Access Community Health Centers
Integrated Primary Care Consulting
Psychiatry Toolkit
Contents
Background.................................................................................................................................2
Why a Toolkit?.........................................................................................................................2
Who Should Use this Toolkit? ..................................................................................................2
Development of this Toolkit .....................................................................................................2
Contact Us ..............................................................................................................................2
Flow: Integrated Primary Care Consulting Psychiatry..................................................................3
References .................................................................................................................................4
Copyright Use
The Access Community Health Centers Integrated Primary Care Consulting Psychiatry Toolkit
exists for the benefit of the health care community. These materials are available free of charge and can
be used without permission; however, we ask that you register with HIPxChange prior to using the toolkit
so that we may provide information on usage to our funders. It is acceptable to link to this Web site
without express permission. If you decide to use these materials, we ask that you please credit Access
Community Health Centers and the UW Health Innovation Program.
1
BACKGROUND
An ever-increasing number of patients with mental health needs has resulted in primary care
being referred to as the de facto mental health system in the United States.1-3 In instances
where patients are referred elsewhere for mental health treatment, less than one-third of the
referrals are actually completed.3 In addition, the stigma involved with receiving mental health
care is a proven barrier to patients seeking care.4-6 These issues, combined with lack and cost
of transportation, distance from service providers, limited clinic hours, and lack of available
appointments or insurance coverage,7-10 have resulted in an uptick of primary care clinicians
taking on prescribing authority for patients with complex mental health issues.2, 11, 12
Increased access to consulting psychiatry allows for potentially better management of patients
receiving psychiatric care within the primary care system through a number of mechanisms. It
provides more convenient access for patients in an environment that they find familiar and
acceptable.13 It also supports and encourages a collaborative effort between psychiatrists,
behavioral health consultants (other mental health providers), and primary care clinicians to
provide efficient, whole-person care.
Further information regarding the development and role of the psychiatric consultation service,
as well as characteristics of the patients and clinics using this model, can be found in the
following article: Zeidler Schreiter EA, Pandhi N, Fondow MDM, Thomas C, Vonk J, Reardon
CL, Serrano N. “Consulting psychiatry within an integrated primary care model.” J Health Care
Poor Underserved (in press).
Why a Toolkit?
This toolkit provided detailed information for those thinking about developing an integrated
model with consulting psychiatry within primary care in order to allow for a population health
focus for the patient population.
This toolkit includes:
•
•
Detailed flow diagram showing how the primary care physicians, behavioral health
consultant, and consulting psychiatrist work together within a clinic.
The key elements of communication during interactions between these entities.
Who Should Use this Toolkit?
This toolkit is intended for clinic directors, managers, primary care, behavioral health
consultants, and psychiatrists, and provides a framework for a team approach to addressing
patients’ behavioral and mental health needs.
Development of this Toolkit
This toolkit was developed by Elizabeth Zeidler Schreiter, PsyD, Nancy Pandhi, MD PhD, and
Meghan Fondow, PhD (all affiliated with Access Community Health Centers and the University
of Wisconsin-Madison Department of Family Medicine) and Lauren Fahey (affiliated with the
Health Innovation Program and the University of Wisconsin-Madison School of Social Work).
Additional support was provided by the University of Wisconsin School of Medicine and Public
Health’s Health Innovation Program (HIP), and the Community-Academic Partnerships core of
the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR), grant
UL1 TR000427 from the Clinical and Translational Science Award (CTSA) program of the
National Center for Advancing Translational Sciences (NCATS), National Institutes of Health.
Contact Us
Please send questions, comments and suggestions to [email protected]
2
FLOW: INTEGRATED PRIMARY CARE CONSULTING PSYCHIATRY
Legend: PCP = Primary Care Provider; BHC = Behavioral Health Consultant; EHR = Electronic Health Record
PCP identifies patient with mental health
issues or symptoms and completes a
warm hand-off to the BHC team.
EHR Referral
BHC determines if psychiatry consult would
be beneficial in collaboration with PCP.
Patients are seen by BHC prior to referral
to consulting psychiatrist.
Important considerations for
face-to-face visits
Potential reasons for a
written consult
Ø Additional follow-up
questions regarding next
steps
Ø Patient seen by consulting
psychiatrist in the past
Ø Patient access barriers
Ø PCP request is a medical
management issue and
doesn’t require a face-toface visit
After completing a chart review and
reading the referral submitted via EHR,
the psychiatrist provides written
recommendations.
