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 your clinic supervisor(s).

Who we are

Our Neuropsychiatry division at Brigham and Women’s Hospital includes several neuropsychiatrists. We are one of the core components of the Center for Brain/Mind Medicine (CBMM). You will work with one primary supervisor per clinic session (4-hour clinic block). Due to cross-coverage, you will likely interact with most of us at some point. We are:

David Silbersweig, MD

Jessica Harder, MD

Juan Carlos Urizar, MD (Geriatric Neuropsychiatry)

Stanley Lyndon, MD

Irene Gonsalvez, MD

Joseph Taylor, MD (TMS)

Shan H Siddiqi, MD, MBBS

Rishab Gupta, MD

Nathan Praschan, MD, MPH

Jacob Weiss, MD

Marie Esther Emmanuel, CNP

There are other neuropsychiatrists and clinicians affiliated with CBMM whom you will meet during rounds (such as Dr. Barry Fogel, Dr. Barbara Schildkrout, and others). You will have the opportunity to learn from them and consult with them as well.

We also have two social workers in Neuropsychiatry whom you may reach out to for clear, issue-focused, short-term psychotherapy referrals. Please refer to the section below 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, MSW, LICSW

Judy Burrows, MSW, LICSW

We also have access to a Community Health Worker (CHW), Debra Aponte, who can provide brief assistance (1-3 sessions) for specific case management needs such as housing and food insecurity, or help with community referrals for mental health treatment, such as establishing psychotherapy with a provider in the community. The CHW may work longitudinally with patients to reduce barriers that affect health outcomes and help navigate the healthcare system. Please refer to the section below for an overview of the services provided by the community health worker.

Lorna Campbell, MSW, LICSW, serves as the Social Work Program Director for Brigham Psychiatric Specialties (BPS), which includes Neuropsychiatry.

CBMM Educational Activities

Please refer to this document for Zoom links to the meetings mentioned below.

• Trainees are expected to attend multidisciplinary CBMM clinical teaching rounds as per their pre-arranged schedule. These rounds occur on Wednesdays from 10 am to 12 pm, conducted via Zoom or hybrid format once a month (usually on the first Wednesday - room location announced via email the preceding week). Each week, trainees are required to present one new case during rounds, focusing on cognitive neurology and neuropsychiatry cases, with presentations limited to 6 minutes. Please inform Kirk Daffner and Stanley Lyndon via email before rounds regarding the case you wish to present during CBMM rounds.

• Management rounds are held on the second and fourth Wednesday of each month for 30 minutes during CBMM rounds. This time is designated for presentations that address specific clinical management questions. Please inform Stanley Lyndon and Nathan Praschan via email before rounds regarding the case you wish to present during management rounds. We encourage trainees presenting cases also followed by another CBMM clinician to notify them in advance for additional input.

• Tuesday evening supervision (5-6 pm) offers in-depth discussions on topics related to Behavioral Neurology and Neuropsychiatry, conducted via Zoom and in hybrid format once a month.

• CBMM Journal Club convenes on Wednesdays from 12-1 pm immediately following clinical teaching rounds, at the same virtual or on-site location.

Other educational meetings of interest to trainees include:

- Brain Circuit Therapeutics Training Program (led by Shan Siddiqi), weekly on Thursdays at 1 pm via Zoom. This program does not run during the summer months.

- MGB Psychiatry Grand Rounds, Thursdays 12-1 pm. Weekly emails provide the topic and location/Zoom link.

- MGB Neurology Grand Rounds, Thursdays 9-10 am. Weekly emails provide the topic and location/Zoom link.

Trainees may also wish to attend various relevant clinical meetings. Please notify the respective attendings below if interested in attending:

- Functional Neurological Disorders Team Meeting (Gonsalvez, Lyndon, Praschan), Mondays 11-12 am via Zoom.

- Neuropsychiatric Symptoms of Dementia (Urizar), 1st and 3rd Tuesdays 1-2 pm via Zoom

- Plaque and Tangle Committee for Anti-amyloid Therapy (Daffner, Erkkinen, Praschan), Wednesdays 8:30-9:30 am via Zoom.

