So thanks for coming. So before I start, I just want to give an overview of why we wanted to do this project and what is the reason why we started up with this whole workshop. So we genuinely think that in general there is a training gap which exists for PCPs, primary care physicians from other specialties. So our thought process when we were starting to put this together for the last three or four years back, our thought process is like we have, when somebody has diabetes or hypertension, not everybody is referred to an endocrinologist. So most of the times the PCPs are comfortable starting them on metformin or they're comfortable starting them on insulin. So if anxiety or depression is also considered as a chronic illness, so why don't they follow the same methodology? That is the question which we had before starting this. So then we realized, and also I have the benefit of my wife being a PCP, so it's easy to kind of ask her a lot more questions, not that she likes it. But when I was asking her, what she explained to me is they don't get enough training in psychiatry as an internal medicine resident. Can anybody here take a guess of how many weeks or months of psychiatry is a part of their core rotations, either in internal medicine or family medicine? Zero. So it's not an ACGME requirement. So whatever they do, they actually come in as an elective. It's not a core rotation. So that was the whole process. Then we were like, okay, there is a training gap. So clearly because of this training gap, folks are not comfortable, like my internal medicine or family medicine colleagues are not comfortable prescribing antidepressants. They're okay with prescribing a lot of gabapentins and every other neurological medications, ficompas and everything else. But when they have to prescribe 25 milligrams of Zoloft, I actually see a deer in front of a headlight expression with all of them. So I work predominantly in the outpatient primary care clinic. So then I was like, okay. Then I was talking with my public psychiatry fellow. I was discussing with them and I was like, is there any way we can bridge this training gap? So that was the conversation. Then we thought we have to set up something called PCP coachings, but the coaching should not be an autocratic model where we actually pick up topics and teach them, but instead we wanted to get information from them of what they wanted to learn depending upon the patient population they're treating with. So we'll go a little bit more in detail as we get into the conversation, but that is what the PCP coaching training entitles. So that's going to be the crux of the presentation today. So PCP coaching, an underutilized but very effective method to increase mental health care availability in the community. So the presenter for today is Dr. Duta Shalini. So she's a PGY-3 resident who is a part of our program and also an incoming public psychiatry fellow at Columbia. So Dr. Mitra Sukparno, so he's the chief resident in training program at our Bronx Care Health System and a public psychiatry fellow at Columbia University. I'm Dr. Gunturu Sashi is my first name. I'm the associate vice chair for education. I'm also the residency training director at Bronx Care Health System, have the wonderful privilege of working with both of them as my residents. One of them is a third year and one of them is a public psych and a fourth year chief resident. I'm the director of psychiatric integrated services, so I oversee behavioral health integration into most of our primary care clinics. I did a public psych and a CL fellowship in the background. So CL fellowship actually helped me to kind of think about integrated services in this particular hospital system. So we don't have any disclosures to report and I'll pass on to Dr. Duta. Thanks. Good afternoon, everyone. I'm Shalini Dutta and first we'll talk about some learning objectives to understand the mental health deficits in the United States, to identify the PCP coaching model and how it works in primary care, to prepare an efficacy assessment tool for the PCP coaching model. This is our agenda that we're going to try very hard to keep to and this is some polling questions that we have. So if everybody can start using their cell phones, we're going to start. It's going to be an interactive session. So we're going to be using Poll Everywhere. So whenever there's a Poll Everywhere software, Dr. Mitra, our in-house technical expert is going to be helping us with that. »» So you can either go to PollEV.com slash S Mitra 116 on your browser, or you can just text S Mitra 116 to 22333 and just answer A or B based off of your experience. »» If anyone has any technical difficulties, you can let me know and I can come and help you. Are we waiting on any more responses? All right, so clearly two-thirds of us in this room think we don't have enough psychiatrists in our programs and one-third think that we, oh, it shifted more. So 71% don't think that we have enough psychiatrists and 29% do think that we do. And Dr. Dutta will kind of give us a little bit of a rundown of the figures as different agencies have shown us. Okay, so we're gonna talk about mental health deficits in the US and I thought it would be good to start out with a quote from APA's very own Dr. Saul Levin. So he said, we have a chronic shortage of psychiatrists and it's going to keep growing. People can't get care. It affects their lives, their ability to work, to socialize, or even to get out of bed. So this is NIMH data from 2019. The number of patients with a mental health diagnosis is 51.5 million and the percentage receiving treatment is 41%. Among adults age 18 or older, the percentage who received any mental health services within the past year increased from 13% or 27.2 million in 2002 to 16.1% or 40.2 million people in 2019. Over that same period, the percentage who received prescription medication for a mental health issue increased from 10.5% or 22 million people to 13.1% or 32.6 million people. The percentage who received outpatient mental health services in the past year increased from 7.4% or 15.5 million people to 8.3% or 20.6 million people and the percentage who received inpatient mental health services in the past year increased from 0.7% or 1.5 million people to 1% or 2.5 million people. So this is data according to the AMA master file and they found that 41,133 psychiatrists were actively practicing across the United States. This is data from around 2018, 2019. As can be expected, the state with the highest number of psychiatrists were states like California, New York, Texas, Massachusetts, states with the lowest amount of psychiatrists were states like Wyoming, Montana, Alaska, Idaho. The national average was 806.5 psychiatrists per state and the county with the most psychiatrists was New York, New York. Of 3,135 total counties in the United States, 1,446 had at least one psychiatrist, 46.1%. The majority of counties had no psychiatrists. So this slide is looking at the number of psychiatrists per 100,000 population and it was found that the District of Columbia had the highest ratio and Idaho had the lowest ratio. The national average was 12.9 psychiatrists per 100,000 state population and the county with the highest ratio of psychiatrists per 100,000 was Charlottesville City, Virginia. So all this data was from 2018, 2019 and I don't have to remind you what happened in 2020, COVID-19 hit and a number of things changed. There was an increased demand for mental health services. The pandemic led to a surge in mental health needs as individuals experienced heightened stress, anxiety, depression and other mental health conditions due to factors such as isolation, loss of loved ones, financial difficulties and uncertainty about the future. There was limited access to in-person care, lockdown, social distancing measures and overwhelmed healthcare systems and limited access to in-person mental health care. Many mental health clinics and practices had to reduce or suspend in-person visits resulting in postponed or disrupted treatments for individuals in need. There were strains on mental health providers. We faced various challenges during the pandemic including increased workloads, burnout and stress due to surge in demand for services. The pandemic led to disruptions in ongoing mental health treatment for many individuals. Some faced difficulties accessing medication management, therapy or support groups which could negatively impact their mental health and stability. There was increased mental health disparities. The pandemic exacerbating existing health disparities. Certain populations such as low income individuals, racial and ethnic minorities and frontline healthcare workers experienced disproportionate mental health impacts. And there was emotional toll on healthcare workers. All of us in healthcare faced immense psychological stress during the pandemic. We witnessed the direct impacts of the virus, experienced personal risk and dealt with intense workloads. So this was a research article that was published in Psychiatric Services. It's called Projected Workforce of Psychiatrists in the United States of Population Analysis. This is again from 2018. So the researchers of the study looked at different data sets from the Association of American Medical Colleges, the American Board of Psychiatry and Neurology and the US Census Bureau. And they used data modeling to try and figure out what the projected workforce would be. The results were that the psychiatrist workforce would contract through 2024 due to a projected low of 38,821 which would have been equal to a shortage of between 14,280 and 31,091 psychiatrists. And they also expected that there would be a very slow expansion starting in 