Welcome, everybody. So today's topic that we're going to discuss is going to be on, I need a psychiatrist but can't find one, an introduction to an integrated care elective, which is to increase the access to care. So I'll just start off by giving a little overview of why we wanted to do it and how we wanted to do it, and then I'll pass it on to Dr. Dutta. So the presenters today, we have Dr. Shalini Dutta, who's a PGY-3 resident at our Bronx Care Program. She's also an incoming public psychiatry fellow at Columbia University. So Dr. Mitra Suparno is a chief resident at our training program at Bronx Care Health System, and also he's a public psychiatry fellow at Columbia University. I'm Dr. Gunturu Sashi is my first name. I'm the associate vice chair for education and residency training director at Bronx Care Health System. Molson assistant professor at Icahn School of Medicine of Mount Sinai, New York. So we don't have any disclosures to present. So the way we were thinking about this is when we were trying to set up an integrated care system or integrating behavioral health into primary care clinics in 2018 as a part of our district, when we were trying to do this, what we found out is the primary care physicians are very comfortable prescribing hard-hitting neurology drugs, endocrinology drugs. They were OK with prescribing pain medications. But for some reason, they were never comfortable prescribing 25 milligrams of Zoloft. So every time I had a conversation with them, they used to keep asking the same question, like, oh, how do we start it? So then I was discussing with Dr. Mitra Suparno, who was my fellow, who is my fellow still for one more month. So we were discussing at that time. And we found out that there is not enough training that medicine or family medicine residents get. So can anybody take a guess of what is the ACGME core requirement of psychiatry rotation in internal medicine or family medicine? In this country, I mean, in the US. Any guesses? One month. Zero. Yeah, it's an elective, but it's not a core requirement. So for example, in our hospital, the medicine people have to pick up as an elective. Even family medicine folks have to pick it as an elective. When I was talking to the residents, everybody wanted to do a rotation, but they did not have an opportunity, or it's not a part of a core requirement. So when we were discussing this, then when we thought about this, then we were like, OK, is it not like a little, if four out of 10 patients that they see in primary care clinics, this is the national average, by the way, have coexisting psychiatric or addiction problems. And in South Bronx, that's where our inner city community hospital is, is six out of 10. So six patients out of every 10 patients we see have some kind of a psychiatric problem. So if that is the case, don't we have to think, at least we need to spend less than 1% of our time in residency with psychiatry or any kind of a behavioral health training? So that is when we started to put this together, because we found this training gap. With that, we created an integrated care psychiatry elective, an elective where family medicine and internal medicine residents can come and rotate with us and learn the basics of diagnosis and identification of disease, and at least when to refer, when to treat, how to treat, and how to start. So the goal is, if I diagnose somebody with diabetes in a primary care clinic, I'm not referring them to an endocrinologist right away. I'm starting them on some metformin. I'm starting them on some kind of an antidiabetic medication, and then referring whenever. So that is the whole goal, is to teach them a certain thing. So in today's topic, we're going to go a little bit into why we did this whole rotation, why we created this, how we created it, and how many people have so far come into the rotation. And we also took a survey of them pre- and post-rotation to see their comfort levels. So we're going to present all this data to them. With that, I'm going to pass it on to Dr. Dutta. OK. Good morning, everyone. Thanks for joining us. We'll start with some learning objectives to understand the increasing and unmet mental health care needs in underserved communities, to gain perspective to the integrated care model we implemented, to understand the novel psychiatry and primary care elective, and also advocating for psychiatry as a core for other primary care specialties. This is an agenda that we will try and keep to. And this is a question that we'll start with. Do you think you have enough psychiatrists in your program? So for this question, we're going to use Poll Everywhere. And what you can do is either open up PollEverywhere.com slash smetra116. I can't see that on the screen. That's strange. Excuse me. Excuse me. It's not sharing our screen. The screen share? Screen share, yeah. That's the problem? It's not showing the Google Chrome link we have pulled up. OK, so I mean, while we are working on the technical issues, I'll just tell you, you can either open up PollEverywhere.com slash smetra116, or you can text smetra116 to 22333. So the number is 22333. Text smetra116 to reach the poll link. And we can move on with the presentation. OK, sure. Say that again, smetra? 116 to 22333. And then you can respond A for yes, if you think you have enough psychiatrists in your program, and B for no, if you think you don't. And I'll share the results as we see it. If anyone has any questions about accessing the poll, we can do it from there. I can come and help you. Okay so so far our response is 100% no. So that kind of answers the question. So we'll come back to the slides. Okay I thought I would start out with a quote from APA's very own Saul Levin. 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 get out of bed. This is from data that was taken from 2019 according to NIMH. So 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 people in 2002 to 16.1% or 40.2 million people in 2019. Over the 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 within the past year increased from 7.4% 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. According to the AMA master file 41,133 psychiatrists were actively practicing across the United States. Again this is the same time frame 2019. As can be expected the state with the highest number of psychiatrists were states like California, New York, Texas, Massachusetts and the state with the fewest number of practicing psychiatrists were states like Wyoming, Montana, Alaska, Idaho. The national average was 806.5 psychiatrists per state. The county with the most psychiatrists was New York, New York and of 3,135 total counties in the United States 1,446 had at least one psychiatrist which is only 46.1%. The majority of counties had no psychiatrists. This is a similar slide looking at psychiatrists per 100,000 population. So the District of Columbia had the highest ratio of psychiatrists with 50.1 and Idaho had the lowest ratio 5.3. The national average was 12.9 psychiatrists per 100,000 state population. So all that information was from 2019 but we all know what happened in 2020 COVID-19. 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 health care systems, limited access to in-person mental health care services. There were strains on mental health providers. Mental health providers faced various challenges during the pandemic, increased workload, burnout and stress. 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 an increase in mental health disparities. The pandemic exacerbated existing mental health disparities. Certain populations such as low-income individuals, racial and ethnic minorities and frontline health care workers experienced disproportionate mental health impacts and there was emotional toll on health care workers. Health care workers faced immense psychological stress during the pandemic. They witnessed the direct impacts of the virus, experienced personal risk and dealt with intense workloads. So this is a research study that was in psychiatric services again from the year 2018 and it looked to project the workforce of psychiatrists in the United States. So in this study the researchers looked at data from multiple data sets, the American Medical Colleges, the American Board of Psychiatry and Neurology, the US Census Bureau and they used data modeling to project what the workforce would be. So they came up with the idea that the workforce would contract through 2024 to a projected low of 38,821 which is equal to a shortage of between 14,280 and 31,091 psychiatrists depending on the psychiatrist to population ratio used and that a slow expansion would occur beginning in 2025 and they projected that by the year 2050 there would be a range from a shortage of 17,705 psychiatrists to a possible surplus of 3,428. So these are two tables that were taken from that study and of note it's interesting to see that in 2024 they were forecasting that there would be quite a number of psychiatrists retiring from the workforce, 2,648 and that number would be lower in the same 2025 and 2026 and then the table at the bottom looked at the projected population and the psychiatrist workforce and then they modeled the psychiatrist needed and the psychiatrist shortage using two different data sets. One of them was the Department of Health and Human Services and one of them was the National Comorbidity Survey replication. And you can see the second column from the right at the bottom that dash represents the idea that there might be a surplus. So the conclusions of the study were that due to steady population growth and the retirement of more than half the current workforce that the psychiatrist workforce would contract through 2024, have a slow expansion starting in 2025 and they weren't quite sure what would happen in 2050 and as with all research studies there's a call for more research. So