Neuropsychiatry Trainee Guide

Welcome to BWH Neuropsychiatry! We look forward to working with you.

This document outlines the most important logistical aspects of our clinical operations. In case of any questions, please do not hesitate to contact Dr. Baslet or ask your clinic supervisor(s).

Who are we?

Our Neuropsychiatry Division consists of 7 neuropsychiatrists on staff at Brigham and Women’s Hospital. We are one the core components of the Center for Brain/Mind Medicine (CBMM). You will be working with one or two primary supervisors per clinic session (4-hour clinic block). Due to cross-coverage, you will likely interact with most of us at some point. We are:

Gaston Baslet, M.D.

Jessica Harder, M.D.

Stanley Lyndon, M.D.

Geoffrey Raynor, M.D.

Shan Siddiqi, M.D.

Joseph Taylor, M.D.

Juan Carlos Urizar, M.D. (geriatric neuropsychiatry)

There are other neuropsychiatrists affiliated to CBMM that you will meet during rounds (Dr. Barry Fogel, Dr. Barbara Schildkrout, and others) that you will have the opportunity to learn from and consult with. We also have two social workers in Neuropsychiatry and you may reach out to them with clear short-term psychotherapy referrals. Click here for an overview of the services provided by neuropsychiatry social workers. You and your supervisor should discuss if a referral to Social Work is appropriate. Our two neuropsychiatry social workers are:

Margaret Latawiec, L.I.C.S.W.

Laura Morrissey, L.I.C.S.W.

We also have access to a Community Health Worker (CHW), Mr. Jean-Ford Figaro. The CHW can provide brief assistance around specific case management needs (ie, housing, food insecurity, etc) and help providing community referrals for mental health treatment (ie, need to establish psychotherapy with a provider in the community). Click here for an overview of the services provided by the community health worker.

Clinical Operations

Our on-site clinical operations take place at the BWH Hale Building, Clinical Neurosciences Center, 60 Fenwood Road, Boston, MA, first floor. Support staff at the clinic will help with requests related to the encounters that take place during your clinic time. This includes: check-in at the front desk, vitals and med reconciliation by medical assistants, and check out at the check-out desk. The check-out staff can assist with setting up a follow-up appointment and with referrals for tests and other specialists (provided that an order in Epic is in place).

Assistance for anything that happens outside of your on-site clinic time (including requests related to virtual visits) is handled by Brigham Psychiatric Specialties (BPS) Call Center support staff (physically located at 221 Longwood Ave). This includes managing phone calls from patients, making changes to your schedules, sending documents, etc. You will be assigned one primary support staff person.

As of July 1, 2021, all trainee clinics will take place physically at 60 Fenwood Road. New patients will be encouraged to schedule an in-person visit (patients may refuse). Follow-ups may be scheduled virtually, if deemed clinically appropriate, and if the patient will be physically in the state of Massachusetts. Every virtual clinical encounter should start by inquiring the patient about their physical location to ensure they are in Massachusetts (if located outside of Mass, a clinical encounter cannot take place, although emergency care can be provided over the phone as clinically indicated).

Maria T. Pires is the practice manager for BPS. For administrative requests specific to a patient (ie, move a patient appointment sooner, sending documents), you should contact your assigned primary support person. For medication-related issues (ie, completing prior authorization forms, getting information from pharmacies), the Psychiatry medical assistants could help. Click here for their names and phone numbers. Maria T. Pires should be included in messages related to changes in your schedule. Please ask your supervisors any questions on who the best person to contact is if you have questions. Any clinical requests should go through Epic’s In-Basket messaging system.

New patients are scheduled through our BWH Psychiatry Triage team (part of BPS Call Center). They may reach out to you with questions about new patients (such as which records you may want to receive beforehand). If asked, always check with your attending supervisor before accepting a new patient.