2025. And they forecast it till 2050 with a range of there being a shortage of 17,705 psychiatrists to a possible surplus of 3,428 psychiatrists. So these are two tables that are taken from that research paper. And it's interesting to note that in 2024, they expected that there would be quite a number of psychiatrists retiring from the workforce, 2,648. And then this table below used two different data sets to look at psychiatrists needed in the psychiatrist shortage. Those data sets came from the Department of Health and Human Services and the National Comorbidity Survey Replication. And the difference in the numbers was due to how many psychiatrists needed for every 100,000 population. So the conclusions of this study was that because of a steady population growth and the retirement of more than half the current workforce, by the time of 2024, there's expected to be a contraction of the workforce with a slow expansion. And as with all research studies, there was a call in need for more data. So there's been a number of measures that have been taken to tackle the shortage of psychiatrists. For instance, increasing the number of residency slots. Efforts are being made to expand the number of available psychiatry residency positions. This allows for the training of more psychiatrists and helps to meet the growing demand for mental health services. Also loan forgiveness programs and incentives. Various federal and state programs offer loan forgiveness or financial incentives to medical students and psychiatrists who commit to practicing in underserved areas or pursuing careers in psychiatry. Telepsychiatry and telemedicine has obviously become a new field. The use of technology is being increased to improve access to mental health services. Psychiatrists are working in collaboration with other mental health professionals, such as psychologists, social workers, and counselors. This team-based approach helps to maximize the efficiency of mental health services and ensures that patients receive appropriate care from the most suitable provider. Increasing the use of advanced practice psychiatric nurses and physician assistants. So in some areas, these other providers can help to bridge the gap in psychiatric care. There have been recruitment efforts and educational campaigns. Various organizations and institutions are actively engaged in recruitment efforts and educational campaigns to promote psychiatry as a career choice. And integrating mental health into primary care. Efforts are being made to integrate mental health into primary care settings. This approach aims to identify and address mental health issues earlier and more effectively, reducing the need for specialized psychiatric care and potentially alleviating the demand on psychiatrists. Okay, I'm going to turn it over to Dr. Kintiru who's gonna speak about integrated care services. I think it'd be good. There's a question. Okay. So, for a second poll everywhere. And just thinking of yours, the program, or the hospital you're working in, does your program have integrated care services? So I'm going to just activate that poll if you give me one second. How many of you are actually aware of integrated services, integrated care services? Okay, fantastic. So, yeah. So for those who just came in, you can either text your response to 2233 by first typing S Mitra 116 and then your response, or you can go to the Poll Everywhere website to respond. I mean, is the statistics surprising, or am I being surprised? I don't know. Okay. Okay, so as Dr. Dutta was mentioning about, as Dr. Dutta was mentioning about integrated care services, or the shortage of a few years back, like three or four years back, probably around 2019, we were kind of seeing these trends, because a lot of our antidepressants and some mood stabilizers were being prescribed in the primary care clinics, a big chunk of them, actually. To be honest, it was mostly Seroquel for sleep, but again, that was the bigger culprit, but overall there was a lot of things that we were seeing in 2019. So we decided, like, we wanted to kind of see our own compliance rates. When we refer somebody to our psych clinic, how many of them actually make it to the appointment? So anybody wants to take a guess? What was our percentage? Twelve. Twelve percent? So 1.2 out of 10 patients, yeah, I'm a little optimistic than that. But actually you're close, but the national average is four out of 10 patients make it to the clinic. Our hospital is in the South Bronx, it's an inner city community hospital, so we were around, like, three out of 10. So out of every 10 referrals which were made to the psychiatric clinic, only three were going to the psychiatric clinic. And out of these three who were going to the psychiatric clinic also, 50% of them stopped going to the clinic after the second appointment. So it was clear to us where the national trend and where the puck is moving, so we understood that we have to create an integrated healthcare system. Working in the silos is not going to work. I'm thinking from the patient point of view, and if it's any of my family member also, I would like to have a one-stop shop. I want to go to one clinic, and I want to get everything at the same place. So then I started to look into, like, what can we do for Bronx-Lebanon or Bronx Care Health Systems, ambulatory clinics. So that was the whole thought process behind having set up this integrated services within the healthcare system. So what we could see is clearly, like, this, the way you want to integrate is you need to screen, if you can, to catch a set of population. Once you screen them, then you treat them, and then you have to measure how things are working and who has to be referred, who has not to be referred. So that is the basic crux of starting this integrated services. So this is something which we created where we have this levels of care, we have this different levels of care system. If you see this, this is called a stepped-up care model. This is not my own invention actually, but when you see this, it happens very commonly in hypertension or diabetes. These are called chronic case management models. So anything which is considered as a chronic illness tends to have this stepped-up care model which they do. From this we kind of made it something, we made something of a similar model which fits our own healthcare system. So if you look at it, so the way it is managed is the least level of severity. For example, somebody needs 20, they're stable on 50 milligrams of Zoloft. Do you think they need to come every month to see a psychiatrist and to see a clinical social workers because now they are referred to an Article 31 or in New York, these are like psych clinics are called Article 31 clinics? Clearly not. So we wanted to, that is the level of care which can be managed by a PCP. That is our thought process. The second one is the collaborative care model. I'm going to talk a little bit about this particular model in a couple of minutes. Then the third thing is called co-located model where I'm also going to talk about this. This is a little higher level of severity. Patients who we are indecisive which level of care they can belong to or these are something, who needs three milligrams of Respiradol BID and they're stable on this particular dose for almost five years. But the PCPs would not be comfortable prescribing antipsychotics, right? But at the same time, they don't need to go to an Article 31 clinic or a psych clinic. These can be managed within these co-located services. So that is what is co-located services. And the last one is the mental health or AOPD. These are like speciality clinics where somebody needs to be on a long-acting injectable or somebody needs to be on clozapine, somebody needs a higher level of care. So that is as you go from left to right on the screen. So the level of severity of these patients vary. So this is in general the model which we have set up in the Integrated Care Model. Everybody who comes in gets a depression or an anxiety screener by the PAs or usually one of the folks in the front desk give them a bunch of questionnaires. Along with this bunch of questionnaires, they are screened for this. If somebody screens positive, the next point of contact is the behavioral health case manager or a clinical social worker who is the person who does the level of care determination. This is a graph which I showed you before. So they assess the patient and they decide which bucket the particular patient belongs to. It's essentially like a triage system so that it helps with the flow of referrals and it helps with the flow of the clinics. So that is where the clinical social workers, those are the people who are going to set up which patient belongs to which particular level of care. So this is our overall integrated care system, integrated services. We think of it as five different faucets. One is the co-located care, which I'm going to talk a little bit more, then the PCP coaching which Dr. Mitra is going to, this is the big crux of today's presentation, how we do PCP coaching. I'm going to talk very briefly about collaborative care. Most of you already know about collaborative care. And the fourth one is ambulatory ICU, which we'll not be going into details in this particular presentation. And then we have set up an integrated care psychiatry rotation just for family medicine and internal medicine residents. And we're going to do a presentation on this on Monday, right? So specifically about integrated care rotation where we created this particular rotation for family medicine and internal medicine. And we have more than 80 people or 60 people who rotated with us so far coming from other departments. Everybody gave us some survey