there have been several measures that have been taken to tackle the shortage of psychiatrists, for instance increasing the number of residency spots. Efforts are being made to expand the number of available psychiatry residency positions. This allows for the training of more psychiatrists and helps meet the growing need, the growing demand for mental health services. There's loan forgiveness programs and incentives. Various federal and state programs offer loan forgiveness for financial incentives to medical students and psychiatrists who commit to practicing in underserved areas or pursuing careers in psychiatry. We all know that telepsychiatry and telemedicine has become a bigger deal. The use of technology such as these is being increasingly utilized to improve access to mental health services. There's collaboration with other mental health professionals. Psychiatrists are working in collaboration with psychologists, social workers and counselors. The idea is that patients should be able to receive the most appropriate care from the most suitable provider. There's increasing use of advanced practice psychiatric nurses and physician assistants. In some areas advanced practice psychiatric nurses and physician assistants are being utilized to help bridge the gap in psychiatric care. There's recruitment efforts and educational campaigns. Various organizations and institutions are actively engaged in recruitment efforts for educational campaigns to promote psychiatry as a career choice. And there's integrating mental health into primary care. Efforts are being made to integrate mental health services 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. So Dr. Guntur will now talk about integrated care services. So I think a couple of things which stood out when Dr. Dutta was presenting was there are 40,000 psychiatrists in the whole country for a population of more than 120 million people which obviously I think when we were designing these integrated care services or when we were thinking of this as an option what happened was in 2018-2019 there is a big push in New York State. I mean if people here who are not from New York. So there is a push for integrating behavioral health and as a part of the push they gave us a funding through a program called DSRIP which is like an incentive payment system. It's complicated but they did give us a lot of money to kind of create a fully integrated health systems and there was an incentive for a lot of programs in New York because most of the studies have actually shown that fully integrated healthcare systems would actually do much better in the outcomes. So when this was happening in 2019 I just finished my fellowship and residency and we were having this discussion within the hospital then we kind of started to think of designing a fully integrated ambulatory care network system within the hospital. So that was where we had the starts of setting up this integrated care services. If we are going to do it in primary care so the integrated care services but so when we do this integrated care services within the Department of Medicine and Family Medicine because most of the primary care clinics are internal medicine and family medicine within our program and we do have some from HIV clinics where some of the ID specialists are also PCPs and there are very few very few pulmonology specialists as PCPs too. So we did design this fully integrated network of behavioral health integrated network within our own primary care network we were trying to integrate behavioral health into all the programs. So there is a question here for Paul everywhere. So the question is does your program have integrated care services or basically where you're working do you have integrated care services psychiatry integrated into primary care. Again you can go to the website poll everywhere.com slash S Mitra 116 or text your response to S Mitra 116 double two double triple three and text S Mitra 116 first and then your response. We'll give it a couple of minutes. All right. Looks like 100 percent have integrated care services. And back to our slides. So I'll briefly describe today about how integrated care services are set up within our hospital system and now we have been doing it for almost five years now. So overall our goal of integrated care services at Bronx Care Ambulatory Network is we're trying to do universal depression screening and we also try to set up something called behavioral health case managers within the network within the primary care clinics who will be helping us with the integration of all these integration of different kinds of programs within our integrated care services. So that is the aim of our integrated care service. Our core mission is we aim to provide comprehensive integrated behavioral health care services for all primary care clinics in all capacities to make it wholesome experience for patients and the primary care team. This will allow the primary care physicians to become more confident in treating common mental health disorders. And what I have seen is most of the patients prefer getting all care in one roof. Like if somebody wants to walk into one any one of our primary care clinics they would be able to get 14 different specialties services in one in one place in one clinic. So we're creating this one-stop shop actually helped a lot with the compliance as well. So this is the workflow model that we we step we we set up in our clinics with this is called the stepped up care model. So in stepped up care model this is not something new. They have been historically doing it with hypertension. They've been historically doing with diabetes. Any kind of chronic illnesses they do have the stepped up care model. So if you see this step this slide if you go from left to right of your screen the level of severity of the patient's psychiatric illness decides which kind of a care they would be they can be placed. For example on the extreme left this is where the PCP can manage some common behavioral health conditions just like how they manage diabetes or hypertension. So example so somebody needs 50 somebody takes 50 milligrams of Zoloft and they've been stable on this for not that 50 milligrams of Zoloft is sub-therapeutic but there are some patients we all we all have them who are stable on that particular dose. So if somebody is like that who've been stable for almost two three years without kind of any without any hospitalizations without any acute excess elevations. So do you do we think they need to come and see us in a psychiatric clinic a specialty psychiatric clinic. Obviously not the PCP will be able to manage this as long as they are comfortable prescribing the 50 milligrams of Zoloft. So that is the extreme left on your screen where you see PCP can manage some common behavioral health conditions. And on the extreme right you see which is the mental health clinic which is our adult outpatient psychiatry department or this is our speciality clinics think of it like an endocrinology or a neurology clinic where the patients somebody in clozapine or somebody on a long-acting injectable or somebody who has an act team or a court order for treatment. So the level of the level of complexity of the patients depending upon the level higher level of complexity those are the only patients we try to refer them to a psychiatric clinic. So we created this menu of options where you have in somewhere in between is collaborative care and co-located care. So this is the stepped up care model that we created. I mean it's easier to create models but much more difficult to implement it. It took me two years for me to understand that its implementation is much more difficult than planning. So the first two years to get people especially the leadership in the primary care clinics to understand this because most of them want to just refer. So whenever it's psychiatry they just want to refer. So the second day I'm in a primary care clinic and I was seeing a patient somebody the consult or the reason they walked the patient to me is because they had a the patient got into an altercation over a parking spot down and the patient came upstairs to the clinic and phq-9 was positive. Obviously if I get a parking ticket my phq-9 is going to be high as well. So he got up phq-9 was high and when he went to the front desk, front desk was dark, he's so depressed. That's not depression that is I mean he was angry at the cop for giving him a parking ticket. So when we have this kind of a culture in many of these primary care clinics it took us a little bit of time to kind of develop this whole model. So as I said there's a I'm going to speak a little bit about collaborative care. I'm also going to speak a little bit about co-located care. So this is the this is one slide if any one of you want to get a take-home message. I think the setting of the stepped up care level models is is important in psychiatry especially when you're integrating behavioral health clinics behavioral health into medical clinics. So this is how the workflow works for us in the clinic. So a patient walks into any of our primary care clinics. They get a bunch of they get a bunch of screening questionnaires. They get the GAD-7s, phq-9s. So they get screening. Once they finish with the screening what happens is if somebody is positive if somebody is positive they are referred if PCP sees the screening questionnaires and the PCP decides okay this person's phq-9 is positive or this person's GAD is positive let me refer this patient to the clinical social worker or we call them behavioral health case managers. In each clinic we have behavioral health case managers who are also clinical social workers. So the PCP then refers the patient to the clinical social worker then clinical social worker does a biopsychosocial evaluation of the patient and they are the ones