consultant and psychiatric consultant.  Mutual trust: Be accessible, confident and whole patient‐oriented. Be an on‐site resource for all things behavioral health.  Effective communication: Identify consistent channels of communication between all team members. Be interrupt‐able.  Measureable processes and outcomes: Identify and use evidence based screening tools for assessing providers, interventions, patient improvement, and the program as a whole. (Mitchell et al., 2012)

APNA 29th Annual Conference Session 3012.1: October 30, 2015 Higgins 3

Members of the collaborative care team

 Patient!  Primary care or medical provider  Behavioral health consultant (PhD or LCSW): Provides diagnostic assessments, brief behavioral interventions, and brief psychotherapy.  Care/case manager (CM) (RN or LCSW): Provides care and resource coordination.  Psychiatric consultant (PMH‐NP or MD): Focuses on subset of patients who present diagnostic challenges or are not showing clinical improvement. (Unützer et al., 2013) The collaborative care model is adaptable to best fit the needs of each practice and patient population and community, but the core principles

• f collaborative, team based care are essential to its success and

must remain intact.

What do PMH‐NP’s bring to the table? We are trained to:

 Complete psychosocial and physical assessment with differential diagnosis of psychiatric conditions.  Communicate and document clearly and concisely.  Understand the medical model of treatment from a nursing perspective.  Manage whole patient care using education, psychotherapy, and medications.  Promote mental and physical health and the reduction of stigma around mental illness.  Understand cultural issues in providing mental health care .  Use data to evaluate interventions and patient outcomes.  Work cooperatively with patients, families, other healthcare practitioners, and communities. (PMHNP, 2015)

Role of psychiatric consultant

 Informal “curbside consultations” to PCP’s, CM’s, and behavioral health consultants  Systematic case review meetings Review patients who are presenting diagnostic or therapeutic challenges  Face‐to‐face consultations in which a patient is seen in person or via televideo  Support medical provider and staff



Always include rationale when making medication or other recommendations to medical providers



Provide primary medical provider with algorithms and other resources



Provide education about brief interventions



Join and attend medical associations, committees and meetings



Provide evidence for fidelity to consultative model to all staff



Learn as well as teach (Raney et al., 2015)

APNA 29th Annual Conference Session 3012.1: October 30, 2015 Higgins 4

Guiding principles and structure: ABCD

 Accept all referrals then refer out as needed  Brief, structured interventions for a wide range of

presenting concerns

 Consultation on all issues related to mental health,

insomnia, substance abuse, emotional health and more

 Medical provider must trust that psychiatric consultant is there

to back him or her up in treating complex patients in primary care

 Clearly established lines of communication: Psychiatric

consultant must be available and interrupt‐able to build trust and prevent delays in treatment

 Telemedicine increases access to remotely located practices

 Documentation supports continued care:

 Clear, concise documentation embedded in the medical

practice’s established system of documentation

 Satisfies patient centered medical home, meaningful use criteria  Development of a simple treatment plan that can be understood

and continued by medical provider and patient

One example: Psychiatric consultant’s role in pain management

 Provide education around signs of prescription misuse  Screen for and treat co‐occurring depression, anxiety, trauma

history, and other complicating factors

 Recommend practice policies that safely support patients

with substance abuse issues and explosive behaviors

 Connect patients and providers to community resources

for different levels of support

 Train and model brief interventions to determine

readiness to change and develop a treatment plan for patient and medical provider

 Help medical provider and patient improve communication

and agree on a safe, reasonable plan with mutual accountability

 Provide support around medical management of gradual

• pioid withdrawal as indicated

(Chronic opioid therapy, 2014; Project ECHO, 2015)

Opportunities to lead & collaborate

 Connect the silos!

 Use your knowledge of community resources and legal issues to

improve ease of referrals and communication between medical and mental health services.  Identify a problem… and solve it!

 Listen to patients, providers, the community and then network and

do some research to lead the charge toward lasting change.

 You have a unique perspective with a foot in each world. Be the

bridge!  Get in the game!

 Go to a lot of meetings, offer to present, and make yourself available

and accessible to all members of the team – clinical, clerical, referral sources, administrative leadership, and others.

APNA 29th Annual Conference Session 3012.1: October 30, 2015 Higgins 5

In summary…

 The collaborative care model is patient centered, evidence based, measurement‐based, population‐ based, and accountable.  The success of this model depends on the health care team, with the establishment of shared goals, clear roles, mutual trust, effective communication, and measureable processes and outcomes.  As independently licensed, holistic clinicians , PMH‐ NP’s are uniquely positioned to bridge the divide between behavioral health and medicine as consult‐liaison psychiatric providers.

Questions & discussion

 Please see case study

References

 Chronic opioid therapy safety guideline for patients with chronic non‐cancer pain. (2014). Retrieved from http://www.ghc.org/all‐sites/guidelines/chronicOpioid.pdf  Leigh, H. & Streltzer, J. (Eds.) (2007). Handbook of Consult Liaison Psychiatry [PDF document]. Retrieved from http://assets.cambridge.org/97805218/26372/frontmatter/9780521826372_frontmatter.pdf  Mitchell, P., Wynia, W., Golden, R., McNellis, B., Okun, S., Webb, C.E., Rohrbach, V., & Von Kohorn,

• I. (2012). Core principles & values of effective team‐based health care. Retrieved from

https://www.nationalahec.org/pdfs/VSRT‐Team‐Based‐Care‐Principles‐Values.pdf  Mount Katahdin, Maine. Personal photograph by presenter. August 26, 2015.  Peek, C.J. (2013). Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus [PDF document]. Retrieved from http://integrationacademy.ahrq.gov/sites/default/files/Lexicon.pdf  Project ECHO: A videoconferencing healthcare delivery model. (2015). Retrieved from http://www.ipcaz.org/project‐echo/  Psychiatric Mental Health Nurse Practitioner (PMHNP). (2015). Retrieved from http://www.graduatenursingedu.org/psychiatric‐mental‐health‐nurse‐practitioner/  Raney, L., Lasky, G., & Scott, C. (2015). The collaborative care team in action. In L.E. Raney (Ed.), Integrated care: Working at the interface of primary care and behavioral health (pp. 17‐41). Washington, DC: American Psychiatric Publishing.  Unützer, J., Schoenbaum, M., & Druss, B. (2013). The collaborative care model: An approach for integrating physical and mental Health care in Medicaid health homes [PDF document]. Retrieved from http://www.medicaid.gov/State‐Resource‐Center/Medicaid‐State‐Technical‐ Assistance/Health‐Homes‐Technical‐Assistance/Downloads/HH‐IRC‐Collaborative‐5‐13.pdf