Novel Psychiatry Programs Ensure Continuity of Outpatient Care

The UB-led programs, Access to Psychiatrists through Intermediate Care (APIC) and Child and Adolescent Psychiatry for Primary Care (CAP PC), are addressing the state’s critical shortage of psychiatrists. 

They are also demonstrating more cost-effective models of mental health care delivery, says Steven L. Dubovsky, MD, professor and chair of psychiatry. 

APIC provides a range of intermediate levels of psychiatric care to autism spectrum and developmentally disabled children, adolescents and young adults — as well as to chronically mentally ill adults — while minimizing the use of the emergency room or admission to a psychiatric unit. 

So far, more than 50 children and 20 adults have been enrolled, with a goal of enrolling a total of 200 patients per year. 

Teams consisting of a psychiatrist and other mental health clinicians assess the needs of patients and families, determine the best treatment, develop comprehensive treatment plans and provide continuity of care with resources for ongoing care. 

Outcomes are being tracked closely as services — ranging from home visits to intensive outpatient treatment — are implemented.

APIC is designed to divert from hospitals and emergency rooms children with developmental disabilities and adults with chronic psychiatric illnesses who make frequent visits to the emergency department or hospital because of inadequate intermediate levels of care in the community.

“There are few programs for the deteriorating chronically ill patient and very little continuity of care,” says Dubovsky. “Our psychiatrists repeatedly see the same children and adults in the emergency department who could be more effectively treated in a continuum of care community setting.”

“There aren’t enough psychiatrists, and especially child psychiatrists, locally or nationally.”

The program addresses issues in New York State’s busiest psychiatric emergency program, the Comprehensive Psychiatric Emergency Program (CPEP) at Erie County Medical Center.

“We catch them at the CPEP level or before, and keep them out of the hospital,” says Dubovsky.

Staffed by UB psychiatry faculty members and psychiatry residents, CPEP — which is headed by Victoria Brooks, MD, assistant professor of psychiatry — saw its annual patient visits jump by about 40 percent following last year’s merger with Buffalo General’s psychiatric services unit.

The purpose of CPEP is to treat true psychiatric emergencies, Dubovsky notes, but even before the merger, in 2012, half of the more than 9,000 annual visits resulted from a lack of services in the community or a non-psychiatric problem.

Many people mistakenly feel that CPEP is the only way to access a psychiatrist, while others believe it was created to meet any needs not being met elsewhere, psychiatric or not, explains Dubovsky.

One of the goals of APIC is to provide early intervention and aggressive follow-up for behavioral disruption in autistic children and young adults with developmental disabilities. 

To improve functioning and prevent future deterioration, the program also devises more effective treatment plans for those with moderately severe symptoms who are poorly controlled in a community setting.

Dubovsky emphasizes that autism spectrum and developmentally disabled individuals, in particular, tend to deteriorate in hospital settings and are not well served in an emergency setting.

“A hospital is no place for an autistic child. When one of these children gets left in the emergency room by caretakers, social agencies view this as a safe environment and therefore feel no need to help find a better placement,” he explains.

“In fact, this is a harmful if not dangerous environment for such children because inpatient psychiatric services are very overstimulating and are not geared toward behavioral management of developmentally challenged individuals.”

CAP PC is the nation’s second largest consultative pediatric mental health program, providing assistance for children who are being managed in a primary care (pediatric or family medicine) setting. 

The program, which is funded by the New York State Office of Mental Health, provides an intensive mini-fellowship training program to help primary care providers understand and select treatments for the mental health needs of children and adolescents in their practices. 

CAP PC helps clinicians manage patients with mild to moderate disorders in their practices and helps with evaluation or referral of patients with emergencies and those who clearly belong in the mental health system, says David Kaye, MD, professor of psychiatry, who directs CAP PC.

CAP PC provides educational and consultative services through a toll-free helpline for family doctors and pediatricians, who are often the first line of psychiatric care for their patients. 

Child psychiatrists who staff the helpline respond in real time to requests for assistance from pediatricians and family physicians, with information about medications, therapy, referrals and resources they can access locally.

A primary tenet of the APIC projects is that patients’ mental health outcomes can be improved significantly while dramatically reducing costs and unnecessary and harmful institutional treatment, says Dubovsky.

“Insurance companies are looking for better models of care, and we want to devise a program that achieves this goal with better clinical outcomes,” he notes. 

“This is a novel, innovative program and an opportunity to design a system that will really work in an era of cost containment. That’s why the university has to be a leader in this, because our job is to develop new knowledge, test the effectiveness of innovative approaches and disseminate them to the community.”

APIC is supported by nearly $2 million in funding from the John R. Oishei Foundation; Patrick P. Lee Foundation; Peter and Elizabeth C. Tower Foundation; and the Margaret L. Wendt Foundation.

The program works closely with primary care providers through UBMD Family Medicine or UBMD Internal Medicine to help coordinate psychiatric care, where appropriate.