CME Educational Activity

Primary Care Psychiatry Integration

Collaborative Care, Safe Prescribing, and Psychiatric Emergencies

Presenter: [Name, Credentials]

Date: [Presentation Date]

Speaker Notes

Welcome participants. This CME activity provides 1.5 hours of AMA PRA Category 1 Credit™. Review learning objectives and establish ground rules for questions. Emphasize that this presentation focuses on practical, evidence-based strategies for integrating psychiatric care into primary care settings.

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CME Learning Objectives

📋 Upon completion, participants will be able to:

Describe the Collaborative Care Model (CoCM) structure and evidence base for treating common psychiatric conditions in primary care
Identify missed psychiatric diagnosis rates in primary care and apply validated screening tools (PHQ-9, GAD-7, C-SSRS) appropriately
Apply treat-vs-refer criteria for depression, anxiety, and other common psychiatric presentations in the primary care setting
Recognize common prescribing errors and implement safe psychotropic prescribing practices, including appropriate dosing and monitoring
Demonstrate documentation and billing requirements for integrated psychiatric care, including CPT 99492-99494 codes

Speaker Notes

These objectives align with ACGME and ABIM competencies for systems-based practice and patient care. The presentation emphasizes measurable outcomes and practical implementation. Ask participants to consider which objectives are most relevant to their current practice challenges.

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The Mental Health Crisis in Primary Care

50%

of all mental health care delivered in primary care settings

65.9-97.8%

missed diagnosis rates for psychiatric conditions

115M+

Americans living in mental health shortage areas

7 min

average PCP visit duration for mental health concerns

🚨 The Reality

Primary care has become the de facto mental health system for millions, yet providers lack the time, training, and support to deliver optimal psychiatric care. The workforce shortage means patients wait 3-6 months for psychiatry referrals.

Crisis Drivers

Psychiatric workforce shortage (only 28 psychiatrists per 100,000 population)
Increasing prevalence of depression and anxiety post-pandemic
Fragmented care between physical and mental health systems
Stigma preventing patients from seeking specialty mental health care

Speaker Notes

Emphasize that primary care IS mental health care for most Americans. The statistics should feel uncomfortable—they represent patients sitting in your waiting room right now. Connect to local context: ask participants about wait times for psychiatry referrals in their community.

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Collaborative Care Model (CoCM) Structure

Psychiatric Consultant

Off-site specialist support, weekly caseload review, treatment recommendations

Primary Care Provider

Diagnosis, prescribing, overall care coordination

Behavioral Health Care Manager

Screening, patient outreach, registry tracking, brief interventions

🔑 Core Principles

Registry-based tracking: Systematic follow-up of all patients
Treat-to-target: Measurement-based care with defined goals
Weekly caseload review: Psychiatric consultant oversight
Accountability: Shared responsibility for outcomes

Speaker Notes

The triangle represents interdependence—no single role can succeed without the others. Emphasize that the BHCM is the "secret sauce" of CoCM. Registry-based care is what distinguishes CoCM from informal consultation. Weekly psychiatric review ensures complex cases get specialist input.

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CoCM Evidence Base

Trial/Study	Population	Key Finding
IMPACT (2002)	1,801 older adults with depression	2× better depression outcomes at 12 months; sustained at 24 months
TEAM (2016)	1,004 patients with depression/anxiety	Superior to usual care for both conditions; cost-effective
Meta-analysis (2012)	79 RCTs, 24,000+ patients	Collaborative care superior to usual care (OR 1.57)
ROI Studies	Multiple payer populations	$6.50 return per $1 invested; reduced ED visits and hospitalizations

📊 Evidence Strength

Collaborative Care has Level 1 evidence (multiple RCTs, consistent results) for depression and anxiety—stronger evidence base than many standard medical treatments. The model is listed as a "best practice" by the APA and recommended by the USPSTF.

