Neuropsychiatry Trainee Guide

Revision as of 15:55, 28 July 2021 by Gbaslet (talk | contribs)

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. See 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, 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). See below 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 Educational Activities

Trainees are expected to attend multidisciplinary CBMM clinical teaching 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.

BWH Psychiatry Grand Rounds take place September-June on Thursdays from 12 to 1 pm and an email is sent each week on the topic and the link.


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 on how to file a section 12). 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 how to access the non-MD pager).


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


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 pt 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 pt 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 pt 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 pt 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 .BPSCHWREFERRAL
  • Enter the needed info
  • Select the <DISP & CC CHART> link from the side nav
  • Forward to Jean Ford Figaro and Lorna Campbell
  • Select <Close Encounter>


Section 12

BTM Section 12 Process

Provider:

  • The provider will notify the administrative support staff by calling EXT: 7-5311 to notify the staff of their need to section a patient before or after hitting the panic button.
  • Provider will fill out the (Commonwealth Section 12) form.
  • Security will remain with the patient while waiting for EMS to arrive
  • Provider will 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 expected ED admission form).
  • Provider will page the C-L team (until 5pm #32368; after 5pm #13088)
  • If provider 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, where basic patient information will be gathered to facilitate the patient's care in the emergency department, ensuring quality and safety for all transferred patients.


Staff:

  • Administrative support staff will confirm they have the correct patient via Epic and repeat back the pertinent details shared by the provider for the section 12.
    • Staff will dial 9-911 and ask to be transferred to ambulatory services.
    • Staff will then call security at EXT:26565 to let them know we are sectioning a patient and provide them with the patient’s current state (i.e., violent or not) and the provider’s location. *Staff will remind security to use the back door to the clinic
    • Ask for an ambulance to be sent to BTM Clinic at 60 Fenwood Rd, provide location, reason for sectioning (providing as little information as possible) and the patient’s demographic information (i.e.: name, date of birth, etc.). *if the patient is violent we will also request BPD.
    • Notify Operations Supervisor/Operations Manager of the situation via phone, page, or text.
    • Print out patient Face Sheet and give to the EMT’s upon arrival.
      • Right click patient’s appointment
      • Form Reprints
      • Print Face sheet [ID 31012006] “ADM Face Sheet (BWH)”
    • Scan a copy of the completed section 12 form 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 pt 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: https://www.mass.gov/files/documents/2017/10/05/section%2012%20order.pdf
    • 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

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

  • For concerns related to intimate partner violence, consider Passageway consult:
  • 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


CBT Groups at Brigham Psychiatric Specialties

BPS Support Staff Phone Numbers

BPS Support Staff

Maria Pires (Operations Manager) 617-278-0533 (office); 857-407-8537 (cell)

Call Center Staff

Megan O’Connor (Operations Supervisor) 617-525-9679

Lesly Calderon 617-278-0815

Beverley Lai 617-525-7499

Hannah McNeill 617-525-9670

Marlon Green 617-278-0813

Sarah Poolman 617-525-9092

Savannah Kingler 617-525-9215

Front Desk Staff

Rogina Isme 617-525-7776

Kathleen Ledesma 617-732-5599

Irvin bailey 617-525-7151

Medical Assistants

Gabriella Childers 617-278-1050

Lissette Mohammed 617-525-9210

Billing Coordinator

Alanna Baker


Brain Health Groups

Flyers for current CBMM groups can be found at:

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

To refer through Epic, go to "Ambulatory Referral to BWH Neurology" >> choose "Cog Rehab/Brain Wellness Groups" under Specialty >> then select the group. If unsure which group fits best, select "Triage".

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