Presenter Introduction

Primary Care Psychiatry Integration: Collaborative Care, Safe Prescribing, and Psychiatric Emergencies

How to Use This Guide

This speaker companion provides detailed talking points, anticipated questions with suggested responses, group discussion scenarios, and a printable quick reference card. Review this guide alongside the presentation slides to prepare for delivery.

60 min
Compressed Version
Skip scenarios, limit Q&A
90 min
Standard Version
Full content + 1 scenario
120 min
Extended Version
All scenarios + extended Q&A

Audience Calibration

PCP-Only Audience

  • Emphasize practical prescribing pearls
  • Spend more time on treat-vs-refer decisions
  • Focus on billing code implementation
  • Assume familiarity with medical model

Mixed Audience (PCPs + Staff)

  • Define clinical terms on first use
  • Explain CoCM roles thoroughly
  • Include BHCM workflow discussions
  • Address scope-of-practice questions

Room Setup

Learning Management System (LMS) Notes

📋 CME Credit Requirements
  • Pre-test: Optional but recommended (5 questions, linked in slide 2)
  • Attendance verification: Sign-in sheet or QR code scan
  • Post-test: 70% passing required for credit (8 questions)
  • Evaluation: Required by accrediting body; include in LMS workflow
  • Certificate: Auto-generate upon completion

Talking Points Per Slide

Slide 1 Title Slide
  • Welcome participants and introduce credentials
  • Announce CME credit availability and requirements
  • Preview that this is practical, evidence-based content
  • Invite questions throughout (or designate Q&A time at end)
"Let's begin by understanding why this topic matters so much right now..."
Slide 2 Learning Objectives
  • Emphasize: All objectives are actionable and measurable
  • Connect objectives to ACGME competencies
  • Ask participants which objectives match their current practice challenges
  • Note that billing and liability are often overlooked but critical
"Before we dive into solutions, let's acknowledge the scale of the problem we're addressing..."
💡 Misconception to Correct

Some participants may think CoCM is "just having a social worker." Clarify that the BHCM role is specific, evidence-based, and includes registry-based tracking.

Slide 3 The Mental Health Crisis
  • Key stat: 50% of mental health care delivered in PC is surprising to many
  • Ask for local wait times for psychiatry referrals
  • Connect crisis drivers to daily practice pressures
  • Emphasize that "integration" isn't optional—it's already happening
"The good news is we have a proven solution that's been tested in over 80 randomized trials..."
Slide 4 CoCM Structure
  • Emphasize: The triangle represents interdependence, not hierarchy
  • Compare to traditional "refer and hope" model
  • Explain registry-based care with concrete example
  • Note that psychiatric consultant can be off-site via telehealth
"This isn't theoretical—let me show you the evidence..."
Slide 5 Evidence Base
  • Key stat: IMPACT trial 2× improvement rate—most rigorous depression trial in primary care
  • Compare to typical medical interventions (blood pressure control)
  • $6.50 ROI gets administrator attention—use this
  • Mention that CMS reimbursement validates the model
"But before we implement solutions, we need to understand why so many cases are currently missed..."
📊 Stat to Emphasize

79 RCTs with consistent results = stronger evidence than many standard medical treatments. CoCM is Level 1 evidence.

Slide 6 Missed Diagnosis Rates
  • Key stat: PTSD 90%+ missed—ask why (trauma non-disclosure)
  • Connect bipolar miss rate to antidepressant-induced mania risk
  • 7-minute visit constraint resonates with participants
  • "The patients in these statistics are in your waiting room today"
"The antidote to missed diagnosis is systematic screening. Here are the tools..."
Slide 7 Screening Tool Suite
  • Emphasize: These take 2-3 minutes—time barrier is surmountable
  • Can be delegated to MA during rooming
  • C-SSRS is free and validated
  • Mention G0444 Medicare coverage for annual screening
"Let me show you how to interpret and act on these scores..."
Slide 8 PHQ-9 and GAD-7 in Practice
  • Key point: PHQ-9 Q9 is standalone suicide screen
  • Demonstrate calculating percent improvement: (Initial-Current)/Initial
  • Treat-to-target = score <5 (remission), not just improvement
  • Document actual numbers, not "PHQ-9 improved"
"Now that we can identify patients, let's discuss who PCPs should treat versus refer..."
Slide 9 Treat vs Refer Algorithm
  • Emphasize: Framework, not rigid rules—clinical judgment applies
  • PHQ-9 18 + SI = refer despite score
  • "≥2 failed trials" means adequate dose and duration
  • Encourage curbside consult when uncertain
"For patients PCPs do treat, let's review common pitfalls to avoid..."
⚠️ Misconception to Correct

Some believe PCPs "shouldn't prescribe psych meds." Clarify that PCPs CAN safely treat moderate depression/anxiety—the standard is reasonable care, not psychiatrist-level expertise.

