AACP Newsletter Fall 2023 Oct

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

In this issue:

AACP Member Reception @ Alliance Health Project in San Franciso, May 2023

@aacp_communitypsych

@aacp123

President’s Column AACP Media Presence is Making Waves!

Updates on the Keystone Products: LOCUS, SMART Tool & the Certification Exam Community Mental Health Journal Hearing from our Members Editor's closing remarks Thank you to our PartnerPRMS

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

President's Column

Altha J. Stewart, MD President, American Association for Community Psychiatry

In another week we’ll be making our annual pilgrimage to what many consider the event where we are re-energized in our mind and spirit as community psychiatrists. The term community psychiatrist is one that I’ve given much thought to as this year has flown by. For example, I’ve always included that identity as one of the points of intersectionality in describing myself and defining my professional image to the world. In fact, recently, in a self-introduction, I stated: “I’m a child of the ’60s born and raised in the Jim Crow south, in a multi-generational two-parent household, who has had a great career in community psychiatry”.

I’ve always seen these identities as strengths, my “superpower” even, as I have journeyed and been challenged in my personal and professional life as a Black woman psychiatrist in America. As I age and see the wisdom highlights proliferate in my hair, I am amazed at how much has not changed since the days of entering the movie house via the outside balcony stairs, and shopping but not being able to try things on in the local department store or seeing “whites only” signs when we ventured beyond the boundaries of my all Black neighborhood in Memphis. Back then, I had no idea what mental illness was or how it came to be, or even what to do if someone “had it”, except they would be sent to the city’s mental hospital (aka ‘Poplar and Dunlap’, the street corner where the hospital was located).

So today, even as we talk openly about mental illness and eliminating the stigma associated with it, I can still see just how much work we still have to do in this area. While we have certainly made some strides, today, whether a celebrity or ‘regular’ person or even a behavioral health professional, there is still a stigma surrounding discussing or admitting to having struggles in this area. Medical schools and training programs are dealing with increasing requests for therapy and incidents of suicide or suicide attempts and we have no idea how many of these go unreported today.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

President's Column- continued Efforts to address these issues are often met with disbelief or short-term responses. And work to increase diversity in the workforce and inclusion in work settings or achieve equity in our treatment systems is now being stalled by legislative and regulatory policies and practices. Poverty, gun violence, the national crisis in children’s mental health, failing schools, increased hate crimes, over-incarceration of persons with mental illness, structural racism, and other community-level health determinants are now part of our work as community psychiatrists.

So why am I starting this discussion now? In part, I think it has to do with recent exchanges on our listserv about the experiences of people around the country who are trying to honor the AACP’s commitment to “promoting health, recovery, and resilience in people, families, and communities”. We all have stories of how the work we do is so often gratifying but also challenging. Members are sharing these workplace experiences, the challenges, and frustrations in detail and asking for assistance and support from others in AACP, and many of you are responding. Thank you for being there for each other for mentoring, networking support, technical assistance, and just your general kind words in some cases. However, I think it was the recent discussion on the listserv from a member relating an experience on an ACT team that struck this particular nerve and led to these comments. The distressing experience itself followed by how it was handled by leadership at his agency led to lots of comments from our group, including sympathy for his experience and frustration, disappointment, and anger that it happened in the first place.

After all, we are psychiatrists and the ACT team model is a part of our expression of humane treatment for those most vulnerable in our community at what for most is one of the worst moments in their life. For this psychiatrist, however, it seems that his own lived experience at that moment did not receive the same type of response we hope for and try to provide for those with whom we work.

That is frustrating on many levels but mostly it’s a reminder that we have a lot of work still to do to create a system that really works – for patients, professionals, and the public. I think however, that this column may also have something to do with an area I’ve been learning about recently, something more personal that describes my own frustration with our field at times and offers a different approach for me when considering strategies for change.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

President's Column- continued It’s called radical recovery and I was introduced to it by the chief of psychiatry at the Institute of Living, Dr. Javeed Sukhera, when he invited me to deliver the Annual Burlingame Award lecture later this month. My conversation with him challenged me to consider what community psychiatry and community psychiatrists can and must do to change our behavior and transform our systems of care during this unique moment of opportunity in the nation to make meaningful changes in America’s mental health treatment system, both for the people we serve and those with whom we work to provide that service. As we spoke, I began to realize that this new term might allow for a different articulation of the forward movement of organizations like AACP to lead the change we want to see in the system.

As a community for community psychiatry, I see a unique role for AACP in preparing the next generation of leaders, influencers, and contributors for the next period of change in the field of psychiatry, demonstrating transformational leadership at every step along the way. We have seen AACP members create quality of care measures, tools to identify and address structural racism practices in treatment settings, and policies to change clinical practices for youth, persons with serious mental illnesses, and those who are incarcerated.

AACP members also advocate for the importance of developing centering and decisionmaking practices that create a sense of belonging for all working in this space, making it their home. We are effective collaborators and on that note, please join me in thanking Rob Cotes, AACP treasurer and our representative to the APA’s MHSC program committee who has led recent efforts to ensure the collaboration between AACP and APA remains strong in support of maintaining a positive educational and networking experience for all meeting attendees. I also want to publicly thank AACP members Margie Balfour and Rob Gadomski for volunteering for extra duty as AACP representative to the Coalition on Psychiatric Emergencies (CPE) and AACP representative to the APA Assembly, respectively.

It is my sincere hope that as we move forward into our future we will do everything possible to make this the place where disruption begins, innovation resides, and where engagement and collaboration are how we approach everything we do to improve services and the profession. If we do, I think psychiatry will be changed for the better and our satisfaction with the field will allow all of us to feel re-energized as we continue the important work we do and love.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

President's Column- continued And while doing it, remember to buy our textbook (the new standard for training, practice, and policy development available at Springer or Amazon) and check out the Community Mental Health Journal (online version free to AACP membershttps://www.communitypsychiatry.org/publications/community-mental-health-journal). You can also participate in our Planks and attend the Policy & Advocacy forum or check us out on social media - The Community Psychiatry Podcast (find us on Spotify and Apple Podcasts), Instagram (https://www.instagram.com/aacp_communitypsych/), Twitter (@AACP123), and our updated website - (https://www.communitypsychiatry.org/home).

In closing, in case you’re wondering, I still believe that the future of psychiatry is community psychiatry, and for the rest of 2023 I intend to work to make that a reality. And I can assure you there will be many more opportunities for each of you to contribute to making this true.

So join us at the Capital Hilton Hotel in Washington, DC on October 12th for a joint AACP/APA welcome reception from 6:30-8:30 pm and the AACP membership meeting on Friday, October 13th from 1:30-3:30 pm during the Mental Health Services Conference.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Trainee and ECP Outreach and Education Network Communication and Collaboration Highlights

By Angela Liu, Hannah Lynch, and Jean Wu

Podcast Highlights Check out the latest episode of The Community Psychiatry Podcast on Apple Podcast, Spotify, Google Podcasts, and Amazon Music!

Since our launch in April 2023, we've published 7 episodes, had 900 total plays, and almost 200 followers.

Instagram Highlights Are you following us on Instagram? Check out our new AACP Instagram page @aacp_communitypsych Since launching in April 2023, the page has grown to 674 followers in September 2023! Since the podcast and IG page, the number of new trainee AACP members from 3/30/23 to 8/25/23 increased by 89% compared to the same time last year.

