UB’s innovative psychiatry programs address critical shortage of community providers

BUFFALO, N.Y. — More people with significant mental health needs in Western New York and throughout the state are receiving quality psychiatric care in the community, instead of the hospital, thanks to two innovative programs developed by University at Buffalo psychiatrists.

Designed by physicians in the UB School of Medicine and Biomedical Sciences, the programs help address the growing need for quality mental health providers in the community, a significant problem, especially for children and adolescents.

“There aren’t enough psychiatrists, and especially child psychiatrists, locally or nationally,” said Steven L. Dubovsky, MD, professor and chair of the Department of Psychiatry in the UB School of Medicine and Biomedical Sciences, who sees patients through UBMD Psychiatry. “As soon as we hire one, their patient load is full immediately.”

In different ways, 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 child and adolescent psychiatrists. They are also demonstrating more cost-effective models of mental health care delivery, Dubovsky said.

Diverting patients from emergency rooms

APIC emerged as a way to address issues in New York State’s busiest psychiatric emergency program, the Comprehensive Psychiatric Emergency Program (CPEP) at Erie County Medical Center. CPEP is located in the hospital’s Behavioral Health Center, headed by executive director Michael R. Cummings, MD, who is also a UB assistant professor of clinical psychiatry.

Staffed by UB Department of Psychiatry faculty members and psychiatry residents, CPEP, headed by Victoria Brooks, MD, clinical assistant professor of psychiatry, saw its annual patient visits jump by about 40 percent – an additional 4,000 visits – following last year’s merger with Buffalo General’s psychiatric services unit.

The purpose of CPEP is to treat true psychiatric emergencies, Dubovsky explained, 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.

“The problem with mental health in Western and Central New York is that it’s a very fragmented system,” said Dubovsky. “There are few programs for the chronically ill patient and very little continuity of care. 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.”

APIC is a demonstration project that provides an intermediate level of psychiatric care to autism spectrum and developmentally disabled children, adolescents and adults, as well as chronically mentally ill adults, without resorting to the emergency room or admission to a psychiatric unit. It 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.

APIC is designed to divert from hospitals and emergency rooms children up to age 26 with developmental disabilities and adults with chronic psychiatric illnesses who make frequent visits to the emergency department or hospital because of inadequate intermediate care in the community. Dubovsky emphasized 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,” Dubovsky said. “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. In fact, this is a harmful if not dangerous environment for such children.”

But for all kinds of patients, CPEP had become a kind of disposition of last resort because, he noted, many people mistakenly feel that it is the only way to access a psychiatrist, while others believe it was created to meet any needs not being met elsewhere.

APIC now assists those patients who can be appropriately served in the community. “We catch them at the CPEP level or before, and keep them out of the hospital,” said Dubovsky.

APIC provides early intervention and aggressive follow-up for behavioral disruption in autistic children and young adults with developmental disabilities, and also serves those with moderately severe symptoms who will do well with consistent care in a community setting. Medications are tracked and adjusted, and therapists work closely with patients, families and caregivers.

Teams consisting of a psychiatrist and another mental health clinician assess the needs of patients and families, determine the best treatment, develop comprehensive treatment plans and seek out other needed services and providers. The program also works closely with primary care providers through UBMD Family Medicine or UBMD Internal Medicine to help coordinate psychiatric care, where appropriate.

So far, more than 50 children and 20 adults have been enrolled, with a goal of enrolling a total of 200 patients/year. Outcomes are being tracked closely as a range of services are implemented ranging from home visits to intensive outpatient treatment.

The goal, Dubovsky said, is to significantly improve patients’ mental health outcomes while dramatically reducing costs.

“Insurance companies are looking for better models of care,” he said. “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 and disseminate it to the community.”

Delivering mental health care as a primary care provider

While APIC serves patients with more profound mental health needs, CAP PC provides assistance in cases where a child can be managed successfully in the primary care setting. Funded by the New York State Office of Mental Health and led by UB, which has now served 4,000 patients in the state, it is the nation’s second largest consultative pediatric mental health program. It was originally funded by the Tower Foundation with additional support from BlueCross BlueShield of Western New York.

CAP-PC provides an intensive mini-fellowship training program to help primary care providers treat the mental health needs of children and adolescents in their practices. It also 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.

David Kaye, MD, UB professor of psychiatry, who directs CAP PC, stresses that the program is for mild to moderate cases, not emergencies or those that clearly belong in the mental health system. However, CAP PC can arrange evaluations and referral to appropriate specialists. More information is available at http://www.cappcny.org/home/