data and all of them think it's a very important rotation. We're actually going to present those findings and how we actually set it up in our healthcare system on Monday. So coming to the co-located care, as I said, co-located by definition means the psychiatrist is located in the same clinic as the PCP is. So that's why it's called co-located care. So the thing of creating this one-stop-shop model, and the same co-located care workflow is the patient, PCP sees the patient and the PCP, if there is some kind of a behavioral health condition that they can think of, then they refer the patient to a clinical social worker who does the initial assessment and the triaging, and they are the ones who refer them to a psychiatrist if needed. I'll give you a quick example. For example, somebody with bipolar type 2, they're pretty stable, they're working, but they're bipolar type 2 and they don't want to go to an outpatient psychiatric clinic because it's very, very farther away, or maybe it's the next available appointment is in eight weeks. So these kinds of patients, if they need 100 mg of Lamictal, I can treat them in a PCP clinic. I may not be comfortable, but I can be located in the same clinic and treat the patient. So that is the co-located clinic. And also think of this as more of a dynamic process, it's not a static process. If somebody belongs to one level of care, it doesn't mean they're going to be in that level of care for their whole life. There are times when we downgrade them, there are times when we upgrade them, depending upon their own clinical situation and what they're going through in their life. So the collaborative care model, we all are aware of this. So this is the new, I would not call it like a new trend, but I think it's been there since 1978. But the whole idea of this collaborative care model is it's going to help with closing a lot of bottlenecks in the healthcare systems. So many of them, this is based upon a lot of randomized control studies. Actually the collaborative care model has more than 2,000 RCTs which have shown them to be effective. So it is a team-driven method. It's a population-focused method and it's measurement-based and evidence-based. I'm going to show you a slide of how it works. How many of you are aware of collaborative care here? I would say like 50-50. So if you look at this particular slide, there are dotted lines. Dotted lines actually show that there is no direct contact between those two people, or those two persons. So whereas the solid lines and the bidirectional solid lines, that is actually there is a face-to-face contact between these individuals. So that is what collaborative care slides, this particular workflow shows. So the patient comes in. They get a screening and the screening is positive for PHQ-9 or probably for GAD. And then the PCP sees the patient and the PCP thinks that this patient needs additional behavioral health workup or they need additional behavioral health support. So then they refer the patient to a behavioral healthcare manager through a process called warm handoff. So they do a warm handoff and they send the patient to the behavioral healthcare manager. So the behavioral healthcare manager sees this patient and they'll be like, yes, this is probably mild to moderate clinical depression. Maybe we can start them on an antidepressant. And then the behavioral health case manager, if they are sure, they would directly talk with the PCP and tell them, yeah, you can start and I'll talk with the psychiatrist to see if they have any additional recommendations. So then I meet with the behavioral healthcare manager usually once every week, meaning a psychiatric consultant in this clinic meets with the behavioral health case manager once every week. And we discuss the cases which are not improving. Because most of our neurons probably have to be spent on places where they need more help. So if a patient is on 50 or 100 mg of Zoloft and they're not improving after six weeks, there is something we are going to be wrong. So those are the kinds of cases usually the behavioral health case manager discusses with them. So we identify cases on their caseload. We don't go through every case. We actually go through only the particular cases which are not improving. And the second kinds of cases which we go through is if they are not sure for a diagnostic clarification. They'll be like, Dr. G, I think you need to see this patient. We are not sure if it's depression or a bipolar type 2. Can you actually come and see, can you evaluate this patient? So then I put them in my co-located slots and I evaluate the patient and I can send them back again. So that is how the collaborative care model works. So in this particular model when I make recommendations, or if I'm making any pharmacological recommendations, the person who prescribes is the PCP here. It's not the psychiatrist. So I send a secure health message and I CC both the behavioral health case manager and the PCP. And usually the PCP ends up prescribing the medications for this particular patient, unless they end up coming back to me in co-located services. Any questions? I know this is a heavy slide. So the collaborative care model, as I said, it's based upon, it's a team-based model. I went through this workflow in the last slide. So the idea is the patient is coding positive on a PHQ or a GAD and they're eligible for collaborative care. Then the PCP evaluates the patient and they refer to the case manager. And then the clinicians, all of them are located in the same clinic. So it improves a lot of engagement. There are so many times by the water cooler or in the hallway the PCP sees me and I want to talk to you about a patient. Can we talk or can we discuss this? Then we usually end up talking with each other afterwards. So the outcomes, I think by far out of any of these projects that I'm involved in, we have seen the best outcomes in this particular project because there is an improved adherence because these patients are not being thrown around different kinds of clinics. And then it's much more cost effective because we are not actually, if you look at this, there are 75 patients on an Excel sheet that we discuss about every week. So it's super cost effective of hiring. And there's also improved patient satisfaction because the patient just goes to the PCP now and gets all the prescriptions. They don't need to see seven different people or five different people whenever. Something can be managed, so why not? So most of our outcomes in all these six facets have actually showed a lot of improvement in so many different ways. So the roles of the team members, as I was telling, the primary care physician is the one who prescribes, who's still the captain of the ship, and they're the ones who are actually prescribing medications, and they're the ones who do the warm handoff, and they're the ones who collaborate and collaborate with both the behavioral health case manager and the psychiatrist whenever it's needed. I think the cog of this whole model is the behavioral health care manager because they are the most instrumental in this whole piece because they're the ones who are the movers and shakers who are talking to the psychiatrist, who are talking to the PCPs, who are talking to the patients. Sometimes we had cases where we did a quick blast of CBT-I on a patient when it's needed, like six sessions or seven sessions. So they actually can do measurement-based therapy as well. So that's the behavioral health case manager's role. So they facilitate referrals. Whenever they need something they reach out to the psychiatrist or the PCP. So the psychiatric consultant, the major role is we do a weekly consultation with these clinics and we review the cases along with the behavioral health case managers. We provide diagnostic clarification whenever there is a need. And also when a patient needs a higher level of care, I'm the one who facilitates, or usually Dr. Mitra who works with me in these clinics, we are the ones who actually end up referring a patient to a speciality clinic. So with this I'm going to move in towards PCP coaching. So as I said, if you're asking the primary care doctors to prescribe medications which they were not trained in, then I think it's, I personally feel like it's my job out of the psychiatrist's role to also educate them. So that is why we started this PCP coaching. »» All right. So Dr. Gunturu gave everyone kind of like the overview of the integrated care system. And for me personally, as a resident going through my years of training, I had no idea what integrated care was. I'd seen Dr. Gunturu's email signature saying Director of Integrated Care Services, and I didn't understand what it was till I think my PGY3 year, when he came and presented about what he's actually doing to us. And for someone who was in outpatient psychiatry clinic, you know, doing med refills, and wondering why am I seeing a patient who is doing absolutely fine while there are patients waiting for eight weeks for appointments. And when he spoke to us about this stepped up level of care and collaborative and co-located care, that was my aha moment. And I kind of spoke to him and asked him, you know, where can I learn more about this? What can I do that I get more confident about this? And he told me about the Public Psychiatry Fellowship and our collaboration with the Columbia program that I signed on for the fellowship. So I've worked in this model of integrated care services since July last year as part of my fellowship. And it has been an amazing experience, very different from the run of the mill psychiatry clinic. I'm providing co-located and collaborative care services to the population in primary care clinics. And my