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Pit Appointments:A new collaborative Psychiatric Assessment
A Race Against TimeDr. Marilyn Thorpe, Psychiatrist
Our Family Doctors in 2013
122Mental health patients per week
= average 17 per day
Our Family Doctors in 2013
Average 43 day wait for psychiatry
(up to 272)
Dissatisfied100%
122Mental health patients per week
= average 17 per day
And the Psychiatrist Survey Says…
• March 2015, 50% of psychiatric consultations could have been treated with less time
• April, 40 patients on the waiting list
• Team reviewed and allotted 36/40 for “pit spots”
• May 14, 2015 began four 30
minute spots 3 days a week
• Proved successful
Pit Assessments at UVic
PIT Project - Specialist Services Committee
UCL
LCL
0
10
20
30
40
50
60
70be
fore
May
-14
Jun-
14
Jul-1
4
Aug-
14
Sep-
14
Oct
-14
Nov
-14
Dec
-14
Jan-
15
Feb-
15
Mar
-15
Apr-1
5
May
-15
Jun-
15
Jul-1
5
Aug-
15
Sep-
15
Oct
-15
Nov
-15
Dec
-15
Jan-
16
Feb-
16
Mar
-16
Apr-1
6
May
-16
Jun-
16
Jul-1
6
Aug-
16
Sep-
16
Oct
-16
Nov
-16
Dec
-16
Aver
age
Wai
t (da
ys)
Pit Assessments Reduced Wait Times to See a Psychiatrist
Before Pit
Pit Starts
UCL
LCL
0
10
20
30
40
50
60
7020
13-0
1-01
2013
-02-
0120
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-10-
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15-1
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0120
16-0
1-01
2016
-02-
0120
16-0
3-01
2016
-04-
0120
16-0
5-01
2016
-06-
0120
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2016
-08-
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16-0
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-10-
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16-1
1-01
2016
-12-
01
Wait Times for Psychiatric Consultations Also Fell After Pit Assessments
Day
s W
ait
Pit Starts
Psychiatry Wait Times Significantly Reduced
4335
231512 11 10
05
1015202530354045
2013 2014 2015 2016
Day
s W
ait
Consultations
Pit Assessments
* transition year
What is a Pit Assessment?
Making a Referral
• Filling out the form
• What is the Family Doctor looking for?
• What is the patient looking for?
• Option: doing it with the patient
Briefing
50
Briefing
Family Doctor describes patient history and current problem
The Pit
Briefing
5
The Pit
250
Introduction Goals Interview
Closing
5 250 30
ClosingThe PitBriefing
Family Doctor organizes treatment plan and prescribes as necessary
Psychiatrist documents
A Pit Assessment
30
5
25
Essential Factors for a Successful Pit
Rapport
1. An established relationship between the family doctor
and the patient (mandatory)
Team Mentality
1. An established relationship between the family doctor
and the patient (mandatory)
2. A collaborative, respectful atmosphere
Clear Expectations
1. An established relationship between the family doctor
and the patient (mandatory)
2. A collaborative, respectful atmosphere
3. Referral Form & Patient Information Sheet
Punctuality
1. An established relationship between the family doctor
and the patient (mandatory)
2. A collaborative, respectful atmosphere
3. Referral Form & Patient Information Sheet
4. Start on time (changed times)
Communicate About Next Steps
1. An established relationship between the family doctor
and the patient (mandatory)
2. A collaborative, respectful atmosphere
3. Referral Form & Patient Information Sheet
4. Start on time (changed times)
5. End with a definitive plan (contingency)
Benefits From a Family Doctor’s Perspective
• Interviews with family doctors revealed pit
assessments:
• Improve their competence
• Improve their confidence
• Teach them about• Medications and treatment options
• How to decipher coping and complicating personality factors
Benefits From a Psychiatrist’s Perspective
• Less paperwork for psychiatrists
• 50% less psychiatry cost than traditional consultations
• Increased team work and support in crisis
• Satisfaction knowing patients will be followed well
• Intense and use high clinical acumen
Patient’s Perspective
• Trust in the family doctor
• Comfort of the doctor and room
• Not having to repeat their story
• Having rapid access to a psychiatrist
Because I was in a crisis … [I had a pit] instead of waiting for [a] consultation. I'm glad that they realized how important it was for me to start seeing someone immediately.
