Providing Interdisciplinary Care: Collaboration Toolkit Podcast
Interdisciplinary care for mental health patients is crucial in healthcare today. This peer-to-peer discussion reviews ways in which NPs can facilitate care between disciplines and providers to optimize patient care.
Transcript:
PM: Hello, I’m Dr Pradeep Manudhane, and I am a psychiatrist.
KM: I’m Dr Kathleen McCoy, and I am a psychiatric mental health nurse practitioner.
PM: Today Dr McCoy and I will discuss interdisciplinary collaboration in mental health care.
KM: Interdisciplinary collaboration is the deliberate coordination of care and sharing of information and resources among healthcare providers for the purpose of providing effective, safe, high-quality care for patients.1 It is also termed care coordination, coordinated care, or multidisciplinary care. Now, why do nurse practitioners need to be concerned about and educated on interdisciplinary collaboration?
PM: Well, Dr McCoy, I see collaboration between disciplines as an essential way to ensure that mental health patients receive optimal care. For instance, if a patient is discharged from an inpatient unit and medical releases are not signed by both the psychiatric office and the medical office, then potential disruptions to care can occur. If all treatment team members are not aware of a patient’s status, optimal care may not be delivered.
KM: I agree, Dr Manudhane. Interdisciplinary collaboration may be particularly critical when a patient is not making progress in their current treatment and can potentially reveal a missed or incorrect diagnosis. Interdisciplinary collaboration is also important because nurse practitioners in nonpsychiatric fields, such as primary care or family medicine, may have some knowledge gaps about working with patients with mental illness. For example, healthcare providers in some disciplines may be unfamiliar with how to appropriately monitor patients on certain medications. This may be especially true when considering treatments that are not commonly prescribed in your usual therapeutic area or those that are newer and that you therefore don’t have much experience with yet.
PM: Yes, it is important to review, understand, and implement protocols such as what labs to order, what factors to monitor and how often to monitor them, and what interventions may be necessary based on the results obtained. For example, some psychiatric medications are associated with weight gain. Regular monitoring of a patient’s weight allows early detection of weight gain and allows the clinician and patient to discuss whether a change in treatment plan should be considered.2
KM: Diagnosis is also a potential area for collaboration. Primary care nurse practitioners may not be familiar with diagnosing certain psychiatric disorders.
PM: Yes, Dr McCoy, there can be knowledge gaps in the mental health among primary care providers (PCPs). It is important to have the knowledge to create a comprehensive differential diagnosis, which leads to making the accurate diagnosis.
KM: Collaboration can help address treatment-related gaps in knowledge. For example, some primary care clinicians may not be familiar with the nuances of addressing incomplete or inadequate responses to initial pharmacotherapy in mental health. It can be difficult to know when to switch psychiatric medications and how to go about making these changes when necessary. It can also be difficult to judge whether switching medications or adding an adjunct medication would be the next appropriate step for a patient in their treatment.
PM: It is natural to feel hesitant about medication regimens that you have not used before or rarely use. For example, using combination therapy, in which more than 1 medication from different classes are combined, requires a clinician to be comfortable with managing potential side effects as well as potential interactions between medications. Also, knowing when to simply leave things alone and take another approach can be difficult—whether that is watchful waiting or adding a nonpharmacologic therapy.
KM: Another important consideration is taking our responsibility seriously as clinicians to continuously educate ourselves and to stay abreast of the most up-to-date clinical research and treatment guidelines.
PM: Absolutely. There may be a tendency to sometimes stick with resources or treatment protocols that we have learned of and became familiar with during training. However, information presented by instructors and preceptors during our training may now be outdated. We must not be complacent and default to what is familiar to us as clinicians.
KM: Yes, it certainly can be the case that the resources, information, and treatment guidelines we learned in training are no longer supported by more recent evidence. So, how can we as nurse practitioners improve our working knowledge of psychiatric diagnoses and recommended therapies, especially keeping in mind that we want to be accessing the most up-to-date information?