As a general rule, NEW patients (not previously seen in Neuropsychiatry) are always evaluated on a consultation basis (without expectation of treatment). If a new patient has established providers at BWH (such as PCP or neurological care), we may be able to offer treatment in our service. If a new patient does not have an established provider at BWH, we can only offer a one-time (or a two-time) consultation and referral back to the referring provider with recommendations (with very few exceptions; for instance, if a program already exists that offers a very limited form of treatment, such as short-term psychotherapy for FND).

All staff listed in this guide, and the support staff assigned to you, are reachable through MGB email. The clinic phone number is 617-732-6753; the clinic fax number is 617-738-8703. These are the numbers that should be given to patients to contact you. For electronic communication with patients, offer patients to use Patient Gateway / My Chart (and advise patients that there is an expected 48 business hour delay for a message to get to you). Do not communicate with patients via email as it is not part of their medical record.

CBMM Rounds

Trainees are expected to attend multidisciplinary CBMM rounds according to their pre-arranged schedule (Wednesdays from 10am to 12pm via Zoom https://partners.zoom.us/j/816006172 or at Hale building, 60 Fenwood Road, 2nd floor, room VTC 2006B). There is an expectation that trainees will present one new case each week during rounds (limited to 6 minutes per presentation).

On the second and fourth Wednesday of the month, we hold Neuropsychiatry management rounds from 11:30 to 12 (during the last portion of CBMM rounds). This time is reserved for presentations that pose a specific clinical management question. You should alert Dr. Baslet before rounds (via email) on the case you would like to present during Neuropsychiatry management rounds.

Tuesday evening supervision (5-6 pm) provides a more intimate discussion of topics related to Behavioral Neurology and Neuropsychiatry. These sessions are currently held via Zoom https://partners.zoom.us/j/195398040.

Time off

If you plan time off (vacation or education-related), please complete the following request form:

https://docs.google.com/forms/d/e/1FAIpQLSd0JCJp-ANjwvgRSPkdEMD5p9F9uW1L8H9T70-OrutJXfRZnw/viewform

and also inform Maria T. Pires (via email) and your supervisor as soon as you know the dates. The hospital has a mission to prevent bumping patients, so the sooner you provide us with this information, the better. The request should preferably be at least one month in advance.

If you are out sick, let your supervisor know immediately and send an email to bpspsychout@PARTNERS.ORG to let the administrative support staff know, so patients can be rescheduled.

Coverage

You are the primary neuropsychiatry provider for your patients and are expected to cover any clinical issues in between clinic days, unless you are on vacation or away for an educational activity. Attendings provide supervision and can be consulted by you for questions in between appointments with your patients.

You need to check your in-basket messages with enough frequency to answer any time-sensitive requests. The psychiatry resident on call answers emergency calls after hours and on weekends only.

In addition to new clinic patients, you will be assigned neuropsychiatry patients transferred from former trainees. If a “transfer patient” was assigned to you and the patient is already scheduled with you, we expect that you will answer any clinical requests from the patient, of course with your supervisor’s guidance. We advise that you do not contact patients not previously seen in our clinic and you always ask your supervisor regarding such requests. If you receive an Epic warning message that a patient you have not met has answered affirmatively to suicidal thoughts on a questionnaire, let the BWH Psychiatry Triage team know, and they will reach out to the referring physician.

During the time that you are away for vacation or for educational purposes, coverage will be provided by the other neuropsychiatry trainees. It is your responsibility to arrange for coverage and assign coverage properly in Epic. You should let Maria T. Pires and your primary support staff person know who is providing coverage for you (send email to BWHPsychiatricSpecialties@partners.org). Please be mindful that different trainees have different clinical loads and coverage should be proportional to your time in clinic. Your clinic supervisor can always provide guidance on how to answer a coverage question.