perspective of working with primary care physicians has changed, and I'm guessing it's the same the other way around as well. My prior exposure to primary care or internal medicine, family medicine was on the CL service where I would get consults for a patient has a history of depression, 10 years ago, please come evaluate. Or we just announced terminal cancer to the patient and she seems sad, please evaluate. So obviously I didn't have the best impression of the people who were consulting us. But as we started on this model and we went through the components of the rotation and the things that we had to do, things changed. And the channel of communication kind of opened up. And one of the important parts of that was the PCP coaching that I will briefly describe of how we are doing it at BronxCare. So what is PCP coaching? A PCP coaching is essentially a series of didactic lectures which are held for all the primary care physicians in a particular clinic every month, once a month. And these topics are based on the most common presentations that people see at their primary care clinic. These are the things that they are probably treating patients for. These are the things that they are probably not comfortable treating patients for. These are the things that they want to refer to psychiatry for. But probably if they had someone to tell them what to do or to provide some guidance or learning, they would get more comfortable doing it themselves. Who chooses these topics? Not me, not Dr. Gunturu, not the behavioral healthcare manager. We had actually, when we started this up, we had sent out a survey to the PCPs and they themselves listed out the 10 most common topics that they encounter and that they face and that they have confusion about. And also they listed out what are the specific parts of those topics that they struggle with, whether it be cross-titering antidepressant, called cross-titrating antidepressants, or managing substance use, or managing anxiety. They listed out their topics and asked us what they would like to learn and that's how we came about preparing our presentations. So what do we generally review with them? We review with them evidence-based guidelines based off of literature and we actually show them the articles based off of what we are recommending or guiding our presentations. And essentially it's meant to support their role in prescribing psychiatric medications to collaborative care patients. And the goal essentially is to meet that gap. We all have probably seen clinic systems or psychiatry clinics where there is a long waiting list or you're waiting to refer a patient to outpatient care and there are no available clinic appointments. And being on the other side in the psychiatry clinic, we on our panel have a list of patients who probably could be downgraded to this level of care where the PCP continues to refill their medications. So that was basically the goal of this. So as of now, this year, these were the topics that the PCPs have chosen for us to present and every month, I carry out one lecture for these presentations. So these included depressive disorders. Obviously, as Dr. Gunturu was mentioning, one of the NEJM articles actually quoted the one that tells about treating depression that 80% of antidepressants, SSRIs, are being prescribed by providers who are not psychiatrists. Psychiatrists are only prescribing 20% of it. So it's especially important for them to be aware of this. Anxiety disorders, PTSD and trauma-related disorders, substance use, management of insomnia, which is a big one. We had a lot of PCPs who were commonly prescribing say, Klonopin for sleep or Seroquel for sleep or Ambien. Benzodiazepine use, misuse, best practices of when to use and when not to use. Bipolar disorder, how to rule it out, what are the differentials you should consider. And basic management and treatment. Personality disorders. We all know how borderline personality disorders so often gets confused for bipolar disorder. Antisocial personality, the predatory violence gets confused for psychotic behavior. And mental health disorders in pregnancy, which is a big thing that the PCPs were struggling with because they didn't know what medications to stop, what medications could they keep on. So weighing the risks versus benefits of treatment of these mental health disorders during pregnancy. So this is a sample coaching schedule. So this actually is a snapshot of this coaching schedule that I got at the beginning of the year to show me what lectures I have to do. So if you see, every month there is some topic. So I'm generally doing it for our Martin Luther King Franklin Clinic, which is a FQHC. And we conduct it in the afternoon with blocked off time for the PCPs. There are four PCPs in that clinic and they all join on for the meeting, for the class. And this happens once a month. And it's not in person as of now because of COVID. We use Microsoft Teams and we present on that. And these topics are covered every month. And now we are running it in essentially three different clinics at this time. So I'm going to go through the sample presentation just to give you all an idea of what it is we are talking about when we are presenting this to the PCPs. And then I'll also finally review a little bit of the feedback that we've gotten from them and how they feel about our presentations. So this presentation is essentially the one we presented on tobacco use cessation and what the primary care doctor can do about it. So what we covered in that was pharmacological agents, our prescription and over-the-counter medications, behavioral change interventions, and the combination, which as we know is most effective. We also discussed nicotine replacement, we discussed nicotine replacement therapy, which is obviously what PCPs go to, but probably they're not very confident on how much to dose and how frequently to dose. So we discussed the benefits of patch, was it short actings, when do you put on the patch, when do you have to take it off, you know, removing at night to prevent vivid dreams, what are the mechanisms of action, and also reviewed some literature which showed the efficacy of NRT and others that showed abstinence of greater than six months, which was double. And there's also like a lower risk of addictive liability and no withdrawal symptoms on discontinuation. We go into dosages, we describe how we should decide the dosages based on the packs per day, and how to supplement that with the PRN oral, either the gum or the lozenges or the sprays. And also how safe is it to combine any of these forms. So also like we reviewed literature as I was saying, there's a Cochrane review showing that the four milligram gum is more superior, significant benefit compared to the two milligram gum, but it also showed weak evidence of benefit from higher doses of the patch, and combining a nicotine patch with a rapid delivery form was more effective than a single type of NRT. And also how to educate the patient. You know, if you just give the patient 30 nicotine gums, they probably wouldn't notice any effect and start smoking again, but the fact that you have to chew it and then plant it in the gums is equally important, and not a lot of PCPs were aware of it. That was one of the most common questions that we kept getting in this lecture. How do you do it? How do they know when they have to chew it back again? Lozenges, so we went over like these particular points. These are actually like points that the PCPs have brought up that how do we tell the patient to use it? And in terms of dosing, two milligrams per cigarette is a good measure to calculate and what are the side effects to look out for? And then we reviewed bupropion. So bupropion and Chantix, the pharmacological treatment of nicotine use was something that the PCPs were very interested about learning, especially how to initiate Chantix. And we generally went over the dosing of bupropion, which conditions to really consider, the contraindications of eating disorders and seizures, and the efficacy in depression and those without, and the dosing that we should start with the SR-150BID, start once a day for three days and then go to BID dosing for 12 weeks. And then we should start at least one week before the projected quit date. So these little nuances were the things that they were not sure of and which I think the PCP coaching really helped them achieve. Chantix, again, they were very unsure about starting. Like, what do we need to monitor? How do we exactly start? So we really went through the mechanism of actions and how to start the medications. So starting with 0.5 milligrams once a day for three days, then moving on to 0.5 BID for four days, and then one milligram twice a day for the rest of the 11 weeks. And then, again, we need to start one week before the quit date. And we can keep continuing for 12 weeks. And a few PCPs actually started the medication and found some effective results for the patients. And we also discussed some behavioral interventions. Obviously, with the Q15 appointments, PCPs would not have the time to do behavioral interventions, but it's good to know about, at least the motivational interviewing parts of it. So behavioral interventions have shown higher quit rates compared to no counseling, higher quit rates than medication alone. And it's unclear if the differences of the differences between individual and group interventions. Some patients prefer groups, some patients prefer one-to-one. So this was a sample presentation. And in my discussions with the PCPs, I think the first two, three months when I did it for the clinics, PCPs, obviously, when you're talking to someone new, you have that thing that the psychiatrist is judging me. And I'm