Proceedings and Recommendations from the
Quality of Mental Health Care in Puerto Rico
Invitational Summit Conference
authors: Nestor J. Galarza, MD, Lloyd I. Sederer, MD, Eric Lister, MD
April 17, 1998 San Juan, Puerto RicoABSTRACT On April 17,1998, over 40 psychiatrists, health care consultants, patient advocates, researchers, psychologists, nurses, social workers, government officials, hospital administrators, and insurance and managed behavioral healthcare personnel held an invitational Quality Summit in San Juan. The conference was called because of a collective desire to influence the direction of mental healthcare under Reforma. What follows is a consensus report on the quality of mental health care in Puerto Rico and recommendations developed at the Summit. Our goal in publishing this report is to influence policy makers and promote legislation that will serve the citizens of Puerto Rico.
INTRODUCTION
Several years ago the Puerto Rico Psychiatric Society (PRPS)requested consultation from the American Psychiatric Association (APA), its parent organization, to analyze and influence radical changes that were occurring in the delivery of mental health services in Puerto Rico as a consequence of government health reform (Reforma). In October of 1997, two APA consultants, briefed by leadership of the PRPS, met with a representative group of psychiatrists, researchers, and leaders from governmental and private health and mental health care agencies and organizations. One conclusion form that meeting was that mental health service delivery in Puerto Rico was lacking in consensus policy development, particularly regarding quality performance standards for patient care. Consequently, a principal recommendation from the initial APA consultation was to convene a Quality Summit in 1998. This Quality Summit was held on April 17, 1998 in San Juan, Puerto Rico. This paper is the result of that meeting.SPEAKERS
Nestor J. Galarza, M.D.
President Elect, Puerto Rico Psychiatric Society
Coordinator, Alcohol/Nicotine Dependence Program
VA Medical Center
San Juan, Puerto RicoEric Lister, M.D.
APA Consultant
Ki Associates, Inc.
Portsmouth, NHLloyd I. Sederer, M.D.
APA Consultant
Medical Director, McLean Hospital/Harvard Medical School
Belmont, MassachusettsThe meeting began with the (then) President-Elect of the Puerto Rico Psychiatric Association ), Dr.Galarza, summarizing the principal concerns of the PRPS. These were: 1) recent alterations in the revision of the 1980 Mental Health Law; 2) the unfortunate conversion of the doctor - patient relationship into a consumer-third party-provider relationship with the consequent loss of professional autonomy and patient confidentiality; and 3) the need to recognize that professional performance is not simply a product of the competency and effort of the clinician but depends heavily on the support provided by the government and mental health delivery organizations.
These are his comments:
1) Changes in the Mental Health Law. The 1980 Mental Health Code is being revised to become the 1998 Mental Health Law. It was Carmen S, a patient at the State Psychiatric Hospital, whose 1980 civil suit against the Hospital prompted the original legislation. Carmen S. is still a frequent inpatient at the Caguas Hospitalization Unit. She is still chronically psychotic with violent exacerbations. She is one of the few patients that require longer lengths of stay than the average. Although not a real code, the 1980 Mental Health "Code" did improve the performance of hospitals and the judiciary in the care of those patients admitted involuntarily. This law, however, paid very little attention to children's rights to treatment for mental diseases. The famous case of Roberto Navarro-Ayala v. Governor of Puerto Rico arose in the 70's as a result of physical abuse to Mr. Navarro-Ayala. The case lingers despite remarkable improvements in the care patients receive in psychiatric hospitals. Emergency and admissions services are now run mainly the Puerto Rico Institute of Psychiatry, with residents staffing the service, under supervision. The outpatient care of persons with mental disorders is now provided both by the public facilities under the local Mental Health and Anti-Addiction Services Administration (ASSMCA) and by private institutions, contracted under the 1993 Health Reform Act. As this has occurred, the Commonwealth Government is in the midst of a political struggle to encourage the US Senate to pass a Plebiscite for Puerto Rico, perhaps finally to allow for the chance for Statehood. Against this political background the Mental Health "Code" was revised. Yet there is a concern that in spite of APA's recommendations, the new law will not stipulate parity of benefits and services for those suffering from mentally illnesses, and that it may not provide protection to patients from some of the abuses of managed care.2) The transformation of the doctor-patient relationship into a provider-intermediary- consumer relationship In psychiatry, the doctor-patient relationship is a fundamental part of the treatment - it is a form of medicine. It is generally not written on the prescription pad but can be a major (and sometimes the only) instrument a psychiatrist uses to enable a needy patient with a mental disorder to engage in treatment. The PRPS is concerned that this instrument is being attacked by fiscal intermediaries who seek to take decision-making role away from both patients and psychiatrists. Doing so increases the pain and suffering of patients and places psychiatrists in a position where advocating for care for their patients can result in economic harm as intermediaries seek to reduce costs and do deselect clinicians with costly patterns of care. Neither effect is acceptable. The Puerto Rico Psychiatric Society is working for mental health legislation that will protect patients as well as the doctor-patient relationship.
