Primary care settings are rich with all types of patients, diseases, diagnoses, celebrations, and providers. As defined by the Patient-Centered Primary Care Collaborative (PCPCC), "The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family” (http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home). The key question that I want to pose in this blog is "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”
I can think of countless times when the family (defined by the patient) has been the missing piece of the healthcare puzzle. The family was the one thing not accessed that helped put things into motion or helped providers realize why there was no motion. Family boundaries can be either enmeshed (no new members in or out), disengaged (no connection to one another), or permeable (new members allowed in and current members allowed out). This information is critical to providers because it may help make sense on why patients are not showing up for appointments, nor following treatment plans, or why some patients, conversely are model healthcare citizens. Of course, attending to the family and their unique dynamics is not the holy grail of medicine but neglecting the family may be another chasm interfering with the quality of care.
For example, a patient presented to his PCP with homicidal ideations. He was in constant pain, clinically depressed, and was waiting to hear whether his final appeal for social security disability was going to be accepted or denied. He scared his PCP with his voiced ideations, plan, and intent. At this point the PCP called in the Behavioral Health Provider (BHP) to collaborate. Both providers were quite convinced of the patient’s intent when he said that if he lost his appeal he was going to follow through with his suicidal plan. Taking necessary precautions the PCP and BHP collaborated and had the patient hospitalized. Surprisingly, the patient was voluntarily committed. Continuing their collaboration the PCP and BHP corresponded with the inpatient psychiatric unit attending to ensure that he had all the information needed and that duty to warn was enacted. The PCP and BHP knew that the patient would eventually be discharged and return to primary care for follow up.
One week later, he was back in their outpatient clinic and one week after that he was having ideations again. Quickly the integrated care team, with the BHP at the lead, contacted the patient’s spouse and brother. The PCP and BHP encouraged the patient to bring them into his therapy sessions. He complied and together they developed a plan for how the patient would be monitored for escalation of ideations. They were educated about his pain, diagnoses, pharmaceuticals, and psychotherapy plan. The family had been scared for years, watching his mental health decline, and did not know what to do. He had seen several psychiatrists and mental health providers, but he never attended more than a few sessions at each. This was the first time since he was injured 5 years ago that he continued with care and that anyone invited his family to be a part of his care. Without the family, the work of the integrated care team would not have resulted in successful management and care for this patient’s medical and mental health needs. Thankfully the patient is continuing to do well, as it has been over a year. Note: His social security disability was declined.
Researchers back the importance of the family role played in patient care and numerous therapeutic models exist for working with families. What we lack is strong policy and insurance incentives to make families a greater part of a patient’s care. We have more barriers than pathways (e.g., privacy laws, exam room size, appointment times, and lack of training). Families can be messy and very complicated but notwithstanding they are silent partners to any PCP/BHP team. They are there in the room with us whether we choose to see or talk to them. Most of the time, unbeknownst to us, they are either reinforcing or discouraging treatment plans. Most importantly, family members often feel like they have important information to share with us but have been told that we cannot hear it nor respond to it. While some may abuse this privilege, most just want to help and be helped.
Again I present to you the following question, "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”
Jennifer Hodgson, PhD, is a licensed Marriage and Family Therapist, Associate Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University, and President of CFHA. She has over 18 years clinical experience and has served on numerous boards and committees related to healthcare and mental health care issues. She is co-author to the first doctoral program in medical family therapy in the nation.