Program That Puts FPs in Touch With Psychiatrists Helps Patients in Maine

September 25, 2013 02:15 pm Matt Brown

Many largely rural states have difficulty ensuring mental health services are available for all their citizens, leaving family physicians in these states to step in to fill the mental health care gap created by the lack of small-town mental health professionals. Maine is one of those rural states, but by partnering with the Maine Association of Psychiatric Physicians (MAPP), the Maine Academy of Family Physicians (MAFP) is able to offer its members some help.

Family physicians in rural Maine had difficulty serving the mental health needs of their patients before a collaboration with the Maine Association of Psychiatric Physicians.

The two organizations collaborated in 2003 to start The Consultation Project, a unique endeavor that provides rural primary care professionals with access to a psychiatrist when they need it and where they need it.

The brainchild of former MAFP President Richard Hobbs, M.D., of Waterville, and (then) MAPP President William Matuzas, M.D., in collaboration with current MAPP Clinical Practice Committee Chair David Moltz, M.D., the statewide cooperative is a valuable resource for family physicians in rural communities.

"I was full-time faculty at the University of Maine-Dartmouth Family Medicine Residency, and we had occasion at that time to have a psychiatrist -- Bill Matuzas -- come and participate in our morning rounds," Hobbs said. "Bill and I became friends, and owing to our positions at the (MAFP and MAPP), we had a lot of conversations about the plight of primary care docs here in this particularly rural state. There are areas that do not have a psychiatrist close by, and as a consequence, primary care docs are taking care of a lot of people with serious mental illness."

Story highlights
  • Family physicians in the predominantly rural state of Maine often step in to fill the mental health care gap created by a lack of small-town psychiatrists.
  • The Consultation Project -- a collaboration begun by the Maine Academy of Family Physicians and Maine Association of Psychiatric Physicians (MAPP) -- provides rural primary care physicians with access to a psychiatrist when they need it, where they need it.
  • Now a grant-funded, self-sustaining operation, the program is administered by the MAPP alone.

Setting up the Program

According to Hobbs, in the early 2000s, 70 percent of the psychotropic drugs in Maine were being prescribed by primary care physicians. "People were out there in the hinterlands trying to manage folks with bipolar disorder, major depression and such," said Hobbs. "We all have some behavioral medicine training, but there are occasions where what you're doing doesn't seem to be working and you are at a crossroads. Bill and I were talking about that and how we could arrange access, at least telephone help, for these family docs."

That help came from Moltz, said Hobbs.

"David had ideas about this, as well, and put together a stakeholders meeting between the organizations to discuss a plan to recruit volunteers from a group of psychiatrists who would be available by telephone to family docs who felt they needed this kind of service," said Hobbs. "He had already tested the waters and found a few people who were willing to participate."

In the beginning, the MAFP and MAPP shared administrative duties, but after Moltz secured a grant for the project, the MAPP took over administration, according to Hobbs. "We promoted it at our annual meetings and online," he said. "But it was a popular grassroots program that built over time and is now going great guns."

According to Moltz, The Consultation Project also began in response to a proposed state law that would have allowed psychologists to prescribe medications, which he said raised "a lot of concern regarding (the psychologists' training) in terms of nonmedical personnel prescribing medications.

"I was full-time faculty at the University of Maine-Dartmouth Family Medicine Residency, and we had occasion at that time to have a psychiatrist -- Bill Matuzas -- come and participate in our morning rounds," Hobbs said. "Bill and I became friends, and owing to our positions at the (MAFP and MAPP), we had a lot of conversations about the plight of primary care docs here in this particularly rural state. There are areas that do not have a psychiatrist close by, and as a consequence, primary care docs are taking care of a lot of people with serious mental illness."

Former Maine AFP President Richard Hobbs, M.D., of Waterville, was instrumental in setting up The Collaboration Project.

"There were parts of Maine where psychologists were consulting about medications for primary care docs," he said. "To me, that was a sign of desperation because the psychiatrists were just not there. So we came up with a pretty simple model to help out with that problem."

As Moltz explained it, psychiatrists and primary care physicians in the project establish an ongoing consultative relationship in which the rural practitioner reaches out for advice and guidance via telephone or e-mail on an as-needed basis. The contacts are informal consultations, rather than treatment or supervision. The family physician is the independent professional who makes treatment decisions, but he or she is informed by input from the consultant. The project currently has 25 consultants who specialize in adult and child psychiatry and who serve 54 health care practices. The project also has the capacity to serve more practices.

"It's an ongoing relationship, so rather than a one-time consult where a psychiatrist says lots of smart things and then never hears from anyone again, the family physician or other primary care provider consults with the psychiatrist, and then, if there are further developments, they can call again," he said. "Also, over time, the family physician gets the benefit of that interaction and expands his or her knowledge base. That is a big plus for patients and physicians alike."

Facts About the Maine AFP

Chapter EVP: Deborah Halbach
Date chapter was chartered: 1951
Number of chapter members: 700
Location of chapter headquarters: Hartland
Website(www.maineafp.org)
2014 MAFP Family Medicine Update: April 9-12, DoubleTree by Hilton, Portland

Patients Benefit From Mental Health Program

Family physician and MAFP board member Martha Stewart, D.O., of Houlton, said that without the program, she would have only limited access to a psychiatrist in her town of 6,000. "I believe there is a psychiatrist that comes to my town once a month, but he has a full caseload of patients, as well as a wating list, so he's not available for consult," she said. "We used to have a psychiatrist living in Houlton, but her goals and those of her employer were not in sync, and so she left eight years ago and hasn't been replaced. So everyone who does primary care in this town does psychiatry, because otherwise, our patients, if they're lucky, have to drive two hours. If not, they can usually find someone in Bangor, which is 115 miles away."

Stewart said she is a fan of The Consultation Project.

"The last time I used it was actually last fall during a joint meeting of the Maine Medical Association and MAFP," Stewart said. "One of the psychiatrists -- a MAPP board member -- who volunteers in (The Collaboration Project) was sitting next to me, and we ended up talking about it. It was really a great experience. I was able to synthesize the problems I couldn't solve with a particular patient, and she gave me some great advice."

The patient, Stewart said, was in a nursing home and having some severe behavioral issues. "The (nursing home) staff was exasperated. I had done some trials with different medications, but nothing was working," Stewart said. "It was an undesirable behavior for which the psychiatrist, who deals with these types of patients on a much more regular basis than I, had a nonpharmacological solution. She had great input.

"I have an undergraduate degree in psychology," said Stewart, "and I had good psych training in med school, as well as good training in residency, but when I first started, I was unprepared for the psychiatry I was doing independently in this rural area. I've become much more comfortable with it now, of course, but it is wonderful to have somebody who has had a five-year residency in psych, to have access to them."


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