Can the Collaborative Care Model Enhance Resident Education in Psychiatric Medicine During Residency Training? David B. Feller, MD Michael R. Ware, MD Joyce A. Feller, MD Aly Listhaus, MPH Karen L. Hall, MD

UF Behavioral Medicine Program: Key Components Didactics & case conferences: Dx of common ψ conditions & their Tx Didactics & case conferences: Dx of common ψ conditions & their Tx Instruction & practice: primary care, patient self- report screening tools Instruction & practice: primary care, patient self- report screening tools Psychiatrist: clinic precepting & resident-patient consultations Psychiatrist: clinic precepting & resident-patient consultations Annual review: ABFM In-Service Training Exam ψ questions Annual review: ABFM In-Service Training Exam ψ questions Monthly Balint group PGY-1s & case discussion group for PGY-3s Monthly Balint group PGY-1s & case discussion group for PGY-3s Psychiatrist: maintains electronic data base of seminal literature on variety of ψ topics, available to all residents & faculty Psychiatrist: maintains electronic data base of seminal literature on variety of ψ topics, available to all residents & faculty

Psychiatric Illness in Primary Care Settings 40% of patients in primary care settings have significant ψ problems 1 40% of patients in primary care settings have significant ψ problems 1 Mood & anxiety disorders: most common ψ illnesses affecting people ages in the U.S. 2 Mood & anxiety disorders: most common ψ illnesses affecting people ages in the U.S. 2 Lifetime prevalence MDD = 16.6% 2 ; comorbid anxiety disorders occur in ≈ 50% (community samples) to > 75% in primary care patients with MDD 3 Lifetime prevalence MDD = 16.6% 2 ; comorbid anxiety disorders occur in ≈ 50% (community samples) to > 75% in primary care patients with MDD 3 NCS-R “minimally adequate treatment” in general medical sector 4 : NCS-R “minimally adequate treatment” in general medical sector 4 : 13.4% with any anxiety disorder 13.4% with any anxiety disorder 14.3% with any mood disorder 14.3% with any mood disorder

Collaborative Care Model: Rationale Untreated or poorly Tx mental illness: ↑ healthcare costs 5-7, severity of medical illness 8, mortality 7-9, health risk behavior 6, & ↓ adherence to medical & surgical therapies 5,6,8,10 Untreated or poorly Tx mental illness: ↑ healthcare costs 5-7, severity of medical illness 8, mortality 7-9, health risk behavior 6, & ↓ adherence to medical & surgical therapies 5,6,8,10 Shortage of psychiatrists → improved models of care to effectively & efficiently deliver needed ψ Dx and Tx 5 Shortage of psychiatrists → improved models of care to effectively & efficiently deliver needed ψ Dx and Tx 5 “Collaborative care”: psychiatrist as core member of Tx team in primary care settings 11,12 “Collaborative care”: psychiatrist as core member of Tx team in primary care settings 11,12 Over 70 RCTs demonstrate collaborative care works (most data derived from Tx of MDD) 5 Over 70 RCTs demonstrate collaborative care works (most data derived from Tx of MDD) 5 Scant knowledge about collaborative care in residency training 1,13-15 Scant knowledge about collaborative care in residency training 1,13-15

UF Residency Program Collaborative Care Psychiatrist instituted routine use of brief, validated, self-rating instruments for all residents starting July 2010 Psychiatrist instituted routine use of brief, validated, self-rating instruments for all residents starting July 2010 Goal of scales: improve detection, diagnosis, treatment and outcome of common ψ disorders seen during Family Medicine Residency Training Goal of scales: improve detection, diagnosis, treatment and outcome of common ψ disorders seen during Family Medicine Residency Training Many instruments available 16 Many instruments available 16 Spanish language versions for three most commonly use scales Spanish language versions for three most commonly use scales

UF Family Medicine Residency: Scales “Triple Screen” “Triple Screen” MDQ (Mood Disorder Questionnaire) 17,18 MDQ (Mood Disorder Questionnaire) 17,18 PHQ-9 (Patient Health Questionnaire) 19,20 PHQ-9 (Patient Health Questionnaire) 19,20 GAD-7 (Generalized Anxiety Disorder-7) 21,22 GAD-7 (Generalized Anxiety Disorder-7) 21,22 SPIN (Social Phobia Inventory) SPIN (Social Phobia Inventory) PTSD-CL (Posttraumatic Stress Disorder Checklist, Civilian Version) PTSD-CL (Posttraumatic Stress Disorder Checklist, Civilian Version) PDSS (Panic Disorder Severity Scale) PDSS (Panic Disorder Severity Scale) MMSE & MoCA (Montreal Cognitive Assessment) MMSE & MoCA (Montreal Cognitive Assessment) FIBSER (Frequency, Intensity and Burden of Side Effects Rating) FIBSER (Frequency, Intensity and Burden of Side Effects Rating)

UF Family Medicine Residency: Scales Screening tools ARE NOT diagnostic instruments: a positive screen requires interview-based confirmation! Screening tools ARE NOT diagnostic instruments: a positive screen requires interview-based confirmation! Psychiatrist & family medicine preceptors: review results with resident, psychiatrist can provide on- the-spot intervention Psychiatrist & family medicine preceptors: review results with resident, psychiatrist can provide on- the-spot intervention Mechanism in place to schedule 1 hour psychiatric consultation with resident & patient: goals are to clarify Dx, formulate Tx plan, and teach resident (interviewing skills, Dx criteria, DDx, institute Tx, documentation) Mechanism in place to schedule 1 hour psychiatric consultation with resident & patient: goals are to clarify Dx, formulate Tx plan, and teach resident (interviewing skills, Dx criteria, DDx, institute Tx, documentation)

UF Family Medicine Collaborative Care Project IRB approved, retrospective dataset IRB approved, retrospective dataset Decision support epic database and chart review Decision support epic database and chart review All non-Medicaid patients 18-90y/o seen by FM residents between 9/1/2009 to 9/1/2019 All non-Medicaid patients 18-90y/o seen by FM residents between 9/1/2009 to 9/1/2019 ICD-9 Dx: anxiety, mood and adjustment disorders in billing data, problem list or medical history ICD-9 Dx: anxiety, mood and adjustment disorders in billing data, problem list or medical history

UF Family Medicine Collaborative Care Project 16,765 patient visits as of 1/22/2015: 16,765 patient visits as of 1/22/2015: Mean age 51.6 Mean age % female 62% female 45.5% single & 38.2% married 45.5% single & 38.2% married 74.9% non-Hispanic white, 12.4% African American 74.9% non-Hispanic white, 12.4% African American

Results to Date: UF FM Collaborative Care Project Examples Number of patients with psych codes that have appropriate scales documented Number of patients with psych codes that have appropriate scales documented Analysis of specific vs. nonspecific codes Analysis of specific vs. nonspecific codes Analysis of diagnosis vs. medication class Analysis of diagnosis vs. medication class