Also, check out the Instagram takeover from Nicolas Fletcher MD/MHSA about the September Component Meetings and learn more about the APA Public Psychiatry Fellowship.

Interested in hosting an Instagram take-over related to community psychiatry?

Reach out to us at communitypsychiatrypodcast@gmail.com.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Trainee and ECP Outreach and Education Network Communication and Collaboration Highlights

By Angela Liu, Hannah Lynch, and Jean Wu

Mentorship Program The Communication and Collaboration Plank has started a mentorship program this year!

We aim to bring together trainees and early-career psychiatrists with established community psychiatrists. This will help to promote the professional, personal, and academic development of both mentors and mentees while fostering our growing community in public psychiatry.

Thank you to everyone who signed up to participate in the mentorship program! We had about 100 people sign up and, by using a variant of the famous residency match algorithm, we created 55 pairs of mentors and mentees with a 100% match rate.

Our Team is expanding! In addition to Hannah Lynch and Jean Wu: Social Media Content Creators Anhkim Pho - MS4 at Edward Via College of Osteopathic Medicine-Louisiana Lilliana Franklin - MS4 at Alabama College of Osteopathic Medicine Jasmine Liu-Zarzuela - MS4 at the University of Texas Medical Branch Amy Gallop - 1st year Child/Adolescent Psychiatry Fellow at the University of Utah Podcast Hosts: Jessica Isom, Rob Gadomski and Angela Liu Podcast Audio Editors Zoe Wyse - MS2 at Creighton University Gabriel Allaf - MS4 at Liberty University College of Osteopathic Medicine and part of the Divine Intervention Podcast team Aldwin Soumare - Medical Graduate of PCOM - GA, psychiatry residency reapplicant, and Co-host of MelaninWhiteCoats Podcast and SNMA Presents: The Lounge Podcast

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Updates on LOCUS The AACP’s core LOCUS team continues to work away at several key projects aimed at promoting broader reach and sustained growth of the LOCUS family of tools. Namely:

Wes Sowers, MD, AACP LOCUS Medical Director

Stephanie Smit-Dillard, MSW LCSW, AACP Operations Director

Valerie Terry, BS, MPAff, PhD, AACP Director of Quality and Training

An updated LOCUS Certification Training is set to be released in October 2023. This self-paced training will be offered asynchronously via the AACP’s online learning management system. In addition to a high-level overview of the tool, its development, purpose, and use, the training includes several opportunities for trainees to complete hypothetical patient vignette scoring, receive instruction on expert ratings and scoring of these vignettes, and to test their acquired knowledge via a post-training certification exam. Upon passing the exam, a certificate of completion will be issued to the trainee. The online learning management system will also give AACP greater opportunity to access, tabulate, and evaluate training data for continuous quality monitoring and improvement of the training.

A revision working group is meeting regularly to begin drafting updates to LOCUS v. 20 with an aim to update language and provide greater clarification in scoring instructions. This update is not envisioned to make substantive changes to the form or function of the tool.

Beta testing, revisions and psychometric testing are expected to proceed throughout 2024, with a target to release the next version of the tool in early 2025. Current tool users will be supported to transition to the new tool over the course of 2025.

The greatest expansion of LOCUS use has been among payer organizations in the past 3-4 years. It would be desirable to see greater uptake among provider organizations. The AACP is now able to do more effective marketing to raise awareness regarding the advantages of LOCUS use at its full potential.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Products and Services Plank Updates

Robert Cotes MD Products and Services Plank Lead AACP Treasurer

We are updating the description of the Medical Director role with an effort to make the role description more reflective of current practice environments, roles, and expectations. We will be working with currently practicing medical directors to elicit their feedback. We hope to share this updated description with AACP membership and beyond by the end of the calendar year. We intend for this to serve as a resource to guide and orient existing and emerging medical directors and their hiring organizations. ·Plank members are in the early stages of exploring the development of a guided self-assessment tool aimed at measuring burnout amongst behavioral healthcare professionals and organizations. We continue to conduct research into this area, which we view as being a key resource gap.

Our plank members continue to provide support and guidance to project leads for several of our keystone projects, including the SMART tool and the Community Psychiatry Certification Exam, with the aim of helping these important products grow their reach amongst our membership and beyond.

All those interested in learning more about this plank and its work can contact Stephanie.Smit-Dillard@communitypsychiatry.org

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Policy and Advocacy Forum

Ann Hackman, MD AACP Secretary

The Policy and Advocacy (P&A) Committee meets monthly with Dr. Altha Stewart to discuss issues important to our organization and to propose plans of action to present to the membership. P&A creates AACP position statements for approval by the Board reviews papers and position statements from other organizations and makes recommendations to the Executive Committee about endorsing such statements. In our past several meetings in the context of the Surgeon General’s most recent statement around the youth mental health crisis, we have been collaborating with other organizations around the child poverty crisis and the elimination of the expanded child tax credit. Dr. Ken Thompson has taken the initiative on leading these discussions. This thought provoking and active group meets on the first Wednesday of each month at 5PM (Eastern Time Zone).

Highlights from the Agenda for our last meeting- Weds October 4th, 2023- Dr. Ken Thompson Update on Findings from recent Census Data on Child Poverty Update on Mental Health findings regarding effect of expanded Child Tax Credit Update on Political Developments at Federal and State levels Update on APA actions

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

The Community Mental Health Journal

Sandy Steingard, MD Editor-In-Chief, Community MH Journal

In the next year, the CMHJ will publish two special issues.

The first one will be our inaugural issue for 2024. Edited by Mark Salzer and Amir Tal, the issue is titled “Impact of COVID-19 on the Lives of People with Mental Illnesses: Theory, Research and Practice.” While we have been publishing papers on COVID throughout the pandemic, this issue specifically addresses the effects of the pandemic on community activities of those who experience mental illness.

Our next special issue is “Recovery at 30: Emancipation, cooptation, or the end of an era?, “ edited by Vandana Gopikumar PhD & Archana Padmaker PhD (Banyan Academy for Leadership in Mental Health); Ro Speight (New York State Psychiatric Institute); Nev Jones (University of Pittsburgh); Rebecca Miller (Yale University). We hope to both honor those who heralded the recovery movement and also reflect upon the concept of recovery, the progress of the recovery movement thirty years after the publication of William Anthony’s seminal “Recovery from mental illness: the guiding vision of the mental health service system in the 1990s.” We are seeking papers from a diverse group of people. The deadline for submissions in December 1, 2023 and we plan to publish by November, 2024 my final issue as Editor.

As always, I remain grateful to those who chose our journal for submission as well as to my editorial board and the legions of people wo serve as reviewers. CMHJ is the official journal of the AACP; your participation is vital to our mission. If you have questions about the journal, please do not hesitate to contact me.

Sandra Steingard, M.D. sandysteingard@gmail.com

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Removal of the X-Waiver: Community Psychiatry Training Programs Have the Opportunity to Positively Impact Marginalized Communities by Continuing the Integration of Buprenorphine Education

Tyler Torrico, M.D. Psychiatry Resident at UCLA-Kern Medical APA/APAF SAMHSA Minority Fellow.

The United States opioid public health crisis continues to escalate, particularly regarding opioid-related overdoses and deaths. Opioid use disorders (OUDs) have widespread public health implications, and limited access to medication-assisted treatments (MAT) has been identified as a significant treatment barrier for those with OUDs (Lambdin et al, 2022).