thinking, I am a fellow presenting to attendings. They probably are judging me and my knowledge. So there was a level of not discomfort exactly, but walking carefully so that no one's offending each other. But by the third lecture, I think we figured out that we are just working with each other to help each other out. So the PCPs were able to kind of explore what are the things that they really need to know. And I was able to explain to them that the goal essentially is not so that you're seeing all of our patients. The goal is so that we are providing the best possible care at the right level to all of our patients. And that really opened up channels of conversation. So now it's to the point where the PCPs call me or text me or send me secure health messages just for a curbside consult. Earlier, it used to be, they are not sure of what to do. Let's get the psychiatrist to see the patient in co-located care. That's not happening anymore. Because also like when they did place a patient on my schedule, the patient wouldn't show up. But now since we have that conversation, the PCP sees the patient and can actually start those interventions. So we've been doing this for, I would say, two to three years. And one of the things that we're trying to gather data on and see how we can measure this or quantify this is to see their prescribing practices. But that kind of gets complex and there's so many confounding factors to see if their prescribing practices are actually getting changing with our intervention. So I just wanted to spend the next 10 minutes having an open discussion. We presented a decent amount of data on mental health deficits, on the integrated care system, and on PCP coaching. And essentially I have, I'm asking for help. What do you think would be a good tool to kind of measure the efficacy of this intervention? Would it be a survey? Would it be a review of their prescribing practices? Would it be seeing the psychiatric referrals and what are they referring for? Or their screenings? Or anything else? So I wanted to open up the floor. Do any responses that you might have, any advice you all might have in terms of what we should do. Yeah. Yes. Go ahead. Sure. Yeah. Yeah. Hello. Thank you for your presentation. I think this is very interesting, and working in an integrated practice, I think it's valuable to try to disseminate that a little bit more. But thinking about actually measuring efficacy can be hard, so I appreciate that it's like the prescribing practices. Well, they might actually already be prescribing pretty, like, accurately or efficiently. So I think looking at self-efficacy is really important. Like, where is their confidence when they started? Where has it gone? But I'm biased. I've done mixed methods research, and I really love the qualitative piece of actually interviewing those providers. If you have someone or provider, fellow who would be interested, because those quotes can also be very valuable to bring back as you continue on cohorts to, like, demonstrate, like, those really poignant quotes that demonstrate where they felt they gained something from the experience. Yeah. Just an idea. I think that's a great point. I just recently got exposed to qualitative research, and just the idea of it sounds really phenomenal. Anyone else? Any ideas of what should we do? We haven't. I mean, that is our nearest, closest plan. We thought before this, three months before this, we were actually thinking to do surveys on the PCPs, pre- and post-lectures, but that's pretty much vanilla flavor. So we were trying to, that is what our thought process, but we also wanted to use this opportunity to pick up a few more brains. Yeah. Hi. Hi. I had a more general question, if that's okay to switch away from the efficacy tools. So I work in a collaborative care setting at UC San Francisco, and one of the, I really appreciated the modules that you had sort of shared with us in terms of your coaching sessions, and also some of the frequently requested topics that you're getting from the PCPs. Now, in your module that you demonstrated for us, it was, like, very focused around, you know, obviously for that particular one about, you know, nicotine replacement therapies and how to work with smoking cessation and all that. But stepping back, one of your slides had listed help with diagnostic sort of formulations related to depressive disorders, bipolar disorder, some of the mental health issues that PCPs often don't feel really comfortable in sort of coming up with a differential and then being able to say, hey, this is really bipolar, or you know what, this is actually more like OCD with some anxious features, not really GAD. Yeah. So I'm just curious, like, how in your coaching modules do you address, you know, the help around diagnostic formulations? And for example, do you incorporate any kind of observed interviewing with patients and give them, like, real-time feedback on, you know, their interviewing techniques or guidance on how you might redirect the questioning towards, you know, information that would be more helpful in formulating a diagnosis? So I think we actually, that's a part of our, we call it, I have given it a name of Collaborative Care Plus, where in family medicine, we have the PCPs and residents joining onto the behavioral health care manager calls and presenting cases for diagnostic clarification or medications. So essentially, a part of it is there, where a lot of times it's like, the patient is not following up. They refuse to come back. They're noncompliant. What do I do? And then we kind of go into, like, those motivational interviewing skills on how to approach the patient and kind of get them engaged in their own care, that part of it. And also, in terms of diagnostic clarification, there's a lot of times, this patient is bipolar or unmanaged. He's speaking fast all the time and is irritable. And then we actually break it down into what the DSM-5 says and also identifying those small little nuances that differentiate, say, bipolar from borderline disorder or bipolar 1 from bipolar 2. So that mostly happens in the collaborative care meetings. And also doing PCP coaching in the individual lectures, like the depressive, anxiety, bipolar, we actually go very much into detail about the diagnostic classification. And we start with the epidemiology. The NRT presentation is a little bit different, but the broad meant mood disorders and psychotic disorders, we actually start with the epidemiology, the DSM-5 criterion, and how to kind of differentiate it from common conditions that it might be mistaken with, and then go into the medications part of it. I mean, and that part is fabulous. I mean, everybody needs that sort of didactic formulation, but I'm just curious, do you ever introduce live patient interviewing or observing them to help in the boots on the ground kind of how this all translates? I can answer that. So we haven't been able to do that live presentations. It's a very good idea. Many times my experience has been with family medicine and internal medicine clinics, it becomes, they have sometimes even 10 minutes for an encounter. So they really don't, what I have observed is when we give these kinds of didactic presentations or any kind of grand rounds or anything, there are a bunch of, especially family medicine residents who reach out to us and ask if they can rotate with us and spend more time with us. So mostly what has happened is they ended up doing an elective four weeks with us. There are a couple of family medicine residents who wanted to go to a child clinic and they wanted to learn just about ADHD, and they came and worked with us for two more weeks. So people who are more targeted and they want to spend more time, most of the times they end up coming and spending extra time. That is the only way they've been spending. We haven't done a real interview or anything with them. It's a very good idea. Many times it's a buy-in from their side, and you are doing these kinds of projects, you have to keep all the stakeholders happy, and probably the hospital administration also happy because they're also always looking at the numbers. So that's how it has worked out so far. Yeah, and when the residents actually come for the electives, we always do the see one, do one, teach one model where they see me do it, then they do one themselves while I observe, and they teach it back to me in the next one. Love the work that you guys are doing. This is fantastic. I'm from New York, too, so nice seeing you out on the West Coast. As an aside, wondering if this came out of the DSRIP work that was happening in New York years back. Yeah. Some nods. Yeah. Yeah. Me too. You had a question earlier about something to measure, and I'm just sort of brainstorming here. One idea, it's sort of a proxy measure, I suppose, but to the extent that this is already sort of a mature process, I might think that it might streamline to an extent the number of patients that are being referred to your specialty clinic. And so I might look at whether or not you've noticed a shortening of the wait list at your Article 31, anticipating that that would go down if this was effective. And then secondarily, I might sort of imagine that this would be a bidirectional stepped care system. So not only are folks sort of escalating up the ladder as acuity increases, but also as patients get better, that they're able to kind of move back down. So you might look also at sort of the number of individual patients that are being seen in the Article 31 with the idea that you're able to see more of them because as they're stabilized, they're able to be passed back to the primary care who's able to take on management, especially because they are now trained. »» In