who decide which level of care is appropriate. The level of care is the slide which I was showing before. So they decide whether this patient is collaborative care, would be good in co-located care, or would they be okay and do they have to be referred to a higher speciality clinic. But also sometimes once the relationship is built between the clinical social worker and the psychiatrist of the clinic the integrated care psychiatrist so there are times when they even discuss okay maybe this patient belongs to this level of care maybe this patient belongs to this so it doesn't mean they get to take a decision but there it's also an open communication. So once the clinical social worker decides which level of care they have to belong to that's when they discuss with a psychiatrist. So these are the five different so when we are creating this integrated care services within within our healthcare system we had to create a recipe for it. So when we are designing or when we are making this cake so we had to create okay what else have to be a part of it. So then we searched a lot of literature what are the different ways different healthcare systems integrate behavioral health into primary care clinics. I found out there is so much literature written about all of this stuff. So this was in 2019 I just was just out of residency and I was thinking figuring it out at the time I just finished a CL fellowship. So there are different then we kind of thought also we have to also take into consideration the population visa. So that is when we decided okay these are the five different methodologies that we can use are the five different ingredients that we can use to create this fully integrated network. So the five the five the five different ingredients are co-located care psychiatrist then we have something called PCP coaching which we did a workshop a few days ago. So then we have collaborative care and then we have ambulatory ICU and then there is the integrated care rotation for the psychiatrist which is which is what Dr. Mitra is going to go in detail but I'm going to talk a little bit about all the other four and what do those comprise. So what we have seen is when you kind of use this design to integrate behavioral health into primary care clinics, it tends to be a much smoother transition. It tends to be a much smoother integration. So what is co-located care? In the name itself, it means that there is a psychiatrist is co-located along with the primary care physician in the same clinic. So there is a physical co-located psychiatrist who is there and the psychiatrist is the one who helps to create this one-stop shop, which we're trying to do. But does every patient need to go see this co-located psychiatrist? So there's obviously not gonna be enough slots if you try to do that. But the idea is if somebody is not improving, there might be times when there is that need for diagnostic clarification. Very commonly what happens in primary care clinics is they're not so good in picking up bipolar type two, especially differentiating depression from bipolar type two. The most common diagnostic clarification question that they come to me is for co-located psychiatrist is to get a differentiating between bipolar and depression, bipolar type two and depression. And the other common time the co-located psychiatrist sees the patient is the, if a patient is on Respiradol three milligrams BID and they're stable, they don't need to be referred to a psychiatric clinic, but at the same time, the PCPs are not comfortable prescribing those medications. So then these are the gaps which can be filled by the co-located psychiatrist who's present in the same clinic. So me and my fellow, both of us are present currently. We are there at four or five clinics, but we have co-located psychiatrist in around 11 clinics within our healthcare system. But we are only one day a week over there, just like every other specialty is. So we try to set up all these slots at the time. So the co-located care workflow, it's almost similar to the other workflow, which is primary care provider evaluates the patient and they refer to the clinical social worker. Social worker completes an initial biopsychosocial evaluation, and they're the ones who decide that the patient has to be in co-located care. And usually either the social worker or the front desk staff has access to my schedule and they are the ones who pick and put the patients on the schedule. And the way we wanna think about this level of care is it's not a static process, it's actually a dynamic process because there are times when we downgrade the patients from mental health clinic, specialty clinic to a primary care clinic and at the same time, there are times when we actually push the primary care folks from primary care clinic to a psychiatric clinic. So it can go bi-directionally. So we wanna think of it more as more of a dynamic process, not a static process, because that also helps us to open the bottlenecks. It helps us to open the bottlenecks when people are waiting for almost six or seven weeks to see a psychiatrist. So these visits, most of these visits are actually the co-located care visits are actually billed to Medicaid or Medicare. If you're a federally qualified health center, you have something called prospective payment system. And there's also Medicaid managed care payment as a flat rate. And the difference is usually called a wrap. So the bottom line of the slide is like, the co-located services are very easy to get paid because everybody knows this, how to get billing for these kinds of services. So then moving to the second thing out of these five ingredients that I was speaking about integrated care services. How many of you here are familiar with collaborative care? You have some version of collaborative care at your healthcare network? Okay. So I'm talking a little bit about collaborative care. You know, it's recently the White House, when they passed, there was a mental health parity bill, which they passed last year. And collaborative care is now a big part of the whole bill, which was written. Those they want to, there is a huge bipartisan push to actually increase access for mental health to many of these clinics. So in a part of that, they're also trying to promote collaborative care because it's one of the few, one of the few scientific evidences, which is robustly available. We have more than 2000 randomized clinical trials, which actually say that collaborative care works much better, if not, works better, if not much better than the regular care and integrated care services. So in 1978, what they found out is like more than 50% of patients with depressive disorder are actually treated in primary care clinics. They don't make it to the psychiatrist either most of the times. And out of these only 20 to 20, 25 to 50% of patients with depression are actually accurately diagnosed and treated by PCPs. How many times we have seen the PCP sending us patients and they're on like either sub therapeutic or a supra therapeutic antidepressant dose. Or else sometimes they actually have the wrong diagnosis. Or sometimes they have patient on Seroquel for sleep. So that is a very common thing that we see. When we did a retrospective chart analysis in our hospital, what we found out is 70% of sleeping medications, sleep medications or even Seroquel in our hospital network is actually prescribed by family medicine and internal medicine docs. So they're not prescribed by psychiatrists. I don't wanna use the word poorly managed, somehow made it to the slide, but they're obviously inadequately managed. So there's either inadequate doses or inadequate duration. So with this, I think University of Washington came up with this beautiful collaborative care model, which was again, taken from the chronic case model, case management models of depression, I started hypertension and diabetes. So what is collaborative care? It's team driven, it's population focused, it's measurement based and evidence based. So these are the four factors which is how our collaborative care model is designed. So what is team driven? It's a multidisciplinary team which works together. So it takes a little bit of time to get used to it. But once you get used to it, I mean, it's a very smooth process. But because everybody is used to our fee for service model, which exists for a long time. So now moving away from fee for services to a value based model does take a lot of time. Does take a lot of cultural shift. So it took us almost, I would say one or two years, I'll show you some numbers of how many folks are actually enrolled in collaborative care within us. So the collaborative care workflow model. So the way the slide works is like, if there is a dotted line, that means there is no direct contact between those two people on the slide. Whereas if there is a solid line, there is a direct contact in person, meaning physical contact between those two people. So for example, if you see there, the patient comes in and the patient's PHQ-9 is positive. And usually the PCP has the screening, when the patient screens positive, the patient makes a referral to the behavioral health case manager. So the behavioral health case manager sees the patient physically and makes a biopsychosocial evaluation. And they have 11 of PHQ, let's assume, or 12 of PHQ. And they're like, this is mild to moderate depression. So this patient doesn't need to see a psychiatrist. We clearly know it's depression. So let us start them on medication. And the PCP is going to tell the behavioral health case manager that can you discuss with a psychiatrist when you meet with him? So what happens is then the behavioral health case manager meets with the psychiatric consultant once a month, sorry, once a week. So when they meet with them once a week, they actually discuss the specific