- Deep Brain Stimulation (DBS) Surgical Conference (Green, Lyndon, Praschan), every other Wednesday 4-5 pm via Zoom.

- Transcranial Magnetic Stimulation (TMS) Weekly Rounds (Taylor, Lyndon, Gonsalvez), every Tuesday 12-1 pm in-person/hybrid.

- Epilepsy Surgical Conference (Barbara Dworetzky, Daniel Weisholtz), every Thursday 1-2 pm in-person/hybrid.

Clinical Operations

Most of our on-site clinical operations take place at the BWH Hale Building, Clinical Neurosciences Center, 60 Fenwood Road, Boston, MA, first floor. We also have Neuropsychiatry services at Brigham and Women's Faulkner Hospital. Support staff at the clinic will assist with requests related to encounters during your clinic time for on-site patients. This includes: check-in at the front desk, vitals and medication reconciliation by medical assistants, and check-out at the desk. The check-out staff can help set up follow-up appointments and make referrals for tests and other specialists (provided that an order in Epic is in place).

Assistance for anything 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 patient phone calls, scheduling changes, and document sending. You will be assigned one primary support staff person.

All trainee clinics physically take place at BWH Hale Building, 60 Fenwood Road, or BWFH, 1153 Centre St. New patients will be encouraged to schedule an in-person visit (patients may refuse). Follow-ups may be scheduled virtually if clinically appropriate and if the patient will be physically in the state of Massachusetts. Every virtual clinical encounter should start by confirming the patient's 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 (e.g., rescheduling appointments, sending documents), contact your assigned primary support person. For medication-related issues (e.g., completing prior authorization forms, obtaining pharmacy information), Psychiatry medical assistants can assist. Click here for their names and phone numbers. Messages concerning schedule changes should include Maria T. Pires and Karina Rosario. Please consult your supervisors for any questions about contacting the appropriate person. All clinical requests should be directed through Epic’s In-Basket messaging system.

New patients are scheduled through our BWH Psychiatry Triage team (part of BPS Call Center). They may contact you regarding new patient queries (e.g., records you may need beforehand). Always consult your attending supervisor before accepting a new patient.

As a general rule, NEW patients (not previously seen in Neuropsychiatry) are evaluated on a consultation basis (without expectation of treatment). If a new patient has established providers at BWH (e.g., PCP or ongoing neurological care requiring frequent visits), we may offer treatment within our service. For patients without established providers at BWH, we can only offer a one-time consultation and referral back to the referring provider with recommendations (with very few exceptions, e.g., existing programs offering limited forms of treatment such as short-term psychotherapy for FND).

All staff listed in this guide, and the support staff assigned to you are reachable via MGB email. The clinic phone number is 617-732-6753, and the clinic fax number is 617-738-8703. Provide these numbers to patients for contacting you. For electronic communication, patients should use Patient Gateway / My Chart (advising a 48-hour delay for messages). Avoid patient communication via email as it is not part of their medical record.

A comprehensive description of Brigham Psychiatric Services is available in the BPS Handbook.

Holiday Calendar

Link to the hospital holiday calendar: https://www.brighamandwomens.org/about-bwh/human-resources/bwh-holiday-calendar

Time off

If planning time off (vacation or education-related), complete the request form. Inform the fellowship directors, your clinic supervisors (for the dates you will be away), and Maria T. Pires via email as soon as the dates are known. Prompt information minimises patient rescheduling. Requests should be submitted at least one month in advance.

For Neuropsychiatry Clinic absences due to illness, promptly inform your supervisor and email bpspsychout@PARTNERS.ORG to reschedule patients.

Clinic cancellations within 1 month

Per BWPO policy, complete a clinic cancellation form for requests within 30 days.