In addition to MAT, psychosocial optimizations are integral to treating OUDs. Psychiatry resident physicians are uniquely positioned to assist the opioid epidemic when considering their training and ability for medication management, psychotherapy, and knowledge of social interventions. However, historically, the Drug Addiction Treatment Act of 2000 (DATA) and its legal requirements for prescribing buprenorphine may have unintentionally mitigated resident physicians’ interest. Despite a general awareness of the seriousness of the opioid epidemic among psychiatry training programs, there has been substantial variation in addiction training among US programs; with approximately 40% of programs previously specifically requiring DATA waivers, while the majority had no specific guidelines regarding the DATA waiver (Schwartz et al, 2018). The barriers to obtaining a DATA waiver included misunderstanding the processes, difficulty finding a training course, and inability to find dedicated time for MAT training. In 2012, only 16% of US psychiatrists had obtained DATA waivers, and by 2017, 42% of US counties continued to lack a single DATA waivered practitioner (Rosenblatt et al, 2015; Andrilla et al, 2018).

California’s Kern County has been significantly affected by the opioid epidemic, with over 200-opioid related deaths in 2020, trending upwards to 230 in 2021. Kern County has significant healthcare inequities, particularly for its Latino and low-income residents, who make up most of the population.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

California’s Kern County has been significantly affected by the opioid epidemic, with over 200-opioid related deaths in 2020, trending upwards to 230 in 2021. Kern County has significant healthcare inequities, particularly for its Latino and low-income residents, who make up most of the population. Further, over 15,000 people in the county have an OUD, and those with a dual diagnosis of a comorbid psychiatric illness have limited access to care from psychiatrists equipped to treat both conditions. In 2021, only 1.9% of providers in the county were estimated to possess a DATA waiver, leaving approximately 50 providers available to treat the over 15,000 with opioid use disorder. Kern Medical is this county’s only institution for general psychiatry residency training. Through active collaboration with Kern Behavioral Health and Recovery Services, the trainees in the psychiatry residency program provide mental health care for this population in both inpatient and outpatient settings. Considering the significant need for MAT in this county, an initiative to increase the number of psychiatry resident physicians with DATA waivers was pursued in 2022, revealing timely and interesting implications regarding the future roles of psychiatrists in the ongoing opioid epidemic.

Methods This initiative took place in Bakersfield, California, at Kern Medical’s general psychiatry residency program between September and December 2022. A postgraduate 3rd-year resident championed it with mentorship from the program director of the on-site addiction psychiatry fellowship program. Inquiry into the number of residents with a DATA waiver was obtained from the prior academic year. A survey was created inquiring about each resident’s knowledge about buprenorphine, legal aspects of prescribing buprenorphine, interest in addiction psychiatry fellowship, and preparedness to treat opioid use disorder in independent practice. Afterward, each resident was offered one-on-one and step-bystep guidance on how to obtain a DATA waiver.

Results Among the 23 psychiatric resident physicians for the previous academic year (2021-2022), none (0%) had a DATA waiver. In the current academic year (2022-2023), after implementing this initiative to directly assist residents in obtaining their DATA waiver, all qualifying residents successfully applied for and obtained their buprenorphine waiver (100%). The initiative included 14 residents with active Drug Enforcement Administration (DEA) licenses. Eight residents (six interns and two 2nd years) were excluded due to being unable to apply due to not having a DEA license yet. Before this initiative, seven residents (50%) responded that they did not know about the DATA waiver.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Only 2 (14%) had taken a prior educational course on buprenorphine. Half of the residents felt unsure about their ability to treat opioid use disorder in independent practice (50%), and the other half felt unable to treat opioid use disorder independently (50%). One resident (7%) has plans to pursue an addiction psychiatry fellowship, two residents (14%) are considering it, six residents (42%) are unsure, and 5 (35%) are not planning on pursuing the fellowship. All residents vocalized that they would be interested in completing an online educational course on buprenorphine but were generally unsure if they could find the time to complete an additional course. All residents expressed that they would complete a course if offered as part of their work hours during residency training.

Discussion The results of this simple intervention revealed multiple implications for resident physicians’ ability to be utilized in the opioid epidemic, and it provides an opportunity for reflections on the era of the DATA waiver. Recently, the Consolidated Appropriations Act, 2023 (CAA 2023) was signed into law in the United States, with section 1262 eliminating the requirement for obtaining DATA waivers. The implications of this are yet to be seen, but most are hopeful that the removal of DATA waivers and patient load caps will increase overall access to buprenorphine treatment for those in need.

In this initiative, half of the psychiatry residents did not know of the existence or purpose of the DATA waiver, which suggests that there was a general misunderstanding of the legal process to provide MAT in OUD, at least among resident physicians. Morris et al (2019). have previously suggested this exact problem as a treatment barrier for those suffering from OUDs. Further, considering that all eligible psychiatry residents obtained their buprenorphine waiver when prompted with direct instruction, it appears that residents have essentially no hesitation in willingness to consider prescribing MAT for their patients in the future. This was even despite residents vocalizing wavering confidence in their ability to do so independently and the cohort’s limited interest in pursuing an addiction psychiatry subspecialty.

To mitigate potential buprenorphine prescribing hesitation among psychiatry resident physicians, it may be helpful for general psychiatry residency training programs to continue increasing the integration of buprenorphine education into their curriculum despite the removal of the need to obtain a DATA waiver. During the era of the DATA waiver, many programs were already providing dedicated buprenorphine education, and their graduates were reported to be prescribing buprenorphine more frequently (38.5%) than their colleagues who did not receive similar training (0%) (Suzuki et al, 2014).

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Although there are barriers to implementing standardized requirements for psychiatry training programs to provide buprenorphine education, some logistical issues may be mitigated by utilizing any of the free online courses provided by professional medical organizations. Further reassuringly, approximately 90% of psychiatry residency programs have reported having onsite supervisors with addiction psychiatry expertise (Schwartz et al, 2018). Targeted educational programs to involve community psychiatrists to treat patients with OUD are currently suggested as an area of research to resolve critical barriers to the ongoing opioid crisis (Franz et al, 2021). The potential of systemic preparations for psychiatry resident physicians to assist in providing MAT for those suffering from OUDs should not be overlooked as part of the broad interventions to address the US opioid crisis, particularly in marginalized and minority communities.

Acknowledgments and Disclosures A complete list of references is available upon request.

Thank you to my mentors at Kern Medical, Ranjit Padhy, Md. Towhid Salam and David Weinstein for their support in this initiative. The APA/APAF SAMHSA Minority Fellowship grant supported this initiative.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

St. Vincent’s Student-Run Free Clinic: A Medical Home Fostering Innovation, Mentorship, Leadership, and Advocacy

Jasmine Liu-Zarzuela, MD/MPH Student University of Texas Medical Branch Class of 2024

While pursuing a Master's in Public Health during medical school, I made it my mission to better understand the interplay between psychiatry and the role of public health in providing services to underserved communities. As I reflect back on the past three years of medical school, I am most grateful for the opportunities to serve the disadvantaged and vulnerable communities of Galveston County through my school’s student-run free clinic, St. Vincent’s Clinic (STV).

When I started medical school in July 2020, I was ecstatic to start seeing patients in an in-person, clinical setting, particularly with the rise of the COVID-19 pandemic that forced all educational activities to be delivered online.

I was immediately drawn to STV’s mission of creating a safe medical home and providing holistic, compassionate care for the underserved community in Galveston. From the beginning of this experience, I witnessed the barriers to receiving consistent and thorough healthcare for our patients, and I aimed to become more involved in advocating for those most in need of support.