case. And as a part of the recommendation, they can make, okay, I think 25 is sub-therapeutic. Can you increase it to 75? So that is how it works. In this model, if you see this, the psychiatric consultant is actually not meeting the patient. So there is no direct contact between the psychiatric consultant and the patient. So the only contact they have is with the behavioral health case manager. Unless somebody is not improving and we need an extra diagnostic clarification or so, there is no direct contact. So that is how a collaborative care workflow works. So this is how it is. So a patient scoring positive, then the positive screening is seen by the PCP who evaluates the patient and refers the patient to the clinic's behavioral health case manager. All clinicians are located in the same clinic. This improves engagement. And also behavioral health case manager acts as a liaison between the PCP and psychiatrist. So there is an improvement of PHQ-9 and GAD-7 is usually the way improvement is defined because it has to be measurement based. It has to be lesser than 10 or it has to be a 50% decrease every time there is a contact between the behavioral health case manager and the patient. So the billing for collaborative care, it's a part of like this, one of the new models. Many times, many healthcare systems are now struggling with billing for this model. But it's because it's so new and it's also value-based. And there are quarterly reports which we submit every quarter to the New York State who actually gives us a capitated base payment. For example, taking care of a patient for three months over a quarter. And if you meet the regular KPI which have to be met, so what happens is then we get, we usually get paid $150 per patient approximately, a give and take. So it's 112.50 cents for a patient. If a patient remains in the program for three or more months, there is also a retention rate which is an additional bonus because they're actually staying in the program. Okay, outcomes. So when what we have seen in this particular, in this particular, doing this collaborative care for over, I would say over three years is there is an increased adherence in this model. There is actually almost twofold increase in adherence. It's more cost effective. Obviously, we also calculated the number of times they're not visiting the emergency room on this particular intervention group. And also we calculated number of times they're not having inpatient hospitalization pre and post intervention. So obviously we've seen it to be more cost effective. And most importantly, when we think of it as patient centrically, I think there is improved patient satisfaction as well. So because the patients are just coming and seeing their PCP, they don't even need to move to a different clinic, they're in the same clinic. So there is also an improved adherence and especially for minority populations and populations living below the poverty levels. And we have something called Bronx Rio, which captures data from all the hospitals in the Bronx, which also shows that collaborative care at Bronx Care shows decreased in acute care utilization. This also expands the reach of the psychiatrist, because right now before we started a collaborative, because every time there is a collaborative care in a clinic, we almost have 75 patients enrolled in that particular clinic. So when you have so many patients enrolled, now we don't have a big wait list at our psychiatric clinic. So our waiting time at psychiatric clinics came down from almost eight weeks to close to four weeks. So anybody who needs an appointment in a psych clinic can get an appointment within four weeks right now. So those are the outcomes. So different team members in the collaborative care, the role of the primary care physician, still the captain of the ship. So they're the ones who actually prescribe medications. In this model, so the psychiatric consultant is just making recommendations. They don't actually send prescriptions or anything. So PCPs are the one who send prescriptions. So they're the ones who review their PHQ-9s, they establish a provisional diagnosis, and they're the ones who introduce the patients to the collaborative care team manager, behavioral health case manager. So the process is called a warm handoff. So the behavioral health case manager, I look at them as more of a cog of the whole program. So in this, they work very closely with the PCPs. The case managers are the ones who facilitate patient engagement. They're the ones who also do patient education. They perform an initial and a follow-up assessment of the patient, and they also maintain the registry. I'm gonna show you our collaborative care registry that we use in our hospital and how those KPIs or the key performance indicators are seen. So the behavioral health case manager, so there are times when somebody has interpersonal problems, a patient. Sometimes the behavioral health case manager also picks up short bursts of therapies that they do, like six weeks or eight weeks in primary care clinics, like CBT-I, or maybe behavioral activation therapy that they pick up and they actually do therapy as well with the patients. So they review the cases with the psychiatrist every week, and behavioral health case managers are the ones who facilitate referrals to the outpatient speciality care clinics, and they're the ones who actually work as a liaison between PCP, psychiatrist, and the patient. So the psychiatric consultant, so what I do or my fellow does in the clinic is we usually meet with the behavioral health case manager once a week, and we review the cases with the behavioral health case manager. So when I am there once a week, my schedule is like I have three to four hours of co-located care, and I have one or one and a half hours of collaborative care, and then I have something called PCP coaching. So all these five things which I'm showing to you as integrated care services, I do all those five things in a day, which I'm there in one of these clinics. So and also every day of my clinic time is in different kinds of primary care clinics. So the psychiatric consultant actually provides weekly consultation in this collaborative care model. They review cases with the behavioral health case manager for patients who are not improving. They also provide diagnostic clarification. They also provide direction for further assessment and medication recommendations. We also identify appropriate referral sources when it's needed. And also most importantly, when we are asking the PCPs to treat, identify, it's also, I think, it's our job to also teach them sometimes if they don't have enough training in specific things. For example, when we go to a pediatric clinic, a lot of times we do sessions on ADHD. Depending upon the clinics, if you go to a geriatric PCP clinic, we usually teach them a lot on dementia and behavioral disturbances. So I think the integrated care or the co-located psychiatrist also plays a role of a teacher in most of these clinics. So this is how a registry looks like, and this is how each patient, we can actually see where the PHQ-9 is trending, so where the GAT-7 is trending. So if you see there, there is a column which shows when was the psychiatric case review done. So the way it works is when I go and sit with the behavioral health case manager once a week, what I do is I ask them, we open the registry, and we see the patients who are not improving because the idea of spending that hour is usually you want to spend on the patients who are not actually improving because that is where you need to spend most of our neurons on. Okay, so this is how many people we have enrolled across all our ambulatory care clinics right now. So we have around 1,045 patients enrolled in collaborative care. These are stats as of different years, but overall we have 101,000. And we also, I think this year is the first year we dropped value-based payment bills and we are actually second or the third healthcare network within New York State who actually got paid for doing collaborative care. So the state has different KPI indicators that they want us to report on. So this is, again, some other statistics of different kinds of enrollment within our collaborative care. These are the performance metrics that we use, me and the other leadership within primary care clinics and also the family medicine clinics. We sit down and we review and we see how effective the program has been so far. So that is collaborative care. Then moving on to the, as I said, there are five ingredients. We already spoke about co-located care. We finished speaking about collaborative care. The third one is ambulatory ICUs. What are ambulatory ICUs? These are ICUs in an ambulatory setting. The way we wanna think of it is apparently 5% of the patients account for 50% of all healthcare spending in this country. And 1% actually account for 21% of spending. So these are the highest of high utilizers. So the idea of these ambulatory ICUs is we have them in one hour every week that where multidisciplinary teams meet, which is the PCPs of the clinic, the psychiatrists of the clinic, the behavioral health case managers of the clinic, and somebody from insurance, managed care folks, usually case managers. And also if they have any family member of the patient wants to come in, they're invited to these meetings as well. And we also have different, we usually have different, we have a health home, our care management team within the hospital network. Even those folks come and join this meeting. So the idea is when we talk about a patient who's a high utilizer, what we found out was at least 70% plus of these high utilizing patients have some kind of a psychiatric comorbidity, if you're not surprised. So then when we discuss what we found out, and sometimes we, very interesting cases, we have a