Frequently Asked Questions

ASSESSMENTS

The assessment has two parts. Step 1 is The Intake Interview. Step 2 includes the Diagnostic Review and a discussion of Treatment Options.

Step 1: Intake Interview

What does the Intake Interview look like?

Without a solid assessment both the provider and client are set-up for failure. The better the Assessment, the better the Treatment Plan. The better the Treatment Plan, the better the outcome.

The goals of a thorough assessment are to:

Understand what some of the core driving forces are behind the symptoms.
Identify contributing factors that initiate, maintain or extend symptoms.
Develop an understanding of the biological predispositions of the individual.
Develop an understanding of the social and environmental factors that contribute to a given set of symptoms.
Develop an understanding of the personal and psychological traits that are relevant to these topics.
Investigate individual symptoms to determine if and how they fit into known diagnostic categories.
Look at the person as a whole
Integrate the unique aspects of this individual person and their history.

What kinds of questions will I be asked?

A psychiatric Assessment at Frontier Health Services (FHS) will be familiar and resemble assessments the individual has had from other physicians in the past (like your family doctor, a pediatrician, or another psychiatrist). The Assessment usually begins with the client talking about why they are looking to have the evaluation done. From there, questions are focused on the history of symptoms, relevant contributing factors, associated symptoms, severity of symptoms and patters over time. Additional questions may be focused on other symptoms and conditions that may seem irrelevant but do need to be ruled out. There will also be times during the interview when more traditional questions will be asked – family history, previous providers, current medications, previous treatments, social history, surgical history and medical history all fall into this category.

How long does the Assessment take?

The first appointment is usually an hour. In rare cases a single one hour meeting can allow for an adequate amount of information to be relayed for the provider to offer a meaningful diagnosis with a reasonable degree of confidence. For adults with any significant amount of complication, multiple diagnoses, previous treatment or need for additional screening, a second meeting will be needed to complete this assessment phase before the diagnosis and treatment options can be discussed. Between these two meetings the provider at FHS will request and review records, labs may be ordered and other providers may be approached directly for more information.

Typically, the provider at Frontier Health Services will provide the client with additional psychological measures to complete at home between the first and second meetings. These are chosen towards the end of the first meeting and are based on the content that was reviewed during that meeting. In nearly all cases an adequate amount of information can be obtained between the first second meeting to allow for a meaningful discussion focusing on diagnoses and treatment options during that second meeting.

Exceptions are more common for assessments that involve children and for more complex adult cases. These populations typically require a third meeting to complete the assessment.

CHILDREN: Assessments for children and teens usually require the integration of information from the youth, the family and other providers. Teachers or other members of the community may be valuable sources of information as well. Multiple interviews are typically needed. There are usually interviews that involve one or more parents with the youth in the room. In certain cases it may make sense to allocate time to one or more of the parents while the youth is outside of the room. A separate interview with the youth is the norm in Pediatric Psychiatry. This typically means that these Assessments will require a third one hour meeting to get to the point where diagnoses and treatment options can be discussed.
- In the case of children, obtaining information from multiple settings is typical (home, school, daycare, a second parent’s home, etc.)
- Except in rare cases the provider at Frontier Health Services will want to interview the child or teenager alone as a part of this Assessment. Care is taken to make sure everyone is comfortable with the process and under no circumstances would this be forced.
  - Confidentiality is made reference to so all parties are aware of the kinds of things that a provider is obligated to relay to a parent and the kinds of things that are covered under the expectation of confidentiality.
COMPLEX CASES: Complex cases are those where an abnormally large amount of data needs to be reviewed. This can occur in cases when there are many previous providers, the client has gone through many different treatments, there have been numerous hospitalizations, and cases where the symptoms and history carry a level of detail that requires a larger time investment. Due to the amount of information to review with the client (both directly during the interview and indirectly via record review and communication with previous providers) these assessments typically require a third one hour meeting.
- Dr. Hjellen has worked inside the hospital setting for years. In that setting he managed the more severe versions of the same mental health conditions that are present in the outpatient world. He is comfortable and experienced in assessment and management of this subcategory of client.

I have had previous providers and Assessments. Will those be reviewed?

Yes. Previous records typically need to be reviewed after the first meeting. This approach allows the provider at FHS to review those records in the context of the known history presented by the client – this minimizes any unintentional bias that would come from the opinion of a previous provider. Those previous opinions are important, but they should not be the deciding factors for future care. Screening labs and other tests are also needed in many cases to rule out medical conditions that may be exacerbating, mimicking or complicating a mental health condition. Sometimes those tests have already been done and can be obtained from other providers. Sometimes they will require a separate set of orders. When these records and screening tests are needed, the assessment always requires a second meeting. The tests and previous records are obtained and reviewed between the first and second meetings.

