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Questions of Collaboration at a Distance

Posted By Kenny Phelps, Thursday, April 28, 2011
Updated: Wednesday, May 25, 2011
Professionals in the collaborative field often speak of moving from silos to co-located and eventual integrated care, especially within the patient-centered medical home. I had the privilege to "come of age” as a therapist in integrated primary care settings. My clinical placements were alongside dieticians, health educators, nurses, physicians, and other health care providers. I found myself intrigued with intervening to control HbA1cs and BMIs through systemic interventions as much as assisting with couple and family discord.

An advantage of this training was to increase my awareness of systems of care and the full biopsychosocial picture. It also taught me about effective (and ineffective) collaboration. A disadvantage of this training was fewer instances of needing to collaborate at a distance. This would be understandable since colleagues were often in the room or down the hall, co-creating treatment plans. However, my acceptance of a position in an academic psychiatry context pulled me away from my primary care roots, as well as the easy access to these providers.

Certainly, my current role includes a great deal of multidisciplinary teamwork under the same roof, including psychiatrists, psychologists, family therapists, social workers, rehabilitation counselors, families, and patients. One could argue that mental health centers serve as the patient-centered medical home for many with chronic and persistent mental illness. This has been the impetus for integration of primary care providers into these environments. However, many individuals treated in our academic clinic present with acute clinical problems, such as adjustment disorders, major depression, panic disorder, or couple and family strife. In these circumstances, patients typically identify the primary care setting as their "home” for medical care. This fact has necessitated creative ways of linking care between primary and specialty care, as to not fall victim to the "out of sight, out of mind” problem.

On a systems level, we are integrating some of our providers into OBGYN, Family Medicine, and Pediatric settings to improve screening and treatment. We also have plans to use telepsychiatry to provide effective care at a distance. I have been involved with giving lectures on The Role of the Consultant Psychiatrist in Integrated Care, thereby increasing our residents’ exposure to the burgeoning efforts to meet patients were they are. While systems level changes are surely essential for improved healthcare, I believe that individual provider must take initiative to link with others while delivering care. Thus, I have developed a few questions that assist me in my clinical practice:

WHO needs to be talking to provide the best care possible?
This first question is the foundation for good collaboration in my opinion. The answer will likely be as divergent as patients’ presenting problems. For instance, a child with oppositional behaviors, asthma, and Asperger’s might warrant collaboration between a therapist, pediatrician, and school teacher; whereas, an adult with panic disorder, hypertension, diabetes, and significant suicidal ideation might warrant collaboration between a family physician, psychiatrist, therapist, and nutritionist. Thus, this is a question I ask myself and will also ask the patient during an encounter. The answer to "Who do you think needs to be talking to provide you the best care possible?” is often answered with "maybe you should talk to my husband, pastor, or friend.” I believe this reiterates the importance of including patients and their support systems on the health care team.

WHAT information should be shared with my collaborators?
The amount and type of information shared when collaborating at a distance often depends on the recipient. Considerations for this question include: What information is relevant to my collaborator? What can I share given limitations on confidentiality? What can I share given the amount of time to collaborate? Too much or irrelevant information may be met with frustration by collaborators, whereas relevant and pertinent information can improve treatment plans. Beyond shared information, the question "What information do I need from my collaborators?” is vital as well.

WHEN should collaboration occur? I typically try to contact collaborators when there has been a significant change to my treatment plan or I have the sense that there have been significant changes to their treatment plan. Beyond the frequency of collaboration, the specific time to collaborate can also be important. For example, I typically do not phone school teachers in the middle of their academic day, but either first thing in the morning or directly after school has been dismissed. If there are specific collaborators that I need to speak with regularly, I might ask "When would be the best time to reach you?” to avoid the familiar and frustrating game of phone tag.

WHERE are collaborators located? Since I prefer face to face collaboration, sometimes I like to ask where my collaborators are located. Collaborative care is a relational process and building these connections is an important piece of any practice. Thus, I will sometimes ask a family physician across town that shares 4-5 patients with me to meet for lunch or will ask a pediatrician if I can stop into their practice on a Monday morning to chat about our shared patients for a few minutes prior to starting our respective responsibilities for the day. While this is not always feasible, I am surprised that colleagues are often 5 minutes down the road.

WHY should I bother? This is probably my favorite question. Historically, I have worked with behavior change in my clinical work. This has involved talking at length with patients who may be precontemplative or contemplative about changing habits of smoking, overeating, or medication nonadherence. I am certainly not exempt from these stages of change either. There have been many instances where I was precontemplative about having to pick up the phone or write a summary letter to a colleague. Thus, asking oneself "Why is this important?” can be especially useful. Even utilizing strategies such as advantages/disadvantages analysis can spin us into preparation or action stages of change.

HOW should I collaborate? Once I am aware of the who, what, when, where, and why elements of collaboration, the final step often involves how I should collaborate. Commonly used strategies include phone consults, summary letters faxed or mailed, or creating a notebook for the patient or family to carry from appointment to appointment. In our setting, we have developed a simple form that includes the patient’s name, appointment date, DSM diagnoses, medication changes, vitals, and other comments (goals, strengths, follow-up) that can be easily completed and faxed to the primary care office after a first appointment. Formulating protocols or forms such as these can ease the process of collaboration at a distance.

While delivering clinical services in an integrated care system has clear advantages, elements of our health care system will always operate at some distance. Electronic health records could significantly diminish this dilemma. Until these technological advances take hold, individual providers can go a long way to improve communication and the overall cohesion of care. I leave you with one last question: "Why did you decide to do what you are doing?” For many of us, it was to provide patients and families with relief from their medical or psychological struggles. In order to do so, we need to collaborate no matter the distance…whether next to one another in an exam room or many miles away.

Kenneth W. Phelps, Ph.D. is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina. He was trained as a Medical Family Therapist at East Carolina University.  Dr. Phelps has been a member of CFHA for many years and currently chairs the Membership Committee.

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Randall Reitz says...
Posted Saturday, June 25, 2011
Ken, your post is great challenge. The world of integrated care is increasingly populated with health systems that have achieved high level integration. Many of these have gone from no collaboration to full integration in one step. Unfortunately, due to financial limitations, most of these gains have been achieved in safety-net clinics, training programs, and vertically integrated healthcare systems. In the for-profit world, collaboration at a distance is still the most sustainable increment. In these areas, I believe more success can be gained by improving the connection between psychiatry and primary care rather than behavioral services (counseling) and primary care. Living in a psychiatry shortage area (Grand Junction, CO) I’m aware that a psychiatrist who empowers primary care physicians to keep most cases in outpatient clinics can do much more than adding another outpatient psychiatrist to the community.

What models have you seen work the best for psychiatry extending?
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