Acad Psychiatry DOI 10.1007/s40596-014-0262-0
COLUMN: EDUCATIONAL CASE REPORT
Multidisciplinary Treatment Planning: An Educational and Administrative Tool for Resource Management in a University Counseling Center D. Catherine Fuchs & E. Rachel Eskridge & David N. Sacks & Melissa Porter & Jessica Parks-Piatt
Received: 9 April 2014 / Accepted: 11 November 2014 # Academic Psychiatry 2014
The evolving complexity of comorbidity of medical illness and mental illness in the context of a changing economy and public policy was noted in the American Psychological Association Presidential Address in 2010 [1]. The address emphasized that professionals in the field of psychology needed to shift their training and focus to a multidisciplinary and integrative approach. In line with this emphasis, our university counseling center identified the need to redesign the system of mental health care on campus. Our counseling center was independent of psychiatric assessment and treatment of students until 2011, at which time individuals trained in psychiatry joined the staff of individuals trained in psychology, social work, and professional counseling. In summer 2012, a child and adolescent psychiatrist was hired as the director of the center to restructure the services. The director identified gaps in communication between medical and therapy providers. A reliance on individual therapy as the treatment modality for all students resulted in the need for services exceeding the available appointment times. The director organized a leadership team tasked with redesigning the system. The team included a psychologist trained in university counseling and an outreach, education, and prevention coordinator with advanced knowledge in education and counseling. This report highlights the use of a clinical case conference to facilitate the development of multidisciplinary treatment plans designed to diversify services, thereby increasing access for students and improving communication among disciplines in a university mental health clinic. University mental health system studies in the past two decades have documented an increase in severity of D. C. Fuchs (*) : E. R. Eskridge : D. N. Sacks : M. Porter : J. Parks-Piatt Vanderbilt University, Nashville, TN, USA e-mail: [email protected]
presenting complaints at university counseling centers [2, 3]. They emphasized a need to shift care toward a “mental health clinic” model [2]. Kettmann et al. [3] reviewed the perception that student acuity has increased in university counseling centers and identified an increase in the complexity of the students seen in university counseling centers, leading to greater service utilization by a subset of students served by the centers. He concluded that counseling centers need a system in which the complexity of students with multiple diagnoses is acknowledged through the development of a range of therapeutic modalities beyond the traditional individual therapy model. Our university counseling center has experienced similar challenges in our efforts to support students who present with multiple diagnoses and complex treatment needs. We anchored our system design to an educational case conference to guide the multidisciplinary staff toward an integrative model that incorporates evidence-based practice for a broad range of clinical presentations. The structure supports a team consultation model that facilitates care of complex students and supports review of resources leading to clinical program development and design of programs for education and prevention on campus. The case conference has enabled the center to successfully implement individual treatment plans and resource review, shifting the care model to prevention and application of evidence-based treatment modalities.
Demographics The university has 13,000 undergraduate, graduate, and professional students with approximately 19 % of the campus population utilizing services at the center. Presenting complaints include difficulty with adjustment, alcohol and other drug use, academic and social stress, trauma, and significant
Acad Psychiatry
psychiatric illness including mood disorders, anxiety disorders, eating disorders, and psychotic disorders.
Process of Implementation The leadership team identified the need for multidisciplinary collaboration to effectively develop a safety net and appropriate services for “complex students”. Subgroups of students who were high utilizers of counseling center resources were identified, including those with a history of acute or chronic trauma, presence of an eating disorder, significant substance use, and non-trauma related anxiety. Four study groups were formed that included representatives from all disciplines in the center. Each group reviewed the literature on evidence-based best practice guidelines, developed protocols for the center, and presented its protocol to the entire counseling center staff in professional development seminars. Each protocol (Alcohol and Other Drugs, Biofeedback, Eating Disorder, and Trauma) delineated stages of treatment and guided the development of services. The director reviewed the skills needed to implement the protocols and arranged for training opportunities in specific modalities of treatment to ensure availability of treatment options and expertise at the center. A multidisciplinary case conference was implemented with goals of (a) communication between psychiatry and the counseling disciplines, (b) application of “best practice” interventions with guidance by the specialty teams, and (c) development of treatment plans to guide appropriate care and resource management. The conference used the format of psychiatry case conference with a case presentation by a center staff member providing a biopsychosocial formulation and evidence-based treatment plan. The center developed two weekly multidisciplinary case conferences; one for review of new patients, the other for discussion of “complex patients” who utilized a disproportionate amount of resources in the center. We used specialty team representation to facilitate engagement of the staff in the implementation of change. The conference was the setting in which trust among disciplines developed, enabling effective collaboration and integration of services.