During my first year of medical school, I collaborated with several other medical students to create and implement the Firearm Safety Education Program. This program assesses for suicide risk, provides education on safe firearm storage, and offers free firearm locks to patients in hopes of preventing firearm-associated injuries and death, such as suicide and unintentional shootings. This project is especially meaningful to me because it combines my passions for public health education and mental health. At the end of my first year, I joined the STV leadership team on the Administrative Committee, where I helped patients apply for and receive free medications from pharmaceutical-sponsored assistance programs. Over time, I have seen how medication delays take a toll on a patient’s physical, mental, and emotional health. Thus, as part of an interprofessional team of students and faculty volunteers, we created and implemented a new electronic system to combat the long wait times for approval. We managed to improve the administrative workflow of these applications, which decreased the approval of medications from an average of 62 days to 15 days.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

One of my favorite aspects about STV is the strong and longitudinal mentorship between faculty, residents, upperclassmen, and lowerclassmen. STV provides a safe, nonjudgmental space for students to learn and ask questions without being evaluated or graded. It is heartening to see how many faculty members and residents volunteer their evenings to give back to their community and teach students. Personally, I have found so much joy in mentoring underclassmen in interviewing, presenting, note-writing, and other clinical tasks, and I am excited to continue building on my passions for medical education and mentorship.

While STV provides the community with a variety of resources, there are still many ways to improve the delivery of services. I, along with many other student volunteers, am constantly searching for innovative ways to improve the clinic’s resources and services.

Some of the projects I am currently working on involve increasing awareness of free psychotherapy appointments, evaluating the availability of telehealth appointments and barriers patients face in attending in-person appointments, implementing the PHQ-9 questionnaire, and educating primary care providers about the Waco Guide, clinical decision support to help others feel more comfortable in treating psychiatric conditions.

STV provides opportunities in leadership, community outreach, interprofessional collaboration, education, and quality improvement initiatives, but most importantly, this clinic teaches students how to best advocate for patients. The longitudinal patient experiences allow students to establish and further strengthen patient relationships throughout their medical education. The diverse healthcare services, which include psychiatry, neurology, general medicine, wound care, physical therapy, occupational therapy, respiratory therapy, and social work to name a few, foster a space that relies on strong interprofessional collaboration. At STV, we view patients holistically, taking into consideration how various social determinants of health play a role in physical and mental health. We are taught to address these barriers and find resources for patients to improve their quality of life. STV has inspired me to continue advocating for underserved communities, with the goal of practicing, teaching, and mentoring in community-based clinics throughout my training and deep into my career. My ultimate goal is to create a community center that provides accessible mental health care, primary care, and public health education to an underserved community. I envision this center as encompassing providers of diverse fields and educational backgrounds, much like STV.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Benefits Of Rural Psychiatry: A Personal Journey Eight years ago, fresh out of residency, I found myself driving through the winding roads of Southern Oregon, my heart filled with a mix of excitement and trepidation. I was Dr. Yetunde Akins, a young psychiatrist, eager to make a difference but admittedly naive about the challenges and rewards that awaited me in rural psychiatry.

I distinctly recall the apprehensions expressed by my peers when I announced my decision: “Will you not experience a sense of isolation in the absence of proximate colleagues?" How do you plan to address Yetunde Akins MD,MPH,FAPA Medical Director the issue of resource scarcity? “Aren't you concerned Sky Lakes Behavioral Health Clinic about the social dynamics within a small community?”

In the present day, armed with the wisdom gained from my personal experience, I aim to share the reasons behind my profound affection for rural psychiatry, despite the initial perception of certain disadvantages. I also hope to convey why you, too, may find yourself similarly captivated by this field.

1. The Phenomenon of Colleague Isolation: An Exploration of its Role in Facilitating Individual Independence and Personal Development Indeed, it is accurate to assert that in rural environments, it is plausible to lack professional associates in proximity, whether it be inside the immediate workplace or even the next town over. However, the experience of isolation compelled me to be resourceful, trust my training, and embrace my intuition. This experience enhanced my clinical skills and abilities. And in instances where I required guidance or counsel? The utilization of online communities like Oregon Psychiatric Assess Line( OPAL), has proven to be of great value. The personal connections that I have established with my other colleagues in rural psychiatry, despite being separated by physical distances, are profound and provide a strong foundation of support.

2. Lack of Access: The Power of Innovation : The constraints imposed by limited access to specific resources necessitated a departure from conventional thinking. I have successfully amalgamated local traditions with current and evidence-based practices, creating a unique therapeutic blend that resonates with my patients.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

These capacities for adaptation not only confer advantages to the individuals under my care but also enhance my professional journey in ways I hadn't imagined.

3. The Phenomenon of Social Isolation: Cultivating Strong Community Bonds In an urban setting, one may find oneself susceptible to becoming disoriented amidst a larger population. Contrasting that with serving in a rural setting, where one can assume an integral role within the community.

The patients under my care transcend mere entries on medical records: they are the proprietors of a grocery shop, an educator within the local school system, the local farmers. These are professions, and careers that are close-knit and intertwined. This proximity has facilitated my own comprehension of the social determinants of health and its influence on mental health, things I took for granted having been raised in a bigger city. I have observed the correlation between food shortage and its influence on mental health, the way housing instability can intensify anxiety, and the dual nature of community roles in terms of both posing challenges and providing support to an individual's overall wellbeing.

4. The Phenomenon of Double Binds: Embracing the Simultaneous Adoption of Multiple Roles In smaller communities, the occurrence of dual relationships is unavoidable. Your patient may also serve as a community religious leader, waitress at a restaurant or a personal friend. At the outset, this undertaking appeared to be a formidable endeavor. However, as time has progressed, I have begun to perceive it as a favorable circumstance. The presence of these overlapping functions results in the establishment of an inherent support system.

I have found myself as a practitioner operating not in isolation but rather engaged in collaborative efforts with a network of people who, via their diverse roles, contribute to the comprehensive well-being of patients.

5. The Aesthetic Appeal of Rural Living: A Soothing Remedy for the Human Spirit Beyond the vocational benefits, the rural environment possesses a deeply therapeutic quality.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

The tranquil mornings, the nights adorned with stars, and the profound affinity with the natural world have served as a soothing remedy for my inner being. The present context has not alone contributed to the enhancement of my individual welfare but has also facilitated the development of my empathic and grounded approach as a psychiatrist.

To the aspiring psychiatrists who are reading this: I cannot guarantee that the practice of psychiatry in rural communities is devoid of challenges. Individuals may encounter various obstacles, experience moments of uncertainty, and experience times when the weight of responsibility will be palpable.

But the benefits are enormous and life-changing. You will experience personal growth in unforeseen ways. One will have the opportunity to observe the tangible effects of their effort. You become a beacon of optimism, a community pillar, and will witness the demonstration of the power of human connection. Therefore, as you stand at a career crossroads, I urge you to contemplate the path less traveled. The journey may be difficult, but one will have the opportunity to gain a deeper understanding of the concept of resilience, both within themselves and among the patients we serve.

Do you have ideas about how to connect our members?

Do you want to be involved with our Instagram page, Podcast, Newsletter or membership meetings?