Slide 10 Common Prescribing Errors
  • Key point: Sertraline 25mg is pediatric dose—adults need 50mg minimum
  • 8 weeks minimum adequate trial, not maximum
  • Fluoxetine + tamoxifen interaction often missed
  • Most failures are inadequate trials, not medication failures
"Let's review safe dosing for first-line medications..."
Slide 11 Safe SSRI/SNRI Prescribing
  • Emphasize: Escitalopram and sertraline preferred first-line
  • Venlafaxine requires ≥150mg for dual reuptake
  • Black box warning applies to ALL patients <25
  • Titration schedule: low and slow, but keep going
"For patients who don't tolerate SSRIs well, consider these alternatives..."
Slide 12 Bupropion and Mirtazapine
  • Key point: Bupropion seizure risk is real but rare at therapeutic doses
  • Eating disorder contraindication often missed
  • Mirtazapine MORE sedating at 15mg than 30mg (counterintuitive)
  • Screen for diabetes risk before mirtazapine—weight gain can be dramatic
"Even with optimal prescribing, psychiatric emergencies will arise. Here's how to handle them..."
Slide 13 Psychiatric Emergencies
  • Emphasize: Psychiatric emergencies in PC are rare but high-stakes
  • Trust your gut—if unsafe, call security/911
  • Catatonia is medical emergency—needs benzodiazepines/ECT
  • Know your state's involuntary hold laws
"Let's dive deeper into suicide risk assessment specifically..."
Slide 14 C-SSRS Protocol
  • Emphasize: Any Level 2+ requires immediate action
  • Document every step—your note is your defense
  • Safety planning (Stanley/Brown) can be done even if patient refuses hospitalization
  • Free tools available at cssrs.columbia.edu
"For non-emergent cases requiring specialist input, telepsychiatry offers several models..."
Slide 15 Telepsychiatry Models
  • Key point: eConsults are underutilized—documented, billable, protective
  • Curbside consults are risky; at minimum document in plan
  • Project ECHO excellent for education but not patient-specific
  • Equivalent outcomes to in-person for depression, anxiety, PTSD
"Speaking of billing, let's review the CoCM-specific codes..."
Slide 16 CoCM Billing Codes
  • Key point: Full BHCM panel generates $150K+ annually
  • Document time meticulously—high audit vulnerability
  • Psychiatric consultant cannot bill separately for caseload review
  • Medicare covers nationally; Medicaid varies by state
"Billing requires specific documentation elements. Let's review what's required..."
Slide 17 Documentation Requirements
  • Emphasize: Mental health parity means documenting psych visits with same rigor as medical
  • Smart phrases save time and ensure consistency
  • Build registries for active monitoring
  • Good documentation is malpractice protection
"Speaking of protection, let's discuss liability considerations..."
Slide 18 Liability Considerations
  • Key point: Documented consultation demonstrates good faith effort
  • Tarasoff duties vary by state—know your local law
  • EPCS requirements now federal for controlled substances
  • Most malpractice in PC psych is failure to refer, not treating
"Even with optimal treatment, some patients need specialty referral. Here's how to ensure they actually get there..."
Slide 19 Warm Referral Protocols
  • Key stat: 3× improvement in show rates justifies the effort
  • Schedule before patient leaves—"call to schedule" fails
  • Closed-loop communication prevents falling through cracks
  • EHR templates should auto-request return notes
"Let's summarize the key messages from today's presentation..."
Slide 20 Key Takeaways
  • Emphasize actionable items participants can implement Monday
  • Reinforce that integration is not "doing psychiatry" but doing PC better
  • Invite participants to share their own implementation barriers
  • Offer contact information for follow-up questions
"For those who want to dig deeper, here are the key references..."
Slide 21 References
  • IMPACT remains foundational—cite frequently
  • SAMHSA implementation guide is free and comprehensive
  • C-SSRS tools available at no cost from Columbia
  • Thank participants and distribute evaluation forms

