Role of Psychiatric Prescriber in an ACT Team
The role of the psychiatric prescriber in an ACT team involves actively participating in team processes, attending meetings, assessing symptoms, providing medication education, conducting therapy, and home visits. They have clinical supervisory responsibilities, provide clinical supervision, monitor clients' status, and establish individual clinical relationships. The psychiatric prescriber functions as a key team member in providing comprehensive and recovery-oriented treatment to individuals with serious mental illnesses.
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What is the Role of the Psychiatric Prescriber in an ACT Team? Christopher Hobart, MD Psychiatrist Central City Concern Old Town Recovery Center
The goals of an ACT program Provision of comprehensive, locally based treatment to people with serious and persistent mental illnesses Acting as a primary service provider for a range of treatment services. Treatment is Client centered and recovery oriented. Providing out-of-office treatment in a community setting or the individual's home. Treatment is individualized, designed to meet each person's needs and help them reach their goals. Treatment that is collaborative.
II) The Psychiatric Prescriber Role in the ACT Model:
The Role of LMP (Psychiatrist or PMHNP) per OCEACT: Actively participates in team processes, including attending at least one full team meeting per week Typically meets with participants at least monthly to assess symptoms and response to the medications Provides diagnostic and medication education to participants with medication decisions based on shared decision making Provides brief therapy Conducts home and community visits
National Program Standards for ACT Teams (2003) The psychiatric prescriber sees patients/clients and has clinical supervisory responsibilities for clients and staff. They function as a team member, not just as a consultant to the team.
Supervisorial Duties Works with the team leader to monitor each client s clinical status and response to treatment. The team leader and the psychiatrist have the responsibility to provide clinical supervision that occurs during daily organizational staff meetings, treatment planning meetings, and in individual meetings with team members. The psychiatrist regularly participates in daily staff organizational meetings and treatment planning meetings. Clinical supervision also includes review of written documentation
Clinical Duties Establish an individual clinical relationship with each client. The psychiatrist is responsible for completing the psychiatric history, mental status, and diagnosis assessment. Psychoeducation provide verbal and written information about mental illness Provide education about medication, benefits and risks, and obtain informed consent
Clinical Duties (Continued) Directs psychopharmacologic and medical services to all ACT clients. Assess and document the client s mental illness symptoms and behavior in response to medication and shall monitor and document medication side effects. Medication Management is a collaborative effort between the client and the psychiatrist with the participation of the Individual Treatment Team The goal of medication management is client self-medication management.
Time/Availability Requirements Works a minimum of 16 hours per week for every 50 clients It is very important that the psychiatrist have designated hours when he or she is working on the team. It is also necessary to arrange for and provide psychiatric backup all hours the psychiatrist is not regularly scheduled to work. If availability of the psychiatrist during all hours is not feasible, alternative psychiatric backup must be arranged (e.g., mental health center psychiatrist, emergency room psychiatrist)
III) The Psychiatric Prescriber Role on OTRC CORE/ACT Teams
Psychiatric prescribers on CORE teams act more as consultants than team members. Lines of supervision of team providers does not include psych prescriber Prescribers do not share office space with the rest of the team. Most prescriber work is office based. Decisions on outreach are done in consultation with the team, but are largely based on psychiatric prescriber preference. Historically, OTRC provided multiple services/programs on site (eg: payee services, groups, Livingroom), and these brought many of our clients to the clinic on a regular basis. COVID has changes all of this.
INTERACTIONS WITH PATIENTS/CONSUMERS AND THEIR SUPPORTS My efficacy as a provider is often based on my ability to be seen as a fellow traveler, not just as a doctor with a prescription pad. At the same time, the holding of prescribing capacity creates a relationship that is different from other ACT providers (social workers, nurses, case managers, peers). Many (most) come to an ACT team with a history of trauma, and this trauma often encompasses their interactions with the mental health system and associated providers.
INTERACTIONS WITH PATIENTS/CONSUMERS AND THEIR SUPPORTS (cont) My ability to provide psychoeducation is dependent on my ability to develop trust with my patients and their supports (eg: friends, partners, parents or other family members). Part of this role is in demystifying diagnosis Part of this role is in demystifying meds Part of this role is in promoting non-pharma approaches to treatment/recovery (eg: Dr. Shapiro s Healing Power approach, CBT, DBT, etc.).
INTERACTIONS WITH PATIENTS/CONSUMERS AND THEIR SUPPORTS (cont) Social/Family Systems: Many of our patients experience significant social isolation, often in the context of broken family/social systems. This can mean that the primary relationship is between the individual and their team. Others may have (variably) intact families of birth &/or choice. In these situations, developing a relationship (or maintaining clear boundaries) may be a significant piece of providing effective care.
INTERACTIONS WITH PATIENTS/CONSUMERS AND THEIR SUPPORTS (cont) Cultural Factors: Multiple factors including race, gender, sexual orientation, age, economic status, and other factors have shaped the experiences and perspectives of patients/clients (and the team members), and an openness to exploring, and understanding these experiences and perspectives is key to effective treatment (and team work).
INTERACTIONS WITH THE ACT TEAM(S) PROVIDERS This is an evolving role that shifts as teams change, the medical/mental health system changes, and a provider s experience grows. Some of the factors:
INTERACTIONS WITH THE ACT TEAM(S) PROVIDERS (cont) Education: Neurobiology Psychopharmacology Medical Administrative: Supervision At OTRC, LMPs do not have official supervisorial role with ACT Team providers. Medical professionals (ie: LMPs, nurses) are organized in a separate silo from other health care professionals. Paperwork Treatment Plans, Assessment Updates, etc. Reviewing referrals for clinical appropriateness Advocacy: With outside systems Within the organization
INTERACTIONS WITH SYSTEMS Coordination of Care with other outpatient medical providers, hospitals (psych and medical/surgical), and other care providers. Working with pharmacies OTC Pharmacy many advantages Flexibility (dispense plans, titration algorithms) Packaging Education Monitoring Outside Pharmacies
INTERACTIONS WITH SYSTEMS (cont) Working with Administrative Agencies SSA (eg: mandating payee, assessments) Courts (eg: jury duty excuses) DMV (eg: driver license revocation) Working with legal system Commitment (testifying at hearings, working with trial visit program) Police APS, CPS
TEACHING/EDUCATION Providing educational opportunities for medical students, residents, fellows, pharmacy students, etc
