ADVANCES IN PSYCHIATRY Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College Embedded Psychiatrists: JUNE/JULY 2014 A Consultation-Liaison Model in the Era of Health Care Reform Jeffrey A. Lieberman, MD As part of the Affordable Care Act, health Psychiatrist-in-Chief NewYork-Presbyterian/ insurance plans sold on the public health exchanges Columbia University must include coverage for mental health care and Medical Center substance abuse treatment. Rules were finally Director, New York State issued last fall to implement a 2008 parity law Psychiatric Institute requiring insurers to provide mental health care [email protected] coverage comparable to their physical health care Jack D. Barchas, MD coverage. The new parity rules, which apply to Psychiatrist-in-Chief most health plans, are effective beginning July 1, NewYork-Presbyterian/ but several plans will not have to comply until Weill Cornell Medical Center January 2015. These significant changes in mental [email protected] health coverage will inevitably lead to an increasing demand for mental health services. Yet at present, this demand will have to be managed by approximately the same number of psychiatrists available before the initiation of these policies. CONTINUING (continued on page 2) Dr. Elena Friedman MEDICAL EDUCATION For all upcoming education events through Advancing Strategies for Agitation in Alzheimer’s Disease NewYork-Presbyterian Hospital, visit www.nyp.org/pro. Three of the four most common reasons for institu- and the treatment of psychosis and agitation. tionalization for individuals with Alzheimer’s “Numerous studies over the years have focused on disease are psychiatric symptoms – agitation, the treatment of agitation, including behavioral wandering, and psychosis. “A number of studies and psycho-educational interventions for the patient have shown that more than 90 percent of patients in conjunction with a family member or caregiver who have Alzheimer’s disease develop one or more in the home,” says Dr. Devanand. “However, these psychiatric symptoms during the course of the studies have shown only a small advantage with disease, including depression, anxiety, and delu- personalized interventions because of the lack of a sions,” says Davangere P. Devanand, MD, Chief control group and the number of variables involved. of Geriatric Psychiatry, Department of Psychiatry We clearly need more large-scale systematic studies at NewYork-Presbyterian/Columbia University that directly compare behavioral management to Medical Center. “But the most common symptom use of medication. They just haven’t been done yet.” seems to be agitation, which can cause, among other things, pacing, sleeplessness, or aggression.” Education and Medication Approaches NewYork-Presbyterian Psychiatry Dr. Devanand, who is also Co-Director of the In coping with agitation, Dr. Devanand emphasizes ranks #2 in the nation. Memory Disorders Center and Co-Director of the importance of educating caregivers about the the Late Life Depression Clinic at the New York nature of the disease. “Caregivers will often say, ‘my State Psychiatric Institute, has earned national wife has just turned against me’ or ‘my husband just recognition for his pioneering studies on the doesn’t like me anymore,’ whereas that is really just a interface between depression and cognitive function of the disease progressing in the brain,” he impairment in the elderly, and for his research into says. “So education is very helpful in getting them to early diagnostic markers of Alzheimer’s disease recognize that the change in behavior is due to the (continued on page 2) Advances in Psychiatry Embedded Psychiatrists: A Consultation-Liaison Model in the Era of Health Care Reform (continued from page 1) The pressure on mental health care services is further exacer- patients may be taking along with their other medications. “Very bated by the rapid growth of an aging population. As people live often medications given in a hospital can make elderly patients longer, there inevitably are more patients dealing with anxiety and worse – more confused or more agitated,” says Dr. Friedman. “For depression due to medical problems. Add to this the number of example, working within the team enables us to make sure that elderly developing some degree of cognitive decline – ranging from elderly patients with dementia are not given medications for sleep or mild cognitive impairment to dementia, which can cause patients anxiety that can actually make them more confused.” to be more prone to delirium and behavioral disturbances – will As an essential member of this team, the psychiatrist plays a expand dramatically in the coming years. Therefore, it is essential crucial role in identifying those patients who need to be transferred to begin leveraging existing psychiatric services so they can provide to a psychiatric service or to a rehabilitation program for addiction care to the growing volume of disorders. “This helps the patient insured patients facing mental and helps the team, and can also health challenges. “ Embedded psychiatrists are better prepared to reduce length of stay, which is One approach promising preempt any psychiatric issues because they are good for the Hospital as well,” to reach more inpatients with alerted early to the admission of each patient their notes Dr. Friedman. comorbid psychiatric disorders team is overseeing.” According to Dr. Friedman, than the standard consultation- — Dr. Elena Friedman this embedded psychiatrist model liaison model is another is a good one. “Working together liaison model – the embedded with a team makes everything psychiatrist model – which was established with inpatient medical function much more smoothly,” she says. “You see each other every teams at NewYork-Presbyterian/Columbia University Medical day and know each other, which helps all of us to take care of patients Center and NewYork-Presbyterian/Weill Cornell Medical Center and to ensure they receive necessary treatment and receive it sooner.” in 2010 and 2012, respectively. In this model, a psychiatrist is a A version of this model is also applied in some of the Hospital’s member of the medical team. Rather than contacting the Hospital’s outpatient clinics, where patients often present with psychiatric and consultation-liaison service for an independent psychiatrist psychological disorders. In these clinics, overseeing psychiatrists who then would work with the team in treating a psychiatric work closely with physicians, nurse practitioners, and social workers, comorbidity, the medical team now need only look to one of its supervising these staff members when necessary and providing direct own members: a psychiatrist who participates in daily rounds and psychiatric care to patients with serious mental health disorders. is an active participant in the care of the patients. “By partnering with inpatient medical or primary care clinic teams, psychiatrists are able to reach more patients, despite not Role of the Embedded Psychiatrist personally interacting with every patient with mental health care “Embedded psychiatrists are better prepared to preempt any needs,” adds Dr. Friedman. “Embedded psychiatrists also have psychiatric issues because they are alerted early to the admission an invaluable opportunity to educate and supervise physicians of each patient their team is overseeing,” says Elena Friedman, and social workers on mild to moderate psychiatric disorders. MD, a member of the Psychiatry Consultation-Liaison Service For example, we work closely with internists who, even without at NewYork-Presbyterian/Weill Cornell Medical Center. “I don’t formal training, are often very well versed in psychiatric issues wait to be consulted. Instead I look through the charts of the new because they see so many patients with these issues. When we admissions to predict any issues that might come up. I can see work together, we really can help more patients and perhaps not right away if there is any history of psychiatric illness, or if the be so overwhelmed by the increasing volume of patients requiring patient has been seen by psychiatry before, or if the patient has had mental health services.” any behavioral disturbances. I can then speak with the team and together we can figure out which patients I should see.” The embedded psychiatrist also works closely with the health care For More Information Dr. Elena Friedman • [email protected] team to manage medications, including psychotropic drugs that some Advancing Strategies for Agitation in Alzheimer’s Disease (continued from page 1) brain disease and not a voluntary action on the part of the patient warning that these medications can increase the risk of death in or some deep-seated problem.” patients with dementia, and subsequently the Centers for Medicare While atypical antipsychotic medications given in very low and Medicaid Services (CMS) decreed that nursing homes should doses have shown to be somewhat effective in reducing agitation, reduce their use. these medications have associated side effects, compounded by “Many nursing homes are trying to do this, but some of a combination of the age of the patients and their disease. In the patients are quite agitated and many are also psychotic so addition, while many patients improve on antipsychotics, the it becomes very difficult to manage their care without these side effects can prevent one from achieving a therapeutic dose. antipsychotic medications,” says Dr. Devanand.