3) The performance of health care providers I believe that the performance of mental health clinicians depends not only on their competency and effort but also the support they receive from the health system in which they work. Board Certification does not assure quality of patient care in the absence of ethical, enthusiastic effort on the part of the individual practitioner nor in the absence of organizational support. My formula for practitioner performance for quality care is: Performance = competence + effort + organizational support. For example, quality of care depends not only on the variety of psychotropic medications in the formulary but on the pharmacy policies and procedures, the capabilities of the pharmacy personnel and the budget of the pharmacy. If any of these is weak, quality may be easily compromised. The PRPS is concerned that in stressing access to care there may be inadequate attention to the training and professional capabilities of health care providers. Moreover, in rushing to make changes in Health Reform while not monitoring the effects of the Health Reform we may be adversely affecting quality and inducing demoralization among health care providers. Patient satisfaction surveys, while important, are only one measure of quality (and vulnerable to bias); other measures, especially clinical outcome measures have not yet been introduced. We have little empirical information on which to base critical policy formation. P> Dr. Eric Lister emphasized that one method for informing policy on services development in Puerto Rico could come from the work of a highly representative group of stakeholders, such as assembled at this Summit, aided by consultants. Dr. Lister noted that initially managed care sought to manage the costs of care. Cost control was achieved principally by decreasing utilization and lowering prices paid to providers. There was little, if any, provider involvement. Continuos Quality Improvement (CQI) was mentioned but seldom put into place. Managed care soon became the demon of health care and was driven by the primacy of the profit motive. Polarization and poor communication between providers and Managed Care Organizations (MCOs) became epidemic. Our advocacy for patients became complicated by our personal needs as professional incomes and even survival for some practitioners was in jeopardy. MCOs and providers became increasingly boxed in by their respective positions with few opportunities for effective communication. But this polarization hurt everyone. Managed Care executives are often trained in public health and clinicians know about the needs of individual patient. We need to talk with each other and use our science. It is irresponsible to talk about quality without talking about resources. It is also morally irresponsible to talk about cost without talking about quality. Though health care policy and resources in Puerto Rico will be decided in the legislature, their deliberations should be guided by a clear, powerful public voice and the substantial developments in evidence-based psychiatry. We have a large body of empirical knowledge on psychiatric diseases and their treatments. It should be brought to the attention of policy makers. When professionals talk from a position without self interest, when patients come first, people listen. It is now commonly known from many surveys that patients don't trust doctors in general but do their own individual doctor. Bring the scientific method to the policy table. Don't only talk about CQI - practice it. Search for the best practices (which typically tolerate variation) that conform to the highest clinical standards and use these to guide the field. Conflict resolution theory says that one can engage in dialogue without betraying basic principles. We must engage in serious dialogue, based upon scientific data, which respects the varied principals at work (e.g., individual patient advocacy, public health, the just distribution of resources) and develop a morally credible consensus to shape clinical practice. We must involve everyone in the dialogue who will be impacted by it. Link these conversations to policy making initiatives whenever possible. Educate the public and the legislature. Make public statements which involve commitments to work together. Develop explicit standards of care. Focus on measurable deliverables. Continuously review and renew our work together.