Provider responsibilities include:

1. Notify designated department approver of cancellations within 30 days of appointment.

2. Submit the Provider Cancellation Notification Form to designated department approver with a cc to Maria Pires.

• Specify cancellation reason: “Provider-Professional” or “Provider-Personal”
• Reschedule new and return patients within recommended timeframes:
  • New Patients: within 10 working days
  • Return Patients: within 20 working days

Coverage

You are the primary neuropsychiatry provider for your patients, so you would be covering clinical issues for your patients between clinic days unless you are on leave. Attending supervision is available for consultation for any issues or questions that come up between patient appointments. Monitor in-basket messages regularly. The psychiatry resident on-call generally handles emergency calls after hours and weekends, but they may reach out to you for questions.

Additionally, you may need to manage requests from neuropsychiatry patients transferred from former trainees but whom you have not yet seen. Address patient clinical requests with supervisor guidance (either one of your regular clinic supervisors or an attending who had recently seen or staffed that patient). Avoid contacting patients never seen in our clinic. For Epic warnings of new patients reporting suicidal thoughts, alert BWH Psychiatry Triage team for follow-up (and on-call Social Work if needed).

During vacation or education leave, arrange coverage with fellow trainees in Epic (using the "Out" function). Inform Maria T. Pires, Karina Rosario, and your primary support staff about the dates you are out and who will be covering patient requests addressed to you by sending an out-of-office email to BWHPsychiatricSpecialties@partners.org the day before you go on leave. Consult clinic supervisors if you have any questions about coverage.

Clinical emergencies

Weekday nights and weekends, on-call psychiatrists (residents) handle urgent needs. On weekdays, refer urgent patients to ED evaluation. Additionally, urgent slots (walk-in clinic, LUCY) provide timely care for severe clinical cases not warranting Section 12 filing. For non-medical crises (requiring SW assistance, e.g., crisis support, referral to partial hospitalisation), use the SW (non-MD) pager. See accessing the non-MD pager.

Navigating an Epic Encounter

For a video guide, please visit this link.

For a detailed guide with images, please visit this link.

When you open Epic, ensure you are signed into the right context ("BWH NEUROPSYCH HALE") and with the correct job for that visit ("Resident/Fellow","Psych trainee with cosign","Psych trainee without cosign").

Epic should open to your schedule. If not, click on the schedule icon in the upper right corner.

Double click the patient in your schedule. If they have already been seen by the MA, the visit will have started. If it is a virtual visit, you will need to start the visit.

The visit will open to the Rooming tab. In this tab, complete the following:

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”. You may also use the "History" tab (click the upper left corner wrench to add to your buttons) while documenting in your note to update past medical, surgical, family, and social histories as you speak with the patient.  

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. Update the medication list with new medications, including important supplements. Delete old medications from the list. After reviewed, check “Mark as Reviewed”. You may also do this under the "Plan" tab.  

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

Next, move to the Charting tab. In this tab, complete the following:

Progress Notes: Add your note here. Use one of the templates for an evaluation/consultation or progress notes (use SmartPhrases .NEUROPSYCHNEW or .NEUROPSYCHNEW2 or .NEUROPSYCHPROG for Epic templates). Note that .NEUROPSYCHNEW is preferred over .NEUROPSCYHNEW2 since it is very detailed and captures the various aspects of a comprehensive neuropsychiatric evaluation. .NEUROPSCYHNEW2 would be helpful if you are building your own template and want to make sure to include all the essentials. Please use one of the NEW templates for transfer evaluations as well, as they are an opportunity to learn aspects of the patient's history that may have been missed in the their previous follow-up visits. During your first follow-up visit with a patient, you can either use the .NEUROPSYCHPROG template and start afresh or carry over your last note written using one of the NEW templates and edit the top sections to reflect that it is a progress note.

For virtual visits please make sure to include SmartPhrase .VVVIDEO or .VVTELEPHONE at the end of the note (depending on whether the appointment was conducted by video or phone, respectively). Feel free to use your own templates if they include all the same data. We expect all patients to have a documented elemental neurological exam and at least a cursory cognitive exam (in addition to mental status exam). Note that all patients have access to their documentation, and it is a good idea to use the note as a tool for communicating the plan with them as well as other providers. If you will be writing about sensitive material (eg details of a traumatic experience), obtain consent to document in detail--otherwise place it in a separate "sensitive" note. Dr. Praschan encourages patients to read their notes and inform him of inaccuracies or disagreements to be discussed.