Speaker Notes

IMPACT trial is the landmark study that established CoCM. Emphasize the ROI data—this isn't just patient-centered, it's fiscally responsible. The evidence is so strong that CMS now reimburses CoCM codes specifically. Note that benefits persist long-term, suggesting true remission rather than temporary improvement.

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Missed Diagnosis Rates in Primary Care

Condition	Missed Rate	Key Barrier
Major Depression	`65.9%`	Somatization, stigma, time constraints
Anxiety Disorders	`71-97.8%`	Normalized as "stress," physical symptoms
Bipolar Disorder	`69%`	Misdiagnosed as depression; delayed hypomania screening
ADHD (Adult)	`50%+`	Symptoms attributed to anxiety/depression
PTSD	`90%+`	Patient non-disclosure of trauma history

Causes of Underdetection

Time constraints (7-minute visits)
Competing medical priorities
Somatization masks psychiatric symptoms
Patient reluctance to discuss mental health
Lack of systematic screening

Consequences

Delayed appropriate treatment
Worsening functional impairment
Increased healthcare utilization
Suicide risk in severe cases
Poor chronic disease outcomes

Speaker Notes

These numbers should be sobering. Bipolar being missed 69% of the time has huge implications—antidepressants without mood stabilization can precipitate mania. PTSD 90% missed is particularly concerning given trauma's impact on physical health. Emphasize that systematic screening is the antidote to these diagnostic failures.

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Screening Tool Suite

Tool	Sensitivity	Specificity	Cutoffs	Time
PHQ-9	88%	88%	5/10/15/20 (mild/mod/mod-sev/sev)	2-3 min
GAD-7	89%	82%	5/10/15 (mild/mod/severe)	2 min
AUDIT-C	73%	91%	Men ≥4, Women ≥3	1 min
DAST-10	81%	95%	≥3 (problematic use)	2 min
C-SSRS	—	—	Any positive = risk	2-3 min

⚠️ Billing Note

Screening with PHQ-9/GAD-7 can be billed under 99492-99494 when part of CoCM. Annual depression screening (G0444) is Medicare-covered. Document scores in every visit note.

Speaker Notes

Emphasize that brief tools are validated—don't let "I don't have time" be an excuse. PHQ-9 and GAD-7 can be done by MA during rooming. C-SSRS is essential for suicide risk—any positive ideation requires follow-up. AUDIT-C and DAST-10 should be routine given comorbidity with psychiatric conditions.

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PHQ-9 and GAD-7 in Practice

PHQ-9 Scoring Guide

Score	Severity	Clinical Action
1-4	Minimal	Monitor; consider lifestyle interventions
5-9	Mild	Watchful waiting; repeat in 2-4 weeks
10-14	Moderate	Plan treatment (therapy ± medication)
15-19	Moderately Severe	Treat with medication and/or therapy
20-27	Severe	Immediate treatment; consider psychiatry referral

🚨 Critical Item

PHQ-9 Question 9: "Thoughts you would be better off dead or hurting yourself." Any score >0 requires immediate suicide risk assessment with C-SSRS.

GAD-7 Scoring Guide

Score	Severity	Clinical Action
0-4	Minimal	None
5-9	Mild	Monitor
10-14	Moderate	Treat (therapy ± medication)
15-21	Severe	Active treatment; consider referral

💡 Documentation Tip

Always document the actual score, not just "PHQ-9 positive." Use scores to track treatment response—aim for ≥50% reduction or score <5 (remission).

Speaker Notes

Treat-to-target means measurement-based care. Show participants how to calculate percent improvement: (Initial - Current)/Initial × 100. Emphasize that PHQ-9 Q9 is a standalone suicide screen—never ignore it. GAD-7 >15 often co-occurs with panic or PTSD—consider broader assessment.