Dr. Lloyd Sederer, our third speaker, began by describing Donabedian's concepts of structure, process, and outcome in health service delivery. Process variables are more easily measured than outcomes, can be good proxies for outcome, and hence are more commonly used. Hospitals seek accreditation from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Health Maintenance Organizations (HMOs) seek accreditation from the National Committee on Quality Assurance (NCQA). Both accrediting organizations are rapidly incorporating performance measurement (through process and outcomes reporting) in the accreditation process. Dr. Sederer further spoke on the differences between technical quality and interpersonal quality. Technical quality refers to whether the appropriate service was rendered to patients. It also refers to whether we demonstrated skill in carrying out the service. Technical quality, therefore, is "doing the right thing right" or "hacer la cosa correcta, correctamente." Interpersonal quality refers to the personal touch, the humane aspects of the doctor-patient relationship, the patient's experience of being care for in a respectful and caring manner. Dr. Sederer remarked that patients understand that providers will be pressured to spend less time and money on them. One critical antidote to the distrust this can arouse is the public reporting of technical and interpersonal measures of quality.
The consultants then offered the following five questions for designated workgroups at the Summit to discuss and report on at the end on the day:
Question #1: How adequate are the measures of clinical outcomes in mental health care in Puerto Rico?
Question #2: How adequate is access to mental health care in Puerto Rico?
Question #3: Are there standards for the appropriateness of care in Puerto Rico?
Question #4: What services are available to special populations in Puerto Rico?
Question #5: What happens next after this Quality Summit?The following is a summary of the comments and recommendations of the various workgroups:
Question #1: How adequate are the measures of clinical outcomes in mental health care in Puerto Rico? The workgroup emphasized the importance of focusing on the population served in order to answer this question. The choice of a measure will depend on the target patient population that is to be examined. For example, in order to study a population of children, a measure developed for assessing children will be needed; the same applies for other age groups or for target diagnostic populations. The group also agreed that outcome measures should not only target the ill but the healthy as well. Performance measures of the quality of care can also include functional status, burden of illness (to the family) upon discharge from hospital care, restrictiveness of care (i.e., whether treatment enabled patients to be discharged to less restrictive care), physical health, patient or family perception of the outcome of the care provided, and satisfaction with care. These are examples of the varied domains of outcome that we would like to see implemented. At the present time, these domains are not being measured. The SF-36 (RAND Corporation and the Medical Outcomes Trust) and other recognized and validated measures was discussed. The need for brief and not excessively burdensome (in time and money) outcome measures was noted. There is a need for measures that are applicable to Puerto Rican populations. Little psychometric work has been done assessing clinical outcomes measures in Puerto Rico. The main problems seem to be that there has been virtually no validation or reliability studies of instruments and no systematic outcome evaluations. Though some population-based studies have been done in Puerto Rico, these are not patient outcomes studies of the type we have identified at this meeting. A non-profit organization, the Quality Improvement Professional Review Organization (QUIPRO), is evaluating care for ASES but principally for physical illnesses with minimal attention to mental disorders. Government and private insurance contracts for the provision of psychiatric services have been inadequate from a quality perspective because there are no requirements for a systematic evaluation of the quality and outcome of care. The workgroup believed that there is little information available on quality performance contracting. In addition, there appears to be a lack of uniformity required by ASES for the paperwork and forms that Managed Care Organizations (and therefore providers as well) must use. It was reported that there are 57 different forms currently in use. Furthermore, ASES has not utilized any external evaluators of mental health care. The group also identified the difficulties involved in treating and caring the severely mentally ill who have special needs. Most mental health Carve Outs in PR that provide care to these severely mentally ill patients, do so by referring these to independent providers in their network". CompCARE instead uses interdisciplinary teams to provide care. The severely mentally ill need the care that only interdisciplinary teams can provide. Referring these patients to individual, non-medical clinicians is generally not appropriate. On the other hand, many proprietary managed care companies have avoided caring for the severely mentally ill because of the clinical complexity and cost of effectively caring for these patients (especially when not paid differentially for their care). If Community Mental Health Centers are closed there likely will be no one to care for these patients._ Question #2: How adequate is access to mental health care in Puerto Rico?