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 (at first appointment, within the “Charting” tab or the hyperlink in the note) OR select “Suicide Screening” and then select “C-SSRS” (subsequent appointments). You can paste the answers from the C-SSRS into your note by adding the Smartphrase .COLUMBIACSSRS (first appointments) or .SUICIDERISKSINCELASTCONTACT (subsequent appointments).   

Next, navigate to the Plan and Wrap-Up tab. On the left...

Visit Diagnosis: Please select your patient’s diagnoses (more than one if indicated). You may also add a diagnosis in the toolbar at the bottom.  

Review: Mark all as reviewed if you have not yet done so already in the rooming tab.  

Problem list: Update the problem list and delete inaccurate diagnoses if appropriate.  

ADD ORDER: Found in the toolbar on the lower right. This is where you will enter a prescription or diagnostics. As you complete the order, you may sign it in the lower right. Always confirm the preferred pharmacy.  

In the right column...

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. 

Charge capture: Ignore. Staffing attending may add or change visit charges rather than use those automatically generated by the LOS. 

Follow-up: The best practice for scheduling a follow-up is to directly find a mutually acceptable time with the patient in your schedule. We suggest denoting this time in your Outlook calendar to ensure follow-up visits are not forgotten. After you have selected a time, under "Send Chart Upon Closing Workspace," message your scheduler with the date, time, length, and location (virtual or in-person) of the visit. You may use the phrase .NCPSCHED or a similar Smartphrase for your convenience. Then click "Send now."  

Final notes:

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 them using the same "Send Chart Upon Closing Workspace" tool as above, entering your supervisor’s name as a “Recipient”, click “Send now." This will route the encounter to your supervisor and they 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. 

Note bloat: BNNP notes are often long due to the complex nature of patients we see. Be careful in subsequent visits to keep information updated and your note legible.

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 patient is being seen for a consult only with MD, the SW team is able to meet with the patient for a needs assessment, planning, and time-limited care coordination but will not be assuming clinical responsibility for patient 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 adding the smartphrase, .BBNGSWREFERRAL, to the bottom of your note and cc’ing all the social workers in the SW team (you can use either the communications section before you sign the encounter -preferable method- or the chart routing option after you sign the chart). This will send an Epic in basket message to the SW team.

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

• If a patient that you are seeing in Neuropsychiatry Clinic is followed by the Multiple Sclerosis Center, use the same process of referral as above but in addition to cc’ing the Neuropsychiatry SW team (Margaret Latawiec and Judy Burrows), please also cc Lorraine Pedro. Similarly, if the patient is followed in Epilepsy, please cc Briana Cast-Clifton, and if the patient is followed in Movement Disorders or Cognitive Neurology, please cc Laura Morrissey.

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

Purpose

• Offer additional layer of support to patients who are in crisis and unable to get in contact with lead clinician​ (ie, assistance with DCF/interpersonal violence cases)
• Risk assessment and management of patients in crisis including referrals to higher level of care​ (PHP)
• Cover high risk patients while lead clinician is out of the office on training or vacation

To Refer:

• Look up the SW on call in the schedule on Microsoft Teams at this link
• Page covering SW with MRN and send details of request via in-basket message (please do not send only an in-basket message or email as it might be missed; alternatively, you can call the BPS call center back line 617-278-0484 and they will page the on-call SW with your contact info and the MRN of the patient for whom you need support)
• Covering SW will respond within 30 minutes
• Covering SW will assume responsibility of assessing needs of case, communicating with patient’s lead clinician and documenting appropriately
• As needed (e.g., if a PHP referral was made and needs to be followed up with), covering clinician will write a sign off for next covering SW, the party who initiated the page, and other relevant staff members

Overview of Community Health Worker (CHW) Role at BPS

Mission: The mission of our Community Health Worker Program is to improve the health and well-being of patients who live in the diverse communities served by MGB.