Step 2: Diagnostic Review and Treatment Planning

What happens at the end of the assessment?

During the final phase of the Assessment the provider at Frontier Health Services will be able to sit down with you (and your family if you wish) to discuss what diagnoses came out of the assessment and what the treatment options are.

DIAGNOSTIC REVIEW: At Frontier Health Services, our approach when discussing diagnoses is to always assume that the client knows more about themselves than we do.
- Step 1: We start this phase by describing what the main areas of concern are. We then begin grouping these concerns into different categories and describe which categories constitute specific diagnoses. We describe why these diagnoses seem to fit the descriptions the client made (often using the client’s own words). We then explain those diagnoses in as much detail as the client wants. The provider is there to answer questions and provide information.
  - We take time to:
    - 1) Describe each diagnosis.
    - 2) Describe how multiple diagnoses may interrelate and affect each other.
    - 3) Describe what expectations for the future can be (prognosis).
- Step 2: We then bring this information back to the client and ask whether the descriptions of these diagnoses seem to fit with what the client has experienced. With this information, clients may now be in a position to provide more information or clarity on previous statements or descriptions of symptoms – this is welcomed.
  - Before moving to treatment options, we make sure that:
    - 1) Everyone understands the diagnosis.
    - 2) Everyone agrees with the diagnosis.
    - 3) Everyone has had their questions addressed.
TREATMENT PLANNING: Dr. Hjellen’s training prioritized an evidence based approach to mental health. It also prioritized the need to make adjustments in how that evidence is applied when looking at the unique aspects of a specific client’s situation and history. At Frontier Health Services our approach to treatment is to provide the client with options not directives.
- During this phase of the Assessment we discuss the different treatment options that are available for a given diagnosis.
  - “I may know these diagnoses and treatments pretty well, but I will never know you better than you know yourself. I feel like I am able to help my clients the most when I can effectively relay good information to them about the illness and the treatment options that are available. This allows the client to make an informed choice about which treatment options make the most sense for themselves.” Dr. Hjellen.
- When appropriate, this approach includes a discussion that contains the treatment options that include medications and those that do not.
  - We will refer to the different success rates and timelines one can expect for improvement when considering different treatment options.
  - When discussing different treatment options (like therapies and medications) we can relay information about how, why and when they should be used together to maximize benefit.
  - In most cases we can take the information from the Intake Interview portion of the Assessment and offer a generalized timeline for symptom improvement.
  - In many cases we can take the information from the initial Assessment and discuss long term plans for those who want to work towards being medication free.
- Typically the Treatment Plan is formed during a discussion that goes beyond simply making reference to different treatment options.
  - During the Treatment Planning process there is often a time when the provider will write down specific schedules for medication adjustments so everyone in the room knows what to expect. These schedules are written down again, and when necessary adjusted, during future appointments. This approach allows all parties to be informed about what the next steps of the Treatment Plan are, how long those steps should take and allows for a better understanding of the treatments and the expectations for improvement.

What if I don’t like the diagnosis Frontier Health Services provides?

At Frontier Health Services, our approach is one where we present the diagnosis to the client AND work with the client to identify additional information and/or oversights that may provide more diagnostic clarity. This occurs during the Diagnostic Review phase of the Assessment before treatment options are discussed. Typically, this approach results in the diagnosis being consistent with the client’s understanding of themselves.

What does a Treatment Plan include?

This varies with every client. A client’s history, diagnoses, symptom severity, practical limitations and personal preferences all become relevant when deciding on a Treatment Plan. These plans are often layered and can involve many types of services in different categories. Some recommendations are straight forward (exercise, sleep hygiene) and some are more involved (medication, therapy). The goal is to piece together a Treatment Plan that is sensitive to all the issues outlined above (history, diagnoses, symptom severity…), but at the same time maximizes the potential for improvement over the shortest time possible.

When a medication is included in a Treatment Plan that medication is reviewed at that time. When this happens, a specific medication is typically decided upon in the office. The profile of that medication is reviewed with questions asked and answered before a consent is signed. This consent is required before a medication can be included in treatment. When this occurs a multiweek plan is outlined that identifies when dosing changes would be expected to occur. This discussion includes details about why that timeline exists, when improvements are to be expected and what additional things can be done to improve the likelihood of success.

What if I don’t want a medication?