Anticipated Q&A — 15 Questions with Full Answers

Our practice doesn't have a behavioral health care manager — can we still do collaborative care?
You can implement elements of CoCM (registry tracking, measurement-based care) but won't be able to bill the specific collaborative care codes (99492-99494) without the BHCM role. Consider starting with systematic screening and registry tracking, then making the business case for BHCM hiring based on patient volume. Some practices use shared BHCM resources across multiple small practices.
How do I bill for the psychiatric consultation time if I'm the PCP?
As the PCP, you bill your usual E/M codes (99213-99215). The psychiatric consultant cannot bill separately for the weekly caseload review time in the traditional CoCM model. However, if the psychiatrist provides direct patient care via telehealth, they can bill standard E/M codes. Some models use psychiatric consultants employed by the practice who are salaried rather than billing separately.
What do I do when a patient needs psychiatry but there's a 6-month wait?
This is exactly why CoCM exists. While waiting: (1) Start treatment yourself if within your scope, (2) Use eConsults for guidance on complex cases, (3) Implement measurement-based care so you know if they're improving, (4) Consider telepsychiatry which often has shorter wait times, (5) Connect with local psychiatric residency programs or community mental health centers. Don't let perfect be the enemy of good—treating moderately ill patients in PC is appropriate.
Is it within my scope to prescribe antipsychotics for my patients?
PCPs can prescribe antipsychotics, but it's generally advisable to have psychiatric consultation for initiation. Once stable on antipsychotics (especially second-generation), PCPs often manage ongoing prescribing with periodic psychiatric follow-up. Key considerations: metabolic monitoring (glucose, lipids), EPS monitoring, drug interactions. If prescribing for off-label indications (e.g., quetiapine for insomnia), document rationale carefully.
A patient screens positive on PHQ-9 but denies depression — what now?
This is common. The screen may have captured normal grief, adjustment to medical illness, or somatic symptoms from a medical condition. Approach with curiosity: "Your score suggests you may be struggling with low mood. Can you tell me more about how you've been feeling?" Rule out medical causes (thyroid, B12, sleep apnea). Offer treatment if functional impairment exists; respect patient autonomy if they decline.
How do I document the Columbia Suicide Protocol without it taking 20 minutes?
With practice, C-SSRS takes 2-3 minutes. Use a smart phrase or EHR template that includes the key elements: ideation level (1-5), behavior type if applicable, protective factors identified, risk mitigations implemented, and disposition. You don't need verbatim questions in the note—a summary statement like "C-SSRS: Level 3 ideation, no plan or intent, protective factors include family support, safety plan created" is sufficient.
What if I start an antidepressant and the patient becomes manic?
Stop the antidepressant immediately—this suggests underlying bipolar disorder. Arrange urgent psychiatric evaluation. Document the episode thoroughly (dates, symptoms, relationship to medication start). This patient will likely need mood stabilization rather than antidepressants going forward. Review your screening process—did you use MDQ? Any history of hypomania? This is why bipolar screening before antidepressant initiation is critical.
My patient is on 4 psychiatric medications from a previous psychiatrist — do I continue them?
Don't change medications abruptly. Obtain records from the previous psychiatrist if possible. Schedule a visit specifically to review medications—patients often don't know why they're on each one. Taper cautiously, one medication at a time, with close monitoring. If the regimen seems inappropriate or unsafe, consult psychiatry before making changes. Document your rationale for any changes thoroughly.
What's the liability if I miss a psychiatric diagnosis?
Liability depends on whether the miss represents a breach of standard of care. Systematic screening reduces this risk. Document your clinical reasoning—if you considered depression but ruled it out based on history, that demonstrates appropriate thought process. Missed bipolar leading to antidepressant-induced mania is high-risk. The best protection is: (1) systematic screening, (2) consultation when uncertain, (3) thorough documentation.
Can I use gabapentin for anxiety in primary care?
Gabapentin is used off-label for anxiety, but evidence is limited. It may be reasonable for patients who can't tolerate SSRIs/SNRIs, especially if they have comorbid pain or sleep disturbance. Cautions: street value and misuse potential, sedation, requires renal dose adjustment, psychoactive substance that can be abused. Document off-label use and monitoring plan. Consider specialist consultation for refractory anxiety.
How do I handle a patient who needs a Baker Act but is refusing?
Know your state law—criteria vary but generally require (1) mental illness, (2) refusal of voluntary treatment, (3) danger to self/others. Call law enforcement or mobile crisis—they will evaluate and transport if criteria met. Document your assessment: specific threats, plan, means, protective factors, capacity assessment. If patient has capacity and refuses, document why involuntary hold criteria are/aren't met. Safety plan if not held.
What's the fastest way to integrate screening tools into our EHR workflow?
Start with paper forms if EHR integration is complex—you can digitize later. Place forms with vitals for MA to administer during rooming. Build smart phrases for documentation. Set up automatic prompts for annual screening. Many EHRs have PHQ-9/GAD-7 calculators built-in. Patient portal administration (patient completes on phone/tablet before visit) saves time and improves accuracy.
How do I talk to a patient about depression when they think it's 'just stress'?
Validate first: "Stress is real and difficult." Then bridge: "What I'm hearing is that the stress is affecting your sleep, energy, and enjoyment of things—those are also symptoms of depression, which is a medical condition we can treat." Use the PHQ-9 as objective data: "Your score puts you in the moderate range. Even if it started as stress, your brain may need help recovering." Offer treatment as a tool to cope better with stress.
What if an eConsult psychiatrist recommends something I'm not comfortable prescribing?
You are not obligated to follow consultant recommendations. Respond with what you ARE comfortable doing: "I appreciate your recommendation of clozapine. As a PCP, I'm not comfortable initiating that medication. I can refer to psychiatry for initiation, and once stable, I'd be comfortable managing ongoing prescribing with your guidance." Document the recommendation, your response, and rationale. Consultation doesn't transfer liability or decision-making authority.
How do I handle a patient who is suicidal but refuses hospitalization?
Assess capacity—does the patient understand risks and alternatives? If capable and refusing, document capacity assessment and Baker Act consideration. Implement safety planning (Stanley/Brown method): identify warning signs, internal coping strategies, social contacts, family supports, professional resources, and environmental modifications (remove means). Schedule follow-up within 24-48 hours. Consider involving family with patient consent. Document everything—your note is your defense.