patient, we had a patient who was getting admitted multiple times for diabetic exacerbations to a point where she had honk and she got admitted to ICU. Then this case, these are the kind of cases we discussed in the ambulatory ICUs. And when we were discussing this case, one of the health home or a case manager went to the patient's house to make sure everything was fine. Clearly it was not because she did not pay her current, the current bills, electricity bills. And then what happened is her refrigerator is not working. So where does she put her insulin? So clearly that was the reason why this patient was actually getting, her diabetes has been uncontrolled. We tend to think a lot about it in silos. We sometimes don't understand what is happening inside the patient's houses. So having this multidisciplinary kind of meetings helps us to get a different perspective. So AICUs in general are good for the patient's complex needs that matter. The doctor is a multidisciplinary help with difficult cases. The hospital has a lot of cost savings since we started to do this. This was also a part of our district programs, but since we started to do the ambulatory ICUs, we tried to pick up where the issues were happening and we were trying to fill up those gaps within the patient's care. So with that, I'm going to pass it on to the psychiatry in primary care rotation. We're not talking about the, what is it, the talk which we did? PCP coaching. PCP coaching, okay. So before I move on to psychiatry in primary care rotation, so one more ingredient that we wanted to mention was the PCP coaching, which we do in primary care clinics. I said five, right? So we finished co-located care, we discussed collaborative care, and we discussed ambulatory ICU. The fourth one is something called PCP coaching because we also, as we said before, we see a training gap and I think it's important for the psychiatrist who is in the co-located clinics have to ask them to pick up these topics and we ask them to, they actually fill out a survey almost every year and they pick up the topics which are most relevant to them because I don't want to teach them about clozapine if they're not prescribing clozapine. So usually PCPs are the ones who pick up these 12 or 13 topics that we discuss with them, and that is called PCP coaching that we do in all these clinics. And so far, we have also been kind of collecting survey data on it, and it's been very well liked by all the PCPs, and they really enjoy getting these lectures from us. So the last one of these five facets of integrated care services is psychiatry and primary care rotation, and I'll pass it on to Dr. Mithra for this. All right, thank you, Dr. Gunturu. So I'm currently a fourth-year resident and also doing the Public Psychiatry Fellowship at the Fast Track. And till my second year, I had heard this term, integrated care psychiatry, but had no idea what it was. How many people here have done consults on medical floors? Does this consult sound familiar? Patient given terminal diagnosis of cancer. She appears depressed. Please recommend medications. Or patient wants to leave AMA, please assess for capacity. So essentially, I was in my second year doing my CL rotation and noticing these consults and obviously getting aggravated and agitated and feeling antagonistic towards the medicine team because in my head, I'm thinking, why are they asking these questions? These are common-sense answers. To get a terminal diagnosis, you're supposed to feel sad. That's normal human reaction. And then one thing I knew for sure was I'm not doing a CL Fellowship. And then Dr. Gunturu came for didactics one day, and he discussed his primary care psychiatry model that he's incorporated into primary care clinics. And when he talked about all of these components and how we are really working with primary care, teaching, educating about psychiatry, and also the fact that they don't get any psychiatry training. For me, that was something that was incredible to hear because we'd been taught so many times that depression, anxiety is basically supposed to be managed by the PCP with complex cases making their way into the psychiatry clinics. Then I went into third year, and I was faced with our 20-minute appointments, medication management, med refills, and that's it. And a lot of times, I was left wondering, why am I seeing patients who are on Zoloft 50 milligrams, and then I'm refilling their medication, speaking to them for 10 minutes, and that's it. And then Dr. Gunturu told us about this fast-tracking option where we work in the primary care clinics and about the stepped-up model of care, and a part of it involving teaching primary care residents to rotate with us about psychiatry. And that kind of appealed to me because it all made sense. I was disgruntled about the fact that they are not aware of what's going on, and here's an opportunity to really work with them, to educate them, and hopefully make some changes to our practices. So I'm going to discuss one of the parts of the model. So essentially, as part of my fellowship, how it works for me is I work three days in the primary care service, and I do my two-day didactics at Columbia. So one of the parts of it is I have residents from primary care rotating with me in psychiatry who basically function not as workhorses. They mostly go to most clinics and just see patients, probably don't get too much supervision or anything like that. And there's no real structure. That's what most people at least explain how their clinics are working. And in our rotation, when they come, it's meant for them to be an educational experience. It's meant to be, you're not here to see patients, you're here to learn as much about psychiatry as you can in these four weeks. So this has been in our integrated care model for almost four years now. And mostly the resident who comes and rotates with us works with either Dr. Gunturu or with the fellow. And basically, how you can imagine it is if you're a primary care resident coming on the elective, you get an email from us two weeks before the rotation with a bunch of reading material. What is collaborative care? What is psychiatric diagnosis? How do you do a mental status exam? Lectures on that. You prepare yourself for the rotation, and you come in on day one. And then you just sit with me throughout the day watching how I'm doing things, asking questions, and also discussing why we are choosing a certain diagnosis and why we are giving certain medications. So what are the goals for this primary care elective? To learn to manage the most common behavioral health conditions that primary care providers are going to be seeing when they start practicing. New York City is a place where we do have a decent amount of psychiatrists. So they do have options of referring patients to psychiatry for mild to moderate depression and anxiety. But most places don't. So how I generally introduce the topic is if you're choosing to go to a state or a county which is more rural or which is in a place where probably there aren't any psychiatrists. There are so many counties in the Midwest where the nearest psychiatrist is 200 miles away. You're the one who's going to be prescribing. There's no way you can tell your patient to keep going for two or three hours to see a psychiatrist to get medications. So it's important that you learn. And it's important that you get this exposure. We also introduce them to these models of care, that the fact that this exists where you don't have to send all your patients to a psychiatry clinic. If you're not confident treating a patient, there is co-located care and collaborative care where you can have indirect consultation with the psychiatrist while you're keeping the prescriber role. And this is basically a four to eight week rotation for psychiatry. There are psychiatry residents also who rotate with us. But it's mainly meant for the internal medicine and family medicine residents and medical students and observers who come to our hospital to rotate through. And we recently also had three pediatric residents who rotated with us. A major part of this is our weekly lecture schedules. We have a topic of the week. And that topic of the week is what they're exposed to. And I'll go into the lecture schedules in the next slides. We give them exposure to co-located care. They join in on collaborative care meetings. They join in on the ambulatory ICU meetings and also participate in the PCP coaching classes. And for the psychiatry residents, because obviously a lot of this stuff may be bread and butter for them, they also develop a QI project on how to improve the practices in primary care psychiatry. So the didactic schedule. We have an eight week didactic schedule which we've developed. And depending on how many weeks of elective you're doing, you get exposed to that many topics. So basically what are the two most common topics that primary care providers care about? Can anyone take a stab at it? Depression and anxiety, right? So week one, they get orientation to primary care. We introduce the whole model, how it's functioning. And most of the time the response is, oh, there's a psychiatrist in the primary care clinic. We didn't know you were in this office right here. We just thought this area was like endocrinology and OBGYN and pediatrics. And then they also get exposed to the overall model. They get introduced to mental status examinations. So day one, we do a whole rundown of the mental status examination through the initial eval that we do on a patient who is coming for the first evaluation for level of care placement. They also get introduction to collaborative care and they attend the collaborative care meetings where we kind of discuss how, instead of directly referring to psychiatry, just join on the meeting, call us, and discuss your case with us. And then