Many of the same problems of measuring the quality of care apply to access to care. The cultural beliefs about mental illness must be understood and considered when assessing a population's access to care. Puerto Rico shows considerable variation in access to mental health care. There are pockets on the island where access is better and areas where access is quite limited. The panel stated that outcomes of care cannot be properly measured if access to care is faulty. It will be very important to know who has been left out of the care system, and why.In Puerto Rico we also have a problem in obtaining information about patient care frominsurance companies. Although ASES states they are measuring access, MCOs report they are concentrating on the basic requirements put forward by NCQA. We do know, however, that while there has been a reduction of inpatient beds in the public sector, admissions to inpatient care have increased since the Reform. A critical, and unanswered question, is whether outpatient services have deteriorated leading to a higher rate of admissions to inpatient care. Inpatient admissions for drug dependent patients for detoxification services has also increased since Reform and there is evidence of what has been called a "boomerang phenomenon" in which privately insured patients are being sent back to ASSMCA when Reform benefits coverage is exhausted. It appears a government insurance card has lead to the increased utilization of services, especially inpatient care. Initially, mental health Reform was organized thorough carve-out MCOS in which patients with mental disorders did not have to go through primary care. Now Reform is planning to require a gatekeeper. Although patients are told they can use the government insurance card in any region, the healthcare insurance companies are different in each region and may not honor a card of a resident of another region. In addition, under Reform, the healthcare system has not attracted enough physician providers to meet patient needs. A sector of care that seems to have been especially ignored by health reform and legislation is that of the employers who purchase health insurance for their employees. Private health insurance companies are allocating 8-12% of premiums for mental health coverage while out of pocket costs have been estimated to be less than 1%. What services are being provided for this costly allocation? Without effective legislation and regulation to insure parity of benefits and services, large expenses are not likely to yield commensurate levels of patient care.
_ Question #3: Are there standards for the appropriateness of care in Puerto Rico?
This workgroup offered the following basic standards of care: 1. appropriate evaluation by competent psychiatrists 2. accurate diagnoses 3. confidentiality in the patient-doctor relationship 4. treatment according to established, evidence- based standards of care provided by well trained and appropriately credentialled psychiatrists 5. care rendered in the least restrictive treatment settings 6. a continuum of care These standards were identified as both basic and desirable but not consistently available in Puerto Rico. Instead, the following problems were identified. Mental health services typically do not provide the patient with continuity of care. Network providers are often not experienced or able to care for the seriously and persistently mentally ill. In certain locations, there are no services available. When effective services have been established, changes in government administration every four years has resulted in the discontinuation of good programs. Mental health care is not adequate because some people have no or very limited access, no ambulance services and cannot obtain necessary medications. Services for children are particularly deficient. There are no strategies or plans for public education about mental disorders and their treatment. Health Reform was rushed in and the expense of patients. Patients who had been chronically ill and under government programs before Reform now have inadequate treatment and lack appropriate rehabilitation services. The workgroup also noted that an important barrier to appropriate care was the lack of involvement of professional organizations in the development of services under Reform. Professional associations cannot assure good care but can be instrumental in determining whether care planned by the government or MCOs will meet necessary standards of care. In the rush in introduce Reform, physicians and physician organizations were not effectively engaged in a collegial manner._ Question #4: What services are available to special populations in Puerto Rico?
