Leaders at Nebraska Medicine and UNMC have been working to help behavioral health patients receive better access to providers. After much study, a plan to improve access will be implemented on Monday, July 1.
Nebraska Medicine Behavioral Health Director David Cates, Ph.D., said limited access to psychiatric providers is a community-wide as well as a national problem.
“Access to psychiatric services at Nebraska Medicine has been limited, with long wait times for new patients,” Dr. Cates said. “We have 12 FTE’s of psychiatrist and psychiatric APP allocated to our outpatient child, adult, and geriatric clinics. Our providers generally follow their patients indefinitely, causing limited slots for new patient evaluations. In fact, in the first quarter of fiscal year 2019, 92 percent of all outpatient psychiatry encounters at Nebraska Medicine were return visits.”
Recommendations to solve this issue include a proposal to have all new patients referred by their primary care provider (PCP), with a few exceptions, including Nebraska Medicine Emergency Department visits, self-referred addictions patients, and services with embedded psychiatric providers, such as oncology and transplant.
Under the new system, after a psychiatric evaluation, patients will be assigned to one of two tracks.
Within the consultation track, psychiatric providers will schedule one to three additional appointments for treatment optimization or refer the patient to a psychiatry subspecialty clinic for brief or intermediate-term care. After treatment optimization, psychiatric providers refer the patient back to the patient’s PCP for ongoing care, with detailed step-wise recommendations.
On the continuity track, psychiatrists or psychiatric APPs provide ongoing management within the Psychiatry Clinic and/or refer the patient to other community psychiatric resources. Patients suitable for continuity track may include those with psychotic disorders, severe conditions, eating disorders, psychiatric medications requiring lab monitoring, recent psychiatric hospitalization, or recent electroconvulsive therapy (ECT).
“After evaluating and stabilizing patients with psychiatric diagnoses, we’re hoping to support our primary care colleagues in following these patients, and to have an ongoing dialogue to refine the process,” Dr. Cates said.
Even with the new system, psychiatry staff will continue to support PCPs in managing patients who are referred back. Anticipatory guidance for PCPs will be included in a standardized note template and viewable in the overview section of the Problem List for easy retrieval from either chart review or within an encounter.
Additionally, the psychiatry department has established a pager, which PCPs can use Monday through Friday from 8 a.m. to 5 p.m. The pager will be available to PCPs who have concerns requiring urgent attention. Furthermore, One Chart messaging can be used for routine follow-up questions, and PCPs may refer back to psychiatry for re-consultation at any time. To help with any concerns, psychiatry providers are happy to present at staff meetings, brown bags, etc., to educate PCPs on particular diagnoses, medications and/or treatment approaches. Finally, with the new system, patients referred by PCPs will no longer have to call the clinic directly.
“Our team has been working hard to balance access for new patients with ongoing care for individuals who have complex psychiatric needs,” said Howard Liu, M.D., chair, UNMC Department of Psychiatry. “We believe this new consultation model will provide expedited evaluations for patients with an established primary care provider. Most of these patients will then return to their PCP with a treatment plan, and our department will be happy to see them in the future for consults as needed.”
Dr. Cates says a large multidisciplinary group met regularly and consulted with primary care leaders to generate solutions to the access problem.
“We conducted an internal review, performed a literature search, and consulted with experts in the field. After this process, we determined that a consultation-based clinic model is the best solution to meet the community’s needs,” Dr. Cates says. “We recognize this is a big change and that we may need to make adjustments as time goes on.”
I would love to see our University/hospital start taking care of inpatient adolescent psychiatry patients. There is a HUGE need in our area.
When diagnosed with Trigeminal Neuralgia a rare incredible painful disease. I felt lost and isolated and depressed. There was little information on this disease and on what my future held for me and my family. The knowledge of a rare disease especially when I live in a rural town and it's treatment options were far and few between. The doctor just gave me the diagnosis and med and sent me on my way. The neurologist s should refer patients to join an online support group to not feel as isolated and to a professional therapist, as well as joining a chronic pain management and a program to deal with chronic pain would be great protocal besides suggesting an informative book all about meds and treatment options called "Striking Back" would be extremely helpful after this diagnose.
Given no direction I managed but the aspect of a extremely pained life with a chronic disease with no cure or how to manage the lack of knowledge of it being rare is difficult and isolating to deal. The doctors shouldn't assume that all their patients have access to your hospital.
People come to it from rural communities but what happens when they leave that office . At least tell them how to access the services they will need on the future. Isn't that how they help people with cancer.
People with rare diseases need an action plan too, even the ones who travel. They will keep coming backto your hospital to maintain the disease rather than fall into a hole of depression or worse, if they know it can managed.
I personally am now in a place of advocating for myself and others on this disease. Please educate your doctors and nurses so that a rare zebra doesn't stand alone
in the pack of horses. They need their own pack to run with or they won't survive.
National Organization for Rare Disorders is a great start for all the zebras out there.
Facial Pain Association is a great support as well.
Thank You
Heidi Therrien
2217 17th Street
Columbus NE 68601
I am afraid forcing patients to go back to their pcp is going to cause people to fall through the cracks and not receive the care they need. I would feel like my issues weren’t being taken seriously and as a long time psychiatric patient, when a professional doesn’t take you seriously, you walk away from the care you need. Also while many pcp’s are great doctors, some aren’t and most have Very limited knowledge of the psychiatric field. I understand the wait times are long. Maybe putting some more emphasis on encouraging more medical students to enter psychiatry and keeping them in Omaha would also be a good idea too.
This is an exciting program, well thought out. Many psychiatry clinics have horrific NO SHOWS for initial visits, follow up visits, etc. Henry Ford Hospital many years ago dealt with this by overbooking (5 slots for 7 patients, lots of apologies if 7/7 showed up). Good luck.
Fred Guggenheim, M.D. Adjunct Professor, UNMC