we can help you decide, do you send to a specialty clinic, do you give medications yourself or just keep the patient in collaborative care? And we also do a lecture on depression. So most of our articles that we kind of discuss in a journal club based model, our practice guidelines, which were published in the NEJM. And some of them are from other journals when we don't find a NEJM article on it. And they are very broken down to a level which is very easy to understand, which clearly mentions how to go about diagnosing a patient on DSM-5 criteria, that just because you're seeing depressive features, don't diagnose it as depression. Look at the overall picture. Look at whether there's something going on in this life that can explain this. Are they meeting the two-week time criteria? Are they having hypothyroidism or any other medical conditions? And most importantly, the part that most people miss is, is it affecting their social and occupation functioning? So that is the exposure that we generally give them. We see our follow-ups together. We see the new patients together. And whenever we have a new patient, I generally go about the didactic part of it. The first one, they sit with me, and we kind of discuss the path of the mental status exam. What did you notice about the appearance, their attitude, the speech, thought process, all of those bits. And then we go into, what do you think is the diagnosis? And then we break it down into what parts of the history kind of made you think of the diagnosis. And then we go into the lecture, which has all of these parts, and also discusses management. So in the depression lecture, we cover most of the SSRIs. How do you dose it? How do you titrate? How often do you titrate? And if you have to cross titrate, how can you think about cross titrating? Then we, in the next lecture, we go into, in the next week, and in this week, they essentially get exposure to seeing depression patients. And on the second or third day, if they're interested in doing so, we give them a patient to see who has a history of depression. And then we see how they are assessing the patient, and how they are thinking of management guidelines, and then we offer them approaches. So it's more of developing confidence in making decisions or coming up with diagnostic practices, and developing the interview skills, because obviously our interview skills and our examination is very different from a medical examination. The next week, we also do, we do anxiety, so we go more into the treatment with, say, BoostPAR or Benzos, and also obviously SSRIs and SNRIs are covered as well. The next week, we go into trauma and the limited number of medications we have for trauma. And week four, we discuss insomnia, which is a very hot topic for primary care dogs, because a lot of times, their patients are talking about sleep issues, and either they're prescribing Ambien or Klonopin or Seroquel. So we discuss better practices, maybe considering CBT-I, sleep hygiene, and then the other safer medications. Then week five, we discuss bipolar disorder, which is another hot topic. A lot of times, we know that bipolar disorder gets misdiagnosed, especially with patients with either borderline personality disorder or any other condition that may mimic bipolar disorder. Then we talk about dementia with behavioral disturbances, which is, again, something they encounter very often on the inpatient unit, and they think it's schizophrenia. And then when we break it down and go through the way to diagnose, say, the delirium or dementia with behavioral disturbances, then things start making sense. And then also week seven or eight is nicotine use disorder, which they run into a lot, especially in the South Bronx, where the consumption of nicotine is very high. And a part of our survey, a part of our rotation, and we are very particular about quality improvement and improving our practices and making sure that our educational program is very tailored to the residents who are rotating with us, so they feel comfortable when they finish to go out and at least manage basic depression and anxiety. So some of the questions that we asked are, have you ever completed a behavioral health rotation? Has behavioral health been part of your teaching curriculum in your current training program, so in your residency, has it been a part of your rotation? Which topics seem to be most important for you? What are the things that you're encountering most commonly? How many patients in your clinic do you have that have a comorbid mental health condition? How comfortable do you currently feel about treating behavioral health diagnosis? And then the post-rotation survey, it's very tiny, I'm so sorry about that, but the questions essentially are, how much did the rotation expand your knowledge about treating behavioral illnesses? How beneficial do you think this model is for primary care? How beneficial do you think the model is for patient care? And how beneficial would it be to integrate a behavioral health rotation in your core curriculum? Basically, should psychiatry be part of your core curriculum? Also, rate your rotation experiences, please provide any feedback to improve the rotation, and what are the aspects of the rotation did you participate in? And how much more comfortable do you feel treating mental health illnesses? And I'll go a little bit into the results. So so far, we have had 70 residents who completed the pre-survey, but out of that, only 43 residents completed the post-survey. That kind of happens when you rotate out of service. So we are presenting data from the 43 primary care residents who completed both surveys. Out of this, 11 were family medicine residents, 29 were internal medicine residents. We had two pediatric residents, the third one came after we prepared the slides, and one pharmacy resident. In the pre-survey, the top row is the entire pre-survey results, the bottom row is the post-survey results. 33 residents did not feel comfortable about prescribing psychotropic medications or did not feel they had enough knowledge about it. 30 residents had not attended a psychiatric rotation, while only 13 had attended. That's one third. And that's amazing, because most of the people that were rotating with us were mostly PGY-2s and some PGY-3s. Most residents were treating 6 to 10 patients a week, which was about 50% or a little less of their caseload who had psychomorbidities, and 31 residents out of 43 did not feel comfortable treating psychiatric illnesses. That's a huge number for people who probably will have to partake in this going forward. Now coming to the post-survey, 90% felt that the model is beneficial for their training. 75% of residents found the rotation to be helpful. 90% felt it's beneficial for patient care. 100% felt that psychiatry should be part of the core curriculum, given the number of patients they see. And 90% of residents felt that the rotation expanded their knowledge. Essentially, to break it down in a nutshell, prior to the rotation, they did not feel comfortable at all prescribing or diagnosing psychiatric condition, and post the rotation, some of that anxiety was gone. Anecdotally, when I was doing CL calls last year, and then I spoke to residents on the primary care service about this rotation, they were able to break it down to being like, hey, prior to this rotation, I was consulting for pretty much everything. If a patient cried, I would consult. But now I'm really thinking through it, and being able to talk to my attending and explain that probably we don't need psych, we can just like think trial a small dose of SSRI. So it's working not only in their outpatient practice, but also in their inpatient practice. And also residents, we have something called Collaborative Care Plus, that's the name I chose to give. So you saw the collaborative care model, we have a modified version in the family medicine clinic, where basically the attendings and the residents join on the call. And they also bring cases, or they have some like basic diagnostic clarification question, interviewing questions, engagement of patient questions. And most of the time, the conversation starts with this patient is not cooperative, they are refusing to come to their appointments, they are doing this. And then we go into the whole motivational interviewing style of how to develop a patient centric collaborative way of engaging the patient. And that also has been useful. We actually in a separate data collection that we did found that our referrals to co-located and even AOPD have decreased since we started this intervention. So now, we've spoken a lot. And now for the last, we have about 20 minutes, I wanted to get everyone engaged and ask questions. But we also need your help. So Dr. Gunturu and I, we've spoken about this so many times this year. And the fact that psychiatry is not a core elective for primary care, given how important it is, and the fact that they're rotating and all other services as a core mostly, and not us, has been something that we've been brainstorming and thinking. This presentation is one of our first steps. And what we kind of envisage doing, it's kind of like a grandiose plan, I think, but we'll try our best, is how do we get this to be a co-rotation? What are our avenues? You know, it used to be a co-rotation. Yeah. And I don't know what happened then. We loved it. Yeah. Exactly. Because, like, even though they were getting a lot of this co-rotation, they were getting a lot of this co-rotation. Yeah. schizophrenics on the medical unit, most of the times they are not the patients that they're gonna be seeing. So it doesn't really help the world cause. So our question is three-pronged. How do we recommend expanding this? How do we take this beyond Bronx, beyond New York City and up? Yes. Yeah, and that's why I think that the collaborative