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CLIPP Index <
 CLIPP
(Consultation and Liaison in Primary Care Psychiatry) Manual
Consultation
General Principles
The Consultation section of the CLIPP model augments general practice
care by providing a specialist review of the patient management. It also
provides opportunity for a psychiatrist and a GP to get to know each other
well, understand each other's strengths and weakness, and establish excellent
communication and working relationships.
In addition to these it provides an educational opportunity for the GPs
to upgrade their skills whilst working under supervision in areas of specific
concern to them. All of these are critically important in the subsequent
success of the shared care model. However it should be noted that the
consultation services and methodology for achieving this may not suit
all services at all times. The use of alternative strategies such as group
work, should be seriously considered in the development of the model.
It is indeed possible that group work may be used combined with occasional
adjunctive use of the consultation liaison protocol. Consultation work
could provide useful substrate for discussion within a group. Various
combinations might prove acceptable and effective, though the model set
out here does provide a set of interventions that have proved robust across
a number of settings.
Key Points
- A psychiatrist will visit the GP clinic regularly, usually for half
a day each time.
- Liaison around particular clinical problems is encouraged.
- A specific consultation protocol provides structure to support this
clinical process.
- Quality assurance measures provide feedback to all involved about
the outcomes.
The GP in the Consultation Process
General Principles
The CLIPP model includes provision of consultation and liaison services
by psychiatrists to General Practitioners. The psychiatrist will be available
on a regular basis at your clinic to enable you to ask for help or advice
about any case or aspect of your work with people with mental health problems.
In addition to this general liaison function, a specific consultation
protocol has been established, and this is set out below. Between these
two components you should find, as a GP, that this gives you access to:
Specialist clinical opinions and advice to support you in managing
your patients - The psychiatrist can provide time to discuss individual
patients. Where you make a specific consultation referral there is an
opportunity for discussion before and after the clinical consultation
by the psychiatrist. It is recommended that 15 minutes be allowed for
each of these discussions. In the first of these discussions you should
be able to ensure that the questions to be addressed in the consultancy
process are the ones you feel are important in the management of this
patient. In the second discussion, the psychiatrist should provide you
with feedback on the patient and any recommendations for the management
of the patient's treatment in a form that is easy to digest. It is very
important that what the psychiatrist says to you is intelligible, acceptable,
and workable for you. On subsequent visits the psychiatrist will be in
a position to offer further advice if required on these patients given
that he or she will have obtained substantial background information on
the patient within the practice setting.
An educational opportunity - The time spent in face to face contact
with the visiting specialist is valuable educationally (In previous implementations
of the model it has been possible to secure recognition by the College
of General Practitioners for Continuing Medical Education at a rate of
2 CME points per hour.) This time can include clinical case discussion,
and arising from the needs of the patient, an opportunity for teaching
and training in the techniques, procedures, or medications, associated
with the treatment of this particular person or persons with this type
of disorder.
Information flows and access - Clinical information will be held
on referred patients both at the practice and in the AMHS. This latter
will be available for retrieval if necessary and is also potentially accessible
by the patient, at least in some states, under Freedom of Information
Act provisions.
Key Points
- GPs should consider the use of the service for any mental health problems
they are having difficulty managing.
- Patients resistant to other types of external referral may find this
model acceptable.
- Whatever financial arrangements are in place, it is important that
the consultation process provides the GP with value other than that
of a financial nature. It is important that the consultation process
is held to be effective in giving the GP the advice and support that
he/she feels they need in the management task presenting. This task
will take some time allocated to it by the GP.
- Educational recognition is one form of compensation for GP time committed.
It is also important that the GP receives feedback that makes the management
task of most of those referred clearer and more efficient. Talking to
a psychiatrist takes time, but so does proceeding in managing mental
health problems with unclear or inappropriate management plans.