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Treat vs Refer Algorithm

PCP Treats
Primary Care Management

vs

Refer to Psychiatry
Specialty Care

✓ PCP Appropriate

PHQ-9 10-19 (moderate)
Uncomplicated anxiety disorders
Straightforward SSRI initiation
First episode, no comorbidities
Patient prefers medication management in PC
Good response to prior PC treatment

✗ Refer to Psychiatry

PHQ-9 ≥20 (severe)
Suicidal ideation or self-harm
Psychosis or severe agitation
Bipolar disorder suspicion
≥2 failed medication trials
Eating disorders, OCD, PTSD
Personality disorders
Substance use comorbidity

🔑 Decision Framework

Consider: severity, complexity, risk, comorbidity, prior treatment response, patient preference, and your own comfort level. When in doubt, curbside consult or eConsult.

Speaker Notes

This is a framework, not rigid rules. A PHQ-9 of 18 with SI requires referral despite the score. "Failed trials" means adequate dose and duration, not "didn't work in 2 weeks." Emphasize that many conditions (eating disorders, OCD) have specific evidence-based treatments best delivered by specialists.

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Common Prescribing Errors

⚠️ Top 10 Prescribing Pitfalls in Primary Care

Underdosing: Sertraline 25mg prescribed indefinitely; therapeutic range is 50-200mg
Premature switching: Changing medications before 8-week trial at therapeutic dose
No bipolar screening: Starting antidepressants without MDQ or hypomania history
Benzos as first-line: Using benzodiazepines before SSRIs for anxiety disorders
Ignoring drug interactions: Fluoxetine + tamoxifen; paroxetine + warfarin
No measurement-based care: Treating without tracking PHQ-9/GAD-7 scores
Stopping too soon: Discontinuing at 3 months instead of 6-12 month minimum
Abrupt discontinuation: Stopping SSRIs without taper, causing discontinuation syndrome
Missing medical causes: Not screening for thyroid, B12, sleep apnea
Inadequate follow-up: First follow-up >4 weeks after initiation

💊 Key Principle

Start low, go slow, but GO. Most failures are inadequate trials, not medication failures.

Speaker Notes

Sertraline 25mg is a pediatric dose—adults need 50mg minimum. Emphasize that 8 weeks is the minimum for adequate trial, not maximum. Bipolar screening is critical: antidepressant-induced mania can be devastating. Drug interactions are common and often overlooked—fluoxetine's long half-life is particularly problematic.

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Safe SSRI/SNRI Prescribing

First-Line Antidepressant Dosing

Medication	Start	Titration	Therapeutic	Max
`Sertraline`	50mg	+25-50mg q1-2wk	100-150mg	200mg
`Escitalopram`	10mg	+5-10mg q2wk	10-20mg	20mg
`Fluoxetine`	20mg	+20mg q2-4wk	20-40mg	80mg
`Paroxetine`	20mg	+10mg q1-2wk	30-40mg	60mg
`Venlafaxine XR`	75mg	+75mg q2wk	150-225mg	225mg
`Duloxetine`	30mg	+30mg q1-2wk	60mg	120mg

⚠️ Black Box Warning

All antidepressants carry a black box warning for increased suicidal thinking in patients <25 years old. Monitor closely in first 4 weeks of treatment.

Titration Schedule

Weeks 1-2: Starting dose; assess tolerability
Weeks 3-4: Increase to therapeutic range if tolerated
Weeks 6-8: Assess response; titrate if partial
Week 12: Evaluate remission; adjust or switch

Speaker Notes

Escitalopram and sertraline are generally preferred first-line due to efficacy and tolerability. Fluoxetine's long half-life is problematic for switching. Venlafaxine requires dose ≥150mg for dual reuptake inhibition. Black box warning applies to all patients under 25—schedule close follow-up.

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Bupropion and Mirtazapine

Bupropion XL

Dosing:	150-450mg daily
Pros:	Activating, weight-neutral, sexual side effect-sparing
Best for:	Atypical depression, ADHD comorbidity, smoking cessation

⚠️ Contraindications

Seizure disorder (lowers threshold)
Eating disorders (bulimia, anorexia)
Abrupt alcohol/benzo cessation
MAOI use within 14 days

Mirtazapine

Dosing:	15-45mg nightly
Pros:	Sedating, appetite-stimulating, antiemetic
Best for:	Insomnia, anorexia, nausea, SSRIs intolerance

⚠️ Considerations

Significant weight gain
Paradoxically less sedating at 30mg+
Monitor lipids and glucose

🔑 When to Choose

Bupropion: Patient reports fatigue, sexual dysfunction on SSRIs, ADHD symptoms, or needs smoking cessation support. Mirtazapine: Patient has insomnia, poor appetite, or cannot tolerate SSRI activation.