care model kind of helps, because you have a psychiatrist dropping notes and kind of assisting you along the way, but just going from, oh this is psych, this is not my problem, to how can we work together is at least a fair game. I think also to your point, there is a fair bit of hesitancy, but when we see the prescriptive models that they, the kind of prescriptions they give, every other medication that they prescribe also have a lot of side effects. In fact, probably antidepressants have much lesser side effects than all the pain medications they prescribe. So I think it's more of a training gap that the hesitancy is, and also my wife is an internist, so when I keep discussing with her at home, I mean not that it's a fruitful discussion, but I think when we discuss at home also, most of the times that conversation is about, it's just that they're hesitant because they don't get trained. So they don't understand what, how do you start a medication, how do you, once we are able to teach them that, I've seen the hesitancy has come down a lot, by a lot, and as what Suparna was telling before, even in the inpatient services, they're much more comfortable. I see the medical students or residents who rotated with us, even when they see me they're like, oh no, no, I did not want to counsel, so that's their first, because they rotated with us, they know that, okay, we taught you all of this, so you should probably, but overall I think since we started doing this teaching and them coming and doing this rotation, I think it has been fairly, like the prescriptive practices have gotten much better, especially in family medicine clinics, because they feel like their scope is more biopsychosocial, they kind of see more psychiatric patients, both in inpatient and outpatient. So to Dr. Mitra's point, yeah sure. In some countries, some of them might be actually from different disciplines, psychologists, or even pharmacists. So they go to different GP surgeries, which is similar to CP, and they do their assessment. So they do a kind of filtering and try not to let GPs make those referrals, and make this long waiting list, and that kind of stuff. So it's very similar. The only thing which is, maybe you explained it and I missed it, I didn't see any zoning system in the middle of this. So basically a patient that falls in red zone because of their medium, that one person you were mentioning, with a 5% compared to amber or green, how frequently they need to be seen, and how intensely there needs to be met. I think one slide which we showed in the beginning, which had a level of care, so which has different levels of care, it's kind of closer to the zoning system. So depending upon which kind of pathology the patient has, and how frequently they have to be seen. Yeah, depending upon the level of care needed, then we put them into a different, for example, if somebody needs to be seen twice a week, or if somebody needs to be seen like four times a month, depending upon the frequency of them being seen, we actually have them even sent sometime to a psychiatric clinic because they need a closer follow-up. So we don't try to match them in a primary care. So to give an example, in two evals I've done in the last month, there was a patient who recently lost her partner and was having depressive symptoms. She did not want to be on medication, and a large part of our care is making sure it's patient-centric and collaborative. She only wanted to talk to someone about it and develop ways to cope with her grief. And the essential level of care determination at that point was PCP continues to follow, and she sees the behavioral health care manager for therapy. On the other side of the spectrum, I had a patient who came in who had a history of five or six admissions in the last four years. She also was court-mandated to treatment and was also being recommended to be followed by an ACT team, or the assertive community treatment team. That's not someone that we in co-located care should be seeing. So we were basically bridging the gap until they got to the ACT team. So we just referred them to our outpatient psychiatry clinic where they could be followed two or three times a month. So that's basically, we function as kind of like the level of care determination, so every patient referred to us does not always stay on our caseload. We kind of determine the level and transfer them out. So one of the big questions that we had for everyone, we are very passionate about this, and we want to get this to the stakeholders who can make it a co-rotation. So one of the ways we were thinking, I just got nominated as the ECB DEPREP for Area 2, so bringing it up as an action paper in the assembly and getting it as a position statement from APA. Another step was presenting it at the ACGME conference and speaking to stakeholders there. I just wanted to open it up to you all to see if there were any other things that you could recommend to us on how we can kind of advocate it outside of here. That would be excellent. We are aligning and taking care of our physicians. Because at the end of the day, that's what we're doing, right? We're trying to support each other so we can support the patients. So I think that that's really, and I would be happy to follow up after this. Thank you. So I think, yeah, so one of the things which we found out, or one of the things which we were, we were putting this together, is like I haven't met any PCP or any program director in family medicine or internal medicine who doesn't think that it's a bad idea. Like they all think it's a fantastic idea. They feel like their residents should be doing, seeing more psychiatric, they need to get more training. So somehow I was like kind of trying to figure out what is the dot that we are missing to connect. So if the primary PCPs want to do it, psychiatrists want to do this rotation, want them to come and get more train, program directors, both psychiatry and internal medicine, want to do it. Just two months back, now pediatrics mandates every, now it's a core for pediatric residents. So they have to do four weeks, starting from next academic year, they have to do four weeks of psychiatry. Before it was an elective, now it's a core. So I was putting, when we're putting this together, okay, so how can we make this wise to play at ACG? But again, this is, we started something three years ago, or four years ago, collecting all this data. But this is our first show on the road. So we just put all of this together. And now this is the first time we're actually presenting it at a national conference. And the idea is also going to present at ACGME. We are trying to see advocacy efforts. We were discussing with APA folks. And as Supi was mentioning, we're also putting a position paper together. So we have to follow the regular routes, which we have to do. But when we also compare with seven different countries, training of post, I was actually discussing, last night I was at a global mental health dinner. I was discussing the training that different countries have for GPs, and also the training they have for family practitioners. All the other six countries actually have some kind of a mandated core psychiatry rotation, which is also surprising for us. Because I think we have to eventually get here at some point of time. But we're just trying to figure out different ways of doing it. Because it's also new for us. There is an AMC, which is American Association for Medical Colleges. So they are the ones who actually endorse things to ACGME. So there is a whole process of we are trying to figure out how to do this. So I think more, yeah, sure, go ahead. Ultimately, budget focus can play quite a role. Because we have exactly the same problem. There are some organizations called CCG, which they recently changed their name to ICB. What they do is that they get budget from local authorities, both municipalities and Department of Health. And we're allocating that budget to primary care. They've got big boxes. So if mental health is not in the menu they're offering, they get less budget. So that makes a difference. I can see that since they started using mental health as a bargaining chip, then GPs are more forthcoming and more willing to engage. Money. Everything follows the dollar. And one other question which we had is, do you think if anyone of you here wants to share if they have their own family medicine or mental health medicine residents who do a psychiatry rotation? Or do you think anybody will be trying to push for this to happen in their own programs? Do any one of you have this here? Whoever is here present, they have this rotation in their health care systems? Yeah, I'm from the Netherlands. The PCP residents, I don't know how to call it, but they have a standard rotation in psychiatry. But it really depends on where they come. I work at the acute psychiatry and I think it's really helpful there because that's where they learn how to see what they have to do when they become a PCP. But they also come on outpatient clinic and other things. I don't know if that's really helpful when you become a PCP. So it's really important where you place the resident. So I think you incorporate it very well. Thank you. So yeah, I think having them in these clinics. So clearly there is some kind of a core mandated rotation that the GP or the primary care residents do in the Netherlands. Yeah, any other thoughts on this particular rotation? Basically, there are two areas that clearly overshadow the work of the US psychiatrists and also primary care. Substance misuse and also pain management. I have seen many patients that come to me complaining of depression, many years old and medication has been changed. But they are addicted to opiate-based ventilators. And the GP or primary care provider, they are contributing to this. In fact, they're