Implementing Multidisciplinary, Team-Based Care in an Academic Outpatient Psychiatry Department

In our large urban academic medical center, legacy outpatient psychiatric care models have traditionally relied on individual relationships between clinicians and patients. “Out of session” work, such as care coordination and treatment review, remained largely unreimbursed and unsupported, leading to a siloed approach to care that has proven to be outmoded and grossly inadequate as demand for psychiatric services and illness complexity have continued to increase. The inadequacy of the existing system of care to meet the evolving clinical landscape has been evident in long wait times (≥6 months) for new patients, limited ability to address multiple psychosocial needs, and dissatisfaction, isolation, and burnout among clinicians.

Team-based care has helped address these concerns and improve outcomes for patients and providers in primary care and community mental health practices for years (1, 2). Until recently, team-based care had not been utilized in the largest outpatient psychiatry program in our hospital. This column describes the selection, funding, and implementation of a novel team-based care model, as well as the organizational cultural norms that had to be changed or sustained for the model to achieve the intended outcomes of reduced intake wait times and financial sustainability, while ensuring high-quality care.

Impetus for Change

Multiple problems at the patient, provider, and staff levels demonstrated to the outpatient leadership team that the existing system of care was inadequate for meeting contemporary needs. At this initiative’s inception, the leadership team agreed that an innovative approach was needed to enact meaningful and sustainable change to improve access to and quality of care for patients and the care experience for clinicians and staff.

A planning retreat was held in fall 2018 to reach a consensus on the greatest barriers to access and to develop a strategy for driving change. The planning retreat was followed by a listening tour to engage providers, staff, medical personnel at primary care practices, and patients. The feedback across stakeholders was consistent in naming significant concerns about limited access to outpatient psychiatry services and fragmented and uncoordinated care.

Patients at the hospital’s Patient and Family Advisory Council shared the following: “We feel forced to say things to get our loved ones care, or else no one will listen”; “The wait time is long”; and “We feel bounced between specialists without coordination, which creates confusion because the diagnosis and treatment plan are not clear.”

Primary care providers (PCPs) and Department of Psychiatry clinicians described the impact of inadequate access: “It is very difficult to get a patient into psych,” and “I feel that patients often don’t get triaged to the right place.”

Intake staff shared that “we feel overwhelmed with requests on multiple platforms” and that “the most challenging aspect is not having available resources for patients and hearing their disappointment, particularly patients who seem severely ill.”

Armed with this direct input validating leadership’s understanding of the problem, we set out to develop a program to improve patient access and clinician well-being, while maintaining financial sustainability and excellent quality of care.

Planning for Change

In contrast to previous attempts to address inadequate access by hiring more clinicians, we devoted significant time to better understand actual and perceived barriers to access. We focused on identifying cultural norms contributing to access issues and explored strategies for making the foundational changes required for real and sustained improvement. We challenged ourselves to take a holistic approach and generated many more questions in the process (e.g., What “back-end” services, if not addressed, will prevent patient access? Where will bottlenecks occur? Which parts of the care process have not yet been discussed or challenged?).

We learned that intake coordinators’ efficiency was limited by the underutilization of work queues due to multiple uncoordinated referral streams. Staff members’ ability to collect information, make a clinical assessment, and properly triage the patient was limited by their background and skill sets. Further, they had limited escalation pathways by which to receive at-the-elbow clinical support for rapid decision making. We worked with leadership from the collaborative care program in primary care practices to identify opportunities for pass-back of treated and stabilized patients so that intake appointments would remain available for those most in need. Finally, we partnered with public health students to perform a comprehensive literature review of team-based care models. Together, these efforts led to the creation of a vision for change.

Early Implementation

Our executive team prioritized creating a sense of urgency and buy-in among department leadership, as recommended by John Kotter’s change-management model (3). We were aided by the contemporaneous transition to a new department chair, who recognized the problems of outpatient psychiatric access and provided critical financial support that enabled innovation in the early stages while also setting an expectation that any new models must be financially self-sustainable through billed clinical revenue.

A dedicated planning group was convened to develop and implement the new team-based care model, called team-based outpatient psychiatry (TOP). In the spirit of multidisciplinary collaboration, the planning group included members with backgrounds in psychiatry, social work, nursing, psychology, and administration. The planning team met weekly during and after the program launch.

An early decision point was to identify which clinical role groups would constitute TOP, informed by mapping the patient journey from referral to evaluation, treatment, and eventual disposition. Once team roles were established, we set expectations for clinical processes to ensure judicious use of TOP resources. This step included creating a triage process in which the social worker and psychologist share responsibility for determining the most appropriate team member to perform the diagnostic evaluation; shifting from a single “intake” to a two-part “consultation” model, in which the clinical impression and treatment plan are collaboratively discussed with the patient; tracking outcomes through patient-reported outcome measures (PROMs); communicating and collaborating with team members; and setting a standardized cadence for reviewing criteria for clinical dispositions (e.g., remaining within the team, community referral, or pass-back to the PCP).

The launch of the first team was planned for July 2020. Recruitment of clinicians for the first team resulted in an incumbent departmental psychiatrist and psychologist transferring clinical hours from multiple other practices to work full-time within TOP and in external persons being hired for the remaining positions. The COVID-19 pandemic in March 2020 added numerous challenges, most significantly the need to convert from in-person to virtual care (4) and hiring delays; despite this, the team was fully functional by September 2020.

The planning group remained in close contact with the team through direct participation in case conferences and huddles and engaged in a process of rapid cycle improvements to quickly identify and adapt to challenges. For example, it quickly became clear that a single case conference per week was insufficient to discuss the many new intakes, so a second case conference was built into the schedule. Additionally, challenges with PROM workflows were identified and addressed in real time with the medical assistant’s input.

