CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Psychiatric Consultation 

GC-2
 
Category: General Considerations
Published Date: October 2019
  1. INTRODUCTION
    1. The integration of mental health with primary care and innovations in technology have broadened the scope of psychiatric consultation. This parameter discusses direct and indirect consultation along with the role and documentation considerations of each.
       
  2. DEFINITIONS
    1. Direct Consultation:
      1. Provided upon request from a clinician who has direct responsibility for the care of a client;
      2. Based upon direct client evaluation; and
      3. Completed for purposes of assessment and initiating treatment, referrals, or recommendations for mental health treatment.
    2. E-Consultation:
      1. Direct or indirect consultation employing digital and primarily web-based technologies involving such services as telemedical evaluation; telepsychiatry; web-based reviews of clinical records; web-based consultation with clinicians, caregivers, and clients; and other related practices.
    3. Indirect Consultation:
      1. Provided upon request from a member of the mental health or physical health care treatment team with responsibility for the care of a client;
      2. Not based upon direct client evaluation and therefore not involving a physician/client relationship; and
      3. Completed for purposes of development and implementation of treatment plans.
         
  3. THE ROLE OF THE CONSULTANT
    1. In direct consultation, the consultant:
      1. Receives a request from a clinician with responsibility for a client’s care to consult with the client;
      2. Provides a face-to-face, in person, or e-consultation assessment; and
      3. Provides a summary of findings and actions taken to the referring clinician and retains a copy for his/her records.
    2. In indirect consultation, the consultant:
      1. Receives a request from a member of a mental or physical health treatment team with responsibility for the care of one or more clients to review various aspects of client care for the purposes of evaluation, recommendations, linkage, or the initiation of psychiatric treatment;
      2. Does not participate in the face-to-face assessment of a client; and
      3. Often develops an ongoing relationship with the mental or physical health treatment team for purposes of integrating care through such mechanisms as:
        1. Being available through phone or other means within agreed-upon times for consultation regarding emergent issues;
        2. Communicating regularly with the team to provide input on a caseload of clients who are receiving mental health services, reviewing all clients who are not improving clinically, and making treatment recommendations to the team or specific team members;
        3. Reviewing information about assessments and scores from screening instruments utilized to monitor the progress of a team caseload;
        4. Identifying possible care challenges with specific clients on the caseload of a clinical team and requesting, when appropriate, additional information in order to make further recommendations;
        5. Requesting additional information when there is insufficient clinical response (e.g. what is the current medical condition, what other factors are present, requesting that the Care Manager consult with the Primary Care Physician);
        6. Communicating directly to the mental or physical health treatment team regarding clients who are not improving in order to provide:
          1. Brief medication instructions and protocols;
          2. Information on medication monitoring and titration; and/or
          3. Suggestions regarding alternative strategies.
        7. Providing non-client-specific information related to mental health treatment to a physical health care provider/team through webinars or in-person at provider meetings.
           
  4. DOCUMENTATION CONSIDERATIONS
    1. The locus of direct and indirect consultation documentation requirements are determined by applicable Departmental policy and will usually be in the clinical record maintained by the consultant’s organization with copies to the primary care clinical team’s organization.
    2. Structure of Documentation
      1. Direct Consultation - The consultation note should address all requested domains of the consultation (e.g. assessment, diagnostic impression, recommendations for treatment, follow-up recommendations the consultant is willing to provide, or recommendations for other referrals).
      2. Indirect Consultation - The consultation note in this arrangement is generally brief and tightly focused on the mental or physical health treatment team’s concerns. The Consultant should:
        1. Provide a structured consultation note that includes a framework for providing information back to the mental and/or physical health treatment team. An identifying statement that succinctly summarizes the client’s presenting condition and the referring clinician’s reason for consultation should be present.
          1. Use language and terminology that is clear and understandable to non-mental health providers.
        2. Include a “Disclaimer” that clarifies the indirect nature of the consult such as: “These recommendations/suggestions are based on conversation(s) with the client's DMH care manager only. The consultant has not personally examined the client. (Additionally, in some cases laboratory studies or other information from the primary care medical record that would be relevant were not available at the time of consultation). All recommendations should be implemented with consideration of the client's relevant prior history and current clinical status. Please feel free to contact the care manager with questions about the care of this client.”
           
  5. REFERENCES
    1. The information regarding the concept for “Indirect Consultation” as defined in these parameters was adapted from the Washington State’s Mental Health Integration Program (MHIP) which incorporates the IMPACT Model for Depression Care, developed by Jurgen Unitizer, MD, MPH, MA, Professor and Vice-Chair of the Department of Psychiatry and Behavioral Sciences, University of Washington.
  1. BRIEF DESCRIPTIONS OF THE MENTAL HEALTH INTEGRATION PROGRAM (MHIP) AND THE IMPACT MODEL FOR DEPRESSION CARE
    1. Developed By Urgen Unitzer, MD, MPH, MA, Professor and Vice-Chair of the Department of Psychiatry and Behavioral Sciences, University of Washington
    2. Mental Health Integration Program (MHIP) Excerpted from: Case Study: Washington State’s Mental Health Integration Program (MHIP)
      1. Care Team: Primary Care Providers, Care Coordinators, Consulting Psychiatrists, and other clinic-based mental health providers
      2. Care Model:
        1. Team approach based on the IMPACT II model of collaborative care
        2. Comprehensive clinical assessment for every client
        3. Use of appropriate symptom measures (e.g., PHQ9, GAD7) during follow up visits to gauge progress and need for treatment changes
        4. Web-based registry to track a caseload of clients in each clinic to make sure clients don’t fall through the cracks
        5. The care coordinator engages clients and provides close follow up to support treatment and facilitate changes in treatment
        6. Designated psychiatrist consults with care manager and primary care provider on the care of clients who do not respond to initial treatments
        7. Referral to community mental health center if client not responding to treatments in primary care
           
    3. IMPACT MODEL FOR DEPRESSION CARE
      1. The five (5) most essential elements are:
        1. Collaborative care is the cornerstone of the IMPACT model and functions in two (2) main ways:
          1. The client's primary care physician works with a care manager to develop and implement a treatment plan (medications and/or brief, evidence-based psychotherapy)
          2. The care manager and primary care provider consult with the psychiatrist to change treatment plans if clients do not improve
        2. Depression Care Manager: This may be a nurse, social worker, or psychologist and may be supported by a medical assistant or other paraprofessionals. The care manager: 
          1. Educates the client about depression
          2. Supports antidepressant therapy prescribed by the client's primary care provider if appropriate
          3. Coaches clients in behavioral activation and pleasant events scheduling
          4. Offers a brief (6-8 session) course of counseling, such as Problem-Solving Treatment in Primary Care
          5. Monitors depression symptoms for treatment response
          6. Completes a relapse prevention plan with each client who has improved
        3. Designated Psychiatrist: Consults to the care manager and primary care physician on the care of clients who do not respond to treatments as expected.
        4. Outcome measurement: IMPACT care managers measure depressive symptoms at the start of a client's treatment and regularly thereafter. The PHQ-9 is an effective measurement tool, however, there are other effective tools.
        5. Stepped care:
          1. Adjust treatment based on clinical outcomes and according to an evidence-based algorithm
          2. Aim for a 50 percent reduction in symptoms within 10-12 weeks
          3. If the client is not significantly improved at 10-12 weeks after the start of a treatment plan, change the plan. The change can be an increase in medication dosage, a change to a different medication, the addition of psychotherapy, a combination of medication and psychotherapy, or other treatments suggested by the team psychiatrist.