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Innovation as a Necessary Skill for the Integrated Primary Behavioral Health Provider

Posted By Joshua Bradley, Thursday, January 30, 2014

This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!


Innovation as Critical

Dr. Polaha recently highlighted the importance of innovation in primary care psychology and especially in newly integrated settings, which has been the case with my employer. Stone Mountain Health Services is a federally qualified health center with clinics in Southwest Virginia that has recently expanded the behavioral health program and currently has 6 licensed psychologists, 2 licensed social workers and a post-Master’s social worker, 2 pre-doctoral psychology interns, a psychiatric nurse practitioner, and a social work intern. Many of the primary care clinics have only recently become integrated, which has led to both exciting opportunities and challenges. As a further exciting, yet challenging development, at the site where I work, the medical providers, pharmacist, and myself are all early career professionals. One of the first hurdles that required innovation was finding ways to demonstrate that behavioral health providers can help patients with chronic health conditions. A second challenge has been addressing appointment and treatment adherence.

Increasing Chronic Health Condition Utilization

 

Although there is nothing innovative about interdisciplinary collaboration in integrated care settings, it soon became clear that there were tremendous opportunities to increase ways for different types of providers to work together in our clinic in new and creative ways. We knew that we had a large number of patients with diabetes so we developed a plan to increase behavioral health and pharmacy involvement in diabetes treatment. In fact, even the idea of "Diabetes Day” was a collaborative effort between myself, Olivia Bhutia, M.D., Natasha Gouge, Ph.D., and Crystal Kilgore, Pharm.D. During the winter of 2012, Dr. Kilgore mentioned the idea of collaborative treatment days, which led me to think about how this could decrease patient time with medical providers while simultaneously increasing quality of treatment. I began to think about how this might look in practice and talked to Dr. Bhutia about the idea.

 

I handed the project development to Dr. Gouge, who was then a predoctoral psychology intern at our site, and she ran with the idea and developed a comprehensive proposal for what would be called Diabetes Day. In short, Diabetes Day would occur once every two weeks on Wednesdays and would include one total hour of care, where patients would rotate among the medical provider, pharmacist, and behavioral health provider, depending upon provider availability. Each patient would spend 20 minutes with each provider addressing the various aspects of diabetes-related care. This plan would increase the number of patients medical providers could see because of the shared responsibility of patient care and could increase the amount of care each patient received because of the teamwork.

The Reality

We quickly learned that systematic change is difficult and requires significant flexibility
Well you know what they say about best laid plans. Getting the plan approved by administration was relatively easy. The administration was supportive and encouraged us to move forward. In fact, the Medical Director decided to implement a variation of the idea in her clinic. We discussed the plan with support staff and everything seemed to be in place for a successful and smooth transition. Unfortunately, we quickly learned that systematic change is difficult and requires significant flexibility. Everything from making changes to our scheduling templates to patient communication about how Diabetes Day appointments were different from standard medical appointments became challenges that had to be managed on an ongoing basis. The professional staff could clearly see the benefits of the service and many patients were extremely happy and often surprised that they were receiving such comprehensive care. Still, there were a few patients who complained about only having their diabetes-related care managed because they were used to having multiple medical conditions and prescriptions written at the same medical appointment. In addition, the change seemed most difficult for support staff and their struggles affected the treatment team members.

One largely overlooked problem was that we had underestimated the importance of having an office manager. Our site manager had left just before the implementation of Diabetes Day and the clinic was left without someone to troubleshoot the challenges we faced on an ongoing basis and who had the authority to handle the issues. Another unanticipated development was the fact that once patients had been to a Diabetes Day, they would not necessarily need to return for another Diabetes Day because patients often thought they received the additional information and care they needed to manage their condition in one Diabetes Day visit. Therefore, we began running out of patients and found that biweekly Diabetes Days would not be necessary to meet the needs of our patient population. As a result, we have decided to expand Diabetes Day to include other health conditions that would benefit from the collaborative care approach (e.g., hyperlipidemia, obesity, COPD) and change the frequency to once a month and call them "Wellness Days.”

Behavioral Health and Treatment Adherence

The next opportunity for innovation was addressing the problem of patients who repeatedly no-show. Because we are a federally qualified health center who serves people who are poor, our administration did not think that charging patients for missed appointments was the right thing to do. The administration also did not want to dismiss patients because of excessive no-shows out of fear that patients would have no other source for medical services. As a result, in collaboration with other treatment team members, I developed a "Treatment Investment Plan.” Basically, after a patient missed 3 appointments he or she would only be allowed to attend same day appointments until meeting with a behavioral health provider to talk about treatment adherence and the importance of attending appointments. Based on an examination of data in our electronic record system, it was clear that same day appointments were attended at a much higher rate than previously scheduled ones. From a financial perspective, decreasing no-show appointments by just 2 a day could increase revenue by approximately $80,000 a year.

The Reality

While a comprehensive proposal has been developed, there are technology related problems that appear to have slowed the approval of the Treatment Investment Plan. However, there are an increasing number of medical and behavioral health providers within the organization asking about ways to address the no-show problem and we hope to get our plan approved in the near future.

Learning and Growth

Below are a few of the important learning points for me during the period of transition to an integrated program:

  • The significant changes associated with integrating behavioral health services and the addition of diabetes day likely added to existing clinic stressors and co-workers may seek out the behavioral health provider. I found it important to set boundaries early on as co-workers may not understand our ethical limitations related to multiple relationships. While I cannot provide treatment services to co-workers I can be a friend and a supportive co-worker.
  • When making systemic changes in the way the clinic practiced it was important to include the whole clinic staff in feedback related to integration of behavioral health services. I found it useful to utilize a 360 degree evaluation that sought feedback and input from providers, nurses, front desk staff, and medical records personnel.
  • Ultimately, the greatest lesson for me was that models and plans don’t always hold true and that there is a vast space between what the textbooks say integrated primary care is supposed to look like and what actually works. In that space is the struggle and the learning necessary to become an integrated primary behavioral health provider.


Joshua Bradley earned his Psy.D. from Radford University in the summer of 2012 and was licensed as a psychologist in November of 2012. Joshua works for Stone Mountain Health Services and his home office is located in St. Paul, Virginia. The St. Paul clinic was recently recognized as a Level 3 Patient Centered Medical Home. He provides integrated primary care services and is the only psychologist in Russell County, Virginia. In August of 2013 he took on coordination duties for the East Tennessee/Southwest Virginia Predoctoral Psychology Internship Consortium. Joshua oversees the weekly didactic trainings and is the clinical supervisor for group supervision. His current clinical interests include sustainability in rural integrated primary care clinics where the context of clinical practice may necessitate a hybrid system of providing behavioral health services.

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