Essentials of Psychiatry in Primary Care: Behavioral Health in the Medical Setting >Enhancing Your Own

Care
Robert C. Smith, Gerald G. Osborn, Francesca C. Dwamena, Dale D'Mello, Laura Freilich, Heather S. Laird-Fick+
Table 11-1.Key Functions and Actions to Provide Team-Based Care for Patients

Functions Actions Examples

Screening for:

•Front office staff distributes screening forms at check-in.a

•Depression (eg, Patient Health Questionnaire-9a)
•Medical assistant administers screening forms as part of intake for
•Anxiety (eg, Generalized Anxiety Disorders 7-item)
Identifying high-risk patients visit.a
•Bipolar disorder (eg, The Mood Disorder Questionnaire)
•Nurse or social worker screens patients with depression for
•Drug and alcohol misuse (eg, CAGE, CAGE-AID)
comorbidities.
•Risk of substance misuse (eg, Opioid Risk Tool)
•Nurse creates and maintains registries.
•Social determinants of health
Creating registries of patients with chronic diseases

•Medical assistant or Nurse completes medication reconciliation

and updates medical record.a
Reconciling medications •Nurse maintains registry of patients on controlled substances and
runs reports from prescription monitoring system.
Identifying problematic and/or positive behaviors
Monitoring controlled substance prescriptions •Nurse maintains registry of patients being treated for depressive
disorders and monitors for remission.a
Observing patient behaviors •Team members participate in huddles to discuss patient care.
•Team members report concerns based on interactions at check-
in, during telephone conversations, and other interactions

•Front office staff schedule patient with primary care provider to

facilitate continuity.
•Nurse (as care manager), physician, and patient meet together
during visits.
•Team members give patients a team business card to reinforce
Maintaining consistent interactions and expectations
Reinforcing care plans roles and available resources.
•Nurse or social worker reinforces treatment plans with patients
Following policies or protocols on medication prescribing and refills
outside of formal visits.
•Physician and physician extender use evidence-based protocols
for patient management (ie, psychotropic medication prescribing,
follow up for chronic pain, minimizing serial testing for medically
unexplained symptoms).

•Physician extender, Nurse, or social worker teaches patient about

Educating patients
self-care practices.
•Nurse or social worker calls to ensure patient is taking medication.
Administering medications in the office
•Nurse or social worker conduct in-person visits.
•Social worker provides contacts for counselors.
Monitoring adherence and effectiveness of therapy
•Social worker provides brief counseling directly.
•Team members participate in huddles to discuss goals for specific
Scheduling appointments with primary team, diagnostic services,
Coordinating care visits or chronic disease management.
or consultants
•Medical Assistants use pre-visit planning sheets or templates to
prepare for visits or obtain data during visits.
Communicating with consultants
•Physicians or other team members perform structured handovers
for patients in case of contact outside business hours or during
Providing or identifying resources (eg, for medications,
absences.
transportation, housing, exercise)
•Nurse manages patient portal to facilitate between-visit care and
to engage patients in self-management.
Performing handovers for complicated patients
•Team members work from buckets or electronic “to do” lists.
aPerformance indicators for patient-centered medical home certification.

Date of download: 12/26/22 from AccessMedicine: accessmedicine.mhmedical.com, Copyright © McGraw Hill. All rights reserved.