(044) Psychiatric Case Conferences in a County-run Clinic: Implementation and Barriers

‎Background/Significance: Efficacy of the collaborative care model, an evidence-based strategy to improve ‎access to mental health treatment in primary care, is well established, however, the literature examining the efficacy ‎of its specific components such as case conferences is less robust. We report on the feasibility and outcomes of ‎introducing psychiatric case conferences (PCC) to a large, resource-limited, county-run adult primary care clinic.‎

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Methods: Patients aged 18 years or older who were empaneled at the clinic were screened using a Patient ‎Health Questionnaire-9 (PHQ-9). Those with scores greater than 10 were eligible to be discussed at weekly case ‎conferences that included a psychiatrist, medical case worker, and social worker. Recommendations for the ‎conferenced patients were communicated to the primary care provider via a brief note in the electronic medical ‎record. Chart review remains ongoing.‎

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Results: A total of 218 patients with elevated PHQ-9 scores were reviewed of which 77 had case conferences ‎and met inclusion criteria. The average conferenced patient was middle-aged, Latino (66%), Spanish-speaking (54%), ‎female (60%), and had multiple chronic conditions. The average initial PHQ-9 was 15.2 (IQR 12-18). The most common ‎recommendations from case conferences were repeating PHQ-9s (84% of patients), referral to social or medical case ‎work (61% of patients), and medication recommendations (56% of patients). Implementation of recommendations ‎was limited at the first post-conference PCP visit: 31% repeated PHQ-9s, 9% were seen by social work or case work, ‎and 16% made or attempted to make medication changes. Despite limited implementation, PHQ-9 scores fell following ‎case conferences to an average of 9.2 (IQR 1-16).‎

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Discussion: PCC are a relatively low-resource intervention and primary care patients with moderate to ‎moderate-severe depression who were discussed in PCC experienced a decrease in depression severity based on ‎PHQ-9 scores mirroring previous findings. In this study, the decrease in depression severity occurred despite the ‎limited implementation of case conference recommendations. Thus, PCC may be an effective way to screen and treat ‎patients with depression in resource-limited settings who were not previously engaged in outpatient mental health ‎care while reserving appointments with a co-located psychiatrist for those who do not respond despite multiple ‎recommendations and interventions.‎

‎Conclusion/Implications: Patients whose care was discussed in PCC experienced a decrease in depression ‎severity illustrating the usefulness of PCC in screening a large volume of patients in a public sector adult outpatient ‎clinic and providing timely interventions to improve mental health outcomes. Given limited implementation of case ‎conference recommendations, further interventions such as targeted education for PCPs, warm hand-offs, and ‎reserved appointments with a psychiatrist for patients who do not respond despite multiple PCC would be beneficial.‎

‎References‎
‎1) Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression ‎and anxiety problems. Cochrane Database Syst Rev. 2012 Oct 17;10:CD006525.‎
‎2) Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative Care for Depression: A Cumulative Meta-analysis ‎and Review of Longer-term Outcomes. Arch Intern Med. 2006;166(21):2314–2321. doi:10.1001/archinte.166.21.2314‎