Clinical emergencies

During weekday nights and weekends, the on-call psychiatrist (a resident) can be available for emergency needs that cannot wait until the next working day. During weekdays during the day, you may need to involuntarily send a patient to an ED for evaluation (see how to file a section 12 if on-site or remotely below). Additionally, BPS offers urgent slots (walk-in urgent care clinic, also called LUCY) for patients that need to be seen before their scheduled appointments and for whose clinical situation is severe or urgent enough that care should not be delayed (yet do not merit a Section 12 filing). Please consult with your attending in these situations.

For non-medical emergencies (requiring the assistance of SW, such as crisis support, referral to partial hospitalization program, assistance with DCF/ interpersonal violence cases, please use the SW (non-MD) pager. See instructions below.

Epic Documentation

When documenting an encounter in Neuropsychiatry Clinic, make sure to cover the following items:

Reason for visit: Chief Complaint.

Episodes: create or check (if already created) a “BPS visit” as a linked episode and “Outpatient psych encounter” as type.

History: Review with patient and check “Mark as Reviewed”.

Medications: The Med Assistant will likely go over the medication list with your patients during on-site visits. If not, you should go through it and, even if already done by the Med Assistant, you should double-check the medications that you are prescribing and those that may interact with them. After reviewed, check “Mark as Reviewed”.

Allergies: Review with patient and check “Mark as Reviewed”.

Progress Notes: Add your note here. Use one of the templates for an initial evaluation or progress notes (use SmartPhrases .GCBINITIAL or .GCBPN2021 for Epic templates). For virtual visits please make sure to include SmartPhrase .VVV or .VVT at the end of the note (depending on whether the appointment was conducted by video or phone, respectively).

Risk Assessment: As part of your note, always include a risk assessment. At least once during your episode of care for a patient, complete a Suicide Screening or Suicide Risk Assessment in Epic (within the “Charting” tab, select “Suicide Risk Assessment” OR select “Suicide Screening” and then select “C-SSRS”; you can paste the answers from the C-SSRS into your note by adding the Smartphrase .COLUMBIACSSRS.

Visit Diagnosis: Please select your patient’s diagnoses (more than one if indicated).

Meds and Orders: This is where you will enter a prescription or you will enter an order.

LOS (Level of Service): ONLY IF YOU ARE AN INDEPENDENT BILLING CLINICIAN, select the level of service for follow-ups: EST LVL (for time-based follow-ups). If you are NOT an independent billing clinician, or if you are an independent billing clinician seeing a patient for the first time, DO NOT select LOS, and rather, cc the encounter to your supervisor for review of the note and final billing.

Facility LOS: ONLY IF YOU ARE AN INDEPENDENT BILLING CLINICIAN, a facility LOS should be selected based on the time spent with the patient for follow-up visits. FOR VIRTUAL VISITS, select GT (for video call visits) or GPH (for phone visits) as modifiers. If you are NOT an independent billing clinician, or if you are an independent billing clinician seeing a patient for the first time, DO NOT select facility LOS.

Scheduling a follow-up: For on-site visits, ask the check-out desk staff to schedule a follow-up. For virtual visits, we recommend that you select the date and time based on your Epic schedule, give it to the patient, then go to the “Wrap up” section of your encounter in Epic, go to “Follow-up” section and complete the “Send Chart Upon Closing Workspace” subsection (under “additional options”) adding your support person’s name and entering a message indicating the date and time of the selected f/u appointment and click “Send now”. If you prefer not to give the appointment to the patient yourself, you can send a message also via Wrap-up -> Follow-up -> Send Chart Upon Closing Workspace and ask your support staff to reach out to the patient to schedule a f/u appointment (ie, “schedule f/u appt in 4 weeks on a Tuesday afternoon”), and click “Send now.”

Closing the encounter: If you are an independent billing clinician during a follow-up visit, you should close the encounter after completing the items above. If you are NOT a billing clinician or if you are an independent billing clinician seeing a new patient, your supervising attending will have to close the encounter. If that is the case, forward the note to him/her by clicking “Follow-up”, entering your supervisor’s name as a “Recipient”, click “Send now” and then close the “Follow-up” section. This will route the encounter to your supervisor and he/she will double-check your documentation and sign/close the encounter.