Speaker Notes

Bupropion's seizure risk is real but rare at therapeutic doses—contraindications matter more than side effects. The eating disorder contraindication is often missed. Mirtazapine's dose-response curve is counterintuitive—more sedating at 15mg than 30mg. Weight gain can be dramatic (20+ lbs), so screen for diabetes risk.

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Psychiatric Emergencies in Primary Care

Suicide Risk Assessment

Use Columbia Protocol (C-SSRS): 5 levels of ideation + 6 behavior types. Any positive ideation requires safety planning. Active intent with plan = immediate intervention.

Acute Psychosis Red Flags

New-onset hallucinations or delusions
Severe agitation or unpredictable behavior
Catatonia (immobility, mutism, negativism)
Neuroleptic malignant syndrome signs (fever, rigidity, autonomic instability)

DIGFAST Mnemonic for Mania

Letter	Sign/Symptom
D	Distractibility
I	Indiscretion (excessive involvement in pleasurable activities)
G	Grandiosity
F	Flight of ideas
A	Activity increase
S	Sleep deficit (decreased need)
T	Talkativeness (pressured speech)

🚨 Emergency Triage

Call 911: Imminent danger to self/others, weapon access, severe agitation.
Baker Act/Involuntary Hold: Mentally ill + refuses treatment + danger to self/others.
Psychiatric Consult: Stable but urgent; unclear diagnosis.

Speaker Notes

Psychiatric emergencies in PC are rare but high-stakes. Trust your gut—if you feel unsafe, call security/911. DIGFAST requires ≥3 symptoms for mania. Catatonia is a medical emergency—requires benzodiazepines or ECT, not antipsychotics alone. Know your state's involuntary hold laws.

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Suicide Risk — Columbia Protocol

C-SSRS Screener Structure

🔴 Ideation Severity (5 Levels)

Wish to be dead
Non-specific active suicidal thoughts
Active ideation with methods (no plan)
Active ideation with intent (no plan)
Active ideation with specific plan and intent

Any Level 2+ requires immediate assessment.

🟡 Suicidal Behavior (6 Types)

Preparatory acts (gathering means)
Aborted attempt
Interrupted attempt
Non-suicidal self-injury
Suicide attempt
Completed suicide

Documentation Requirements

Specific ideation level and/or behavior type
Protective factors identified
Risk mitigations implemented
Disposition and rationale

💡 Liability Protection

Documented C-SSRS assessment demonstrates standard of care even if patient declines hospitalization. Offer voluntary admission; if refused, document capacity assessment and Baker Act consideration.

Speaker Notes

C-SSRS takes 2-3 minutes once practiced. The key distinction is between ideation (levels 1-5) and behavior (past attempts predict future risk). Document every step—your note is your defense. Safety planning (Stanley/Brown) can be done even if patient refuses hospitalization.

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Telepsychiatry Models

Model	Format	Billing	Turnaround
Curbside	Informal phone/text	No (liability risk)	Immediate
eConsult	Async documented review	Yes (CPT 99446-99449)	3-5 days
Direct Telepsychiatry	Synchronous video visit	Standard E/M codes	Scheduled
Project ECHO	Hub-and-spoke education	No CME credit	Ongoing

📊 Evidence Summary

Telepsychiatry demonstrates equivalent outcomes to in-person care for depression, anxiety, and PTSD. Patient satisfaction is consistently high. Medicare covers telehealth psychiatric services with parity to in-person visits.