Resultant Clinic Functioning Development of treatment plans in the case conference influenced implementation of evidence-based programs including biofeedback, trauma informed therapies, medically informed therapies, and workshops to guide students toward development of skills for stress management. The overall number of students treated at the center remained steady at approximately 2400 per academic year while services provided were diversified to address individual treatment plans supported
by evidence-based protocols. Collaboration between therapists and psychiatric providers increased. In 2012–13, there were 352 initial medical evaluations; in 2013–14, there were 574 initial medical evaluations. Group therapy services were expanded from 4 groups per week to 18 groups per week; the primary therapists added group facilitation to their weekly productivity expectations, the majority co-facilitating 1–2 groups per week with a psychology intern, psychiatry resident, or a practicum student. In 2012–13, 2.9 % of patients received group therapy; this proportion increased to 10.6 % of patients in 2013–14. The average individual therapy panel size for primary therapists increased from 45 in April 2013 to 52 in April 2014. This increase was largely a result of shifting the frequency of individual appointments from weekly to every other week as determined by acuity and the treatment plan. Students requesting weekly therapy who were functioning well both academically and socially were referred to community providers. The biofeedback team was developed in December 2012. In 2013–14, the team served 7.5 % of students seen at the center. A triage service was initiated in spring 2013 to ensure timely resources for students in crisis; triage contact numbers in 2013–14 were 695. We expanded efforts to educate faculty, staff, and student campus leaders on recognizing at risk students and appropriate campus responses. The center revised our interactive training to educate campus “gatekeepers” regarding suicide risk. In 2012–13, 232 individuals were trained; in 2013–14, 402 individuals were trained. A pre/post survey supported the efficacy of the program: participants in the 2013–14 academic year who agreed or strongly agreed that they recognized risk factors for suicide increased from 34 % prior to the training to 65.4 % post-training. With the addition of workshops and educational interventions, the number of students served through outreach and prevention programs expanded, allowing us to provide treatment to those most in need. In 2012–13, 18 students attended preventive workshops. This number increased dramatically to 247 in 2013–14. We had an overall increase in participation in outreach from 4067 to 6163 students over the same years. The total number of students seen for new appointments for clinical interventions was 1684 in 2012–13 and 1372 in 2013– 14, while appointments for workshops and preventive educational interventions increased by more than 400. The percent of students receiving a combination of services increased in a structured manner, ensuring ability to respond to the needs of the complex students through application of our protocols. The case conference facilitated diversification of services, and students who now contact the center are assigned to a therapist or, when indicated, a medical provider for an initial assessment and treatment planning over one to three sessions. Students in crisis are encouraged to come directly to the center to be assessed by the triage team. The provider reviews the
Acad Psychiatry
available modalities for prevention, support, or treatment and makes recommendations based upon evidence-based protocols. All clinicians at the counseling center present patients at the case conferences, facilitating collaborative discussion of treatment needs of individual students and guiding implementation of multidisciplinary treatment plans. The treatment planning process requires providers to be aware of the skills of each discipline and to understand the available resources. We conducted a student satisfaction survey in spring 2014. Students rated the overall helpfulness of services at the university mental health center as 88.8 % very good or excellent and 10.3 % good, suggesting student satisfaction with the service model at the center.
conference focused on treatment planning is a dynamic approach to addressing these challenges. Implications for Educators • A multidisciplinary treatment planning conference can be used as an effective communication tool for facilitating the integration of a university counseling center with a medical team. • The use of a multidisciplinary treatment planning conference emphasizes teaching a competency-based approach to care while facilitating assessment of the system’s ability to respond to the needs of the students. • College counseling centers should have a dynamic internal system for review of individual students and assessment of resources in order to provide excellent, cost-effective care ranging from prevention and psychological support to treatment of mental illness.
Conclusions There are significant ongoing challenges. College students represent an age group at high risk for impulsive decisionmaking, negative consequences of decisions regarding substance use, and initial onset of psychiatric illness. Students are living independently and learning to function as adults while still not fully independent. They have variable levels of support in their environment, which is dependent upon multiple factors. Stigma may interfere with seeking treatment, and financial challenges impact the system resources. Management of these challenges will require ongoing review of support and treatment needs in balance with treatment plans that review risk versus benefit and resources. A multidisciplinary case
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Bray JH. The future of psychology practice and science. Am Psychol. 2010;65(5):355–69. 2. Pledge SD, Lapan RT, Heppner PP, Kivlighan D, Roehlke HJ. Stability and severity of presenting problems at a university counseling center: a 6-year analysis. Profes Psychol: Res and Practice. 1998;29:386–9. 3. Kettmann JDJ, Schoen EG, Moel JE, Cochran SV, Greenberg ST, Corkery JM. Increasing severity of psychopathology at counseling centers: a new look. Profes Psychol: Res and Practice. 2007;38:523–9.