Erroneous encounter: If you opened an encounter by mistake but the patient did not show, you have to enter “Erroneous Encounter” in the Diagnosis field and the service field. This should help you close the encounter. If you have difficulties, please ask your supervisor and they can guide you on how to close the encounter.

Timing: Please complete documentation and forward the note to your supervisor by the end of the 4th day after the encounter AT THE LATEST. That will give enough time for the supervisor to review the note, make edits and close the encounter. Please be aware that the hospital has a rule that every encounter MUST be closed within 7 days of encounter date.

Referrals: To refer patients to other services within the MGB system, when you are within the encounter in Epic, click the “ADD ORDER” button in the bottom left corner, and type the service (for instance, “Ambulatory referral to BWH Neurology”), then fill out the information and click “Accept”. A similar process takes place for lab orders, imaging orders, etc. You will need to link a diagnosis to the referral.

Overview of Neuropsychiatry Social Work

Services provided by social work in the division of neuropsychiatry include:

• Short-term, goal-directed treatment using a variety of evidence-based practice including CBT, behavioral activation, DBT, Mindfulness, etc.;

• Individual, group and family interventions to reduce the impact of psychiatric and neurological disorders on daily functioning;

• Crisis intervention to mitigate risk associated with poor judgment, impulsivity, aggression, elder abuse/neglect, suicidality, self-injurious behaviors, substance abuse, etc.;

• Coordination of care with treatment team and outside providers;

• Consultation about services and referrals specific to neuropsychiatric patient population/care planning (e.g., psychiatric vs. adult day treatment, advanced directives, end of life planning).

Following is the criteria for appropriate referrals to Neuropsychiatry Social Work:

1. Diagnosed with a psychiatric and neurological disorder with neuropsychiatric sxs (mood, anxiety, conversion, psychosis, etc.) being primary target of treatment.
2. Ongoing, active treatment with a BWH neuropsychiatrist
   1. Please note: if the pt is being seen for a consult only with MD, the SW team is able to meet with the pt for a needs assessment, planning, and time-limited care coordination but will not be assuming clinical responsibility for pt care beyond that.
3. Psychiatrically complex
   1. High safety risk
   2. High risk of dropping out of treatment
   3. Extremely complicated psychosocially
   4. Excessive utilization of services
   5. Need for coordinated multidisciplinary treatment
4. Need for short term targeted therapy and/or active monitoring of sxs/safety risks associated with neuropsychiatric condition
5. Caregiver and family system assessment and short term support
6. Assessment of social, financial and community needs

To Refer to Social Work

• Patients may be referred to SW by sending an In basket message the SW team (Laura and Margaret).

• Please communicate promptly with the social work team that you are referring a pt to them and what the purpose of the referral is prior to the SW evaluation. This can be done by adding the smartphrase, .BBNGSWREFERRAL, to the bottom of your note and cc’ing the SW team through in basket, or entering the smartphrase, .BBNGSWREFERRAL, in an in-basket message and sending it to the Neuropsychiatry SW team.

• The SWs will determine who will pick up the case and have the front desk reach out to book the pt in their schedule.

• If a patient that you are seeing in Neuropsychiatry Clinic is followed by the BWH MS Center, use the same process of referral as above but instead of cc’ing the Neuropsychiatry SW team (Laura or Margaret), please cc Lorraine Pedro.

To Refer to the SW Pager (for non-medical emergencies)

For urgent non-MD assistance, please use the SW pager. To use this service, call the BPS call center back line (617-278-0484). They will page the on-call SW with your contact info and the MRN of the patient you need support with. Please do not send only an in-basket message or email as it might be missed. The SW (Non-MD) Pager is best used for:

• Assessment of risk

• Referrals for partial hospitalization programs (PHPs)

• Assistance with DCF/interpersonal violence cases

• Crisis support