Levels of CHW Support

1. Longitudinal Team Based Care – goal is to help patient become more self-sufficient in navigating the healthcare system and reduce barriers that interfere with patient’s health outcomes
   1. Improve Health Related Behaviors
      1. Work closely with TX team to provide feedback and identify tx targets
      2. Create and achieve personal health and wellness goals with pt
      3. Check in regularly about progress toward meeting those goals
      4. Weekly check ins via phone to follow up on referrals and MH Tx Plan
   2. Reduce Barriers to Care
      1. Assist patient schedule and prepare for appointments
      2. Plan transportation or other logistical details
   3. Community Resources (currently virtual only)
      1. Identify resources in the community and develop plan how to access them
      2. Complete referrals and follow up on completion of referrals
      3. Advocate for patient in the healthcare setting and with community resources
2. Brief Case Management
   1. 1-3 sessions of assistance
   2. Identify resources in the community and plan how to access them
   3. Assist patient with filing paperwork like Short Term Disability/SNAP/DMH
   4. Assist patients with health literacy to transition to MH services in community
3. Community Mental Health Referrals
   1. Call patient to determine needs for therapy (e.g., location, type of therapy, insurance)
   2. Send patient list of referrals
   3. Follow up with patient in 1 month on progress

To Refer to CHW

• Open <Documentation> under the EPIC button
• Select the <Create Note> button
• Enter the SmartPhrase .BPSREFERRALCHW
• Enter the needed info
• Select the <DISP & CC CHART> link from the side nav
• Forward to the pool of CHWs: P BWH PSYCH CHW
• Select <Close Encounter>

Section 12

The most updated version of the Hale Section 12 policy can be found here.

BTM Section 12 Process (last updated 5/2024)

Provider:

1. The clinician should press the panic button if:

  * The provider feels unsafe.
  * A patient is unwilling to be Sectioned (go with EMS to Emergency Dept for evaluation) or attempts to elope.
  * Never attempt physically to stop a patient. Call Security at EXT 26565.

2. Notify the Hale staff of need to Section their patient by calling EXT: 7-5311 (This is a number that goes to all on-site staff.)

3. Fill out the Commonwealth Section 12 form. (A copy is available in Microsoft Teams Section 12 folder.)

4. A clinician will explain to the patient the process of constant observation while in the clinic awaiting EMS transport (see also handout)

5. A search will be conducted by police/security with clinician presence per Hospital policy (see 1.6.13)

6. At time of placing a Section 12 on a patient, the patient is placed on continuous observation (to ensure safety as part of Section 12 document concern for imminent danger to the patient) conducted by a BWH Police and Security team until EMS arrives to transport the patient to the ED (Emergency Department).

  * Request additional clinic room for patients from on-site administrative staff (EXT: 7-5311) where constant observation by Security can continue.
  * If the clinician determines it is necessary to stay with the patient until EMS arrives, reach out to the 221 Longwood administrative team to reschedule/cancel scheduled patients as needed. (EXT: 8-0484).

7. If the patient requests to use the bathroom while awaiting EMS transport, police/security will escort the patient to bathroom room # 01254 or 01525 in the K hallway. The police/security officer will remain posted outside of the door, which must remain open just enough to ensure visualization of the patient while in the bathroom.

  * Patient should be offered, whenever possible, a gender-preferred trained clinic staff member (i.e., nurse, medical assistant, medical practice assistant) to accompany the police/security officer and patient to the restroom. In these instances, the police/security officer will remain within view of the clinic staff member to immediately intervene if the patient is observed performing behaviors that may cause self-harm or harm to others.

8. Complete an Expect Note in EPIC:

  * Go to the patient's chart -> select the encounters tab -> select "more" -> select "rarely used" -> select "emergency" -> fill out the expected ED admission form.
  * If clinician is unable to put in an Expect Note before the patient is taken by EMS to the Emergency Department, please call the BH Access Center at 617-732-8903 to provide basic information that will facilitate the patient's care in the emergency department, ensuring quality and safety for all transferred patients.
  * Complete clinical note as soon as possible.