PM: There are many respected, peer-reviewed psychiatric journals that can be obtained without cost. Some that I recommend include the Journal of Clinical Psychiatry and Current Psychiatry.
KM: Of course, the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition, Text Revision (DSM-5-TR) is the gold standard in psychiatric diagnosis and also provides information about best practices. During a busy clinic day when you need to access patient education handouts or reference a clinical rating scale, the NP Psych Navigator website can be a valuable tool. Although these resources do not take the place of working with a colleague in mental health, they can help make nurse practitioners more aware of the latest empirical findings in the field.
PM: I agree, Dr McCoy. Staying up to date with current research and treatment guidelines in our field is important, but it does not take the place of interdisciplinary care. One important topic to stress here is the role of PCPs in caring for patients with mental health symptoms. Evaluating patients with, for example, depressive symptoms may feel like a burden to some PCPs; it may be something that you don’t feel equipped to evaluate and tend to refer out of your practice. There are several reasons why PCPs should recognize their true and significant value in seeing and caring for these patients. First, there is a serious shortage of psychiatrists and specially trained mental health care providers in the country. In fact, over 100 million Americans live in an area with a mental health service shortage.3 For this reason, the ability and willingness of primary care clinicians to initiate evaluation and, if comfortable, treatment for their patients with mental health concerns is of paramount importance.
KM: Yes, I encourage my primary care colleagues to consider initiating evaluation for such patients. For patients presenting with depressive symptoms, for example, you can download the Patient Health Questionnaire, or PHQ-9, to give to patients while they are in the waiting room before their visit. This 9-item clinical scale is often used by primary care clinicians initiating evaluation for depression. Keep in mind, screening for depression in the primary care setting is recommended for all adults by the US Preventive Services Task Force (USPSTF).4
PM: To know that our primary care colleagues are caring for mental health patients is so important, especially given that it can be difficult for them to schedule with a specialist, which could lead to delays in evaluation and care.
KM: Of course, there will be times when a primary care clinician feels that referral to or discussion with a specialist is in the patient’s best interest. Collaborative or integrated services can help reduce disparities that result in patients experiencing a lag in diagnosis or treatment. It can also facilitate earlier intervention, reduce or prevent comorbidities, and help patients who would never seek out psychiatric specialty care access these specialty services or be treated by their primary care nurse practitioners or provider.5 When we collaborate across disciplines, we are more likely to offer care that is safe, effective, and efficient for our patients.1
Implementing Interdisciplinary Collaboration
PM: Now that we have reviewed the importance of interdisciplinary care, we will discuss its implementation, including the “nuts and bolts” of what interdisciplinary collaboration means and how this may be accomplished. Dr McCoy, when would you recommend to our primary care colleagues that collaborations with psychiatry may be the next best step?
KM: I recommend that primary care clinicians collaborate with psychiatrists whenever the situation is complex, such as when a patient is not making progress on their treatment or when there is a problematic side effect. Collaboration can also be beneficial when you are having difficulty making a diagnosis or identifying which medication might be best suitable for an individual patient. I think it is important to get in the habit of collaborating on a regular basis. Psychiatric mental care is, in some ways, a team sport. It can be important and beneficial to have input from multiple clinicians.
PM: When reaching out to specialists to discuss a patient, always remember to protect patient privacy. Ensure that your method of communication meets HIPAA (Health Insurance Portability and Accountability Act) standards. Remember that SMS text messaging is not HIPAA compliant if your text contains protected health information (PHI).6 You can use SMS text messaging to send non-PHI, like consultation requests.
KM: That is such an important point to remember in this day and age. When I consult specialists, I sometimes use more formal communication channels, such as sending a letter or communicating through our portals. Other times, when I happen to cross paths with a specialist, for example, I will “curbside consult.” I ask them for general advice that I may be able to apply to a patient.
PM: When referring a patient to a psychiatrist, it is vital that the primary care nurse practitioner contacts the psychiatrist’s office first and explains why they are referring the patient. Do not just give the patient the psychiatrist’s name and contact information and expect them to set up the appointment. Patients may not understand why they are being referred to psychiatry, and they will not be able to discuss the clinical scenario as a professional can.