This workgroup asked what is unique about special populations? They noted that children and geriatric patients are at high risk for mental disorders, have very specific diagnostic and treatment needs, especially require continuity of care, and are highly dependent on others. These patient populations cannot tolerate managed care limitations such as on availability of specific medications. They also require high levels of communication among clinicians and other involved services and agencies; this communication has not been achieved under managed care contracts. Because these groups often have little political voice and power, greater advocacy efforts are needed with government agencies. Barriers identified in providing quality care to special populations include conflicts of interests. In addition, managed care (especially with risk based, capitated contracts) has created profound ethical dilemmas among clinicians as they struggle to balance economic incentives with medical ethics. The workgroup emphasized that effective credentialling of healthcare providers as well as the use of clinical guidelines will be as important as adequate reimbursement. Puerto Rico has an adequate number of child psychiatrists but they lack the clinical infrastructure needed to work effectively (e.g., therapeutic nurseries and residential treatment facilities). The group thought that both autistic children and demented patients are particularly underserved in Puerto Rico._ Question #5: What happens next after this Quality Summit?
This workgroup stressed the need a continuing dialogue on quality as well as improved relations among professional organizations. The workgroup stressed that the dialogue be among groups of psychiatrists as well as between psychiatrists and other mental health associations. It recommend an interdisciplinary dialogue through the creation of a new committee on interdisciplinary collaboration. Because so little has been done in the area of collaboration between psychiatrists and primary care practitioners, the workgroup urged that representatives of primary care be invited to the Psychiatric Convention that will be held in September of 1998. The group also stressed the need to improve upon working relations with government agencies. The APA Puerto Rico District Branch President-elect should be assigned to the interorganizational collaboration committee. Important work needs to be done among the three different organizations of psychiatrists in Puerto Rico. The Puerto Rico APA District Branch would greatly benefit from an executive director. It would be very valuable for this director to have special expertise or experience with governmental affairs and public relations to best meet the goals of the district branch. Collaborative work with organizations that represent nurses, pharmacists, social workers, psychologists, and occupational therapists should be a priority for the psychiatric district branch. Political advocacy efforts will be more likely to succeed when all disciplines speak with one voice. Furthermore, along the same line, the workgroup suggests the creation of an multidisciplinary political advisory committee or interdisciplinary coalition. Dr. Lister's summation: There is a need to make a more powerful impact on the Puerto Rico legislature; to obtain uniform data from insurance companies and managed care vendors; to assure that quality standards are met by attracting and focusing the attention of government agencies on mental health care on the island. Dr. Sederer's summation: Quality can be defined and its measurement operationalized. This Summit has demonstrated how a diverse but representative group can work together to begin to create clinical performance standards for the practice of behavioral health care in Puerto Rico. Because "Reading maketh a ready man, conference maketh a learned man, and writing maketh an exact man" (Francis Bacon), Dr. Sederer urged that this Summit proceed beyond "conference" to produce a written report that would be used to more exactly depict the work done today and to use that document to continue the important political and interdisciplinary work ahead._ CONCLUSIONS AND RECOMMENDATIONS
This report has attempted to summarize the Quality Summit. The following indicators were recommended to measure access and quality of care: 1) the number of people receiving care 2) frequency of visits 3) time intervals between visits 4) types of treatments provided 5) evidence that patients are provided information regarding diagnosis and treatment 6) evidence that the diagnosis rendered was appropriate to history and examination 7) evidence that treatment was appropriate to the diagnosis 8) evidence that care was provided in a cost effective manner The conference participants also recommended that future managed care contractual arrangements be written to require systematic and externally conducted evaluations of the quality of care rendered. In addition, parity and confidentiality legislation must be enacted if there is to be any assurance that mental health services will be adequate to the needs of the citizens of Puerto Rico. In order to assure that access is uniform throughout the island, information on indicators of acces must be provided in an open and timely way from ASSMCA and MCO's.The following indicators were recommended to measure appropriateness of care:
1) effective credentialling, based on licensure and training, of all professionals providing patient care 2) monitoring of hospital readmission rates 30 days post-discharge 3) a treatment standard of 50% of patients returning to a primary social role 4) peer review of 50% of active cases 5) prescribing privileges for medications is restricted to those with proper licensure and training 6) a standard of 0% be set for requiring the submission of a complete medical record for purposes of utilization review by insurance or managed care organizations 7) surveys of psychiatrists indicate that at least 80% believe they are able to offer the an optimal standard of care for their patients.The conference participants urged the maintenance of a continuous dialogue between clinical groups and managed care organizations which prior to this conference had not occurred on Puerto Rico. Furthermore, the Puerto Rican District Branch of the APA should be actively engaged in reviewing government service delivery plans for patient with mental disorders and in providing peer review for care offered through managed care contracts. In order to protect the doctor-patient confidentiality, legislation should be enacted that protects the privacy of this relationship. All care for major mental disorders should require that a psychiatrist oversees, supervises or actually provides the direct care to the patient. Finally, an adequate budget should be set and funded that will assure a universal and thorough education of citizens regarding the Health Reform and how to successfully obtain entitlement services. The participants also recommended the further development of consumer-advocacy groups. Enactment of the new Mental Health Law was strongly supported as was increased activity by the State Planning Council within ASSMCA. Regarding special populations, the conference participants urged the creation, by law, of an agency that would be charged with oversight of the managed care companies and government contracts with the MCOs. There is a particular need for reimbursement of patient care services beyond acute care, such as rehabilitation and services provided in schools. We need also need to measure and monitor longer term social outcomes for the functioning of children and the elderly who are served by the mental health sector. In order to assure that the voice of the mentally ill and disadvantaged is heard, there must be an agency that will provide oversight for the functioning of the system. This agency should report directly to the legislature or to the Insurance Commissioner to guarantee proper and consistent input in policy and budgetary matters.P> Today's discussion on quality should become a continuous dialogue on quality. Moreover, every effort should be made to improve relations among the professional organizations representing psychiatrists as well as between psychiatrists and other mental health associations. We are recommending an interdisciplinary dialogue through the creation of a new committee on interdisciplinary collaboration. Because so little has been done in the form of collaboration between psychiatrists and primary care practitioners, the latter group should be invited to the Psychiatric Convention in September 1998. We also need to improve upon and solidify relations between professional organizations and government agencies. The APA Puerto Rico President-elect should be assigned to lead the proposed inter-organizational collaboration committee. The Puerto Rico chapter of the APA would benefit from an executive director with government a public relations skills. The district branch must reach out to nurses, psychologists, pharmacists, social workers, occupational therapists and other mental health disciplines. The work of the organizations, collectively, would be greatly enhance by the creation of a committee that represented a coalition of interdisciplinary organizations.
_ Group I. Glorisa Canino, Erick Santos, Rosso, Margarita Alegria, Jorge Torres, Pilar Christian
Group II: Llado, Polo, Carlos Perez Cortes, Roberto J. Fumero, Rita Rodriguez , Myrna Segarra, Harold Figueroa, Enrique Vazquez Quintana, Marina Diaz, Irma Moreira, Felicita Cintron, Sr. Rebollo, Luz Medina.
Group III: Ramon Parrilla, Luis Canepa, Ileana Vazquez, Angela Diaz, Jose Luis Lopez, Ramon Ortiz
Group IV: Nuria Sabate, Varela, Olmo, Caro, Caban, Fransceschini, Lima, Huertas.
Group V: Galarza, Costas, Silvia Arias, Rosita Esteras, Jose Nunez Lopez, Luz Minerva Guevara, Maria Sanchez Bonilla.
CONSENSUS DEVELOPMENT PANEL Glorisa Canino
Director, Research Institute
Medical Sciences Campus
University of Puerto RicoErick Santos, M.D.
Chief Drug Dependence Treatment Program
VA Medical Center,
San Juan, Puerto RicoJorge Rosso
Consultant on Health to the Governor
Fortaleza
Government of Puerto RicoMargarita Alegria, PhD.
Researcher,
Medical Sciences Campus
University of Puerto RicoJorge Torres Administrator,
First Hospital Panamericano
Cidra, Puerto Rico,Pilar Christian
President,
Mental Health Planning Board
Mental Health and Anti Addiction Services Administration
Goverment of Puerto Rico
San Juan, Puerto RicoVictor Llado, M.D.