The Program

The TOP care model was influenced by features of high-performing primary care practices, including a stable team structure, provider colocation, panel management, clearly defined roles and workflows, and emphases on staffing ratios and effective communication. In contrast to many other clinicians in our department, all team members work on the team full-time; there is no division of hours with different clinics or practices, and each member works on only one team (i.e., there is no floating between different teams). It was critical to shift the culture of care in the department from long-term (often indefinite) relationships with single providers to a more short-term, targeted engagement focused on multidisciplinary intervention and seamless care transitions, including pass-back to the PCP following psychiatric stabilization.

Team Structure

Each team has five members: a psychiatrist, psychologist, nurse practitioner, licensed clinical social worker, and medical assistant. All qualified team members perform diagnostic evaluations. The psychiatrist and nurse practitioner focus on medication-oriented treatment, supported by the medical assistant, who collects relevant information (vital signs, PROMs) and performs administrative tasks, including insurance prior authorizations and patient communications. The psychologist and social worker both perform time-limited, skills-focused psychotherapy. The entire team is responsible for the entire panel of TOP patients, and all members participate in case reviews and huddles. The social worker holds responsibility for leading the huddles and case reviews and overall panel management, which includes case management tasks such as facilitating community referrals and locating resources.

Comparison Between Legacy and New Programs

Bottlenecks at referral contributed to long intake wait times, stemming from multiple systems challenges within the legacy approach: high volume, inadequate new intake expectations for clinicians, inadequate administrative staffing and practices, and low turnover back to primary care. The TOP care model addressed these challenges by creating collaboration between TOP teams and the linked practices. This approach required consensus with medical practice leadership, collaborative design of the pass-back process, and commitment from both disciplines to communicate changes and follow up on utilization of the model.

Schedules

The team meets in daily huddles and twice-weekly case conferences. Clinicians operate on templated schedules and are not responsible for productivity expectations, although productivity is tracked to ensure financial sustainability. Time for documentation, academic work, and professional development is included. Table S1 in the online supplement summarizes weekly workloads by role group.

Preliminary Outcomes

The analyses described in this column were conducted as a quality improvement initiative and were therefore deemed exempt from review by the institutional review board. Assessment of progress toward identified outcomes is discussed below.

Increased Patient Access

Strict adherence to templated schedules by full-time clinicians significantly improved access to care in the first 12 months. The case mix has remained at 18% new patient evaluation slots and 82% follow-up slots, compared with just 4% new evaluation slots in the legacy program, resulting in decreased wait times for new evaluations.

Improved Clinician Well-Being

Although formal satisfaction surveys have not been administered, the TOP team has reported the experience of shared management of complex patients to be positive. Specific benefits include ease of cross-coverage of urgent patients, support for active caseload management, and enhanced ability to facilitate care transitions as a routine part of treatment. Likewise, referring PCPs have expressed great appreciation for increased access and having a specific team care for their patients.

Financial Sustainability

Financial modeling suggests that by the second year, TOP will be financially self-sustaining via billed clinical revenue alone.

Discussion and Early Lessons

The TOP care model shows early promise for sustainably improving patients’ ability to access outpatient psychiatry in our academic medical center, although more time and research are needed to assess relevant outcomes.

Achievement of these goals will be meaningful only if the quality of care provided is high. PROM data will be compared with those of the legacy program to objectively assess the impact of this care model on patient-centered outcomes.

Our experience has yielded several lessons. Implementation of this care model required buy-in from key stakeholders, including departmental leadership and referring PCPs. Shifting expectations about care requires clear communication via dedicated meetings with external PCPs about the changes being piloted and longer-term implications. For example, PCPs had to understand and agree that in exchange for more rapid access to outpatient psychiatric services, they would be asked to assume longitudinal medication management upon clinical stabilization and to trust that the TOP team would connect patients to community supports and facilitate easy re-referral when needed. A greater effort should have been made to anticipate the reaction of clinicians operating within the legacy system to the new TOP model and to clarify and communicate the distinctions between and relevance of the two models.

Establishing expectations for a new model of care with members of the TOP team has been crucial. We hired professionals who appreciate the vision of team-based care, including the vital public health need to increase access, and therefore provide targeted, time-limited care. Personal attributes well suited for these tasks include flexibility, efficiency, a collaborative work style, and strong leadership skills.

A critical identified need was psychotherapy availability. Many of the advantages associated with the TOP model require clinicians to work within the same system. Roughly 60% of patients receiving psychopharmacologic care from the team would benefit from the type of time-limited, skills-focused therapy offered by the psychologist and social worker, yet due to capacity limitations, a majority must be referred elsewhere. We have added part-time psychologists and social workers; the ideal allocation of time and caseloads for these therapy-specific roles per team is yet to be determined. Similarly, this process highlighted the burden of unreimbursed administrative work that takes place in the care of patients with complex psychosocial needs, which must be adequately supported within any clinical/financial model that seeks to adequately care for these patients.

Finally, we have learned the importance—and challenges—of systematically assessing the impact of an entirely new paradigm of care. Collecting, recording, and analyzing relevant patient outcome measures has proven to be challenging but remains critical for rigorously evaluating success. We now have three teams, all still relatively new, and more time is needed for patient throughput to reach equilibrium. Future studies should systematically evaluate the model’s impact on patient access, clinician satisfaction, and cost; assess whether quality of care remains high; and describe operational data, including caseload size and patient length of stay.

Conclusions

We developed and piloted a novel, team-based, multidisciplinary model of outpatient psychiatric care that demonstrated preliminary feasibility and early positive effects on patient access and clinician satisfaction. More research is needed to evaluate clinically relevant outcomes as well as the model’s impact on quality of care and its long-term financial feasibility.