Implementation Tips

Ensure HIPAA-compliant platform (Zoom Healthcare, Doxy.me, VSee)
Verify patient location at visit start (licensure requirements)
Have backup plan for technology failures
Document telehealth modifier (95, GT) appropriately

Speaker Notes

eConsults are underutilized—documented, billable, and create liability protection. Curbside consults are common but risky; at minimum, document in "Plan" that you discussed with consultant. Project ECHO is excellent for ongoing education but doesn't replace patient-specific consultation.

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CoCM Billing Codes

CPT Code	Description	Time Req	Approx. Reimbursement
`99492`	Initial month, BHCM services	≥70 min/month	$150-180
`99493`	Subsequent months, BHCM	≥60 min/month	$130-150
`99494`	Add-on: additional 30 min	+30 min	$60
`99492 + 99494`	Initial month, extended	≥100 min	$210-240

Documentation Requirements

Psychiatric caseload review with consultant (weekly, documented)
Patient-specific care plan in medical record
Brief interventions (motivational interviewing, behavioral activation)
Outcome monitoring with validated tools
Relapse prevention planning

⚠️ Coverage Notes

Medicare covers CoCM codes nationally. Medicaid coverage varies by state—check local policy. Private payer coverage is expanding but requires verification. BHCM must be employed by practice or integrated arrangement.

Speaker Notes

CoCM codes are practice revenue opportunities, not just cost centers. A full BHCM panel (80-100 patients) can generate $150K+ annually in billable services. Document time meticulously—audit vulnerability is high. The psychiatric consultant cannot bill separately for caseload review time.

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Documentation Requirements

Mental Health Parity Compliance

Document psychiatric diagnoses and treatment with the same specificity as medical conditions. Avoid stigmatizing language. Apply utilization management standards equitably.

Required Elements

PHQ-9/GAD-7 scores in every visit note
Black box warning informed consent (age <25)
Medication reconciliation at each visit
Diagnosis codes (F32.x, F41.x, etc.)

Follow-up plan with specific interval
Suicide risk documentation when indicated
Consultation notes and recommendations
Patient response and side effects

💡 EHR Integration Tips

Create smart phrases for PHQ-9/GAD-7 interpretation
Build registries for active monitoring
Set up automatic score trending graphs
Link patient portal for self-administered screens

📋 Note Template

Assessment: Major Depression, moderate (F32.1)
PHQ-9: 14 → 8 (43% improvement)
Current med: Sertraline 100mg, tolerated
Plan: Continue, f/u 4 weeks, CBT referral

Speaker Notes

Good documentation is malpractice protection and clinical care. The example template shows all required elements in 4 lines. Mental health parity violations (documenting less thoroughly for psych visits) are increasingly audited. Smart phrases save time and ensure consistency.

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Liability Considerations

Standard of Care for PCP Prescribing

Obtain informed consent for psychotropic medications
Screen for contraindications (bipolar, seizures, pregnancy)
Monitor for adverse effects and drug interactions
Document rationale for treatment decisions
Maintain appropriate follow-up intervals

Key Liability Risks

Scenario	Risk Mitigation
Missed diagnosis leading to harm	Systematic screening, consultation for atypical cases
Antidepressant-induced mania	Bipolar screening before initiating (MDQ)
Suicide after treatment start	Document black box counseling, close monitoring
Drug-drug interaction	Check interactions; document discussion with patient

⚖️ Duty to Warn (Tarasoff)

If patient makes credible threat against identifiable victim, duty to warn/protect varies by state. Document threat specifics, consultation, and actions taken. When in doubt, consult risk management.

✓ Consultation as Protection

Documented psychiatric consultation demonstrates good faith effort to meet standard of care. It does not transfer liability but supports defensible practice.

Speaker Notes

PCPs CAN safely prescribe psychotropics—the standard is reasonable care, not psychiatrist-level expertise. The key is knowing when you're outside your comfort zone and consulting. Tarasoff duties vary—know your state law. EPCS (electronic prescribing) requirements for controlled substances are now federal.