COLUMN: EDUCATIONAL CASE REPORT
Multidisciplinary Treatment Planning: An Educational and Administrative Tool for Resource Management in a University Counseling Center D. Catherine Fuchs & E. Rachel Eskridge & David N. Sacks & Melissa Porter & Jessica Parks-Piatt
Received: 9 April 2014 / Accepted: 11 November 2014 # Academic Psychiatry 2014
The evolving complexity of comorbidity of medical illness and mental illness in the context of a changing economy and public policy was noted in the American Psychological Association Presidential Address in 2010 [1]. The address emphasized that professionals in the field of psychology needed to shift their training and focus to a multidisciplinary and integrative approach. In line with this emphasis, our university counseling center identified the need to redesign the system of mental health care on campus. Our counseling center was independent of psychiatric assessment and treatment of students until 2011, at which time individuals trained in psychiatry joined the staff of individuals trained in psychology, social work, and professional counseling. In summer 2012, a child and adolescent psychiatrist was hired as the director of the center to restructure the services. The director identified gaps in communication between medical and therapy providers. A reliance on individual therapy as the treatment modality for all students resulted in the need for services exceeding the available appointment times. The director organized a leadership team tasked with redesigning the system. The team included a psychologist trained in university counseling and an outreach, education, and prevention coordinator with advanced knowledge in education and counseling. This report highlights the use of a clinical case conference to facilitate the development of multidisciplinary treatment plans designed to diversify services, thereby increasing access for students and improving communication among disciplines in a university mental health clinic. University mental health system studies in the past two decades have documented an increase in severity of D. C. Fuchs (*) : E. R. Eskridge : D. N. Sacks : M. Porter : J. Parks-Piatt Vanderbilt University, Nashville, TN, USA e-mail: [email protected]
presenting complaints at university counseling centers [2, 3]. They emphasized a need to shift care toward a “mental health clinic” model [2]. Kettmann et al. [3] reviewed the perception that student acuity has increased in university counseling centers and identified an increase in the complexity of the students seen in university counseling centers, leading to greater service utilization by a subset of students served by the centers. He concluded that counseling centers need a system in which the complexity of students with multiple diagnoses is acknowledged through the development of a range of therapeutic modalities beyond the traditional individual therapy model. Our university counseling center has experienced similar challenges in our efforts to support students who present with multiple diagnoses and complex treatment needs. We anchored our system design to an educational case conference to guide the multidisciplinary staff toward an integrative model that incorporates evidence-based practice for a broad range of clinical presentations. The structure supports a team consultation model that facilitates care of complex students and supports review of resources leading to clinical program development and design of programs for education and prevention on campus. The case conference has enabled the center to successfully implement individual treatment plans and resource review, shifting the care model to prevention and application of evidence-based treatment modalities.
Demographics The university has 13,000 undergraduate, graduate, and professional students with approximately 19 % of the campus population utilizing services at the center. Presenting complaints include difficulty with adjustment, alcohol and other drug use, academic and social stress, trauma, and significant
Acad Psychiatry
psychiatric illness including mood disorders, anxiety disorders, eating disorders, and psychotic disorders.
Process of Implementation The leadership team identified the need for multidisciplinary collaboration to effectively develop a safety net and appropriate services for “complex students”. Subgroups of students who were high utilizers of counseling center resources were identified, including those with a history of acute or chronic trauma, presence of an eating disorder, significant substance use, and non-trauma related anxiety. Four study groups were formed that included representatives from all disciplines in the center. Each group reviewed the literature on evidence-based best practice guidelines, developed protocols for the center, and presented its protocol to the entire counseling center staff in professional development seminars. Each protocol (Alcohol and Other Drugs, Biofeedback, Eating Disorder, and Trauma) delineated stages of treatment and guided the development of services. The director reviewed the skills needed to implement the protocols and arranged for training opportunities in specific modalities of treatment to ensure availability of treatment options and expertise at the center. A multidisciplinary case conference was implemented with goals of (a) communication between psychiatry and the counseling disciplines, (b) application of “best practice” interventions with guidance by the specialty teams, and (c) development of treatment plans to guide appropriate care and resource management. The conference used the format of psychiatry case conference with a case presentation by a center staff member providing a biopsychosocial formulation and evidence-based treatment plan. The center developed two weekly multidisciplinary case conferences; one for review of new patients, the other for discussion of “complex patients” who utilized a disproportionate amount of resources in the center. We used specialty team representation to facilitate engagement of the staff in the implementation of change. The conference was the setting in which trust among disciplines developed, enabling effective collaboration and integration of services.