3 Group Discussion Scenarios

Scenario A: Implementing CoCM
Setup: A medium-sized primary care practice (5 providers, ~8,000 patients) is considering implementing the Collaborative Care Model. The practice administrator is concerned about costs and workflow disruption. The providers are interested but skeptical about adding "more work." The practice has no current behavioral health integration.
Discussion Questions:
  1. What are the primary barriers this practice faces in implementing CoCM?
  2. What would be the first concrete steps in a phased implementation?
  3. How would you make the business case for hiring a BHCM?
  4. What are realistic success metrics for the first year?
  5. How might you address provider concerns about "more work"?
Facilitator Notes

Key teaching points: Start with registry and screening (no BHCM required), make business case based on 99492-99494 reimbursement ($150K+ for full BHCM panel), emphasize that BHCM actually REDUCES provider workload by handling patient outreach and tracking. Phased approach: (1) screening implementation, (2) BHCM hiring, (3) psychiatric consultant contract, (4) billing optimization. Success metrics: % patients screened, registry enrollment, patient outcomes (PHQ-9 improvement), provider satisfaction.

Scenario B: Missed Bipolar Diagnosis
Setup: A 42-year-old woman with chronic pain, fatigue, and PHQ-9 of 16 has been treated by her PCP for "treatment-resistant depression" for 10 years. She has tried sertraline, fluoxetine, venlafaxine, and bupropion—all with "no help." On careful history, she reports that about twice a year she has periods of 3-4 days where she sleeps only 3-4 hours, feels "wired," starts ambitious projects (repainting the house at 2am), and spends money impulsively. She's never mentioned these periods because she feels good during them.
Discussion Questions:
  1. What diagnosis should be considered, and what screening tool would help confirm?
  2. Why did multiple antidepressants "fail" for this patient?
  3. How should the PCP approach the conversation about reconsidering the diagnosis?
  4. What are the treatment implications if bipolar II is confirmed?
  5. What systems-level changes could prevent similar missed diagnoses?
Facilitator Notes

Key teaching points: This is classic bipolar II—depression is the predominant symptom, hypomania often not recognized as pathology. Antidepressants without mood stabilization can worsen bipolar (antidepressant-associated mania/hypomania or rapid cycling). MDQ (Mood Disorder Questionnaire) would help screen. Treatment shifts to mood stabilizers (lamotrigine first-line for bipolar depression, though psychiatrist initiation recommended). Systems fix: systematic bipolar screening before antidepressant initiation, especially for "treatment-resistant" depression.