KM: The PCP should supply all important details about the patient’s case, so the psychiatrist has essential information such as the patient’s history, current diagnosis, medications and other treatments, current functional status, and any safety concerns (for example, if they are a potential danger to themselves or others). When planning to refer a patient for specialty care, ensure that they sign a medical release so that their medical records can be freely exchanged without delaying care.
PM: Make sure to give the psychiatrist’s office your updated contact information to facilitate communication. Also, if labs or studies are ordered, consider copying the consultant’s office on the results.
KM: Yes, and another thing to remember when referring a patient out for specialty care is that you should not assume what treatment plan a specialist may decide on. For this reason, it is important to avoid suggesting treatment recommendations to the patient that you think the specialist might prescribe or recommend. We should always allow consultants to complete their own evaluation and avoid muddying the waters unnecessarily.
Key Elements to Successful Interdisciplinary Collaboration
PM: It is wise to establish access to many other healthcare providers in your area to maximize your pool of potential collaborators, including both specialists you may refer patients to and providers who are likely to refer patients to you.7
KM: Remember, clear communication between all members of the treatment team is essential. This becomes especially important when it comes to care transitions. It is important to ensure that the patient’s entire history is shared with new clinicians joining or taking over roles within the care team.7
PM: In collaborative care, everyone should be focused on the overall well-being and needs of the patient, not just the aspect of care that pertains to their particular expertise.7
KM: Absolutely. Ensuring that you communicate with patients about who is involved in their care and why, about using patient-centered, nontechnical language when doing so, can help facilitate this collaboration.7
Interdisciplinary Collaboration and the Therapeutic Alliance
PM: Therapeutic alliance can be tricky in the context of collaboration because you do not want your relationship with the patient to be negatively affected by you bringing another provider into the picture. Some patients may feel like you are “unloading” them onto someone else or that you do not want to help them. It is important to ensure that patients don’t feel abandoned. Honest and open communication can help to facilitate this.
KM: I agree that open and honest communication is key in building relationships with patients. You should do your best to help your patients understand that the process of bringing in another healthcare provider to assist in their care is for their benefit—that you are doing this because you care and because you want the patient to get the best care possible.
PM: It can be useful to establish a solid therapeutic alliance before collaborating with a specialist so that the collaboration does not disrupt your relationship with the patient. Some ways to foster a therapeutic alliance include listening carefully to what patients say and prefer. When appropriate, consider treating patients as partners in identifying their needs and their treatment goals as well as in developing their specific care plans.
KM: Other ways to help in fostering this therapeutic alliance include synthesizing all the information discussed so that the patient understands everything, processing the informed consent with them, and allowing them latitude for treatment preferences. It is crucial to meet patients where they are.
PM: Yes; as we know, Dr McCoy, it is the patient who decides what they will or will not engage in. If the patient is unwilling or unable to work collaboratively with you, such as due to a lack of insight, then having an advocate such as a family member or trusted community member accompany them to appointments may be beneficial.
KM: Some steps you can take to build a therapeutic alliance with a patient referred to you may include letting the patient know that if there is someone important in their life who they want to be a part of their mental health care, they can bring that person to any visit that they desire.
PM: Also, asking referred patients to sign releases for all hospital stays, emergency room visits, and previous psychiatric and medical offices where they have been seen helps to ensure that you have access to all the necessary information about their healthcare history.
KM: Additionally, you can review any obtained records with the patient. This shows the patient not only that you are being thorough, but also that it is important for you to understand where their treatment journey started and any twists and turns they encountered along the way. This can help you to better understand where they are today.
PM: As always, be sure to advise patients of the common side effects of any medication they are taking and what, if anything, can be done to mitigate those side effects should they occur. This helps build a therapeutic alliance because it shows you care about the patient’s comfort with their treatment and that the two of you are working jointly to treat their condition.
