1. Mental Health Triage Clinic Intersection of Patient Care & Resident Education Emilee J. Delbridge, PhD, LMFT Daniel S. Felix, PhD, LMFT IU-Methodist FMR, Indianapolis, IN

2. NONE TO REPORT

3. Learning Objectives Recognize the value of including medical learners in the focused assessment of patients with behavioral & mental health needs. Identify chances to address mental health needs of patients, while providing focused education to medical learners. Identify inter-professional providers/educators who can provide comprehensive care to address patients’ mental & behavioral health concerns.

4. Evidence-based Approach Depressive & anxiety disorders best treated with 2-prong approach (1) Direct observation & provide feedback (2, 3)

5. Mental Health Provider Dilemma Decrease the “black hole” of therapy referrals Training multiple learners (4) Inappropriate referrals – Type of patient needs – Patient readiness

6. The Challenge Facing Residents Many pts have mental health symptoms and challenging lives. It’s difficult to train residents to address all medical & mental health components at once. Most of Behavioral Science knowledge is learned in didactic, small groups.

7. Goals of Mental Health Triage Clinic Goals for Medical Learners Understand mental health resources Skills to assess patient needs Interviewing skills feedback Providing recommendations (modeling) Warm handoff Practice independently Goals for Patients Focused session for mental, behavioral health needs Symptom assessment Medication management Specific referral to meet current needs

8. Case Examples Martha, 58 y/o AAF PHQ-9: 9 GAD-7: 5 Complex medical differential Difficulty sleeping Janelle, 38 y/o CF PHQ-9: 24 GAD-7: 16 Possible PTSD, Bipolar sxs

9. Pre-Session Flow Resident has patient fill out form * Reviewed for acuity & fit If outside referral, call pt directly for referral. If inside referral, given to Scheduler. Scheduler makes MHTC appt. Resident’s tasks for Pre-session Checklist*

10. PGY2 Resident sees pt Pt fills out Forms*, provides hx, sx info 40 min session (99213) Resident discusses case, plan with Faculty Recommendation given to pt; Modeled by PhD OR Provided by Resident Observed by PhD faculty Precept with MD faculty *Other learners observe session*

11. Post-Session Resident writes clinical note (SOAP) Sends to PhD faculty to sign Sends to MD faculty to sign Resident sends message to referring provider & PCP If in-house counseling, Resident sends message to Scheduler to contact pt

12. Statistics 15 MHTC sessions/6 months 47% show rate – 60% referred to in-house counseling – 40% referred out 14 Residents in MHTC

13. Patient Feedback PROS Personalized referral Medication management Psycho-education Counseling at physician’s office CONS At times, expect therapy, rather than triage Complexity of MH treatment

14. Interdisciplinary Training Feedback Strong knowledge of clinic resources Moderate knowledge of area resources Outcomes Appropriate pts for therapy MH screening tools Area MH agencies Focused interviewing skills Appropriate psychiatric referral process Observe sessions (PAs, etc.)

16. References 1. Wiles N, Thomas L, Abel A, Barnes M Carroll F, Ridgway N, et al. Clinical effectiveness and cost-effectiveness of cognitive behavioral therapy as an adjust to pharmacotherapy for treatment-resistant depression in primary are: the CoBalT randomized controlled trial. Health Technol Assess. 2014:18(31). doi:10.3310/hta18310 2. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37-43. doi:10.1016/S0140-6736(12)60240-2 3. Reed S, Shell R, Kassis K, et al. Applying adult learning practices in medical education. Curr Probl Pediatr Adolesc Health Care. 2014:44:170-181. doi: 10.1016/j.cppeds.2014.01.008 4. Priest H, Roberts P, Dent H, Blincoe C, Lawton D, Armstrong C. Interprofessional education and working in mental health: in search of the evidence base. Journal of Nursing Management. 2008:16(4):474-485. doi: 10.1111/j.1365-2834.2008.00867.x

17. Forms* Counseling Referral Form (Pt completed) MHTC Checklist (for Resident) Mental Health Symptom Screening Form (Pt) Area Mental Health Agencies Referral List

18. Sample Counseling Referral Form

19. Sample Mental Health Screening Form

20. Sample MHTC Checklist _____Prior to the CIT clinic, look up the patients and read their pertinent history. _____Get the referral forms from Scheduler’s office. _____Call the patient from the waiting room to the Counseling Room. _____Review the 2-page mental health screening tool that the pt filled out. It includes the PHQ-9, GAD-7, & items re. trauma, panic attacks, & manic sxs. _____Meet with the patient for 20-25 minutes to assess reason for referral. _____Staff pt with Bx Sc faculty preceptor, who will be in the room or in Video Observation room. _____Provide specific recommendations to address pt’s reason for referral. _____Staff all pts with an MD preceptor. This can be done during a break in clinic, regarding a complex patient, or at the end of clinic. Make sure you briefly review the action plan with these preceptors. _____Write a SOAP note. (Clearly state the Plan.) _____Send the SOAP note to Bx Sc Preceptor and the MD preceptor. _____Send message to referring provider and PCP (if different that referring physician). _____If the plan is to refer the pt to in-house brief counseling, send a message to Scheduler and the Bx Sc Preceptor, and indicate that the pt was seen in the CIT Clinic and is referred to one of the three therapists at the FMC. ______If the pt does not show up for the appointment, please send a Cerner message to the referring provider (and PCP, if a different person) that the pt did not show up for the CIT Clinic appt. _____Fill out Billing Sheet; leave with preceptor once complete. The code will generally be 99213 for 1-problem visits.

21. Contact Info IU-Methodist Family Medicine Residency Indianapolis, IN Emilee J. Delbridge, PhD, LMFT edelbrid@iupui.edu Daniel S. Felix, PhD, LMFT dfelix1@IUHealth.org