Collaborative Care of Complex Patients: The Medical-Psychiatric Coordinating Physician

The ranks of our associates at the Center for Collaborative Psychiatry, Psychology and Medicine have swelled to now incorporate a pediatrician, two family medicine physicians, and an integrative medicine practitioner. We are excited by the broadening of our scope and reach. Behind these changes is the new model of care we have developed and call the Medical-Psychiatric Coordinating Physician (for more about this project, please see our recent article in Marin Medicine). The primary clinical focus for this practitioner are the “complex cases” with medical, psychiatric and psychosocial requirements we have described in the past two newsletters, Complex Cases, Part I and Part II.

Despite these changes at the Center, we are no less committed to the broader mental health and health care community. In addition to the fact that Center Co-Director, Diane Engelman, is a neuropsychologist, and that one of our charter members, Phil Erdberg, is a psychologist who is widely known for his work with psychological assessment, our hearts remain with collaboration. The coordination of mental health specialists is our primary focus and our model has always been and remains collaborative.

Returning to “clinical complexity,” the complexity to which we refer may derive from a number of sources, including (1) difficult to sort out diagnostic issues, as well as complexity introduced by factors (for example socio-economic or cultural) associated with but external to the diagnoses, (2) the complexity introduced when multiple professionals (interacting with and providing services for the family and patient) are involved with a case, and (3) considerations related to integrating and managing these professionals and care systems. A much more detailed analysis of the topic of clinical complexity can be found in the previous newsletter, Complex Cases, Part I.

We continue with Solomon, a 67 year old man with Scleroderma. In addition to scleroderma Solomon suffered from a number of other systemic medical and psychiatric afflictions. Always at hand for his treatment team was the question of which to take on, and when. He suffered from multiple complications of scleroderma, including skin lesions that required regular debridement. At the point he was referred to me (Steve Frankel) for treatment, Solomon required TPN (tube feedings) feeding for GI problems that included dysphagia (difficulty swallowing) based on the immobility of his now fibrotic (rigid) esophagus. Further complicating problems maintaining his nutrition, Solomon had a long-standing eating disorder, and had always insisted on regulating his diet to maintain a sub-optimal weight.

Solomon had sustained two hip replacements within the past 5 years. These resulted in pain and limitation of movement, restricting his ability to walk. He was developing pulmonary fibrosis (loss of lung elasticity), skin lesions that for the first time were becoming infected, and had recently had lost consciousness on two occasions resulting in falls from which he could not right himself. Complicating his personal life was the recent failure of his forty year long marriage and a forced move from Minnesota to California to be closer to his son and daughter-in-law. This move suddenly deprived him of his long-standing group of friends and physicians.

Solomon and Steve admired Solomon’s internist. He was a superb physician, but repeatedly had bad news for Solomon, news Solomon didn’t want to hear. He realized that without Solomon’s heartfelt cooperation the treatment he offered would be impossibly handicapped. Solomon would sit endlessly in his apartment watching cooking shows on TV, moping while he stared at gourmet dishes he would never again be able to eat because of the toll his scleroderma had already taken on his esophagus and stomach. The internist liked Solomon but hardly had the time to work with his depression and emotional inaccessibility.

Steve did have that time, however. The strategy they, the internist and Steve, developed together included some meetings between Steve and Solomon at Solomon’s apartment. Solomon’s mobility was limited and he understood Steve’s willingness to come to him as an appropriate response to his disability. Also, they decided that Steve would occasionally accompany Solomon to his medical appointments, since Solomon’s complicated medical care had become disorganized and Solomon tended to neglect and miss these appointments.

There was a further complication, as well. Solomon’s treatment was burdened by a son and daughter in law who insisted he was being dramatic about his disabilities. Mediating this disjunction between Solomon and his family became an important part of Steve’s role, an activity that evolved later to helping the family be of assistance as Solomon succumbed to a pneumonia that eventuated in his death.

Here’s where we leave our case and return to the Medical-Psychiatric Coordinating Physician (MPCP) model of care. Care for patients like Solomon usually requires the involvement of multiple physicians and allied health care professionals, as well, often, of more than one medical care delivery system. Close collaboration among all the involved professionals is a requirement for working with the complex diagnostic and management issues of this group of patients.

The MPCP assembles, leads, and coordinates each case, organizing and directing the multi-disciplinary treatment teams required for the management of these patients. He or she establishes treatment goals and is accountable for revising these as well as monitoring results. Given how frequently these cases include complex medical illnesses we hold that this coordinating person should be a physician. An MPCP’s training and experience as a physician provides that person with a unique ability to understand and prioritize these clinical issues, as well as effectively manage the work of other medical and allied health care professionals. By identifying a single practitioner who assumes this level of responsibility for patient care, clinical outcome is likely to be optimized and medical costs handled most efficiently.

The MPCP method is intended to address the problem of fragmentation in the delivery of care for the “complex patients” we have been discussing. Because of the excessive demands these patients make, as well as well as the multiplicity of professionals who inevitably become involved in their care, their treatment tends to be loosely structured and lacking in organization. Administrative and intra-team difficulties often confound these efforts. The MPCP addresses these issues through case and team management, beginning with an initial comprehensive evaluation and reassessments as treatment evolves. He or she organizes and works with the individuals making up the treatment team, as well as monitors their interactions with the patient and family.

Cases like these are our primary focus at the Center. Our associates are working with several complex cases at this time, and we will be writing about them and the unique problems they present in coming newsletters.