Physician Assistants in the Psychiatric Workforce: A Practical Guide to Training, Implementation

and Innovation

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Margie Balfour, MD, PhDVP for Clinical Innovation & Quality,Chief Clinical Officer, Crisis Response Center,Assistant Professor of Psychiatry, University of Arizona

Joshua Leslie, MPAS, PA-CExecutive Director: Urgent Psychiatric Care CenterPhoenix, Arizona

Crisis is a subspecialty

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Crisis servicesgo here!

Agenda

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• Who we are and what we do• The case for PAs in the crisis setting• Training psychiatric PAs in crisis care• PAs and integrated care

Who we are

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We are a physician-owed organization specializing in facility based crisis services

“We address any behavioral health need at

any time.”

Urgent Psychiatric Centerin Phoenix, AZ

Crisis Response Centeron the Banner-University Med

Ctr Campus in Tucson, AZ

What we do

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• Facility-based health crisis programs that provide• 24/7 on-demand access• A safe and welcoming

environment• Rapid triage and psychiatric

assessment• Crisis Stabilization:

• Via counseling, medications, peer groups, family engagement, etc.

• Connection to community resources

Studies show this model reduces:• ED boarding1,2

• Inpatient hospitalization1,2

• Arrest3

1. Little-Upah P et al. (2013). The Banner psychiatric center: a model for providing psychiatric crisis care to the community while easing behavioral health holds in emergency departments. Perm J 17(1): 45-49.

2. Zeller S et al. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. West J Emerg Med 15(1): 1-6.Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. PsychiatrServ 52:219-22

3. Steadman HJ et al (2001). A specialized crisis response site as a core element of police-based diversion programs. Psychiatr Serv 52:219-22

Low clinical barriers to access

• “No wrong door”• We do our best to take everyone:

– No such thing as “too agitated”– Can be highly intoxicated– Can be voluntary or involuntary

• Fewer medical exclusionary criteria then many inpatient psychiatric hospitals

• Police are never turned away

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23-Hour Observation Unit

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• Staffed 24/7 with MDs, NPs, PAs• Medical necessity criteria similar to that of inpatient psych

(danger to self/other, etc.)• Diversion from inpatient:

– 60-70% discharged to the community the following day– 70-80% conversion from involuntary to voluntary treatment– Early intervention

• Median door to doc time is ~90 min– Interdisciplinary team

• Including peers with lived experience– Aggressive discharge planning– Collaboration and coordination with community & family partners– Assumption that the crisis can be resolved

Why PAs for psychiatric care??

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A good psychiatrist is hard to find!

We have long depended on

multidisciplinary teams – including PAs and NPs

– to make our model successful.

Merritt Hawkins Top Searches by Specialty

Why Physician Assistants?

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National Commission on Certification of Physician Assistants, Inc. (2017, March). 2016 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants. Retrieved Date, from http://www.nccpa.net/research

• There were approximately 80,019 Certified PAs at the end of 2010; the profession grew 44.4% over the next 6 years reaching 115,547 Certified PAs at the end of 2016.

• On Dec. 31, 2016, there were 115,547 Certified PAs. The number of PAs has grown 6.3% between 2015 and 2016.

Why PAs for psychiatric care??

• Physician Assistants aren’t heavily marketed for psychiatry. Current data shows only 1.3% of all PAs are currently practicing in Psychiatry

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National Commission on Certification of Physician Assistants, Inc. (2017, March). 2016 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants. Retrieved Date, from http://www.nccpa.net/research

Why PAs? For primary care.• We need to keep our patients out of the ED

– Sending patients to the ED unnecessarily opposes our tx model– We have encouraged our psychiatric providers to “doctor up” and treat

basic medical issues• We need to do a better job with chronic medical illnesses

– Our population is becoming more medically ill– More focus on whole health and wellness– Let’s do a better job engaging these hard-to-track patients in primary

care while they are with us• This is a challenge with psychiatrists

– Who are already hard to find– And even harder to find for the crisis subspecialty

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Perhaps with dual supervision PAs can help with both?

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Psychiatry Primary Care

Training Psychiatric PAs for Crisis Care

• Analyze facility need:– Urgent Psychiatric Care Center:

• In 2007, 12 million, or 12.5% of total ED visits, were related to mental health and substance abuse.