BHC determines
whether a written or oral
psychiatry consult will suffice or if a
face-to-face appointment is more
appropriate. The lead BHC triages
patients & schedules appointments with the consulting
psychiatrist.
Ø Never schedule visits more
than 2 weeks in advance to
limit potential no-shows
Ø If a face-to-face consult is
necessary and the wait is
longer than 2 weeks, the
psychiatrist will provide a
written consult until patient
can be seen in person
Ø Have patients bring in all
medications to visit to get
sense of current adherence
Written/Oral
Consult Only
Face-toFace Visit
Patient is contacted by the BHC team to
schedule an appointment.
Lead BHC meets with psychiatrist and
PCPs at outset of clinic to review
schedule of the day, reviews reason for
referral, insurance status and history.
After completing a chart review, the
psychiatrist sees patient in-person (~45
minutes), formally assesses the patient’s
mental health history, past medication
trials and completes diagnostic interview.
Recommendations can
include:
Ø Medication: Indication,
monitoring needs, dosing
and titration, patient
education needs, etc.
Recommendations are
algorithmic and provide
stepwise options for
pharmacologic
interventions, taking into
account possible failed
trials.
Ø Behavioral: Continue
engagement with BHC
team, receive psychiatric
care in the community, etc.
Psychiatrist formally documents
recommendations to be
implemented by PCP.
If necessary, sends an EHR email
to the PCP (not formally attached
to patient’s chart).
Reasons for EHR Email
Message:
Ø Allows for informal dialogue
between PCP and
psychiatrist
Ø Ability to include stronger
opinions
Ø Reminders to check labs/
other quality of care issues
PCP is always the main point of
contact and maintains
prescriptive authority.
Psychiatrist encourages patientPCP follow-up to discuss
implementation options based on
psychiatrist recommendations.
3
REFERENCES
1.
Cummings NA, O'Donohue W, Hays SC, et al. Integrated Behavioral Healthcare:
Positioning Mental Health Practice with Medical/Surgical Practice. San Diego: Academic
Press, 2001.
2.
Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a
public health perspective. Arch Gen Psychiatry. 1978 Jun;35(6):685-93.
3.
Mechanic D, Bilder S. Treatment of people with mental illness: a decade-long perspective.
Health Aff (Millwood). 2004 Jul-Aug;23(4):84-95.
4.
Pietrzak RH, Johnson DC, Goldstein MB, et al. Perceived stigma and barriers to mental
health care utilization among OEF-OIF veterans. Psychiatr Serv. 2009 Aug;60(8):1118-22.
5.
Kim PY, Thomas JL, Wilk JE, et al. Stigma, Barriers to Care, and Use of Mental Health
Services Among Active Duty and National Guard Soldiers After Combat. Psychiatric
Services. 2010 Jun;61(6):582-8.
6.
Pailler ME, Cronholm PF, Barg FK, et al. Patients' and caregivers' beliefs about depression
screening and referral in the emergency department. Pediatr Emerg Care. 2009
Nov;25(11):721-7.
7.
Goldner EM, Jones W, Fang ML. Access to and waiting time for psychiatrist services in a
Canadian urban area: a study in real time. Can J Psychiatry. 2011 Aug;56(8):474-80.
8.
Kruzich JM, Jivanjee P, Robinson A, et al. Family caregivers' perceptions of barriers to and
supports of participation in their children's out-of-home treatment. Psychiatr Serv. 2003
Nov;54(11):1513-8.
9.
Mechanic D. Removing barriers to care among persons with psychiatric symptoms. Health
Aff (Millwood). 2002 May-Jun;21(3):137-47.
10. Pieh-Holder KL, Callahan C, Young P. Qualitative needs assessment: healthcare
experiences of underserved populations in Montgomery County, Virginia, USA. Rural
Remote Health. 2012 Jul;12(3):1816.
11. Pirl WF, Beck BJ, Safren SA, et al. A Descriptive Study of Psychiatric Consultations in a
Community Primary Care Center. Prim Care Companion J Clin Psychiatry. 2001
Oct;3(5):190-4.
12. Norquist GS, Regier DA. The epidemiology of psychiatric disorders and the de facto mental
health care system. Annual Review of Medicine. 1996;47:473-9.
13. Lang AJ. Mental health treatment preferences of primary care patients. J Behav Med. 2005
Dec;28(6):581-6.
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