A monthly conversation facilitated by AACP Director of Communications Dr. Mira Bodic Fourth Wednesday of every month 6pm EST Meeting ID: 816 2166 5584 Passcode: 597019

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

PCP Coaching: An Underutilized but Very Effective Method to Increase Mental Healthcare Availability in the Community

Souparno Mitra Lucia Roitman Shalini Dutta Sasidhar Gunturu Dept. of Psychiatry, BronxCare Health System, Bronx, NY

According to NIMH estimation, one in five adults in the US lives with a mental illness. Less than half of them had accessed mental health services within the past year, defined as having received either inpatient or outpatient treatment/counseling, or having used prescription medication for problems with emotions, nerves, or mental health. According to the AMA Masterfile, 41,133 psychiatrists are actively practicing across the United States. Psychiatrists are densely populated in states such as California and New York but scarce in states like Montana and Wyoming.

Extrapolation of the number of providers compared to the expanding population, show that a contraction of the psychiatric workforce will occur in the year of 2024 before a slow expansion begins the following year. It is evident that innovative solutions are needed to combat increased demand for mental health providers.

In this article we discuss Primary Care Physician (PCP) Coaching as a means of increasing access to mental health care. This in-service tailored intervention allows PCPs to request formal didactics from the psychiatrists based on the topics most relevant to their patient population, with the goal of increasing evidence-based practice and the levels of comfort in treating the most common mental health disorders.

The PCP Coaching model is an integral part of the Integrated Care Service at our community hospital, BronxCare Health System which is comprised of the following parts: Co-located care involves a psychiatrist being co-located in a primary care clinic as a consultant. This strategy intends to provide transient specialist care to patients who have mental illnesses that require specialist intervention but are not severe enough to warrant treatment at a specialty clinic. The psychiatrist sees the patient every 2-3 months and adjusts medication with the goal of at least 6 months of stability on the same dose prior to referral back to the PCP.

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Community Psychiatrist Fall 2023

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Collaborative Care: This model, formalized by the University of Washington wherein a PCP manages the mental health needs of patients with Major Depressive Disorder or Generalized Anxiety Disorder.

The PCP collaborates with a Behavioral Health Care Manager who has a dual role of therapist and liaison between the primary care team and psychiatrist. The psychiatrist does not directly see the patient but meets with the behavioral health care manager on a regular basis to discuss cases that need “indirect” consultation, and recommendations can be implemented by the PCP. Ambulatory ICU: This is a collaborative team meeting for members of the care team (PCP, psychiatrist, social workers, care managers) in which treatment plans of patients who have been recently hospitalized or are at risk of hospitalization are discussed, Integrated Care Elective: This is a 4–8-week elective for primary care residents to rotate through the integrated care service and learn about managing psychiatric illnesses at the primary care clinic.

PCP Coaching: We found that one of the core reasons that PCPs refer patients to psychiatry is related to the comfortability with the nuances of diagnosing mental illness and managing medications. A focus group discussion yielded the solution of PCP Coaching and produced a plan to have 2-3 weekly didactic lessons (via video conference) for PCPs. The curriculum for this year include Depressive and anxiety Disorder, Bipolar Disorder, Psychosis Spectrum Disorder, Substance Use Disorder, Suicide Risk Assessment, Common Off Label Use of Psychotropics, Cardiac/ Liver Issues with Psychotropics and Insomnia. The lectures focus on practical aspects of diagnostics and treatment, with real case examples that the psychiatrist would present. The instructional portion would be for 30 minutes, then 15 minutes were spent discussing common problems encountered by PCPs in managing these diagnoses. The curriculum is decided yearly by PCPs via a survey and regular feedback is sought on the areas of improvement. Data is being collected on the impact of these interventions on PCP prescribing practices and referrals to psychiatry. The psychiatrist conducting these classes has noted greater engagement and participation from PCPs, who reported positive feedback about the program and increased level of confidence in managing common psychiatric diagnoses.

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Community Psychiatrist Fall 2023

Volume 39, Number 2

Discussion Data suggests that up to 60% of patients with a psychiatric disorder are seen exclusively

by PCPs, and only 13% of the mental health care delivered is described as “minimally adequate” [4], partially due to underprescribed psychotropic medications and a severe lack of structured counseling. PCPs identified multiple barriers to mental health referrals, including patients’ resistance, stigma, and inadequate insurance coverage. In the article “Adult Primary Care Physician Visits Increasingly Address Mental Health Concerns”, the authors addressed the need to adjust organizational designs and support to enable PCPs to adequately address mental health needs.

As our model to address this continues to grow, we aim to standardize the curriculum and identify additional topics to address such as modes to implement our team-based approach and identification of resources as part of discharge planning. We plan to improve our assessment instruments to receive feedback related to the impact of our program and assess the effect that our intervention had on the prescribing habits and skills of PCPs. Our feedback process will assess patient satisfaction and monitor the improvement of outreach. The assimilation of the PCP Coaching model with other elements of integrated care can improve patient access to care, including decreasing the wait time for patients to receive care, thus expediting their recovery.

A list of references can be provided upon request.

Part One:Introduction and Background Part Two:The Basics: The Pillars of Community Psychiatry Part Three: Core Competencies for Community Psychiatrists Part Five:Creating Healthy Communities Part Six:Supportive Services for Community Living Part Seven: Special Populations Part Eight: Development and Administration of Services Part Nine:Shaping the Future Links to purchase: Springer or Amazon)

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Federally Qualified Health Centers (FQHCs): A Unique Federal Initiative to Bridge Healthcare Gaps

Souparno Mitra, MD Clinical Instructor, NYU Grossman School of Medicine

It was in my year as a Public Psychiatry Fellow at Columbia that I (Souparno) chose the Bronxcare FQHC (Federally Qualified Health Center) system as my job site. I chose this site knowing that it would serve as a wonderful opportunity to integrate mental health care in a primary care setting and allow for expanding access to care for the underserved population of the Bronx. I was not disappointed. I treated populations that were uninsured and worked on integrating mental health care to populations in a one-stop shop setting which made access to care even easier for the patients.

I distinctly remember the case of Mr. Q, a 40-year-old male who had been struggling with depression for over 10 years and who sought treatment for it from only his primary care doctor. He was unwilling to seek care at a mental health clinic due to the stigma associated with mental health in his community. Mr. Q agreed to see us when he came to know that he could just come to his primary care clinic for this and with careful adjustment of his medication regimen experienced a remission of his depression.

We also realized that a lot of my colleagues were not fully aware of the history of FQHCs and hence we present a brief overview of the FQHC system.

History of FQHCs The origin of FQHCs dates back to 1964 when President Lyndon Johnson passed the Special Economic Opportunity Act which promised to open Neighborhood Health Centers for underprivileged people. The first two centers were opened in Mound Bayou, Mississippi, and Columbia, Point, Boston.

The term FQHC was used for the first time in 1989 as part of an act that would modernize these centers. In 1991, FQHCs were added as a Medicare and Medicaid benefit. Lawmakers also termed these centers as “safety-net providers” which served the homeless and migrants.

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In 1996, the Health Center Consolidation Act was passed, which defined these centers as primary care centers bringing together migrants, homeless people, and community and public housing health care programs. In 2010 FQHCs, became part of the Affordable Care Act and by this time their reach doubled.

What constitutes an FQHC? As per HRSA, to qualify as an FQHC, a center must: qualify for funding under Section 330 of the Public Health Service Act (PHS); qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits; serve an underserved area or population; offer a sliding fee scale; provide comprehensive services (either on-site or by arrangement with another provider), including preventive health services, dental services, mental health and substance abuse services, transportation services necessary for adequate patient care, hospital and specialty care; have an ongoing quality assurance program and have a governing board of directors FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, health center program “look-alikes” and outpatient health programs or facilities a tribe or tribal organization or an urban Indian organization operates.

