So, a few questions have been streaming in. So, there are a couple questions about people talking about which way to integrate. Should they bring primary care to the psychiatrist so that the patient comes to the psychiatrist and gets the one-stop shop there? Or do we bring a psychiatrist to consult in primary care? And we're wondering if you had any thoughts on that. Yeah, no, that's a great question. And so, it really depends on the population. I mean, I think the AEM Center's work, right, which I imagine you all are aware of, that's the collaborative care model that's been shown in like over 80 randomized trials to be effective, that brings a psychiatrist into primary care settings to serve as a consultant there. And that's shown to be beneficial for treating depression in primary care settings. Here, I think there's opportunity to do both, but my bias, because people with serious mental illness, so I'm focusing on people with schizophrenia, bipolar disorder, those that go to community mental health settings, my view is that those who are there in community mental health settings who are receiving all the wraparound services that they might need, and often come in maybe once a month or every other month, that that's where we should be integrating primary care in there. In the ideal setting, in my opinion, there'd be a full, you know, that all of our systems would be fully integrated, and that there'd be an urgent care drop-in clinic right there that, you know, that we would be able to access our primary care docs immediately, right, and that we'd be working in full integration and full partnership. We're not there yet, right, and so for now, it's, I think that's why I've been developing through Cranium this idea of having more of a consultant to primary care consultant, where you can kind of facilitate some of this early treatment while actively trying to connect to your patients to primary care settings. Perfect. Sort of a follow-on to that is, how can we help our primary care physicians feel more comfortable with this population? I know you mentioned a lot of people you've worked with who maybe had a tendency or comfortableness with this population, but sometimes we're in sites where the primary care physician has no interest, but we really have no choice. We really need them to be comfortable with this population. What do you recommend? Yeah, that's such a great question, too, and there is such a variety in how comfortable primary care providers are in treating this patient population. It was interesting because a colleague of mine had talked about potentially starting up a clinic where primary care patients just, that's all they saw was people with schizophrenia, and I was like, well, it'd be hard to find people who wanted to do that, right? But I think that our primary care colleagues are so skilled at using algorithms and I think they don't need a lot of support, but they need some. Actually, I'm working with a really fantastic primary care colleague now, Dr. Lisa Ochoa-Frangia, who has a HRSA Career Development Award, and she's in a safety net primary care clinic, and we're working on helping to leverage remote psychiatric consultations where the psychiatrist could be available more on-demand to an internist if they were treating a patient. It's often in these resource-poor settings that you don't have a full-time psychiatrist that can just jump in there with all of the patients, but wouldn't it be nice if we could pick up the phone and talk to a psychiatrist and say, hey, I'm here with my patient. They're struggling with these voices still. They don't want to go to specialty mental health settings. I'm thinking about starting this medicine. Is that okay? And that they could get a little bit of help from the psychiatrists in doing that. I think also another thing that I was talking to Amy about that you all can see on your screen is this consult request. I was saying maybe we should be making sure our primary care colleagues know about this consult request opportunity through SMI Advisor. That they could ask if maybe they're in a setting that they don't have a psychiatrist around, and they can put in a consultation here to be able to talk to a provider. I think that they don't need actually that much. When you hear Dr. Unitzer, who's the chair at the University of Washington, and Seattle, and head of the AIM Center, when he talks about the collaborative care model, he says, I have a pager, and people can call me whenever. They call rarely. They really need a little bit of support. Right. I'm thinking of a project that we did outside of SMI Advisor, and one of the things, one of the skill sets that we really focused on to help primary care providers was some motivational interviewing in the face of negative symptoms. When your patient has a lot of negative symptoms, and you're not getting a lot of feedback, or you don't see a lot of energy around the goals, to talk a little bit about how to do motivational interviewing in the face of that. That has also been successful, we found, with some primary care physicians. It's funny, because I think that's true, too. I think as we are increasingly asking our primary care colleagues to do more and more behavioral health in those settings, we need to be thinking about being with them in requests, as we're thinking about reimbursement for this kind of work. They're so busy. They're with these complicated patients and have 10 or 15 minutes. That's a lot. Allowing them to have more time, and being able to bill for more time, and have more primary care providers that are able to access some tools that we can give them are good. I love