9. Page the C-L team (until 5pm #32368; after 5pm #13088)

10. Give a copy of the section 12 form to the Admin to scan into the chart.

If the patient attempts to elope, never attempt to stop the patient alone. Follow at a safe distance, notifying others. Do not get in an elevator alone with a patient who is angry and/or has a potential weapon in his/her possession. Instead, alert BWH Police and Security Department or local law enforcement to the location of elevator. BWH Security at EXT: 26565

Staff:

Hale staff will confirm they have the correct patient via Epic and repeat back the pertinent details shared by the provider for Section 12. Staff will then:

1. Dial 9-911 to let them know we are sectioning a patient and provide them with the patient’s current state (i.e., violent, or not, aware they are being sectioned) and the provider’s location.

  * Ask for an ambulance to be sent to 60 Fenwood Road, 1st floor. Provide location, reason for sectioning and the patient’s demographic information (i.e., name, date of birth, etc.). If the patient is violent, request BPD.

2. Call BWH Police and Security at EXT: 26565 to let them know we are sectioning a patient, and they are to stand by until EMS arrives and provide the building, floor, and room #.

3. Print out patient Face Sheet and give to the EMT’s upon arrival.

  * Right click on patient’s appointment
  * Form Reprints
  * Print Face sheet [ID 31012006] “ADM Face Sheet (MGB)”

4. Scan a copy of the completed section 12 form (include patient MRN label) into patient chart in Epic.

Filing a Section 12 for a patient at home:

If a patient you’ve assessed to be at imminent risk of harm to self/others, you can section them from their residence by following these instructions:

• Recommend patient go to an ED for an evaluation and that you will call emergency services to assist, ask patient to remain at their current location and await emergency services
• Call 911

  * State the reason for the call: “I am a psychiatrist and a patient I evaluated is at imminent risk of suicide.”
  * 911 will forward you to the local police department, who will review reason for call and ask for physical description of the patient and any safety concerns (weapons).
  * Ask the police department for their fax number

• Prepare Section 12a

  * Form can be found here
  * For “Application to Facility Name,” put nearest hospital that you are aware of near patient and “or, if necessary, alternative appropriate facility” 
  * When filling out S12a, clearly describe concerning symptoms (likely in more detail than usual) as you may not be able to converse with the receiving hospital 
  * Fax Section 12 to police department
     * Can use Doximity to fax from phone or home computer
     * Fill out form using a PDF program and call the 221 back line at 617-278-0484 to let BPS support staff know that you will be emailing them a section that will need to be faxed from onsite. 
  * If sectioned to a specific hospital, call ahead to inform of ED expect
  * Document in Epic

Caring for High Risk Suicidal Patients in the Virtual Setting

This information is available in the Epic smartphrase .BPSSUICIDECHECKLIST

When there is concern for patient’s ability to maintain safety from suicidal ideation or self-harm behaviors, next steps may include:

In Session Interventions

• Ensure that patient’s address, phone number and emergency contact are up to date in Epic
• Verify patient’s current location
• Consider using Columbia Suicidal Assessment Scale and Suicide Risk Assessment (found within the “Charting” tab of an Epic encounter).
• Create Safety Plan with patient (.BPSSAFETYPLAN) and send a copy to patient through Patient Gateway
• If patient is unable to complete Safety Plan or participate in safety assessment, follow Section 12 Protocol or contact police department in patient’s geographic area to complete wellness check
• If sending patient to BWH/BWFH ED under Section 12, enter ED Expect note or page Psych CL team (BH pager: 13088; BWFH: pager 61568 or evenings/weekends: 66001)
• Additional clinical interventions may include:
  • Identify ways to mitigate risk (discuss disposal of extra medications, ensuring no weapons present, etc.)
  • Limit high risk medication refills to 14 day supply. Contact patient’s other prescribers to discuss limiting refills.
  • Consider contacting patient’s family/supports for collateral information and to increase support for patient

Ongoing Interventions

• Consider referral to Partial Hospital Program. BWFH PHP is currently functioning virtually, with specific telemedicine requirements, including – patient must be in Massachusetts, and have Patient Gateway activated. Further info is here: https://www.brighamandwomensfaulkner.org/programs-and-services/psychiatry/partial-hospital-program