The Reach and Impact of FQHCs: As per 2021 statistics, 1 in 12 Americans depend on FQHCs for their care. The estimate as of 2019, is that 29 million people are served by FQHCs. These include nearly 14 million people in poverty, 8.7 million children, 1.4 million homeless patients, 385,000 veterans, and 95,000 patients receiving medication-assisted treatment for Opioid Use Disorders.

23% of patients are uninsured, 48% are on Medicaid and 10% are on Medicare. 63% of patients belong to Racial and Ethnic minorities. 68% of the patients are at or below the Federal Poverty Line.

In the US, there are 1367 FQHCs nationwide serving the 29 million people mentioned. The annual federal funding under the Affordable Care Act was approximately 1.99 billion dollars in 2007. However, with the expansion of FQHCs and the ever-burgeoning need for services, the Federal Government set aside 11 billion dollars to assist the expansion between the period of 2011-2015.

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Community Psychiatrist Fall 2023

Volume 39, Number 2

Important Information Related to Billing and Payment Systems FQHCs are allocated a budget for the services they provide based on the needs of the community they serve. With the increased dependence of Medicaid insured patients, the cost is split between Medicaid and Federal Funding.

Some of the important terms when it comes to billing include: 1.Prospective Payment System: The single bundled rate provided for each patient visit fixed based on historical costs of the FQHC to provide comprehensive care to patients 2.Medicaid Managed Care Payment: The Fee For Service rate which is paid by the Medicaid Managed Care Organization 3. The Wrap-up: The balance amount which is paid by the Federal Government.

In conclusion FQHCs have definitely impacted the uninsured and underserved communities by providing access to high-quality primary care to those greatly impacted by healthcare disparities.

FQHCs have reduced costs while increasing outreach and enabling a community voice on the board and they are definitely an important tool in improving the access to health care and mental health care services in the community.

Acknowledgement- for supervision and support to Dr. Sasidhar Gunturu Director, Psychiatric Integrated Services and Program Director, Psychiatry Residency, Bronxcare Health Systems

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

The Educational Value of Medical Student Participation on Assertive Community Treatment Teams

Jean D Wu Virginia Commonwealth School of Medicine, MS4

Assertive community treatment (ACT) is a model of community based psychiatric care that employs a multi-disciplinary team to deliver mental health services to patients with severe mental illnesses (SMI).

In medical school patients with SMI are primarily painted by acute presentations to the emergency department, a cross-sectional oversimplification of a much more nuanced experience, all which feeds into the stigma surrounding SMI.

ACT teams differ greatly from traditional models of care, employing a more holistic approach to care, as team members assist patients with not only disease management but also tasks of everyday living. However, few medical schools offer the opportunity to participate in ACT during the core psychiatry clerkship (Kanofsky et al., 2019). Inspired after shadowing ACT teams, I developed a program that allowed medical students to participate in an optional ACT experience during the core psychiatry clerkships, in hopes of humanizing patients with SMI. In this piece, I argue for the educational value of medical student participation in ACT teams, as evidenced by qualitative findings from an IRB-approved survey at VCU SOM. The results of this project have been shared at local and national conferences.

Below, I share some of the qualitative data from the study. Several themes have emerged with key student comments highlighted (N = 15).

Theme 1: Broadened understanding of psychiatry “Psychiatry is a very humanizing field in medicine...ACT helped me realize that psychiatry really is about building relationships of trust and allowing that to also be of therapeutic benefit to patients” “I have more respect for psychiatry as a field, not to mention appreciation for the complex care that is provided.”

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Theme 2: Broadened understanding of medicine “It showed a different side to medicine that is neglected in medical school since so much time is spent in the hospital.”

Theme 3: Increased understanding of the bio-psycho-social model “Being able to visit patients in their home and see their environment allowed me to really see how their psychiatric conditions affect them and how different it can look when they improve.”

“I now see how much goes into the care of a patient, from groceries, housing, doctor's appointments, and family care!”

Theme 4: Appreciation of the complexity of care “It showed how crucial and difficult it is for some psychiatric patients to get the care they need to improve...” “...it helped me better understand how to maneuver conversation and certain situations that may be unique to patients with severe mental illness.”

Theme 5: Humanizing SMI “The ACT experience provided me with a different perspective of the patients we normally see in the hospital and have little to no understanding of their personal lives. It gave a more humane approach to working with patients.” “...was extremely eye-opening! It's very valuable to see how patients are when they are not in the hospital and how they interact in the community!”

Other “I absolutely loved this experience... I left the program in awe, inspired, and appreciative of the opportunity. Excellent job Jean and your team for putting this together.”

Psychiatry clerkships, and medical training in general, often provide little opportunity for medical students to see patients in a non-clinical setting. Assertive community treatment, by way of its multidisciplinary patient-centered care model, provides a unique experience to see patients in their homes – to not only learn but experience the socio-environmental factors that influence psychiatric care. The overwhelmingly positive survey results suggest that the ACT program was a valuable experience for students and may be an underutilized avenue to broaden medical students’ perception of psychiatry. We hope through sharing our pilot program framework and annual findings of an ACT experience into 3rd-year psychiatry clerkships, we can inspire other medical schools to create similar programs and increase engagement with community psychiatry.

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Community Psychiatrist Fall 2023

Volume 39, Number 2

Join me to Address the Need for “RecoveryOriented Discharge Planning”

Wonyun Lee, MD PGY2 Psychiatry resident, Maimonides Health, Brooklyn NY APA Public Psychiatry Fellow

“I just watch TV at home all day. I’m bored but I have nothing to do. I used to have many friends, but I stopped talking to them. I don’t talk to anyone anymore.”

This was a 17yo male at his second inpatient psychiatry admission. He had been diagnosed with schizophrenia, due to experiencing severe command auditory hallucinations telling him to kill his bother with scissors.

This time, the patient himself requested to be brought to the hospital due to these intrusive voices. He felt incredibly guilty about having homicidal thoughts towards his own loved brother. He was ashamed of his symptoms and was not willing to share any further information with the treatment team.

Later in the day, I went back to him and started asking “random” questions. “I heard you don’t go to school or work. What do you do all day? Do you stay home every day? You don’t go out? Aren’t you bored?” I finished my master’s degree in medical anthropology a year before, and my training brought in curiosity about patients’ daily lives and subjective experiences of their illnesses. He told me that he was insufferably bored. He had stopped going to school after his last admission. He had nothing to do at home and was watching TV all day to kill time. He used to have many friends however he had stopped talking to them due to immense shame caused by his psychotic symptoms.

I asked him if he plans to ever get back to school. He blankly stared back at me as if I was being ridiculous for expecting him to get back to his old life. Then I asked what he had wanted to do in the past. He said he wanted to become a veterinarian. He shared with me his love for animals. He used to be a good student with above-average grades. However, now his dream seemed too far away for him to even dream about.

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Community Psychiatrist Fall 2023

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With an appropriate dose of antipsychotics, his voices appeased shortly. The treatment team started preparing for discharge. Yet, I was unsatisfied. He will go back to the same house, with the same amount of shame, guilt, and hopelessness. He does not go to school, he lost his friends, lost all hopes for the future. He will continue to stay home and watch TV, knowing he is wasting away his life. He will continue to believe that he will never achieve anything in his life.