KM: Be hopeful but realistic in the treatment expectations you share with your patients. Conveying unrealistic expectations can set patients up for disappointment and can lead them to lose faith in the treatment plan or in treatment and clinicians broadly.8
PM: If your patient has an inadequate response to medication, and you have previously reviewed with your patient that not every treatment for their condition will be successful for every patient, they may be less likely to lose confidence or interest in continuing to pursue care.8
KM: It is important for patients to feel that you have confidence in their ability to be in treatment and to work on recovery.
Conclusions
PM: As a psychiatrist, I thoroughly enjoy collaborating with primary care clinicians, including nurse practitioners. I encourage my primary care colleagues to consider referral to psychiatrists or psychiatric specialists when you have a patient who is not showing an adequate response to treatment, who is experiencing a non-emergent problematic side effect to medication, or when a diagnostic dilemma presents. Remember to communicate clearly and thoroughly when working with other professionals toward our common goal of providing high-quality mental health care to our shared patients. I always appreciate having heard the reason for the referral and any important details of the patient’s history when I first evaluate them.
KM: As a psychiatric mental health nurse practitioner, I am grateful to our physician colleagues in cases of patients with complex clinical scenarios. I view psychiatric mental health care as a team sport and frequently collaborate with professional colleagues toward the shared goal of patient wellbeing. I find it imperative to the improvement of my patients’ health that we form a therapeutic alliance. I do this through active listening and showing each individual that their health is important to me. I invite my patients to be a partner in their own unique care plan to achieve their specific goals.
PM: Thank you so much for joining us today in this discussion on providing interdisciplinary care in mental health. We hope this discussion has been helpful and that you visit us again soon at NP Psych Navigator.com!
Pradeep Manudhane, MD
Dr Pradeep Manudhane is a clinical assistant professor at Northeast Ohio Medical University, where he presents lectures to third- and fourth-year psychiatry residents at Cleveland Clinic Akron General. Additionally, he works as a community mental health psychiatrist at Phoenix Rising in Canton, Ohio. He is the head psychiatrist on their Intensive Treatment Team. Dr Manudhane has practiced in Northeast Ohio for the past 30 years. He earned his Doctor of Medicine from Northeastern Ohio University’s College of Medicine and completed his psychiatry residency at Akron General Medical Center.
Kathleen McCoy, DNSc, APRN, PMHNP-BC, PMHCNS-BC, FNP-BC, FAANP
Dr Kathleen McCoy is an associate professor in the Department of Community and Mental Health at the University of South Alabama. She also works as a nurse practitioner for Integrated Telehealth Partners, where she provides psychiatric mental health care to patients. Dr McCoy earned her Master’s degree in Psychiatric Nursing from the State University of New York at Stony Brook and her Doctor of Nursing Science from the University of Tennessee Health Science Center.
References
Agency for Healthcare Research and Quality. Care coordination. August 2018. Accessed November 9, 2022. https://www.ahrq.gov/ncepcr/care/coordination.html
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. American Psychiatric Association; 2010.
- Health Resources & Services Administration. Health workforce shortage areas. 2023. Accessed November 9, 2022. https://data.hrsa.gov/topics/health-workforce/shortage-areas
- Siu AL; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
- Ellis H, Alexander V. Eradicating barriers to mental health care through integrated service models: contemporary perspectives for psychiatric-mental health nurses. Arch Psychiatr Nurs. 2016;30(3):432-438.
- HIPAA Journal. HIPAA regulations for SMS. 2023. Accessed February 21, 2023. https://www.hipaajournal.com/hipaa-regulations-for-sms/
- NEJM Catalyst. What is care coordination? Innovations in Care Delivery. January 1, 2018. Accessed November 9, 2022. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0291
- Rosenfield MN, Bernstein MH. The importance of patient expectations: a mixed-methods study of US psychiatrists. Front Psychiatry. 2021:2154.
This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.
NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributors are paid consultants for AbbVie Medical Affairs and were compensated for their time.
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