Note: BWFH PHP often has a wait for admission, may not be rapid admission

• For concerns related to intimate partner violence, consider Passageway consult:
  • https://www.brighamandwomens.org/about-bwh/community-health-equity/passageway-domestic-abuse-intervention-and-prevention
  • Provider can contact Passageway directly to request consult; if requesting that Passageways contact patient, make sure patient is aware of this and agrees.
  • Passageway Mon-Fri 8:30am – 5:00pm (all locations)
    • BWH Passageway 617-732-8753
    • BWFH Passageway 617-983-7854
    • To page a Passageway advocate after hours, call 617-732-6660, beeper 31808
• Remember to engage in the self-care component of working with high-risk patients. Access support from supervisor, EAP, or other discipline-specific groups.

Clinical Support

• Alert supervisor of your specific concerns. Supervisor may review with Medical Director, Risk Management, or other systems supports.
• Review high risk patients with your supervisor on ongoing basis.
• In case of adverse event (self-harm, attempted suicide, overdose, etc.) file PMIRT and Safety Report
• Consider seeking support from On Call Social Worker for assistance with PHP Referral or other resources

Ethics Consult Service

Patients, families, and medical teams may experience uncertainty or disagreement when deciding how to proceed in a given case. The Ethics Consultation Service can assist and support clinicians, patients, and patients’ loved ones as they navigate difficult situations.

Contacting the Ethics Service:

• Page Ethics at 18590 (Mon-Fri, 8am-4pm) or email BWHEthicsConsultTeam partners.org
• Place consult to Ethics in Epic (also page or email – there is no alert for Epic orders)

Autism Spectrum Disorder (ASD) Resources

With thanks to Dr. Susanna Mierau for the list.

For Clinicians:

Autism Speaks:

• Toolkit for challenging behaviors
• Clinician Guide: Program development and best practices for treating severe behaviors in autism

Autism 2019:

• "‘People should be allowed to do what they like’: Autistic adults’ views and experiences of stimming." This paper provides views on stimming from articulate autistic adults.

For Patients and Caregivers:

Lurie Center for Autism:

• Patient Resources
• Coffee Convo Presentation Series
• Parent and Caregiver Workshops
• Behavioral Consultation Services for Families (With Nicole Simon)
• For the latest workshops, please refer to Dr. Susanna Mierau's Epic smartphrase, .SMLURIEWORKSHOPS.

Short articles that explain different reasons why a person may engage in repetitive speech and other behaviors:

• Reducing self-stimulatory behaviors in individuals with autism
• Repetitive behaviors and stimming in autism explained

BPS Support Staff Phone Numbers

BPS Phone number for patients

• Main number: 617-732-6753
• Fax: 617-738-8703

BPS Support Staff

• BPS Support Staff List

Other useful phone numbers

• Medical records: 617-726-2361
• Financial services: 866-736-1510
• Pacific Interpreters (interpreter services): 617-732-6639
• Passageways (domestic violence program): 617-732-8753
• BWH Registration: 855-278-8009
• Patient Gateway: 800-745-9683
• ARP (Addiction Recovery Program): 617-983-7060
• Bridge Clinic: 617-278-0172
• Patient Family Relations: 617-732-6636
• BWFH Outpatient Front Desk: 617-983-7474 - option 1
• BWFH Psychiatry Triage: 617-983-7060 - option 1

Brain Health Groups and Neuropsychology

Flyers for current CBMM groups can be found at:

https://brainhealth.bwh.harvard.edu/renew-flyers/

To refer through Epic, go to the order entry form and enter either "Ambulatory Referral to BWH Cog Rehab/Brain Wellness Groups" or "REF210752." The correct referral order will then appear. You can select the group that best fits the patient’s needs. If you’re unsure which group is the most appropriate, choose "Triage."

To refer a patient for neuropsychological testing through Epic, go to the order entry form and enter either "Ambulatory Referral to BWH Neuropsych Testing" or "REF210751." The correct referral order will then appear.