Specifics for the GP
Identifying Suitable Referrals
Consider for referral anyone with any type of psychiatric problem which
you feel could benefit from assessment and some guidance on appropriate
management from a psychiatrist. Such patients may include
- A situation where you feel reasonably confident about the diagnosis
and management, but would be reassured by the advice of a specialist
before carrying out management yourself.
- A patient you are thinking of referring on to a secondary service,
but are not sure whether this is indicated, or, if it is to be done
how or where best to do it.
- A patient you want to manage yourself but could benefit from clarification
of some specific points, for example:
- Someone with a significant prior psychiatric history, perhaps a psychosis,
who is evidently going through some stressful life situation and you
are not sure whether or not this is provoking a relapse of their previous
disorder.
- A situation where you have already made a diagnosis, and initiated
treatment, but where there are difficulties in compliance with the treatment
or the patient appears not to be responding.
- A patient about whom you are confused or perhaps feeling a sense of
loss of direction and hopelessness.
Client Discussion
As the GP you should discuss the possibility of referral with the patient
and let them know the following about the process:
- The psychiatrist will support you by providing assessment and advice,
but will not take over the patient's care.
- The patient can expect to spend up to an hour with the specialist,
who will ask them about the history of their problems. The psychiatrist
will then give the patient an indication as to what may best be done
to help with their problems.
- When this is concluded, the patient should make another appointment
to see you. It is your role to carry on helping them with their problems,
in conjunction with others if indicated.
Arrangements Surrounding the Appointments
Once you have an agreement from the patient to proceed, make an appointment
with the psychiatrist at the time available. Generally speaking the visiting
psychiatrist will see two patients for consultation liaison work in a
session.
The Day of the Assessment
A CLIPP 01 form should have been completed by the time of the appointment.
You should allow 15 minutes for discussion with the psychiatrist before
and after the patient is seen.
It is important that you discuss the situation and any problems you are
having with the situation. It may be helpful to spend some time together
with the psychiatrist and the patient, but this is discretionary. Hold
the psychiatrist to the task of giving you some helpful response to the
matter at hand. This section of the process should be flexible, and responsive
to the needs of the particular clinical issue and the person presenting.
Follow Up
As the GP you should review the patient in the next few days and continue
the management as discussed. If there should be any need for further supervision
or discussion then the psychiatrist can be available to you for that.
Two months after the initial episode of consultation you will be sent
a CLIPP 03 form to complete, which will ask for a brief update on the
progress. This is an important quality assurance measure within the project.
The CLIPP team will identify any cases that have deteriorated and will
subject these to a detailed clinical audit.
The Patient in the Consultation Process
The following text is designed as source text for a patient information
leaflet about the referral and consultation process.
General Principles
In this practice a psychiatrist regularly visits and provides advice
to GPs for help with people who require psychological or psychiatric assistance.
GPs have considerable ability in the management of mental health problems
generally. It is by no means the case that all mental health problems
need the full care of a specialist psychiatrist any more than chest problems
need the care of specialist chest physician. However it is often the case
that a GP's care can be helped by being guided and supported by working
with a psychiatrist.
Key Points
- The GP will speak to you about being referred to the visiting psychiatrist
and arrange an appointment.
- The appointment is an opportunity for you as the patient to have your
mental health problems assessed by a specialist.
- The psychiatrist will advise your GP about treatment and management
and will then be available to provide your GP with continuing support
in your treatment.
Specifics
- Your GP will speak to you about the possibility of being referred
to the psychiatrist and arrange an appointment time for you to meet
with the psychiatrist.
- The consultation with the psychiatrist will generally take up to one
and a half-hours. Hopefully things will run to schedule but if there
is a bit of a delay please bear with us. It is advisable not to make
other appointments too close to the time of your appointment with the
psychiatrist.
- In the consultation the psychiatrist will introduce him or her self
and will usually make clear to you that they expect to see you just
the once. The opinion given by the specialist psychiatrist will help
your GP care for you. It is not expected that the specialist will take
over your care. This will remain primarily with the GP, although the
psychiatrist can offer support and advice.