that regards, the first one we did measure, the wait times for seeing an Article 31 psychiatrist has come down from six weeks to around three weeks, five days or something like that. But again, there was a beginner's luck in that. So in the beginning, we measured it like two years ago at the end of DSRIP, when the first DSRIP got ended. We didn't measure the other side. I think that's a very good idea. Many times we did, again, this might be anecdotal, but what I have observed is the clinical social workers and the Article 31 psychiatrists or the specialties care, they also like to hold the stable patients. They somehow don't want to discharge these people. »» Right. That is the element, the elephant in the room, right? We want to be in a position that we're saying, we as specialists are taking on the most difficult and challenging patients. But the reality is, that is exhausting. And most clinicians want the ability to hang on to some of those stable patients. And so figuring out a system to deal with that is important. And I guess the last thing that I would add, this is sort of piggybacking on the last point. I know that it is difficult for all of the reasons that you cited. I think it is gold if you are able to occasionally spend some time shadowing those PCPs. And whether that is the residents or the attendings or both, there is no substitute for that live, on the ground supervision and teaching. And so I hope you'll continue to look at that and see if there's a way that the institution would tolerate it. »» Thanks a lot. Thank you. »» Do you guys do case studies with them? »» You mean? »» Present together? »» Yeah, yeah. We do case studies. We do present together. Yeah. »» Thank you for your presentation. You know, going back to your question about that, one of the things you talked about, how you did actually survey with the PHQ-9 and sort of seeing over time whether that actually reduces, you know, for your population. And to the extent, I'm responsible for the rollout of collaborative care within a sort of national kidney care, near in-state, in-stage renal disease. And we obviously have the advantage of seeing the cost for our population because it is a capitated structure, our prospective payments. So to the extent you have that, I think it also gives you an idea of the effectiveness of your work, at least from a financial side. »» Thank you. »» Thank you. I think it's a terrific idea. We are actually just starting to get paid. We are actually, if I'm not wrong, we are the first or second organization in New York City or state to start getting paid for collaborative care models and collaborative care. We have around 900 patients enrolled right now. The problem is it's also a value-based payment method. It's not a fee-for-service kind of model. So obviously, so there are a little complexities which are involved when we are measuring because we just started to get paid. We are not even able to measure the cost effectiveness. The only way we were able to measure so far the cost effectiveness within our healthcare system is to see how many times they haven't, they have stopped going to the emergency room or inpatient setting. So that is the only thing which we are measuring at this point of time. »» That's consistent with our data. Just as an interesting bit, what we, and we've actually been working only in some of our markets for three or four months. But what we found is that even one touch from a social worker reduced some of those costs by a quarter. »» Yeah. Yeah. That's a very interesting point. Thank you. »» I was going to bring the cost kind of side up as well. So I don't know that my question is necessarily unique. But I'm a first year attending psychiatrist at an FQHC in Sacramento. And you know, coming in fresh out of residency with all these ideas for a clinic that has kind of been doing things a certain way for a while and not getting much support. So I guess, yeah, coming in with more of an economic kind of perspective seems to get a little bit more of a foothold. But it is hard to get reimbursed. Medi-Cal doesn't reimburse for e-consults, for example, for psychiatric e-consults, which is something I was trying to start. But it's encouraging to be here with you all and know that this is happening. And I'll keep trying with everyone else in the room. »» I think, thank you. Thank you. Just to make a couple of points on the FQHCs or Federally Qualified Health Centers. All the four clinics that Dr. Mitra, our fellow works, are FQHCs. So BronxCare, Bronx-Lebanon has a weird, I don't want to use the word weird, but it has a different system where it's a combination of FQHCs and also they have their own non-FQHC sites. So I think it helped us a bit because the finances can be financially engineered. That's what the word my CFO asked me to use, is financial engineering is like what they were doing, how to kind of make sure we take funds from one place and be able to substitute at the other place, how they can actually play it out. So I think that helped us, to be honest. But I think overall, even in FQHCs, they are figuring out a way for this value-based payment methodology because whether we like it or not, I think collaborative care is here to stay and it's going to be the future. And even a big push now, I don't know how many of you read the recent Biden plan, and that collaborative care is actually a big piece of the Mental Health Act. So it's going to stay here. So I think they're going to figure out a way. But people who are ahead of the curve will not need to reinvent the wheel at that time. For example, now, if they're ready to pay us, we have 900 patients ready to be submitted. So instead of then starting from the scratch. But that's how the FQHCs are going to play out. That's my assumption. Yeah, and I've been attending the assembly and the amount of conversation I've heard in the assembly about collaborative care is also like showing how important this is becoming. So I think it has big potential. Hello. I actually practice in Alabama in a rural area, and we have a family medicine residency that we work with. We're trying to start a psych residency program. But we were the first, I think, and only time that the APA came about eight, nine years ago to implement collaborative care in a primary care clinic. And we basically support the residency training of family physicians, and that's a major mission of ours because we're so rural and so under, like every county in Alabama is a mental health professional shortage area. So this is the strategy we have taken because there are very few psychiatrists where we live. So it's very important, and I'm glad to see that it's happening in the urban areas as well. Because it started out, you know, with Lori Rainey in rural underserved areas where there were no psychiatrists, okay? So I think this is great. What I would do in terms of measurement is look, because what we've seen is we get a huge number of referrals to our clinic for the kind of things you've discussed, to psychiatry, when the new interns come in and when they hire a whole bunch of new family medicine attendings, because they haven't gotten the education and the training. And then we have to go through this whole process again and explain why it's important that, you know, kind of how to kind of go through this whole new re-education process. And so what we saw was during COVID that these numbers went way up and we had to kind of pull back on some of the ways we were teaching residents. So just to give you some examples of the way we have integrated in with the family medicine didactics is we start from day one. When they're interns, we do quarterly reviews of interviews of patients. They record the interviews, they come to psychiatry, we get assigned, each of us gets assigned four or five family medicine residents we're mentoring for their whole three years of residency. And then we observe them as they interview patients, even though they're in the family medicine clinic, right? And we say, hey, this is how you talk to, you know, kind of even basic interviewing skills, right? We're not even talking about how to diagnose. So sort of just the patient interaction. And we do that in their intern year. And then from day one of their intern year, we're going to re-institute that this next coming year with a new group of residents, because during COVID, you know, whatever, we're hopefully moving out of that phase. Well, what we do is they present us a case and we have a psychologist and a psychiatrist and the family doc says, okay, these are cases that we want to talk about, okay? And we do a biopsychosocial formulation every week. The residents and family, these are family doctors, are learning how to think biopsychosocially integratively, okay? So we're trying to do it that way because you have to get them in their education because, you know, when they're already done with education, it's hard. It's too much for them to like process all of that because they're so busy seeing a gazillion patients a day, right? And then in their second year, they do a month with us in psych and in their third year, they present an R3, they take a case, and they meet with their mentor quarterly, and they have a difficult case or a topic or whatever, and they present an R3, which is their third year resident, sort of little mini grand rounds, and they do a biopsychosocial, they present the case, and then we all go do like a back and forth. So that's how we do it. I'm not saying that's how everybody has to do, but I thought I would present that, because this is being a rural area, because most of our physicians go back and work in rural underserved areas, because they are gonna be the primary one presenting. I also wanted to mention