Jennifer Hodgson, PhD, Family Therapist East Carolina University  I was setting up an integrated care clinic in a family medicine residency setting in Florida. It took a while to earn the trust of the residents and faculty but even harder were the nurses. They were the gatekeepers...protectors of the providers and patients.

My students struggled getting exam room time to see patients. The providers wanted us to see their patients but the patients were processed so quickly. Then one day it hit me like a brick. We were hanging out in the precepting room joining with the providers but completely neglected joining with the nurses.

One day, a nurse was upset about something personal. We asked her if she way okay. She shared her struggle and we sat with her in her pain. The next week we had received a referral to see a patient. We were so excited. When the behavior health provider exited the room he saw a note stuck to the door, "Do not disturb. Therapy in Progress."The referrals started pouring in from that point forward. We were schooled. In our haste to join with the "physicians" we neglected the critical role of the nurses.

I cannot imagine integrated care now without them; except for now we prefer the note,
"Therapy in progress. Please disturb."

Norm Rasmussen, EdD, Psychologist Mayo Clinic  Recently I modified my integrated behavioral healthcare (IBH) approach for service delivery and teaching residents in my position as a Behavioral Healthcare Provider (BHP) in the family medicine department at Mayo Clinic. For 25 years, I used the co-located model of collaborative healthcare. My office was in the family medicine clinic, the collaboration was called the Psychology Preceptorship, and my office space was in general referred to affectionately as the "annex.” I was linked to and accepted by the family medicine staff and residents because they value collaborative care.

The recent change that I devised has been re-named as the Main Street Model of IBH. There are two important methodological differences between the prior approach and the new Main Street model. First, I now am physically in the office space where the resident physicians are located and I sit at the table where the medical preceptors reside – thus, I have migrated from the annex to main street! Second, I now have the potential to provide a significantly increased number of same day or virtually immediate IBH services such as curbstone consultation, resident physician-psychologist co-visits in the patient exam room, and "warm handoffs” from staff and resident physicians.

The first two weeks in implanting the Main Street model, I assumed the role of sitting at the medical preceptor table but remaining quiet and waiting for an invitation to be involved. Big mistake! I had assumed the resident physicians and medical preceptors would know how to involve me in this new model – all they had to do was ask! Indeed I was "invited” one or two times per a four hour block. This was not working as I had envisioned. Thus, I decided to move my chair into close physical proximity of the resident physician-medical preceptor discussion to form a triad. Immediately the requests tripled for either a curbstone consultation, warm handoff, or invitation to accompany the resident physician back to the exam room to either do a brief and focused IBH intervention for the resident to observe or to observe and train the resident doing an intervention that they were learning in the didactic work that I was doing with them. The message was clear: BHP proximity and visibility were critical but insufficient. In this new model, I needed to "move in closer” and reconfirm my role as the BHP on the healthcare team. Don’t expect family physicians to find you – rather find them and show your interest and enthusiasm in being a member of the collaborative healthcare team. As we all know, one can never be too experienced, not just early in one’s career, to make a mistake involving foresight or judgment.