Scott Zeller, M.D.Vice President, Acute Psychiatry, VituityAssistant Clinical Professor of Psychiatry,
University of California, Riverside
Psychiatrists and Case Management: More than just the Medication
How Psychiatrists Can Get InvolvedIn Case Management Of Individual Patients
• Can be very helpful in the big picture and long-term plans
• Can assist with determination of appropriate placement• Can provide definitive diagnoses that may remove
barriers or open new possibilities• Can reassure exit resource sites about patients fitting
into their capabilities• Can recommend treatment plans to ensure long-term
stability and minimizing disruption
Zeller’s Six Goals of Emergency Psychiatric Care
• Exclude medical etiologies of symptoms and ensure medical stability
• Rapidly stabilize the acute crisis• Avoid coercion• Treat in the least restrictive setting• Forge a therapeutic alliance• Formulate an appropriate disposition & aftercare plan
from Zeller, Primary Psychiatry, 2010
How Psychiatrists Can Help Case Managers: Differential Diagnoses• Ensuring that patients’ diagnoses are accurate• Ensuring the degree of impairment accurately reflects the
patient’s care needs• Inaccurate psychiatric diagnoses may interfere with transfers• “I think he caught Schizophrenia”
How Psychiatrists Can Help Case Managers:Clarification of Medication Needs• Proactively address need for psychotherapeutic drugs, and/or
addressing if prescribed antipsychotics are truly indicated.• Understanding Psychotropic/Psychotherapeutic Medication:
A broad category of medications, psychotropics are administered by physicians in many healthcare and community settings, including hospitals, skilled nursing homes and assisted living centers. The term psychotropic is an all-encompassing description which includes mood stabilizers (anti-manic agents), anti-depressants, anti-anxiety, hypnotics and antipsychotics
California Association of Health Facilities (CAHF) Data
• California performs better than 45 other states, ranking 5th lowest in the nation in using antipsychotics in skilled nursing facilities
• Many CAHF members took part in a national effort to safely reduce the unnecessary use of antipsychotic medication in skilled nursing homes by 15 percent by December 2013. The goal was reached and surpassed. The actual reduction as of Q2 2019 was 48.5 percent
• Each facility is required to have a pharmacist review the use of psychoactive medications each month and report any irregularity to the attending physician, and director of nursing for prompt follow-up action
• Federal regulations also require that proper medication is administered by attending physicians and that residents must be free from unnecessary drugs. An unnecessary drug is any drug when used:In excessive dose (including duplicate therapy): orFor excessive duration; orWithout an adequate monitoring; orWithout adequate indications for its use; orIn the presence of adverse consequences; orAny combination of the reasons above.
FEDERAL REGULATIONS Regarding Psychotropic Med Use in SNFs
• The regulation’s intent is that the medication regimen helps promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being, and each resident receives only those medications, in doses and for the duration clinically indicated to treat the resident’s assessed condition, non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, and clinically significant adverse consequences are minimized.
FEDERAL REGULATIONS Regarding Psychotropic Med Use in SNFs (cont.)
CA State Additional SNF Psychotropic Med Regs• The state of California also requires informed consent for use of
psychotropic meds in SNFs• Residents and/or their families must be informed about their
medications. No one receives psychoactive medications without their permission or the permission of their authorized decision-maker
• Resident health records must document that informed consent has been obtained for the administration of psychotropic drugs.
• Residents have the right to refuse treatment• Skilled nursing facilities face routine, unannounced inspections.
Fines are issued for non-compliance
Special Case: Psych SNFs• Facilities provide 24-hour care to residents with a primary psychiatric
diagnosis who may also possess a co-existing medical conditions or to residents with 24-hour medical needs who have secondary behavioral conditions
• Facilities are generally locked units, licensed by the California Department of Public Health and certified by the California Department of Mental Health. Physicians and psychiatrists often appropriately prescribe antipsychotic medication to patients with diagnosed mental disorders including delusions, hallucinations and schizophrenia. These programs also provide individualized plans of care, including behavior modification and special activities to help residents maintain quality of life and the highest level of functioning
How Psychiatrists Can Help Case Managers: Suggestions for Behavior Management Strategies
• Effective behavior management interventions can help reduce dosage or even need for some medications
• Required to consider for SNF patients
How Psychiatrists Can Help Case Managers: Suggestions for Behavior Management Strategies (cont.)
• Environmental modifications• De-Escalation techniques• Cultural Competency
How Psychiatrists Can Help Case Managers: Supporting Partnerships with SNFs and Other Community Providers
• Providing suggestions, support and education to exit resource programs
• Individual patient consultation for SNF residentsTelepsych options for SNFs now common
How Psychiatrists Can Help Case Managers:Operational Implications• Avoiding hospital readmissions• Facilitate return to SNF following ED visit • Avoid initial transfer to ED from community programs• Support informed consent process for psychotropic meds
Questions?
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