Then you won't be starting one. As indicated above, our approach is to provide options, not directives. We have many clients that have similar preferences. In many cases there may be factors that naturally result in Treatment Plans that do not include a medication. In other cases, a Treatment Plan may be chosen that does not include a medication due to a client’s personal preference. We start with the belief that our clients know themselves better than we so. We may know the diagnoses and treatment, but we also know that the science and statistics may not apply perfectly to every individual.

Two limitations are:

We want our clients to make informed choices.
- This may mean that in some circumstances we may not endorse a treatment plan if the client overtly refuses to receive any other information.
  - As of the date of this posting/update this has never happened at Frontier Health Services.
We will not prescribe a treatment that we believe will be harmful.

As long as 1) our clients are informed of what their options are and 2) we are not knowingly hurting our clients, we take the position that the client is in the best position to make the final decision. If a diagnosis or set of diagnoses exists that would typically involve the inclusion of a medication, then all sets of treatment options should be discussed. In these cases, it would make sense to review the medication options with the provider so that all of the options are included and the client understands the risks and knows what to expect over the short and long term with the treatment options(s) that s/he chooses. The different rates of success when medications are included or omitted are usually reviewed as this can inform decision making. The different timelines that a client might expect for improvement when different treatment plans are considered are usually reviewed for the same reason.

What if I don’t like the Treatment Plan?

At Frontier Health Services, our approach is designed to prevent that from happening. Because our approach involves a more collaborative process with the client making choices, this is extremely unlikely. Our approach is one where we want (in many cases need) the client to be involved in the treatment planning process. This process is flexible as we go into every meeting with the belief that the client knows themselves better than their provider ever can. For this reason, the Diagnostic Review and Treatment Plans require the input of the client. This process allows for adjustments to be made before a specific plan is decided upon.

Do I have to decide right then?

Definitely not. The information presented to a client during that final phase of the Assessment may be a lot to take in. The client may want to go home and think things through, look things up on their own and/or discuss their options with a family member, a friend and/or another provider. Typically the Assessment process does end with the formation of a Treatment Plan, but that is not a requirement.

FOLLOW-UP MEETINGS

Most clients want the specialist who completed the Assessment at Frontier Health Services to manage their Treatment Plan. This is done during following-up appointments with the specialist at specific intervals to address treatment changes and to reassess symptoms. This plan will be different for every client. During the Treatment Planning portion of the Assessment, the provider will typically draw out a multi-week plan identifying when the next few visits would be expected to occur and why. Because the Assessment is fairly detailed, and the Treatment Plan is outlined during the first meetings, the follow-up plan is usually well understood by all parties involved. All plans are designed to be flexible and allow for adjustments when necessary.

Do I have to follow-up with my provider at Frontier Health Services, or can I take my Treatment Plan to another clinic?

When requested, we can relay our treatment recommendations to other providers allowing them to follow-up with the client using the agreed upon Treatment Plan as a template.

How often will I need to follow-up?

When a Treatment Plan is chosen that involves starting or changing a medication, the appointments tend to be more front loaded. This results in a higher frequency of appointments while the new medication is being titrated up to its therapeutic dose. Once the medication is stable and symptoms are improving, the appointments typically become less frequent. The frequency of visits is outlined in the Treatment Plan and discussed with the client towards the end of the Intake Assessment - this frequency ends up being unique for every client.

In general follow-up appointments tend to be more front loaded - meaning they are more frequent early on and less frequent as treatment progresses and stability is established.

Will you work with my therapist?

Yes. We have many therapists in the community that we communicate with regularly. This is important for obvious reasons. Our preference at Frontier Health Services is to make every effort to help our clients get off their medications. Doing so almost always requires the involvement of a qualified therapist. This works best when the therapist and Frontier Health Services are able to communicate while using complimentary approaches that focus on the same long term treatment goals.

Can I get my therapy at Frontier Health Services?

Dr. Hjellen is one of only a few Pediatric Psychiatrists in Anchorage. As there are additional therapists in the community that can provide a good therapy service but only a few physicians who can provide the diagnostic and treatment services that we do at Frontier Health Services. This places a community service obligation on us to prioritize the diagnostic and treatment services that people in the community would otherwise not be able to obtain. In rare circumstances Dr. Hjellen will provide therapy services, but typically this service is referred out to one of the many of therapists that we work with in the community.

Assessments

What kinds of questions will I be asked?

How long does the Assessment take?

CHILDREN

COMPLEX CASES

I have had previous providers and Assessments. Will those be reviewed?

What happens at the end of the assessment?

DIAGNOSTIC REVIEW

TREATMENT PLANNING

What if I don’t like the diagnosis Frontier Health Services gives me?