the idea of helping them do more motivational interviewing. They can do a little bit of that, but this is a whole career to figure out how to help the primary care colleagues deal with some of our patients in those settings. I think it needs a lot of work. A really great question came in, which is something that I hear a lot when I'm in the field, which is, can we discuss scope of practice issues with psychiatrists evaluating and treating medical conditions? That's a great question. Actually, we get into that in our module. I think one of the main things about our module is we are talking about really three conditions, hypertension, diabetes, and dyslipidemia. All of those are known side effects from our prescription of the medications, the antipsychotic medications that we give. There's plenty of studies that have been shown about that. In regard to the scope of practice, initiating some preliminary treatment. Again, these are baby doses of medicines. I think in some ways, it's actually we're more at risk documenting how badly controlled people are and not treating anything at all. We're in a, look, this is not the ideal system. The ideal system would be there being that the patient would be able to see their internist and the internist would be able to do that, or we'd have a full-time nurse practitioner on-site who'd be able to do all these things. We don't. How I feel about it is we're doing a little bit of what we can. Definitely, we've talked to legal around this. You're within your scope of practice if this is something that other providers will do, which has been documented about and published on about people starting metformin and other treatments to deal with the metabolic side effects. Also, just that you're trying to do no harm, that your patients at risk for early morbidity and mortality will not connect with primary care. You're initiating some work while actively trying to connect them with primary care services. I'm not saying that somebody with psychiatry start managing insulin. I don't think that would be considered outside of our scope of practice. However, starting a little bit of metformin I think is. We're a doctor, we're in the house, and our patients are having a hard time connecting with the primary care colleagues. While that's a problem and we're seeing them regularly, I view it as our role to try to help them. We've had a couple of questions. Remind us again how we could access your module. Sure. I'm not sure if it's on the SMI advisor. Maybe we want to go back to it so we can show there. It's comorbid-health. We spent a lot of time building this and we've gotten lots of good feedback on it. Please put your feedback on the SMI advisor website if that's available. I hope that's helpful to you. This makes it as easy as possible and shows all the different side effects and deals with scope of practice. You've mentioned several times the AIMS. Can you talk a little bit more about that model? Oh, of course. I'm sorry I don't have a slide on this, but I'm wondering, Amy, if you have something on the AIMS Center. I'm not sure if you do. Do you? We don't have anything particular, but we certainly could answer questions about that if needed. If you wanted to maybe just give a little introduction and then we can direct people to a consult. Sure. Basically, the AIMS Center, you could just put it into your Google, AIMS Center, A-I-M-S. That's a center in the University of Washington. That is a center that built something called the Collaborative Care Model. The Collaborative Care Model has four main components. One is a team-based care, so they have a psychiatrist, a depression care manager, and a primary care doc, all working around the patient. Then they have a population health method, so they use registries, meaning a list of your panel of patients to manage things. They use evidence-based screening measures, so they use PHQ-9 or GAD-7. Then they have standardized treatment protocols, evidence-based treatment protocols, which also include problem-based therapy and other non-medication treatment. This is all aimed at treating depression in primary care settings. Kind of similar to how we were talking before, a lot of people with depression don't come to psychiatry. They go to primary care. The AIMS Center and the Collaborative Care Model was built to deal with those patients who were in primary care settings and make sure that they got evidence-based depression care. The work that I'm talking about today was more the reverse, where I'm talking about people with schizophrenia surgeon, specialty mental health settings, who have these metabolic problems and other problems, and how can we start treating them and screening them in our setting. Does that help? Yeah, I think that helps. I would just point out on the screen right now, you have the mobile app. Within that, on the lower right, you can see the tile that says rating scales. In that, we have the PHQ-9 and the GAD-7, which you can do with your patient with the app open, and it will automatically score it and give you interpretations of the scores. If you wanted to use the measurement-based care to see if this is working well and you're actually having some impact on these symptoms, you could easily do those rating scales through the app every time the person visits. I think there are some tools there. Plus, as you mentioned, at SMI Advisor, we do have certainly knowledge-based questions and answers, frequently asked questions about collaborative care, and we also have some resources there via webinars.

primary care

psychiatric services

collaborative care model

depression treatment

mental health integration