The Consults:

1
Crista E. Wetherington, PhD, Gabriela Reed, PhD,
Julie N. Germann, PhD, Jamie A. Grollman, PhD,
Jami N. Gross, PhD, Mary C. Lazarus, PsyD,
Corinne E. Fribley, MD
The Center for Pediatric Psychiatry, Childrens
Medical Center Dallas The Department of
Psychiatry, UT Southwestern Medical Center
INTRODUCTION
NEEDS ASSESSMENT
RESULTS
CHALLENGES

• This poster describes the process for
  conceptualizing an integrated program for
  psychology and psychiatry training within a
  pediatric teaching hospital
• A hospital-based psychiatry consultation-liaison
  (C/L) service that is well-integrated across
  mental health disciplines can offer rich and
  unique opportunities for psychiatry and
  psychology trainees, as well as benefit patients
  and families
• The psychiatry C/L team within the Center for
  Pediatric Psychiatry at Childrens Medical Center
  Dallas offers an environment for this type of
  cross-discipline training
• Childrens Medical Center is a private,
  not-for-profit academic healthcare facility
• Licensed for 483 beds
• More than 50 subspecialty programs
• Only Level I trauma center for pediatrics in
  Texas
• With one of the busiest pediatric emergency
  departments (EDs) in the country and 360,000
  patient visits per year, the demand for mental
  health services is significant
• Through its affiliation with UT Southwestern
  Medical Center, Childrens has a strong
  commitment to training and serves an urban area
  with a diverse population
• The development of an integrated training
  program, its implementation, challenges faced,
  and future directions are discussed

• The Consults
• Average Monthly Consults by Discipline in 2008
• The Training
• Goal of providing quality training opportunities
  within a rich and unique environment for
  cross-training
• Weekly individual supervision for all trainees
• Weekly didactics and group supervision for
  psychology interns and postdocs

• Synthesis of Clinical Demands Training
  Priorities
• Inherent differences in nature of clinical
  responsibilities
• Psychology and play therapy
• Outpatient appointments, clinics, and consults
  to medical floors
• Psychiatry
• Medical floor/ED consults primary responsibility
  during consult rotation

• Implementation did not meet expectations and
  raised unforeseen challenges, but yielded
  accomplishments
• Generated discussion about training/clinical
  needs
• Consult Grand Rounds positive experience for
  team
• New shared office space for trainees completed
• Team members felt fragmented
• Triaging calls became more complicated
• Difficult for consult nurse to stay informed
• Variability in how different teams carried out
  rounds
• After a few months, consult team drifted back
  toward more traditional one-team model
• Team members surveyed recently to understand
  perception of rounding model and attitudes on
  team
• Like 1-team model 100 agree or strongly agree
• Prefer 2-team model 10 agree, 50 disagree or
  strongly disagree 30 neither agree nor disagree
• Consult Team Survey

DISCUSSION FUTURE DIRECTIONS

• Fewer psychiatry fellows in 2009-2010 will
  affect responsibilities of team members and
  division of labor
• Psychiatry attendings will complete more
  consults
• Social workers will complete most ED evaluations
• Psychology trainees will need to adjust schedule
  to accommodate more new consults
• Likely more opportunities for psychology
  trainees to work with psychiatry attendings on
  cases
• Revisit idea of a team model
• Round and see patients as two teams meet as an
  entire team weekly for in-depth case
  presentations
• Strengthen role of each discipline on the
  service
• Scheduling monthly meetings focused on continued
  improvements
• Development of a successful model should
  consider
• Goals of training
• Clinical needs
• Team members roles
• Buy-in and investment from team members
• Education and explanation regarding changes and
  the rationale for them
• Building teams cohesiveness across disciplines
• Emphasizing strengths of disciplines and
  inter-connectedness of skill sets

Question
NEEDS ASSESSMENT

• Recent growth in patient volume and staff has
  increased the importance of examining the
  training model on the C/L team and encouraging
  cross-discipline collaboration
• The Consult Team
• 3.5 psychiatry attendings
• 6 psychologists
• 1 consult nurse
• 2 half-time clinical therapists
• 5 ED psychiatric social workers (LCSWs)
• 3 half-time predoctoral psychology interns
• 1 full-time psychology postdoctoral fellow
• 2 child psychiatry fellows (10-week rotations)
• 2 adult psychiatry residents (4-week rotations)
• 1-2 medical students (3-week rotations)

IMPLEMENTATION
of team members endorsing rating
CHALLENGES

• Primary Goals
• Cross-discipline collaboration on individual
  patients
• Briefer, but more in-depth rounds
• More teaching opportunities during rounds
• Increased discussion and case conceptualization
• The Model
• Plan implemented in Fall 2008
• Divided into two teams comprised of
  representatives from each discipline on the
  service
• Teams met simultaneously but in different
  rounding rooms
• New consults divided between teams when triaged

• Team Members
• Model difficult for those without a counterpart
  teams missed input of disciplines attending only
  one rounds
• Appreciated social aspect of meeting as a single
  team
• Transitions in leadership (e.g., new medical
  director, new psychologists and psychiatry
  attendings)
• Increased Volume
• Growth in staff ? more need for mental health
  services
• Necessary to divide and conquer to work
  efficiently