something. So you may want to measure at the beginning of residency and after to see if the numbers go down, because we notice by the middle of the year, the number of referrals from family medicine goes down. You know, so, but anyway, I just wanted to mention, because I'm a child psychiatrist, and there are very few of us where I live, like hardly any. I think we have as many child psychiatrists in Alabama as there are in the DC metro area, maybe. I mean, I'm just telling you, we're in the desert, okay? So we have to be very creative about how we provide our services. So this pediatrician who I work with, who's in our medical, we're in a regional campus, and he's a behavioral pediatric, well, he sees foster care kids, he does a lot of psych. We're like, well, these pediatricians keep talking, because I noticed you didn't mention pediatrics. You did internal medicine, and you did a family medicine. And the pediatricians call me every week. I got this kid with suicidality. I got this autistic kid that's aggressive. I mean, on and on and on. They don't know what to do. They get zero training in residency. So what we've decided to do, this is like our little plan. Maybe I'll present it at the APA next year, ACAP. We're going to do videos. We're going to do kind of like, the pediatrician and I are going to have conversations, and we're going to do, because we have the ability at the University of Alabama to be able to video, beautiful technology to videotape this, like little vignettes. And then for the rural docs, and also for the pediatricians in the community, let's talk about autism, if you got a kid who's aggressive. Kind of a conversation, as opposed to doing it super evidence-based, which people are going to start falling asleep after 10 minutes. I mean, I'm not trying to discredit. That's important to do. But like, these pediatricians in the community are like, I have this problem and I need this help, because I know you're busy and I can't send this kid to you. How do I help this kid? So that's how we're going to take that approach to take a very practical approach, do little video vignettes, and we're going to package them like whatever the new thing is now in video. I'm not really good with video technology and all that, but that's how we're going to do it. And hopefully we'll be able to send it out to the local pediatricians and people in the community, because that was our idea. So I just thought I'd throw that out. No, I think it's terrific. I think all your ideas, I mean, all the ideas you shared are fantastic. Just to comment on the pediatrics bit, we are actually doing, we just started with collaborative care and PCP coachings in the pediatric clinics, but we are presenting it at the ACAP. So that's why we didn't touch too much on that particular topic right now. We actually got a grant for doing it, which is called early development grant. So we actually got an early development grant for doing it. So we actually have a child psychiatrist who does collaborative care and also PCP coaching center over there. And I just want to say, I think that the best, because we are, you know, the thing is we should not be treating the walking well. I have very strong feelings about this, you know, and I know that it's hard to give up those easy patients, but we are specialists. Should not be seeing the easiest patients. We should be seeing the sickest patients. And I think, you know, this is a big problem because all these people now are depressed and we get this deluge of people that get referred to us. And we have to really think long and hard about who we see and our ethical responsibility as psychiatrists about population health, because I also work in the jail. And so my concern is with all these depressed people, what's happening to the seriously mentally ill? Are they getting stuff behind? Because they're the people we should be seeing. So I think, you know, we need to be very careful about that. Those are the people, you know, family medicine, internal medicine, Peds should be taking care of the lot. The people who are mild to moderate depression. You know, we need to be seeing the hardest patient. And it's hard, I'll tell you, I have patients in my clinic, they hold on for dear life. They do not want to be referred back to their primary care physician. It's really hard to change culture when it's already set up that way. But if you're starting a program, because we're trying to start a residency program, we are gonna start it out from the beginning. You do not see the site. You come to see us, we get you stable, you're out. You're back to your primary care doctor. I think you summarized our presentation. So I think, yeah, thanks a lot. Thank you. Yeah, I was just saying, like, what you're describing, the educational model, especially for trainees when they start out, that's, we've kind of incorporated that in us, which we are presenting in our second presentation. So, and the residents really, and we have data from that particular cohort at that particular intervention. And the residents have thoroughly enjoyed being part of these electives. And essentially, I think, Dr. Gunturu is now my kind of pet project to somehow project this on a national scale, that we get psychiatry as a core elective. Yeah, he's giving a screenshot of our next presentation, but, yeah, when probably doing on Monday, the whole goal of what we are trying to do is all the data which we have in this particular integrated care rotation, we are trying to present it to ACGME, along with the program directors from different programs, to kind of try to push and see, hopefully, is to push and try to see if we can make this as a core elective of psychiatry being a core for family medicine and internal medicine. Anybody who wants to partner, we are all, obviously, we are interested to partner with people. But also, this is what we're going to present on Monday. Do we have, how are we doing with time? We have a lot of time. Okay, so any other questions, anybody else? I know we asked our question, but if anybody else has any questions about integrated care or the PCP coachings, we'll probably take some more questions, yes, please. As far as PCP willingness to take patients back or take on prescribing of maybe non-SSRIs, stimulants, for example, I have been seeing some pushback from that, like, well, basically, an argument against my suggestions to implement something like this is like, oh, well, PCPs here aren't comfortable with stimulants, for example. And so, how do you kind of, I mean, I think that's what the PCP coaching is trying to address, right? But as far as more of the soft side of things, as far as political things within a clinic, personality, dynamics within a clinic, have you found strategies that kind of help through that when there is some more resistance to accepting patients back or accepting certain prescribing responsibilities, I guess? My experience, thanks for the question. I think it's very important that we, this is a very common thing which we encounter when we are in these clinics most of the time. So I think what we have seen in many of our family care clinics is, I think trust is a part which is the one which is lacking when we usually start in many of these clinics. Trust is what is lacking in many of them. So once the trust is built between both the parties, because we think they send us patients unnecessarily, they think we are trying to dump them back in the patient, back patients to them. So what I have seen is trust has been more vital. And once the trust is established, I think trust and progress are directly proportional. That is what I have seen. The first year has been the hardest year for me when we are establishing these kinds of things. But as it goes to second year, third year, once they get the sense that, okay, these people are not just trying to put work to us, but they're actually helping us. I think that particular cognitive behavioral therapy, which I do for all the PCPs, by the way. I'm kidding, but I think in general, what I've seen is that has been the most helpful. Once the trust is built between the PCPs, any time they can come to my office, I never, I don't start a conversation by telling negative words. So that strategy has helped. And some informal talks, sometimes some of them have questions about their own family members, and they have questions about other staff members. Not the chatting questions, but something psychiatry related. What I have seen is, and also sometimes their residents come and rotate with us. So I fill out evaluations for them. Then I talk to their program directors. So there is so many other things which take place outside the clinic, which helps to build a relationship. Now I call anybody, they call me at any point of time, and I send them an email, they respond right away. When they want something, they ask me right away. And I think the same thing with Supi also. I think that is what most of the times we have seen is that trust has been built in all the four clinics that he works or I work right now. In these four clinics, nobody thinks psychiatry is trying to dump a patient. Neither do I think that they're asking me unnecessarily. And nobody wakes up in the morning. What I've seen is that PCP does not wake up in the morning and think, oh, let's harass this psych consult people. That's not their attitude. So they really ask us because they don't know. It might be a trivial question, but they really don't know. Nobody wants to keep a consult or ask us unnecessarily. It's my baseline. And I also did a CL fellowship. That helps, because my CL director used to tell me, think that you're talking to a third class, somebody who's going to a third grade school. So always tell them the