Training the 21st Century Psychiatrist for the Patient Centered Medical Home Jeralyn Jones, MD Alex J. Reed, PsyD, MPH Collaborative Family Healthcare Association 14 th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Session # FB5 October 6, 2012

Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

How are people integrating family medicine and psychiatry? How are people integrating family medicine and psychiatry training?

Objectives Participants will understand the rationale and forces driving integrated health care. Participants will be able to describe different models of psychiatric collaboration with primary care providers. Participants will explore the challenges and benefits of educating today’s trainees for the integrated care practice of tomorrow.

Boun Bonner Kootenai Benewah Shoshone Latah Clearwater Nez Perce Lewis Idaho Adams Valley Washington Payette Canyon Boise Ada Owyhee Twin Falls Jerome Blaine Lincoln Minidoka Cassia Power Oneida Franklin Bear Lake Bannock Caribou Bingham Lemhi Custer Clark Fremont Teton Jefferson Madison Bonneville Butte Gooding Camas Elmore Gem Idaho Mental Health Professional Shortage Area Service Areas Geographic HPSA State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 4/07 – please contact (208) for updates Facility

Idaho Primary Care Health Professional Shortage Area Service Areas Geographic HPSA Population Group HPSA State Office of Rural Health and Primary Care, Division of Health, Department of Health and Welfare, 5/12 – please contact (208) for updates Bonner Kootenai Benewah Shoshone Latah Clearwater Idaho Adams Washington Payette Canyon Ada Owyhee Twin Falls Jerome Blaine Lincoln Minidoka Cassia Bear Lake Custer Clark Fremont Gooding Camas Elmore Gem Bannock Valley Lewis Nez Perce Lemhi Power Franklin Oneida Boise Butte Bingham Jefferson Madison Teton Caribou Boundary Bonneville

Patient Centered Medical Home AAFP AAP ACP AOA ?APA

Elements of PCMH Personal Physician Physician directed medical practice Whole Person Orientation Integrated/Coordinated Care Enhanced Access to care Quality and Safety Payment Reform Psychiatry

Accountable Care Organization (ACO) An ACO is an entity that will be “held accountable” for providing comprehensive health services to a defined population Cost HMO in Drag? Accountability Primary Care focus

University of Washington Idaho Advanced Clinician Track/ Primary Care Psychiatry Training or…

EXTREME INTEGRATED PRIMARY CARE!!!! Somewhat Censored !!!

Mental Illness in Primary Care Most patients with mental health disorders initially present to their PCP. Primary care is the “de facto” mental health system for 70% of the population. 80% of all psychotropic medications are prescribed by nonpsychiatric medical providers* * Katon, W., Reis, R.K., Kleinman, A. (1984). The prevalence of somatization in primary care. Compr Psychiatry, 25 (2).,

Chronic Conditions and MH Cost w/o Mental Health Condition Cost w/Mental Health Condition All Adults$1,913$3,545 Heart Condition$4,697$6,919 High Blood Pressure$3,481$5,492 Asthma$2,908$4,028 Diabetes$4,172$5,559 Agency for Healthcare Research and Quality (2003). Medical Expenditure Panel Survey, Rockville, MD.

Depression in Patients with Comorbid Medical Illness Comorbid Medical IllnessPrevalence Rate (%) Cardiac Disease17-27 Cerebrovascular Disease14-19 Alzheimer’s Disease4-75 Epilepsy – Recurrent20-55 Epilepsy – Controlled3-9 Diabetes – Self-reported26 Diagnostic interview9 Cancer22-29 HIV-AIDS5-20 Pain30-54 Obesity20-30 General Population10.3 Evans et al. (2005). Mood Disorders in the Medically Ill: Scientific Review and Recommendations. Biol Psychiatry, 58,

Traditional Mental Health

Primary Care

Typical Morning in FM Practice 56 y.o. diabetic w/ poor control 19 y.o. smoker for annual exam 33 y.o. w/ multiple somatic issues 7 y.o. with otitis media 67 y.o. with insomnia 70 y.o. with sinusitis 52 y.o. with HTN 28 y.o with chest pain & SOB Anxious Smoking Cessation Depression Enuresis Alcohol Abuse Family Violence PTSD Panic Disorder Gunn, W. B. & Blount, A. (2009). Primary care mental health: A new frontier for psychology. Journal of Clinical Psycholog, 65 (3),

Tell me and I forget, Show me, and I may remember Involve me, and I will understand Confuscius

Patient Centered Medical Home One Day per week PGY3 and PGY4 Psychiatrist Continuity clinic PAC Precepting with FM Psychologist WBC-Brief Behavioral FM Didactics Psychiatry Resident FQHC—Federally qualified health center Safety Net Clinic Patients with complex medical/psychiatric illness, few resources Sawtooth Model

PAC/WBC Continuity Clinic Attending Room Evolution of the 21 st Century Psychiatrist

Sawtooth Model Measurement driven referrals Teach/Expert Understand/access FM Direct OP observation patient care/teach Learn new model Collaborate FM/Psych Help!!! Education psych Learn new model Recognition illness Access care Comprehensive model Patient FM Resident Psychiatry Resident Supervisor

Determinants of Health Schroeder, Steven A., We Can Do Better -- Improving the Health of the American People, N Engl J Med :

Wellness Behavior Clinic Opportunity to see patients for behavioral health visits using specific assessment and intervention techniques Can use these techniques to provide behavioral health interventions on the fly Residents rotate into the clinic and learn these techniques while being observed by the “team” in another room

Let’s Play… Program: Support top down UW Psych FM Funders interested Faculty comfortable FM Evolving model

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!