Solving the Diffusion of Care Problem (Part 2)

What a Well-Formulated Treatment Approach Looks Like

Continued from PART 1 Who is responsible?

Last week I asked: Who is actually responsible for the patient’s care?

Every day, complex patients, with fragmented histories, land in the lap of a new clinician. The patients suffer with the diffusion of their care.

This situation is a structural failure of the mental health care system, so normalized that we hardly notice it. It reflects a diffusion of responsibility operating at all levels of care itself. The result is predictable: fragmented treatment and worsening outcomes.

In this post, I describe SIX (6) structural elements that could prevent crises and perhaps help us maintain a clear focus on caring for complex patients. Here’s my suggested approach.

1. Develop A Written Longitudinal Case Formulation, Linking History, Diagnosis, and a Plan

Lack of the aforementioned is one of the most common failures in modern mental healthcare. Clinicians need to be able to answer / deliver:

• What is a formulation? It’s a reasoned understanding of the patients problems.
• What does it answer?
  • The why now? The real reason the patient is seeking treatment.
  • How are the biological, psychological, and social forces interacting to create the dysfunction?

Do This: Create a one-page, plain language document for all involved clinicians.

Remember, a diagnosis is not a formulation. Every patient, with the same diagnosis, may have totally different clinical needs.

2. Name a Treatment Leader Accountable for the Overall Plan

Designate a treatment captain who owns the case.

The treatment captain:

• Assigns the roles within the treatment team.
• Knows what all clinicians are doing and ensures everyone follow the same goals.
• Prevents diffusion of responsibility.

3. Utilize Explicit, Measurable Goals, Revisited at Defined Times

• The team sets behavioral and observable, graded, time-bound, and goals.
• The patient collaborates and determines the goals.
• When goals are not being met, the case needs an improved formulation and treatment plan.

4. Include a Decision Protocol: If X Hasn’t Improved by Y Weeks, We Do Z

• Set a time limit on meeting psychotherapy goals and decide what’s next if they are not met
• Set psychopharmacology goals and timelines for symptom reduction, along with next steps, if goals are not met.
• Determine the level of care needed. If the current level of care is not working, change it.

5. Develop Regular Cross-Provider Communication — And Not Only at Crisis Points

• Schedule structured team contacts at clinically meaningful intervals. For complex patients, the captain should convene a brief monthly case conference.

6. Make Active Discharge Plans from Day One

• From day one, determine the specific conditions required for next steps to delineate the entire treatment plan.

Final Thoughts

This is an example of an ideal plan. It takes a tremendous amount of energy to work this way in a system that resists long-term planning—a system that does not reimburse for the time it takes to create a case formulation and long-term treatment plan.

Psychiatrists are well position to be team leaders. Good psychiatric training covers the key areas needed for comprehensive case formulation and long-term planning.

The problem? I am not at all sure current psychiatric training desires this role or supports this vision.

This leaves me where I began, still asking: “Who will be responsible?”

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Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell
Psychiatrist, Psychoanalyst, Educator, and Supervisor Contact: Feinster@1052699pwpadmin
Owner & Founder Empathian LLC ( An Online Mental Health Education Company) Empathian.com

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