Expanding Access to Psychiatric Care: Implementation of Psychiatric e-Consultation and Tele-consultation for Primary Care in a Safety-net Health System.

Technology can expand access to specialty health services for disadvantaged and underserved populations. A novel psychiatric consultation service involving both electronic consultations (e-consultations) and telephonic consultations (tele-consultations) was implemented by hospital-based staff and trainee psychiatrists in 12 primary care sites within a public safety-net health system. Utilization data were collected over a three-year period. A brief provider satisfaction survey was distributed to primary care providers. Over the three-year study period, 490 technology-enabled consultations were provided, of which three-fifths were e-consultations and two-fifths were tele-consultations. Most addressed medication questions (81%). Average time spent by the consulting psychiatrist was 30 minutes. Four-fifths (80%) of primary care providers reported being extremely or moderately satisfied with the service. The model represents multimodal support for primary care providers in providing community-level mental health care, including the provision of same-day consultation. This report demonstrates the feasibility of such a service in lowresource settings.

Primary Care Behavioral Health Integration for Anxiety Management in a Safety-Net Health Care System.

This report describes the implementation of a primary care behavioral health integration program for anxiety management at Cambridge Health Alliance (CHA), a safety-net health care system. Using a staged implementation process, CHA built upon existing capacities to create a comprehensive infrastructure for managing behavioral health conditions in primary care.

Uptake of depression treatment recommendations among Latino primary care patients.

BACKGROUND: Primary care providers (PCP) are the entry point for public sector depression treatment for many Latino patients. However, many Latino patients do not initiate their PCPs' recommended treatment, which likely contributes to ethnic disparities in depression treatment. This study examined factors related to Latino patients' uptake of their PCPs' recommendations for depression treatment. METHOD: Ninety Latino primary care patients who received a depression treatment recommendation from their PCP participated in a telephone interview. Patients rated their working alliance with their PCP and their PCP's cultural competence. They also reported their treatment preference, the type of recommendation, and their intended and actual uptake of the recommendation. Patients were contacted at two time points (Time 1: M = 14 days after PCP appointment; Time 2: M = 84 days after PCP appointment) to report their uptake status. RESULTS: At Time 1, 23% of patients had initiated uptake of the treatment recommendation, increasing to 53% at Time 2. Patients who received a medication recommendation were more likely to have followed though on the recommendation, compared with patients who received a psychotherapy recommendation. The working alliance was positively associated with intention to follow up on a treatment recommendation, and also mediated the relationship between cultural competence and intention of following up on the recommendation. CONCLUSION: PCP's treatment recommendation and the PCP-patient alliance play a role in Latino primary care patients intention to follow a treatment recommendation for depression. An improved understanding of this role could enhance efforts to improve depression treatment uptake.

Physician staffing for the practice of psychosomatic medicine in general hospitals: a pilot study.

BACKGROUND: The treatment of psychiatric illnesses, prevalent in the general hospital, requires broadly trained providers with expertise at the interface of psychiatry and medicine. Since each hospital operates under different economic constraints, it is difficult to establish an appropriate ratio of such providers to patients. OBJECTIVE: The authors sought to determine the current staffing patterns and ratios of Psychosomatic Medicine practitioners in general hospitals, to better align manpower with clinical service and educational requirements on consultation-liaison psychiatry services. METHOD: Program directors of seven academic Psychosomatic Medicine (PM) programs in the Northeast were surveyed to establish current staffing patterns and patient volumes. Survey data were reviewed and analyzed along with data from the literature and The Academy of Psychosomatic Medicine (APM) fellowship directory. RESULTS: Staffing patterns varied widely, both in terms of the number and disciplines of staff providing care for medical and surgical inpatients. The ratio of initial consultations performed per hospital bed varied from 1.6 to 4.6. CONCLUSION: Although staffing patterns vary, below a minimum staffing level, there is likely to be significant human and financial cost. Efficient sizing of a PM staff must be accomplished in the context of a given institution's patient population, the experience of providers, the presence/absence and needs of trainees, and the financial constraints of the department and institution. National survey data are needed to provide benchmarks for both academic and nonacademic PM services.

Patient follow-up in primary care after behavioral health screening in an urban public hospital system: a prospective, observational study of 2686 patients.

OBJECTIVE: Patients with psychiatric conditions are known to experience poor and often disparate health outcomes. To investigate one potential mechanism for this phenomenon, we examined whether patients who screen positive for psychiatric comorbidity are lost to follow-up from primary care at higher rates than screen-negative controls. METHOD: Patients in a public hospital system were followed prospectively for an 18-month period after an initial routine behavioral health screening in neighborhood health centers. Screening data were linked to electronic medical record visit data, and loss to follow-up was ascertained using Cox proportional hazards modeling. RESULTS: A public hospital health program screened 2686 patients from March 1998 to December 2000, and their visits were counted prospectively for 18 months. Nearly one third (N = 772, 29%) screened positive for a psychiatric condition. The screen-positive group had lower rates of censoring and a shorter time-to-event than the controls, indicating a higher continuing visit rate in primary care. This relationship persisted after adjustment for demographic variables, insurance type, substance abuse, and violence exposure. CONCLUSION: Patients who screen positive for psychiatric comorbidity are not lost to follow-up at higher rates than screen-negative controls. This finding suggests that disparate outcomes for mentally ill patients in a public hospital system may not be based on reduced access to or lack of contact with primary care providers. Further study of systems or provider-related factors is needed to ascertain the pathways toward poor health for this population.