Scenario C: New-Onset Psychosis
Setup: A 25-year-old man presents to urgent care with his mother, who reports he's been "acting strangely" for the past week. He believes neighbors are monitoring him through the TV and has covered all windows with aluminum foil. He seems guarded and suspicious when asked questions. Vitals are normal. Urine drug screen is pending. No prior psychiatric history. Mother reports he's been under stress at work and using "more marijuana than usual."
Discussion Questions:
  1. What is your differential diagnosis, and what distinguishes each possibility?
  2. What immediate workup is indicated in the urgent care setting?
  3. Is this patient safe to discharge? What factors determine disposition?
  4. How should the urgent care provider document this encounter?
  5. What follow-up plan should be established before disposition?
Facilitator Notes

Key teaching points: Differential: (1) First-break psychosis/schizophrenia spectrum, (2) Cannabis-induced psychotic disorder, (3) Medical causes (thyroid, B12, NMDA receptor encephalitis, temporal lobe epilepsy), (4) Substance-induced other than cannabis. Workup: CBC, CMP, TSH, B12, folate, UA, consider CT head if neurological signs. Disposition: If cooperative, no immediate danger, reliable support, can discharge with psychiatry follow-up within 24-48 hours. If paranoid, refusing, or uncertain, involve psychiatry consultation or consider ED transfer for observation.

APA Reference List

  1. Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., ... & Coventry, P. (2012). Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, (10), CD006525.
  2. American Psychiatric Association. (2020). Practice guideline for the treatment of patients with major depressive disorder (3rd ed.). Washington, DC: Author.
  3. American Psychiatric Association. (2023). Telepsychiatry via video conference: Guidance for psychiatrists. Washington, DC: Author.
  4. American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.
  5. American Society of Addiction Medicine. (2023). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions. Chevy Chase, MD: Author.
  6. By the American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674-694.
  7. Centers for Medicare & Medicaid Services. (2023). Collaborative care model (CoCM) billing guide. Baltimore, MD: CMS.
  8. Katon, W. J., Lin, E. H., Von Korff, M., Ciechanowski, P., Ludman, E. J., Young, B., ... & McCulloch, D. K. (2010). Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine, 363(27), 2611-2620.
  9. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.
  10. Miller, C. J., Grogan-Kaylor, A., Pfeiffer, P. N., Dalack, G. W., Jankowski, M., & Zivin, K. (2013). Collaborative care for patients with bipolar disorder: A randomized controlled trial in an HMO. Psychiatric Services, 64(11), 1116-1124.
  11. Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., ... & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277.
  12. Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.
  13. Substance Abuse and Mental Health Services Administration. (2022). The Collaborative Care Model: An approach for integrating physical and mental health care in Medicaid health homes. Rockville, MD: SAMHSA.
  14. Tarasoff v. Regents of the University of California, 551 P.2d 334 (Cal. 1976).
  15. Unützer, J., Katon, W. J., Callahan, C. M., Williams Jr, J. W., Hunkeler, E., Harpole, L., ... & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA, 288(22), 2836-2845.
  16. Veterans Health Administration. (2023). VA/DOD clinical practice guideline for the management of major depressive disorder. Washington, DC: Department of Veterans Affairs.
  17. Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., ... & Goldstein, B. I. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.

Handout-Ready 1-Page Summary

Primary Care Psychiatry Quick Reference Card

CoCM at a Glance
PCP Diagnosis, prescribing, overall care coordination
BHCM Screening, outreach, registry tracking, brief interventions
Psychiatric Consultant Weekly caseload review, treatment recommendations
Screening Tool Cutoffs
PHQ-9 5/10/15/20 C-SSRS Any pos = risk
GAD-7 5/10/15 AUDIT-C M≥4, F≥3
Treat vs Refer
PCP Treats: PHQ-9 10-19, uncomplicated anxiety, straightforward SSRI Refer: PHQ-9 ≥20, SI/HI, psychosis, bipolar, ≥2 failed trials, eating disorders
CoCM Billing Codes
99492 Initial month ≥70 min ~$150-180
99493 Subsequent ≥60 min ~$130-150
99494 Additional 30 min ~$60
🚨 Psychiatric Emergency Red Flags
Suicide: C-SSRS Level 2+ ideation, active plan, preparatory acts
Psychosis: Command hallucinations, severe agitation, catatonia
Mania: DIGFAST (Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity, Sleep deficit, Talkativeness)
Action: Call 911 if imminent danger; Baker Act if danger + refuses treatment

Primary Care Psychiatry Integration • CME Educational Activity
For questions: [Presenter Contact] • Resources: cssrs.columbia.edu • aims.uw.edu

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