BPS Psychology Groups

Please refer to the link below for the most current list of group therapy offerings, including CBT, from BPS Psychology. Use the smartphrase .BPSREFERRALPSYCHOLOGY for the referral and route the note to the BWH PSYCH PSYCHOLOGY pool.

BPS Psychology Groups

Referrals to Psychotherapy in the Community

If the patient is capable of finding their own psychotherapist, you can offer the following guide:

How To Find A Psychotherapist

Other resources you may consider:

1. For patients with MassHealth or Medicare, consider sharing website for Massachusetts-mandated Community Behavioral Health Centers (CBHC), where patients can find their closest CBHC: https://www.mass.gov/community-behavioral-health-centers

2. Other resources that may require private insurance:

• Boston Evening Psychotherapy 617-738-1480 https://bostoneveningtherapy.com

• Lifestance 781-551-0999 https://lifestance.com

• Kinder Mind 866-846-7765 https://kindermind.com

3. Asking for help from the CHW team (see above)

Referrals to Interventional Psychiatry

For Transcranial Magnetic Stimulation (TMS), search for "Ambulatory referral to BWH Transcranial Magnetic Stimulation (TMS)" or "REF12132" and complete the required details. TMS is performed in the Hale Building. More details can be found here: https://www.brighamandwomens.org/neurosciences-center/transcranial-magnetic-stimulation

For Electroconvulsive Therapy (ECT) and ketamine/esketamine, use "AMB REFERRAL TO BWFH PSYCH INTERVENTIONS" or "REF5111" and complete the necessary details. Do not select "ECT/Ketamine BWFH Psych Interventions" that also comes up in the search results. Both these procedures are conducted at Faulkner Hospital. More details can be found here: https://www.brighamandwomensfaulkner.org/programs-and-services/psychiatry/interventional-psychiatry

Referrals to Partial Hospitalization Programs

Partial hospitalization (PHP) and intensive outpatient programs (IOP) are helpful alternatives to hospitalizations if patients are struggling with day structure and would benefit from additional support, but do not merit or would not benefit from an inpatient psychiatric hospitalizations. Patients participate in a PHP during the day, typically on a 9 AM - 3 PM schedule, either by attending in-person or virtually. They may last 1-4 weeks. The structure of these programs is typically based on group psychotherapy, focusing on psychoeducation, distress tolerance skills-building, and cognitive-behavioral therapies. Most programs involve meetings with a psychiatrist to help make adjustments to medications as well.

There are several PHPs within the MGB system, including BWFH (general adult, in-person) and Salem (general adult, hybrid). Other well established programs within the area include JP Hospital PHPs (general adult, dual-diagnosis), HRI Hospital PHPs (general adult, women's and trauma-informed care, LGBT+), CHA, and others.

To refer a patient to the BWFH PHP, complete a Documentation encounter and populate a note with the the SmartPhrase BPSREFERRALBWFPARTIAL, complete the form, and route to BWF PSYCH TRIAGE inBasket pool.

To refer a patient to a PHP other than BWFH, please reach out to SW on-call: https://partnershealthcare.sharepoint.com/:x:/r/sites/BWHAmbulatoryPsychiatryAll-StaffTeam/_layouts/15/Doc.aspx?sourcedoc=%7B587979E9-8A7E-43B4-A7DA-F41317778B66%7D&file=SW%20Pager%20Schedule%20July%20to%20Dec%202023.xlsx&wdLOR=c2CD72601-CF13-E843-B2F6-6A7F9AD517A4&action=default&mobileredirect=true. See discussion of SW roles and responsibilities above for more details.

Link with Important Tip Sheets

Teams folder with useful documents and tip sheets: Click Here

Examples of what you will find here include:

• How to do a suicide and safety assessment
• How to connect to MGB system via VPN
• How to use interpreter services in Zoom
• How to use Doximity
• How to add a camera for your virtual visit
• How to create a list of open encounters in Epic
• How to create a caseload tracker in Epic
• In Basket efficiency tips
• ... and much more