Having the doctor with me as an advocate was very helpful. I find being alone with psychiatrists very difficult.
I got in very quickly, the [psychiatrist] already had an understanding of my history as given to her by my doctor,and we were able to focus on what was the issue at the present time.
Most Students Preferred the Shorter Wait
22%
78%
0 5 10 15 20
Would have preferred a longer wait for a full consultation
Preferred shorter wait for a pit assessment
Number of StudentsN = 23
13% 45% 42%
-5 5 15 25 35
Number of StudentsN = 38
Not Helpul Mildly Helpful Very Helpful
Pit Assessments
Most Students Find Pit Assessments Helpful
Who is Suitable for Pit Assessment?
• Medication question
• Consult wanted (by community or patient) but not indicated
• Question of complicating personality disorder
• Differentiating bipolar disorder from personality disorder
• Verification of present treatment
• Triage for psychotherapy
Either Pit Assessment or Consultation
• Recommendations for crisis management
• Recommendations with potential medical-legal worries
• Questioning Autistic Spectrum Disorder (patient
tolerance specific)
Better Suited for a Psychiatric Consultation
• Psychosis
• Management of complicated affective disorder
• Patient with multiple acute priorities and a long
complicated history
Suitable for Reason for Referral
Pit Assessment • Medication question• Consult wanted (by community or patient) but not indicated• Triage for psychotherapy• Is this case being complicated by a personality disorder• Differentiating bipolar disorder from personality disorder• Am I on the right track with my treatment?
Psychiatric Consultation
• Psychosis• Management of complicated affective disorder• Patient with long complicated history and I do not know
where to start
Either type • Recommendations for crisis management• Recommendations with potential medical-legal worries• Is this Autistic Spectrum Disorder? (patient tolerance
specific)
Let us show you
If implemented at your organization, pit assessments could:
Decrease wait times to see a psychiatrist
Reduce the number psychiatric consultations necessary, and decrease wait times for them
Decrease emergency room visits
Help patients get well faster
Improve knowledge of family doctors
Help students succeed academically and live well
Work smarter, not harder
The Pitfalls and Buy In
A Pit Assessment
30
5
25
The Buy In
http://webarchive.nationalarchi
ves.gov.uk/20150401220127/
http://www.institute.nhs.uk/ind
ex.php?option=com_spread_
and_adoption
Spread
Other universities?
General community Family Practice?
Funding
family doctors
two physicians billing simultaneously
travel time
Suggestion for Ontario:
thanks to Denise Belanger, U Ottawa at CACUSS:
We made part of our health services a “Family Health
Team” which gives us sessional “fit funding” to pay for
psychiatry.
Project Team (Pit Crew) Members
Funding for this initiative was provided for by the Specialist Services Committee (SSC), one of four joint collaborative committees representing a partnership of Doctors of BC and the BC Ministry of Health.
SECONDARYDr. Andre Kushniruk – Co-InvestigatorDr. Elizabeth Borycki – Co-InvestigatorDr. Judy Burgess – Clinic DirectorDr. Leigh Greiner – Data Analyst
COREDr. Marilyn Thorpe – Project LeadHelen Monkman – Project ManagerDr. Oona Hayes – GP Mental Health LeadDr. James Felix – GP Mental Health LeadTheresa Brown – MOA for Mental Health Geraldine Kiss – MOA for Family Doctors
FAMILY DOCTORSDr. S. Baskerville-Bridges Dr. J. Bowles Dr. M. Brydon Dr. W. DysonDr. B. Fraser Dr. K. Foster Dr. J. FryDr. C. Gray Dr. T. GarnettDr. J. KimDr. C. LeviaDr. S. MartinDr. B. Meeker Dr. S. StewartDr. L .Warder
PSYCHIATRISTSDr. E. BurrellDr. M. CooperDr. J. CheekDr. C. DuncalfDr. M. Ganzer (Resident) Dr. I. LorinczDr. P. Singh (Resident)
MH NURSECathy Buchan
Special thank you to:
• Natalia Jaworska (U Calgary, McGill U)
• Elisea De Somma (U Calgary, York U)
• Bernice Fonseka (U Calgary)
• Emma Heck ((U Calgary, Queens U)
• Glenda MacQueen (U Calgary)
Mental Health Services for Students at Postsecondary Institutions: A
National Survey, Can J Psychiatry. 2016. 61(12): 766-775
Thank you!
Questions and Suggestions?