I took my attending to the side and asked her what else we could do. He is a brilliant kid, but he is not going to school. He used to dream about becoming a veterinarian, but now he is watching TV at home all day. What should we do? Can’t we do more? This is when I was introduced to the Fountain House model. My attending told me that there is a peer-led program in New York (and similar clubhouses throughout the country), where our patients can go hang out with people, make friends, and get help with their education and career goals. After this conversation, we discharged him with 30-day prescriptions, outpatient follow-up, and a referral to Fountain House.

The week after, my attending organized a field trip to the nearby Fountain House where we got a tour from one of the members who is a patient himself. Members were playing pool, chatting over coffee, cleaning, and cooking. I thought to myself, this is how patients get better!

A year later, rotating in the inpatient unit, I saw many people in the same situation. My patients were not just suffering from voices and delusions. They were suffering from family conflicts, abuse, boredom, isolation, financial insecurity, homelessness, not being able to find a job, and dropping out of school. Most importantly, they were devastated by the lost meaning of their lives. These were all their psychiatric symptoms. Yet, we give 30 days of antipsychotics and send them back home with an unrealistic hope that our medications alone will fix their lives. Only if they had stayed “compliant”!

We send our patients back to the exact same environment, with the exact same triggers and stressors. I see them coming back time after time with the exact same presentation. I gradually realized that prescriptions and outpatient psychiatry follow-up as a discharge plan were not good enough. Inpatient psychiatry needs to do much more than a prescription and an appointment. It is time for recovery-oriented discharge planning.

According to a study that asked service users for strategies to help prevent rehospitalizations, psychiatric discharge plans should include resources to support functional day-to-day life and engagement with psychosocial services such as peer support.

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Community Psychiatrist Fall 2023

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Patients emphasized the importance of having meaningful activities, being part of a community, and having “something to do” as essential factors in preventing relapse. A systematic review of factors affecting the risk of rehospitalizations found being connected to the community, being enrolled in case management programs, and having peer support or a recovery mentor as protective factors.

We need more comprehensive discharge plans, that will appropriately meet patients’ needs: Recovery-oriented discharge planning. This needs to include: 1) identifying and discussing patients’ own recovery goals, 2) discussing the strategies to create daily structure and engage patients in meaningful activities, 3) providing support systems for financial, employment, and educational assistance, and 4) re-connecting patients to community.

In an effort to achieve this goal, I started a recovery-oriented discharge planning project in my residency program. The aim is to create a workflow that will help physicians think of discharge plans in an organized and structured manner that will result in comprehensive recovery-oriented plans. Please contact me (md.wonyun@gmail.com) and share your experiences and thoughts. Let’s talk about how we can stop the “revolving door” patterns of inpatient psychiatry. Let’s build a plan to make this happen together.

A publication of the American Association for Community Psychiatry www.communitypsychiatry.org

Community Psychiatrist Fall 2023

Volume 39, Number 2

Time to Rethink the Routine Med Check?

Ben Crocker, MD

I’m on the verge of retirement and experiencing the freedom of a limited private practice after a career of mostly doing brief encounters with patients regarding medication. Most of the time this has been in standard nonprofit community outpatient clinics. Looking back on my lifetime work I am dissatisfied with the structures of encounter I have accommodated to.

The community mental health system that was envisioned 60 years ago expected that funding mechanisms beyond fee for service would be developed, and for a while they were, but for many years fee for service reimbursement has been the rule. In routine outpatient services, this and the failure of behavioral health to integrate with general health services has led to outpatients being scheduled at regular one to 3 month intervals to see a psychiatric provider regardless of clinical need or patient preferences. The provider almost always prescribes a psychotropic medication, often with the assumption that patients will need to be seen indefinitely as transition to primary care is often difficult. Adherence to routine psychiatric appointments is often thought to be required for the maintenance of disability benefits.

Long term, routinely scheduled care selects for adherent and stable patients, with the result that outpatient schedules are often filled months in advance and there is little room for acuity. Patients who are non adherent to this kind of scheduling are often extruded by outpatient services, leaving them in limbo.. Waiting lists and requirements that patients have primary care in place select for patient, relatively stable people.

There is a fear that unstable patients will be too demanding and interrupt the smooth productivity generated by a predictable patient population. Over time this tends to make outpatient providers avoidant of patients with acute needs. I know that happened to me.

At this time all settings of behavioral health treatment, public and private, are relatively inaccessible, so often patients wind up using intensive services when earlier access to outpatient services would have sufficed, or more commonly getting no treatment.

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Community Psychiatrist Fall 2023

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We may hope for a reorganization of behavioral health services and funding that will structurally improve access to care, but in the short run this is unlikely. In the meantime we must work within the underfunded. segregated, fee for service system of care to provide only necessary and desired psychiatric services to stable patients while freeing up psychiatric teams to serve more acutely presenting patients. In other words to make treatment more patient centered rather than provider centered.

Linking reimbursement for ongoing treatment to the prescribing of medication overemphasizes the role of medication in recovery and constrains the role of psychiatric providers who may be better utilized evaluating and initiating treatment of flexible intensity for acute patients and supervising ongoing team care. If we are clear about specific recovery services we offer patients it is possible that fee for service billing for these could evolve, as billing for behavioral health integration into primary care has begun to.

The technological advances in communication that have become almost universal since COVID can now be used to make all levels of outpatient treatment more of a continuous, team based, patient centered process based on patient need and less of a series of prescheduled billable events. Even within the strictures of fee for service billing, more flexibly scheduled visits may suffice with the option of just in time scheduling if there are problems. Real time electronic communication can facilitate more flexible scheduling and team communication with patients while maintaining enough billable contacts to keep the lights on. If the tradition of quarterly treatment plan updates continues to be required, much of this can be done online by teams, freeing patients and prescribers from the 3 month lockstep. In many clinics no shows have significantly decreased during periods of virtual visits that are more convenient for patients, so flexible scheduling can increase billing. Patients who desire regular in person contact can be seen in groups by treatment teams that include a prescriber but offer more psychoeducation and socialization than is possible in brief 1:1 meetings. The new technology increases options for patient empowerment and education and for asynchronous communication which can be used to supplement billable services. The latter has to be properly managed and if need be linked to billable events, as primary care is discovering from the overuse of patient portals.

It is unlikely that universal health insurance, widespread retail capitation or integration with primary care are likely to happen soon. In the meantime we need to think creatively about how to optimize fee for service billing so that it moves closer to the calculus of capitation for populations.

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Community Psychiatrist Fall 2023

Jules Rosen M.D. Summit Behavioral Health Consultants, President and CMO Michelle Hoy MA, LPC, CAC III Whitewater Consulting, President

Volume 39, Number 2

Introduction to Phase-based Care The average wait time to see a psychiatric provider or therapist in the U.S. is typically 10 weeks or more, depending on locale and insurance status. Community Mental Health Centers (CMHC), the ‘safety net’ for patients on Medicaid or without insurance coverage, can have wait times of 4 to 9 months or more.

Behavioral health treatment in the U.S. is dominated by a culture requiring patient visits according routinely scheduled appointments at a pre-ordained regular intervals, often 1-3 months regardless of acuity or clinical need. In fact, Medicaid regulations in many states mandate this policy. As a result of this practice, many programs face waitlists of 500 – 1000 patients, and delays of one year or more prior to engaging in treatment.