prescribing. So the last thing we want is for you to change that to the person or someone who you think this time became miserable because it's not getting enough opiates. And it happens a lot. Substances, alcohol, everything. So it's very unusual for this system not to be linked. Putting together it's almost like imagining a car with two wheels, front and four wheels. It's so siloed. I think it's kind of clearly now we started up, set it up, everything in silos and now we are trying to connect the silos. We're doing reverse engineering clearly. Yeah, I'm a member of UCSF and they just received a grant to try to build out a psychiatry location for their primary care residents. I'm not directly addressing that, but the build out costs are being funded by the grant, but it is going to be a required location for about eight primary care residents a year. And I would say that one thing I'm very happy about is the clinic that you've already built out that seems like it can incorporate outside residents very easily. Because the challenge, and I'm sure there's something similar in New York, is that mental health is so siloed, the delivery of mental health is so siloed in California. You have specialty mental health, this year it's mental illness, now it's moderate illness. It's probably out on the medical plan. And you have multiple different individual providers. And so kind of organizing that, creating a substantive rotation by sending UCSF residents to an organization here that delivers trauma-focused therapy to a county clinic here. Setting up all those kind of reviews and all that stuff is pretty complicated. And I can see why oftentimes it's just default to why don't we just put them on a unit other than the psychiatric emergency room and just let them get the experience there, which is what they're looking for. Yeah, I think one of the things that we are also looking for is, like you're saying, you're trying to incorporate this into the UCSF program. There's strength in numbers, right? So if more programs are doing it, and then we can come together and kind of project it even more, the more likely it is that we can get the core, essentially. I'm going to do cross-collaboration between different... There are some other programs within New York City who we've been talking, they've been doing some form of the psychiatric rotation. Yeah, so more numbers, definitely. I mean, there is so much power in numbers, so we're going to try to put all of this together. We're writing a paper for our advert. We're submitting for the journal, which we're going to show our survey data. So I think, to your point, I definitely think they should be doing something if that is a good starting point, just like our MI patients, that we do more MI for the patients. I think if somebody wants to start with an ER or an inpatient unit, that's fine. At least we are getting them to start coming to our psychiatric units. But eventually, I think 80% of the care happens in clinics, and not only 20%, but the acute care settings are predominantly the most costly ones. But most of the care happens 80% in the primary care clinics. So I think having set up this in primary care clinics adds so much value, and the number of referrals come down drastically after year two or year three, because they're very comfortable in prescribing these medications. Okay, so just to be respectful of everyone's time here, we have the last five minutes, and this is, I think, something we do for all the workshops. We have three questions, same format, poll everywhere. We are going to go through the self-assessment, and then we'll be done. You said S-G-I-M, right? Thank you. That's a good resource. So the first question that we have, as per the NIMH data from 2019, number of patients with a mental health diagnosis and the percentage receiving treatment is? And you can do the same thing. You can either text it on Poll Everywhere or respond on the Poll Everywhere link. We'll give it like a minute per question, and then we'll see the answers. All right, so that is the right answer. It's 51.5 million and 41%. Thank you. The next question, the key components of the integrated care model are co-located care, collaborative care, PCP coaching, or all of the above, or none of the above? If you think it's none of the above, you can choose option E. Yes, sorry. There we go. That is correct. All of the above is the right answer. And the last question, who is consulting the psychiatrist in the collaborative care model? Is it the PCP? Is it the psychiatrist themselves who is finding cases? Is it the behavioral health care manager? Is it the patient? Or none of the above? Yep, everyone got 100% on all three questions. So going back and making sure that we don't have any slides left. We have two minutes left for questions, if anyone has any last comments or questions. And then we'll move on to the next slide. We have two minutes left for questions, if anyone has any last comments or questions. So we do have LMSWs and LCSWs, clinical social workers for the most part. And they're conveying, they're presenting a specific patient to you. You're recommending new medicine or changes in medicine. They're conveying that word of mouth back to a primary care doctor. A primary care doctor, right. Does anyone have any discomfort about that arm's length transmission of treatment recommendations on specific patients? What we do, I mean, obviously in the beginning everybody has questions about it. How are they prescribing without even seeing the patient? But I think eventually, after a couple of months, the PCPs were much more comfortable. The PCP coachings and everything were helpful too. But one thing to add to your point is when we give recommendations, what we have seen is if we reduce the barriers, we send the recommendations just not to the case manager, we also CC the PCP on it. Because that actually reduces the error. So the lesser bottles to communicate, it's easier to communicate in that way. So what we did, what we do is usually when we send them back recommendations, we send a secured health message to both the case manager and the behavioral health case manager and the PCP at the same time. There are times when they ask us a question back. They'll be like, okay, this patient's liver enzymes are not so good, so can we prescribe something else? It's a very fluid communication channel once the trust is developed. And I was just saying that we actually incorporate it in a note, which we forward to the PCP. So we've been doing a collaborative care model in our accuracy for a number of years. It works extremely well. To your point earlier, there's the issues in the detail. So how do you get the care manager to pay for it and do that? So we do, they work in the primary care person's note, so we've done some paid-up things. My question is, if you're doing collaborative care effectively, robustly, do you think you still need to do the co-location care piece? From our experience, it has been helpful. I think the biggest help is the PCPs have a feeling when we are present at the same place. They feel like we all are the same team. I think there is definitely a psychodynamic component to it, but also many times they need a diagnostic clarification. What I've seen is they want to do it, but they're not sure, so they usually send somebody for it. And also, as I said, there are some patients, especially in family practice clinics, who also manage schizophrenia patients. They do take some higher-level psychiatric severity. So what we have seen is those clinics, especially the family practitioners or internal medicine, patients are stable. I was telling somebody before, they're on Respiradol 2mg BID. They're stable. But the PCPs are not comfortable prescribing antipsychotics. They're comfortable prescribing antidepressants. So should we send them to a psych clinic? Because there is already a big wait list for going to speciality clinics. If I'm the co-located psychiatrist, I can see this patient. I mean, the patient is pretty stable. They don't need some kind of a case management services or a wraparound services. So I think that helps. That particular level of care of having a co-located psychiatrist helps for those people who fall in those gray zones between primary care clinic and psychiatric clinic. I've seen it. Our schedules are full. We've been pretty. I like it. I mean, I think it has worked out so far for us. No, we don't. Most of the times, if it's a short-term treatment or a diagnostic clarification, sometimes if they have a level of care determination question that the behavioral health case manager is not able to solve, so then they send them to us. Very rarely we do have some patients in some family practice clinics especially who have been with us for a long time. They have stayed there because they're on like 15 milligrams of Zyprexa, but they're stable on olanzapine for almost five or eight or ten years. So if they're stable, why should I send them to a psych clinic? What extra would a psych? I always think of, okay, if I'm sending them to a speciality clinic, what more would they get there? If they're not getting anything more there, I can treat them here. I mean, it actually saves the patient's time because they don't need to go to six different appointments. They can come to one clinic and get everything done there. Currently it's single-session therapy as well. Yeah, that's a very good point, actually. The warm handoff has been very helpful in our case. It has been very helpful. Any other last thoughts? Thank you so much for attending. Thank you. Thank you. Thanks.

psychiatric care

underserved communities

integrated care systems

behavioral health

primary care clinics

collaborative care models

training gaps

psychiatric medications

cost-effective

patient satisfaction

residency programs

psychiatric curriculum