- The psychiatrist will keep confidential clinical notes during the
visit. The notes will be kept with the AMHS, along with a record of
your name and address so that your notes can be retrieved, if necessary,
for helping you in the future. The psychiatrist will also place a report
on your assessment in your GP's file. All of these records are covered
by full clinical confidentiality. Should you wish, you can request access
to AMHS notes under Freedom of Information provisions. (This is the
case in Victoria.)
- The psychiatrist will understand that talking about mental health
problems can be difficult. Please come with a willingness to talk through
your problems and to share your difficulties with the specialist. Usually
at the end of the consultation the specialist will give some guidance
and some suggestions as to what might happen in your future treatment.
- At this point it will be time for you to make your next appointment
with the GP. After the specialist has seen you he or she will talk to
the GP and so the next time you see your GP he or she should have available
some input from this consultation.
- We hope you find this whole process helpful, any comments that you
have on the whole process are welcome, and can usually best be relayed
through your GP.
The Psychiatrist in the Consultation Process
General Principles
Regular visits to general practices will generally take place on a fortnightly
basis, although this is fluid and can be arranged in relation to the needs
of the practice. It is important to negotiate timing ahead as far as possible
to facilitate interaction with all the GPs working at the practice. Being
at the practice over lunchtime is a good idea.
The care of patients referred by GPs will only be taken over by the psychiatrist
in exceptional circumstances and with the agreement of all concerned.
A consultation report, and continuing advice, will assist the GP in further
management of patients. In the event of a patient needing the attention
of psychiatric services this can be arranged.
The psychiatrist should discuss the patient with the GP before and after
the consultation.
It is desirable that someone from the practice advises the psychiatrist
of patients' appointments by telephone the day before a clinic. It is
also a good idea that practices remind patients of their appointments
on the day or the day before. Usually no more than two new full consultation
assessments should be booked for each session. The positive cooperation
of reception staff is critical. If the clinic has a practice manager then
the relationship with this person is likely to be pivotal in making the
attachment a success.
Key Points
- Regular visits to general practices will generally take place on a
fortnightly basis.
- You should allow time before and after a consultation to discuss the
patient with the GP.
- Usually schedule no more than 2 new assessments per session.
- Provide a consultation report and continuing advice to assist the
GP with further management of patients.
Specifics
Meet GP
Psychiatrists should meet with the GP or discuss the case by telephone
if this is not possible. Psychiatrists should try and guess from the information
provided what the needs of the patient are likely to be and how the GP
might be able to meet them. Seize the opportunities this may present to
give useful educational input to the GP within available time constraints.
Greet the Patient
First of all it may often be useful to open with a statement to the patient
about what can be expected in their appointment with you. Let them know
that you are a psychiatrist who regularly visits this surgery. Explain
to the patient that your role is to provide the GP with support in the
way of a consultant's opinion, and that you do not take over the care
of people from the GPs in the practice. Affirm the skills and competencies
of the GP to the patient. You also need to let the patient know that you
have already spoken to the GP and that you will share your observations
about their condition with the GP. Complete patient registration form
for the AMHS.
Commence the Clinical Consultation.
As the Psychiatrist you need to:
- Carry out the best standard assessment that is possible given the
time constraints of the consultation.
- Consider the management plan for the patient and what is possible
for the GP to provide for the patient.
- Explain to the patient in lay terms what you think the problem is
and what you think should be done to help alleviate the problem.
You may wish to sketch out a management plan with the patient and then
advise that follow up will be through their GP, although you may continue
to discuss their case with the GP as the need arises.
Referrals and Reports
Referrals and reports should be done on the forms provided (for examples
see CLIPP 01-02 in Appendix 2). All patients
seen should be registered with the AMHS and a record file created. The
CLIPP administration officer will coordinate the collection of reports.