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Warm Referral Protocols

20-30%

Cold referral show rate
(traditional referral)

60-75%

Warm handoff show rate
(collaborative model)

Warm Handoff Steps

Introduce in visit: "I'd like you to meet our BHCM who can help with..."
Schedule immediately: Before patient leaves the office
Provide contact info: Phone, email, patient portal access
Set expectations: First appointment within 1-2 weeks
Follow up: Track completion and re-engage if no-show

Referral Letter Components

Reason for referral and specific questions
Current medications and response history
Relevant labs and medical history
Risk assessment (suicide, self-harm, violence)
Urgency level and desired timeframe
Your contact information for questions

🔄 Closed-Loop Communication

Request consultation note back within 2 weeks. Schedule PCP follow-up within 4 weeks of psychiatry visit. Track patient in registry until stable.

Speaker Notes

The 3x show rate improvement makes warm handoffs worth the effort. The key is scheduling before the patient leaves—referral orders that "call to schedule" fail. Closed-loop communication prevents patients from falling through cracks. EHR referral templates should auto-request return notes.

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Key Takeaways

01

Collaborative Care Works

CoCM doubles depression treatment response rates and generates $6.50 ROI per dollar invested. The three-role model (PCP + BHCM + Psychiatric Consultant) is evidence-based and billable.

02

Systematic Screening Saves Lives

With 66-98% of psychiatric conditions missed in primary care, routine PHQ-9/GAD-7 screening is essential. Any PHQ-9 Q9 positive requires C-SSRS assessment.

03

Treat-to-Target, Not Guess-and-See

Measurement-based care with documented scores guides treatment. Most "failures" are inadequate trials—8 weeks at therapeutic dose minimum before switching.

04

Know Your Limits, Use Consultation

PCPs can safely treat moderate depression/anxiety. Refer severe illness, psychosis, bipolar suspicion, eating disorders, and treatment-resistant cases. Documented consultation protects you.

05

Documentation Is Your Defense

Every note needs scores, informed consent, follow-up plan, and risk assessment when indicated. Good documentation demonstrates standard of care and enables billing.

Speaker Notes

These five points capture the essence of safe, effective primary care psychiatry. Emphasize that integration is not "doing psychiatry" but doing primary care better. The evidence supports this model—implementation is the challenge. Invite questions and discussion.

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References

Unützer J, et al. (2002). IMPACT: Collaborative care for depression in primary care. JAMA. 288(22):2836-2845.
Katon WJ, et al. (2010). Collaborative care for patients with depression and chronic illnesses. NEJM. 363(27):2611-2620.
Archer J, et al. (2012). Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. (10):CD006525.
Substance Abuse and Mental Health Services Administration. (2022). Collaborative Care Model Implementation Guide. Rockville, MD: SAMHSA.
American Psychiatric Association. (2020). APA Clinical Practice Guideline for Depression. Washington, DC: APA.
Kroenke K, Spitzer RL. (2002). The PHQ-9: A new depression diagnostic and severity measure. J Gen Intern Med. 16(9):606-613.
Spitzer RL, et al. (2006). A brief measure for assessing generalized anxiety disorder. Arch Intern Med. 166(10):1092-1097.
Posner K, et al. (2011). The Columbia-Suicide Severity Rating Scale. Am J Psychiatry. 168(12):1266-1277.
American College of Physicians. (2023). Billing and Documentation for CoCM. Philadelphia, PA: ACP.
Tarasoff v. Regents of University of California. (1976). 551 P.2d 334 (Cal. 1976).

📚 Additional Resources

American Psychiatric Association: Integrated Care (psychiatry.org)
Agency for Healthcare Research and Quality: CoCM Tools (ahrq.gov)
University of Washington AIMS Center: IMPACT Tools (aims.uw.edu)

Speaker Notes

IMPACT trial remains the foundational study. Cochrane review confirms robust evidence base. SAMHSA implementation guide is free and comprehensive. C-SSRS is available at no cost from Columbia University. Thank participants and distribute evaluation forms for CME credit.