Private Practice of Psychiatry
Past President PR Psychiatric Society
San Juan, Puerto RicoDr. Polo, M. D.
Consultant to the Administrator
Mental Health and Anti Addiction Services Organization
Government of Puerto RicoCarlos Perez Cortes, M.D.
Private Practice of Psychiatry
President, Commitee on Psychotherapy
PR Psychiatric SocietyRoberto J. Fumero, M.D.
Caribbean Behavioral HealthCare
Trujillo Alto, Puerto RicoRita Rodriguez-Falciani ,Esq.
Consultant to ASSMCA
San Juan, Puerto RicoMyrna Segarra, M.D.
Training Director
Puerto Rico Institute of PsychiatryHarold Figueroa,
Private Practice
Former Consultant to ASSMCA Administrator
Guaynabo, Puerto RicoEnrique Vazquez Quintana,
President, Puerto Rico College of Physicians and Surgeons
Hato Rey, Puerto RicoMarina Diaz,
Consultant Options Inc.
San Juan, Puerto RicoIrma Moreira,
Director
Caribbean Behavioral Healthcare
San Juan, Puerto RicoFelicita Cintron,
Consultant
ASSMCA
San Juan, Puerto RicoSr. Rebollo,
Luz MedinaRamon Parrilla, M.D.
President, Puerto Rico Psychiatric Society
San Juan, Puerto RicoLuis Canepa, M.D.
Medical Director
Options Inc.
San Juan, Puerto RicoIleana Vazquez, M.D.
Private Practice
Treasurer, Puerto Rico Psychiatric Society
San Juan, Puerto RicoAngela Diaz, M.D.
Liaison Psychiatrist
VA Medical Center
San Juan, Puerto RicoJose Luis Lopez, M.D.
Psychiatric Resident
Puerto Rico Institute of Psychiatry
San Juan, Puerto RicoCarlos Perez Cortes, M.D.
Private Practice
Humacao, Puerto RicoRamon Ortiz
Patient Representative
Alianza Puertorriquena de Salud Mental
Ponce, Puerto RicoNuria Sabate, M..D.
Child and Adolescent Psychiatrist
Private Practice
San Juan, Puerto RicoAlberto Varela, M.D.
Private Practice
Inspira
Hato Rey, Puerto RicoNeftali Olmo, M.D.
Medical Director, CompCare
Hato Rey, Puerto RicoOsvaldo Caro, M.D.
Private Practice
Caguas, Puerto RicoCarlos Caban, M.D.
Past President PRPS
Private Practice
Condado, Puerto RicoJose Fransceschini
Private Practice
Bayamon, Puerto RicoJose Lima
Private Practice
San Juan, Puerto RicoSarah Huertas, M.D.
Private Practice of Child Psychiatry
President Elect
Puerto Rico Psychiatric SocietyHaydee Costa, M.D.
Private Practice of Forensic Psychiatry
Former President, PRPS
San Juan, Puerto RicoSilvia Arias, PhD
President, NAMI Puerto Rico
NAMI Board Member
San Juan, Puerto RicoRosita Esteras,
Executive Director
MEPSI Center
Bayamon, Puerto RicoJose Nunez Lopez,
Former Commissioner for Mental Health
Caguas, Puerto RicoLuz Minerva Guevara,
Chief, Department of Psychiatry
University of Puerto Rico
Medical Sciences CampusMaria Sanchez Bonilla
Private Practice of Geriatric Psychiatry
Hato Rey, Puerto Rico_ PLANNING COMMITTEE
Ramon Parrilla, M.D.
President, Puerto Rico Institute of Psychiatry
Medical Director
First Hospital Panamericano
Cidra, Puerto RicoCarlos Caban, M.D.
Past President, Puerto Rico Psychiatric Association
Private Practice
Condado, Puerto RicoCONFERENCE SPONSORS
American Psychiatric Association
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