All patient contacts need to be recorded on the appropriate patient information
recording system.
You will:
- Receive CLIPP 01 from GP.
- Complete Registration form & CLIPP 02.
- Photocopy the CLIPP 01 and CLIPP 02.
- Leave in the GP's notes:
- Photocopy of CLIPP 01
- Original copy of CLIPP 02
- Return to CLIPP administration:
- Original copy of CLIPP 01
- Photocopy of CLIPP 02
- Registration form
- Case notes
- Contact records for AMHS.
See Appendix 2 for a copy of the above mentioned
forms.
The Administrator in the Consultation Process
General Principles
As the administrative worker you should ensure that all CLIPP related
activity data is received and entered into the appropriate information
system, and monitor completeness of data sets. You will receive the following
documentation:
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Form
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Use
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Used By
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Registration form
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Patient registration
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Psychiatrist
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CLIPP 01
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GP Consultation Request to psychiatrist
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GP
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CLIPP 02
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PSY response to GP
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Psychiatrist
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CLIPP 03
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Follow-up information
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GP
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Key Points
- Follow up report collection from psychiatrists.
- Ensure all documentation in packs complete.
- Process all documentation appropriately.
- Manage electronic reminder systems for information follow up.
Specifics
See Appendix 2 for the forms.
Check and Copy
As the administrator you will:
- Receive data packs from psychiatrists
- Check the completeness of data
- Make photocopies of CLIPP 01 and CLIPP 02 for secure archives within
the CLIPP service.
Create Register
As the CLIPP administrator you should:
- Create CLIPP register entry, (kept on a password locked computer or
file) for each patient. Generally in a spreadsheet file format (such
as Excel) with: unit record number, patient name, GP name and practice;
psychiatrist name; CLIPP 01 date, CLIPP 02 date, CGI-1, CLIPP 03 date
(when it is received), CGI-3 and change score fields. The last three
fields will at this time be left empty.
- Use the date on the CLIPP 02 to enter a two month reminder in an electronic
diary system. When prompted two months later you send a reminder to
GP to complete a CLIPP 03 form.
- Register patient in the applicable data system using the information
on the registration form.
- Use Contact information provided to enter contacts in the relevant
client data system.
Create Patient File
It is necessary to create a patient file to store the registration form,
case notes, CLIPP 01 and CLIPP 02. The file should be securely lodged
in the appropriate medical records location.
It is your responsibility to maintain complete sets of the forms and
should follow-up with the psychiatrist if information is incomplete.
Processing for CME Points and Remuneration for GPs
As the administrator you also have a role in supporting the educational
aspect of the CLIPP program. The following assumes that the local CLIPP
program has been accredited through the Royal Australian College of General
Practitioners (RACGP) Continuing Medical Education (CME) program, as have
the CLIPP programs already established in Melbourne. To allow for the
GPs to receive their due points through the CME program, you must notify
the RACGP of the participation of each GP in the CLIPP program, and how
much time each GP has spent in discussion with the psychiatrist every
three months. Usually this should be calculated as a half an hour for
each patient seen in consultation but there may be exceptions to this
that the psychiatrist may advise.
The administrator should liaise with the RACGP once the CME accreditation
is approved and establish regular flow of information to the RACGP to
ensure the participating GPs receive their due point allocation.
Completion and Analysis
When reminded to by the Diary, send the CLIPP 03 to the GP. Ensure it
returns and if necessary, politely chase the GP.
As the administrator you are responsible for analysing this information
and alerting the supervising psychiatrist to any problems. Compare the
CGI scale with the baseline from CLIPP 01 (use the CLIPP register as detailed
above under the heading Create Register). also
look at the change score on CLIPP 03. Where CGI has deteriorated or change
score does not show improvement, discuss the matter with the supervising
psychiatrist who will review the case and consider if any action is necessary.
Also alert the supervising psychiatrist if any CLIPP 03 returns indicate
that patients have not been followed up by the GP.
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