Delays in care are associated with symptom deterioration, reduced engagement, less improvement, increased dropout rates, overburden in emergency departments, and intense client and community dissatisfaction.To address this problem, we created “Phase-based Care”.

Phase-based care (PBC), developed through a year-long Lean Six Sigma initiative at a community mental health center in Colorado, reduces wait-times and enables patients to engage in treatment immediately with a multi-modal treatment team to rapidly achieve recovery. This is primarily accomplished by front-loading the therapy and med management resources to new and acutely ill patients, and using treatment teams to maintain wellness once recovery is achieved. For acute phase patients in PBC, the primary outcome measures are: (1) time to access AND engage in comprehensive care, (2) intensity of engagement and resources used to achieve recovery monitored weekly, and (3) treatment outcomes at specified time intervals.

PBC uses rating instruments at each touch to inform (but not mandate) treatment intensity, provides walk-in visits to weekly clinics as well as scheduled appointments, has multi-disciplinary teams with a single care plan that changes with acuity change, and uses mathematical algorithms to assign appropriate staffing levels to meet the needs of patients in all phases of care (acute through recovery).

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Community Psychiatrist Fall 2023

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The “rapid recovery clinic” (RRC) for mood disorders provides the most robust PBC data, however data of other clinics showing similar outcomes are available.

PBC Reduces Wait-time and Provides Immediate Engagement: Rapid Recovery Clinic (RRC) Over three hundred mood disorder patients were admitted to the RRC over 3-years with an average, initial PHQ-9 score of 22.5. The average time to access AND engage in care went from 3-4 months to 3-4 days. Recovery rates, defined as PHQ-9 of 10 or less, at weeks 6 and 12 were 63% and 78% respectively. Of note, “recovery” designates the end of the “acute phase” (not remission) and stimulates a team / patient discussion of a revised care plan based on lower acuity and different clinical needs. No additional staff or resources were needed.

The psychiatry/provider time required to achieve recovery (or at week 12 without recovery) was between 2-3 hours, and average therapy time was 3 hours (range 0 – 8 hrs.).

Once stable, patients utilize time-limited individual psychotherapy, brief med management appointments, group programs, and other members of the treatment team, including peer support specialists and case managers. Algorithms, based on data provided by the clinical staff, are used to match community needs patient volumes with discipline specific staffing guidelines for each PBC clinic.

Eliminate Long Waitlists with PBC: Clinical and Financial Outcomes Programs facing hundreds of patients on a waitlist are often paralyzed by the magnitude of that challenge. Those waitlists must be eliminated, and re-emergence prevented to meet their communities’ needs. A community behavioral health program in the southern U.S. struggled with a waitlist of 702 patients. Using the principles of PBC, the waitlist was eliminated.

Weekly meetings for 4-months addressed the culture changes needed to implement a PBC program. Then, the team proposed and initiated their PBC plan. Within 3.5 months, the waitlist was eliminated. In the two months following, no waitlist re-emerged. High acuity clients could engage in therapy without delay.

New behavioral health evaluations scheduled per month per therapist were 6.5 and 18.6, pre- and post-PBC, respectively. Moreover, new evaluations completed per month per therapist were 3.1 and 12.0 pre- and post-PBC – a four-fold increase. No-show rates were 52.3 and 35.4 respectively over the same periods. This translated to approximately $7000 additional Medicaid revenue per month post-PBC, excluding revenues associated with follow-up care.

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Community Psychiatrist Fall 2023

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The key principles of PBC are: 1.Symptom acuity is measured with rating scales at every touch to guide treatment.

2.Patients choose the modality of evidence-based treatments. For example, non-psychotic depression responds equally well to CBT as to meds, so either modality can be selected.

3.Scheduled visits and walk-ins (or video call-ins) are encouraged for all patients in the acute phase at a weekly clinic. Stable patients starting to relapse do not wait for an appointment with their therapist or provider weeks away; they simply come to their weekly clinic.

4.Each patient has a unified treatment plan including medication management, individual and group therapy, peer support, and case management.

5.Weekly team meetings review all patients in the “acute phase” examining engagement, rating scale scores, and resources used. Based on progress, or lack of progress, the team can upgrade or downgrade the intensity of the treatment plan.

While the key principles are listed above, every program designs its own PBC clinic according to its patient population and current staffing capabilities.

NATIONAL AND STATE AWARDS: ·Golden Light Bulb Award; Colorado Behavioral Healthcare Council, 2019 ·John Q. Sherman Award for Excellence in Patient Engagement; Institute for Healthcare Innovation (IHI) 2019. ·Award of Excellence; National Council for Mental Wellbeing, 2020

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Community Psychiatrist Fall 2023

Volume 39, Number 2

Editor's Closing Comments June 2023 marked the end of my first decade in practice as a public psychiatrist and I wondered how best to celebrate this important milestone. As I looked back at my clinical and academic involvements, I was proud of what I have achieved so far, but still, something was missing.

Mira Bodic, MD AACP Director of Communications Newsletter Editor

I completed the Public Psychiatry Fellowship at Columbia/ New York State Psychiatric Institute, but I never pursued the Certification Exam in Community Psychiatry offered by AACP. The 10-year mark since graduation seemed like the perfect time to tackle this- yet, another exam in the long list of tests we are subjected to in our medical careers.

Armed with a coffee and 2.5 hours blocked on my calendar I embarked on this new adventure. I was not sure what to expect, and while I have done well on standardized tests in the past, I do not see them as a good way to assess someone’s worth or skill as a doctor.

I was pleasantly surprised as I started reading and reflecting on the questions, on how targeted and thoughtful they were! Knowing some of this information is the core of what makes one a patient-centered, recovery-oriented, social justice-minded community psychiatrist!

And for those of you interested in formal or informal leadership roles, there are plenty of questions on systems, funding, and structural issues in organizations.

I have not been happier to have taken an exam before in my professional life, or prouder to have passed, and join the growing (but unfortunately still too small) group of AACP Certified Community Psychiatrists out there! I’m inviting (actually strongly encouraging!) all of you who meet the criteria, either through completing a Public and Community Psychiatry fellowship or having worked in the field for at least 1 year, to take this exam and proudly display your certificate for the world to see. As our president Dr. Altha Stewart says “The future of psychiatry is community psychiatry”, so join me in building the future!

Thank you to everyone who submitted to the AACP Newsletter, to everyone who reads it, and to everyone who contributes to the Community for Community Psychiatry.

WE PROTECT

PSYCHIATRISTS FORENSIC PART-TIME CHILD & ADOLESCENT

MILITARY TELEPSYCHIATRY

ADDICTION GERIATRIC MOONLIGHTING RESIDENTS & FELLOWS A POLICY WITH PRMS® COVERS YOU FOR THE TYPE OF PSYCHIATRY YOU PRACTICE

Professional liability protection is just one part of our comprehensive insurance program. When it’s time to select your insurance provider, choose the program that puts psychiatrists first!

More than an insurance policy 800.245.3333 PRMS.com/Dedicated TheProgram@prms.com

Insurance coverage provided by Fair American Insurance and Reinsurance Company (FAIRCO), New York, NY (NAIC 35157). FAIRCO is an authorized carrier in California, ID number 3715-7. www.fairco.com.

PRMS, The Psychiatrists’ Program and the PRMS Owl are registered Trademarks of Transatlantic Holdings, Inc., a parent company of FAIRCO.