Resultant Clinic Functioning Development of treatment plans in the case conference influenced implementation of evidence-based programs including biofeedback, trauma informed therapies, medically informed therapies, and workshops to guide students toward development of skills for stress management. The overall number of students treated at the center remained steady at approximately 2400 per academic year while services provided were diversified to address individual treatment plans supported
by evidence-based protocols. Collaboration between therapists and psychiatric providers increased. In 2012–13, there were 352 initial medical evaluations; in 2013–14, there were 574 initial medical evaluations. Group therapy services were expanded from 4 groups per week to 18 groups per week; the primary therapists added group facilitation to their weekly productivity expectations, the majority co-facilitating 1–2 groups per week with a psychology intern, psychiatry resident, or a practicum student. In 2012–13, 2.9 % of patients received group therapy; this proportion increased to 10.6 % of patients in 2013–14. The average individual therapy panel size for primary therapists increased from 45 in April 2013 to 52 in April 2014. This increase was largely a result of shifting the frequency of individual appointments from weekly to every other week as determined by acuity and the treatment plan. Students requesting weekly therapy who were functioning well both academically and socially were referred to community providers. The biofeedback team was developed in December 2012. In 2013–14, the team served 7.5 % of students seen at the center. A triage service was initiated in spring 2013 to ensure timely resources for students in crisis; triage contact numbers in 2013–14 were 695. We expanded efforts to educate faculty, staff, and student campus leaders on recognizing at risk students and appropriate campus responses. The center revised our interactive training to educate campus “gatekeepers” regarding suicide risk. In 2012–13, 232 individuals were trained; in 2013–14, 402 individuals were trained. A pre/post survey supported the efficacy of the program: participants in the 2013–14 academic year who agreed or strongly agreed that they recognized risk factors for suicide increased from 34 % prior to the training to 65.4 % post-training. With the addition of workshops and educational interventions, the number of students served through outreach and prevention programs expanded, allowing us to provide treatment to those most in need. In 2012–13, 18 students attended preventive workshops. This number increased dramatically to 247 in 2013–14. We had an overall increase in participation in outreach from 4067 to 6163 students over the same years. The total number of students seen for new appointments for clinical interventions was 1684 in 2012–13 and 1372 in 2013– 14, while appointments for workshops and preventive educational interventions increased by more than 400. The percent of students receiving a combination of services increased in a structured manner, ensuring ability to respond to the needs of the complex students through application of our protocols. The case conference facilitated diversification of services, and students who now contact the center are assigned to a therapist or, when indicated, a medical provider for an initial assessment and treatment planning over one to three sessions. Students in crisis are encouraged to come directly to the center to be assessed by the triage team. The provider reviews the
Acad Psychiatry
available modalities for prevention, support, or treatment and makes recommendations based upon evidence-based protocols. All clinicians at the counseling center present patients at the case conferences, facilitating collaborative discussion of treatment needs of individual students and guiding implementation of multidisciplinary treatment plans. The treatment planning process requires providers to be aware of the skills of each discipline and to understand the available resources. We conducted a student satisfaction survey in spring 2014. Students rated the overall helpfulness of services at the university mental health center as 88.8 % very good or excellent and 10.3 % good, suggesting student satisfaction with the service model at the center.
conference focused on treatment planning is a dynamic approach to addressing these challenges. Implications for Educators • A multidisciplinary treatment planning conference can be used as an effective communication tool for facilitating the integration of a university counseling center with a medical team. • The use of a multidisciplinary treatment planning conference emphasizes teaching a competency-based approach to care while facilitating assessment of the system’s ability to respond to the needs of the students. • College counseling centers should have a dynamic internal system for review of individual students and assessment of resources in order to provide excellent, cost-effective care ranging from prevention and psychological support to treatment of mental illness.
Conclusions There are significant ongoing challenges. College students represent an age group at high risk for impulsive decisionmaking, negative consequences of decisions regarding substance use, and initial onset of psychiatric illness. Students are living independently and learning to function as adults while still not fully independent. They have variable levels of support in their environment, which is dependent upon multiple factors. Stigma may interfere with seeking treatment, and financial challenges impact the system resources. Management of these challenges will require ongoing review of support and treatment needs in balance with treatment plans that review risk versus benefit and resources. A multidisciplinary case
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Bray JH. The future of psychology practice and science. Am Psychol. 2010;65(5):355–69. 2. Pledge SD, Lapan RT, Heppner PP, Kivlighan D, Roehlke HJ. Stability and severity of presenting problems at a university counseling center: a 6-year analysis. Profes Psychol: Res and Practice. 1998;29:386–9. 3. Kettmann JDJ, Schoen EG, Moel JE, Cochran SV, Greenberg ST, Corkery JM. Increasing severity of psychopathology at counseling centers: a new look. Profes Psychol: Res and Practice. 2007;38:523–9.