recommendations that way. Not because they're not smart or not, it's not to insult them by any means, but you have to tell them every recommendation has to be told to them in a certain way and also trying to educate. I think that has helped us to build a trust. It took us a year, to be honest. And culture is very difficult to change. But once it took us the second year, third year, and fourth year. Now it's fourth year or fifth year we're doing this in this clinic. Everybody knows what psychiatry does in the clinic. And whenever they want to send a referral, so they talk to me. Sometimes they even talk to me before sending a referral. It's very hard to have a PCP send me an email about all the history and everything to actually ask a question. I think with the controlled substances bit of it, what I have found useful to my experience is whenever there is such a referral for prescribing, I generally reach out to the PCP and speak to them about why do you think this person may need a controlled substance and kind of do my own evaluation. And I support them by sending the first few prescriptions if it is indicated. And then kind of we, while in the conversation, discuss that this patient is stable. All I'm doing is checking. I stop it. You also have access to the PMDP? Yeah, PDMP. And then there's nothing more that I am really doing. Let me open up a slot for another new patient that you might want me to see instead of having them wait for four weeks. And that kind of makes them comfortable. And also I think we have this thing called the six monthly or annual psych exam where these patients, just so that they get like a psych note recommending the medications for liability purposes, we see them every six months to one year and then put in our recommendations. So that kind of reduces the number of visits from six to one. And they feel comfortable prescribing as well. I think it's a very practical question that you asked. I mean, it's a very common problem that we actually have. Anytime you set up this thing in these clinics, that is what, I think what Supi was saying, I think that's a very good strategy. Also sometimes I don't reject any concept right away. I say, let me see them once and let's discuss after seeing them. In that way, they will understand that we're actually trying to help. We're not just trying to send you back a patient or anything. I think that strategy has helped. And the other thing I've seen also is you have to cater to your audience. When you're in family medicine clinics, their approach is a little biopsychosocial model when they're actually more willing to prescribe antipsychotics and even any other controlled substances like stimulants. Whereas I don't see that in internal medicine clinics. Because they would be okay with prescribing SSRIs, that's what I've seen. They would be okay with prescribing some mild doses of mood stabilizers. I have never seen them being very comfortable with antipsychotics. Or never seen them being very comfortable with, because I think their kind of training is very different from family medicine training, what kind of training they get. That's my anecdotal experience. Nothing against PCP, as internal medicine folks, but I think their way of approaching is a little different. You have a question? Anyone? You had a comment. I actually had a comment. What about patients? Sometimes patients would pick and choose, like, oh, I don't want to work again. I don't want to work with the primary care. How do you resolve that? That actually comes, I have had that situation a couple of times, and that actually works out as more armament in my favor. So then I tell the PCP, listen. I feel like they're preferring you as a pre-exercise doctor. Yeah, so sometimes the patient might prefer me but then how we present it is, listen. You're coming in for five appointments to see physiotherapy, endocrinology, this, that, everything else. You have been on the same doses of medication. You come and see me for 10 minutes. I ask you about your sleep and appetite and do your risk assessment and send your medications. Why not just see a PCP in one sitting and get the medications instead? And that generally kind of makes sense for most patients. And obviously we- What I was admitting to, I think it's important that you're open to communication. The two, I mean, something if I can add to what Sufi was telling me, is the way if I find somebody too addicted to me, I withdraw them. So the way I withdraw them is like, this is, by the way, it happens in our primary care team. They're so used to coming. Some of them come and show their new clothes. Some of them come. So they do it very often. It's the community. So that is how they feel. They feel a part of the whole system. They come, they say hi to the front desk people. They say hi to the security. So they miss it. So some of them, if you look at the psychodynamic perspective, some of them don't have families. I mean, this is South Bronx and one of the poorest neighborhoods in the country. So actually, essentially the front desk folks and all of us are their family. So I don't, I tell them openly what my plan is, but at the same time, I kind of, yeah, so to kind of create a level expectation. And also I slowly taper them, meaning how do I taper them? It's like from a monthly appointment, I move them to bi-monthly, sorry, once every two months and then to three months, six months. After a certain time, they'll set up a new support system. Once I feel like they're ready, that's when I kind of like slowly send them back to the PCP. So, but my strategy is always patient-centric. If a patient likes to come, they want to stick with their PCP or if they want to stick with me, either way, bidirectionally, I feel like I need to meet where the patient is at because that is when the compliance rates are much better. How do I figure how that's work is my job. So I figure out different ways of trying to use different, there is no evidence on how to taper a patient from my addiction, but this is all like the things which runs in my mind of how I kind of sign out or how I hand off. So these are all the things which we develop usually. I just wanted to make a comment. So we also are doing this local sort of teaching of primary care, family transition, and I think your model would be great. Have you thought of taking it to other labs? We haven't thought about it. I mean, there was a brief, I mean, for now, we have some thoughts of next year because I'm actually moving a little bit away from my clinical role. So we have different thoughts of kind of putting up all the PCP coachings from different clinics into one particular model, like having this hub-and-spoke situation. But once it's all technology, it can be done to anywhere else. It can be expanded to anywhere else. I think that's a great idea. Because WHO is also trying to promote this model of primary care. So I think your model would be very globally acceptable. Yeah, we've thought about it. We even thought about like recording our session and putting it online to be available for folks. It doesn't need to be synchronous. It can be asynchronous video, too. So we were thinking of asynchronously presenting, even for residents can go and look at it. So there are different things that we can really do. But once I go back to New York, life becomes very busy. Yeah. But then, yeah, we're like spreading the word would always be. Yeah, if there is. We're doing it in Pakistan. Yeah, if there is anything we can partner, if there is anything we can do, we'll be always open to, open for. Collaborating. Collaborating and about collaborative care. Yeah. Yes, so I know we are almost out of time and we have the self-assessment questions that are part of every, or so I've been told is part of every presentation. I might be wrong. So there are three questions that you may have seen on the abstracts for this presentation. So again, we are gonna just do poll everywhere for like three minutes on each of these. The first question is, who decides the curriculum of PCP coaching? And these are the options. Option A, psychiatrist. B, PCP. C, behavioral health care manager. D, clinic administrator. Or none of the above. That's option E. I didn't put the E. So if you can just respond to these questions for the self-assessment. And then we'll move to the next one. Do you need to activate the question? Oh yes, sorry. Good catch. There we go. How did the response disappear? But yeah, the overwhelming majority got it right. These lectures are decided by the PCPs. All right, so the next question that we have is, as per the NIMH data from 2019, the number of patients with mental health diagnosis and the percentage receiving treatment is option A, 45 million and 60%. Option B, 51.5 million and 35%. Option C, 51.5 million and 41%. And option D, 45 million and 35%. All right, yes. So 100% got it right. And the last question for the day, the key components of the Integrated Care Model are co-located care, collaborative care, PCP coaching, all of the above, none of the above. So this is about the Integrated Care Model as a whole. Yep. So again, overwhelming majority got it as all of the above. So co-located care, collaborative care, PCP coaching, ambulatory ICU and integrated care elective. These are the five main parts of our Integrated Care Model. So that concludes the self-assessments. Let me just make sure I'm not missing any slides. And that's it. Any last comments, questions? Okay, guys. Thank you.

primary care physicians

mental health management

training gap

psychiatry rotations

PCP coaching

integrated care systems

chronic disease management

collaborative care models

co-located care

psychiatric medications

resource utilization

mental health accessibility