• American College of Emergency Physicians (ACEP) conducted a survey in 2008 which found that 99 percent of emergency physician admit psychiatric patient daily

• Ideal candidates and recruitment efforts may shift pending data analysis (PA’s with ER experience vs. Psych experience)

• Analyze facility resources:– Supervising Physicians– Multidisciplinary approach– Hours and resources available for new hire training

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International Association for Healthcare Security and Safety (2015) http://ihssf.org/PDF/foundationbhpatientboarding.pdf

Hiring Process

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• New graduate PAs • Experienced PAs• Qualities for successful

integration• Clinical Rotation experience• Fellowship programs• *References*

• General Medical vs. Psychiatric

• Years of experience • Certification of Added

Qualifications (CAQ)• Multidisciplinary approach• *References*

First 30-45 Days(New Grad or Experienced)

Day 1-15: “Deer in Headlights”• Expect NOTHING• Standardized New Employee Orientation • General overview of facility infrastructure• Creation/Integration of multidisciplinary resource team

– Integrated Care Approach• Supervising Physician relationship

building– Need time/resources allocated to

this process

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First 30-45 Days(New Grad or Experienced)

Day 15-45: “Test the waters”• Shadowing approach

– Educational– Relationship Building– Identify Strengths/Weaknesses– Resource Allocation

• Direct Patient Interaction– Supervising Physician Involvement– Multidisciplinary Team Involvement– Case Reports– Disposition and Treatment Recommendations

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First 30-45 Days(New Grad or Experienced)

Day 30-45• Performance Evaluation

– Identify strengths– Discuss weaknesses– Initiate a performance

improvement plan (PIP)

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Day 45-90Professional Development Phase (PDP)

Establish a standardized workflow from the Performance Improvement Plan (PIP)• What level of Shadowing/Direct Oversight/Auditing is required

(State vs. Facility)• Begin weekly case studies• Continue developing relationship with Supervising Physician

– *Allocate Time and Resources*– Weekly to Biweekly meetings

• Engagement with multidisciplinary team to assist in PDP – Weekly to every other week– Identify strengths/weaknesses– Challenge team to improve development efforts

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Day 90: Performance EvaluationClinical Expectations: New Graduate vs. Experienced PA• PIP overview• Treatment Plans and Medication

Recommendations• Multidisciplinary integration• Career Path and Development• Resources for success

(PIP, case studies, auditing, etc.)

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Challenges and Next Steps

• Pearls:– *Only take on 1 new grad at a time if possible*– Focus on the long term- “Loyalty is earned”– Prepare for regression along the way

• Multidisciplinary team support

• Next Steps:– PA Emergency Psychiatry Fellowship

• Integrated with emergency medicine fellowship

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Integrated Care Model

• Dynamic Approach to Psych PAs– Integrated Care Model with two supervising

physicians• Psychiatry & General Medicine • Scope of Practice• Delegation Agreements• Training Protocols

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Integrated Care Model

• Patient and PA outcomes– Full integration of body and

mind– Improve patient

satisfaction/compliance– Ideal for both rural and urban

settings– PA recertification and

professional responsibilities

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Integrated Care Pilot at the CRC

• PAs with two supervising physicians– Psychiatrist– Family medicine physician

• Case reviews, on-call for phone consultation

• Alternating weeks to avoid “pigeonholing”– One week focused on psychiatric care– Next week focused on primary care

• H&Ps on the inpatient unit and 23h obs unit • Followups and consults as needed• Work with social services on care coordination for primary care

followup• Helps with psych care when H&Ps are done

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Outcomes

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We didn’t see a big change in the percent of patients requiring transfer to the ED

UCL 8.6%

CL 6.0%

LCL 3.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Oct

-15

Nov

-15

Dec-

15

Jan-

16

Feb-

16

Mar

-16

Apr-

16

May

-16

Jun-

16

Jul-1

6

Aug-

16

Sep-

16

Oct

-16

Nov

-16

Dec-

16

Jan-

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Percent of patients requiring ED transfer But anecdotally:• Less transfers for minor

issues• More transfers for

serious issues that may not have been picked up before

• Bad outcomes averted by more thorough medical care

• Staff and patients like it

Challenges and next steps

• Challenges– Finding the right people for this unique role– Constantly having to resist the urge to pull the

primary care PA to do psych care when there are coverage issues and surges in volume

• Next Steps– Reimbursement for H&Ps– More preventative care for this difficult to track

population while they are a “captive audience”25

Questions?

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• Margie.Balfour@ConnAZ.com• Josh.Leslie@connectionsarizona.com• www.connectionshs.com

Now THIS guy could really use some crisis intervention.