Posted By Montefiore BHIP Team,
Friday, December 12, 2014
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This is the second of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week!
Our pediatric practice, which is part of a large, urban medical center, recently experienced a collaborative care “triumph” that we truly believe would not have been possible without our model of integrated behavioral health. When Ms. Perez (all names have been changed to protect confidentiality), a 24-year-old Latina woman diagnosed with cerebral palsy and depression had her first child, Aiden, now age 3, she brought him to see Dr. Gee, who had also been her own pediatrician. Given Ms. Perez’s physical challenges, cognitive deficits, and psychosocial stressors, Dr. Gee referred the Perez family to the Healthy Steps program. Healthy Steps offers developmental and behavioral guidance and support to high risk families and children. Ms. Perez’s trust in Dr. Gee transferred to Dr. Stern, the Healthy Steps Specialist, who worked intensively to support Ms. Perez as she parented Aiden and then Aliyah, who was born approximately 16 months ago. Dr. Stern identified Aiden’s delayed development early. He was diagnosed with persistent developmental disorder, and Ms. Perez obtained Early Intervention support for Aiden. During Ms. Perez’s pregnancy with Aliyah, she became increasingly exhausted and overwhelmed, and struggled with her own mental health issues. Dr. Stern referred Ms. Perez to Ms. Gordon, a Healthy Steps Specialist who focuses on providing individual psychotherapy to the mothers/caregivers of the children in the program. Ms. Perez began attending weekly therapy sessions with Ms. Gordon, in the pediatric practice, as she prepared for the arrival of her second child.
|It was clear that her daughter’s health was only the first of numerous stressors |
After Aliyah’s arrival, Ms. Perez’s levels of depression and anxiety escalated. Aliyah was born prematurely and Ms. Perez was terrified that she, too, would have developmental issues. Aliyah needed frequent pediatric visits for a variety of respiratory issues, including hospitalization for RSV (Respiratory Syncytial Virus). Dr. Gee saw both children for frequent pediatric appointments, and Dr. Stern continued to provide Ms. Perez with parenting guidance (e.g., promoting healthy sleep, managing challenging behaviors, managing her feelings of anxiety and depression so as to be present to parent). Ms. Scott, the practice’s clinical social worker, also assisted Ms. Perez with concrete services (e.g., housing issues, homemaker application). Ms. Gordon continued to see Ms. Perez in individual psychotherapy, but felt that Ms. Perez would greatly benefit from psychotropic medication. Ms. Perez, however, was very resistant and felt that she was not in need of “pills.” Still, her symptoms worsened.
In mid-September, Ms. Perez presented to the clinic concerned about the health of Aliyah, who was congested and exhibiting increased respiratory effort. During check-in, a nurse who knows the mother very well noted that Ms. Perez was “not her usual bright self” and asked for assistance. Ms. Perez was introduced to Dr. Ray, the psychiatrist who had recently joined the Healthy Steps team. He also noticed that she was overwhelmed and tearful. He provided reassurance and support, highlighting the fact that despite her anxiety, she was making appropriate decisions caring for her sick child. The pediatrician recommended supportive care, Ms. Perez felt some relief, but it was clear that her daughter’s health was only the first of numerous stressors. Others included discord with her husband, avoidance of parents, and a sense of isolation. Dr. Stern joined the session with Dr. Ray, where Ms. Perez acknowledged passive suicidal ideation. Once safety was assessed, Dr. Stern highlighted the fact that the Healthy Steps team had been encouraging her to consider medication for some time. Given the acute nature of her distress, coupled with the fact that she had now established contact with a psychiatrist clearly trusted by the clinic team, she agreed to set up an appointment for a psychiatric evaluation the following week. At the end of the session, Aliyah’s condition worsened and could be quickly re-evaluated by the pediatrician and transferred seamlessly for inpatient admission.
Three days later, Ms. Perez returned to the clinic for both her psychiatric evaluation and her daughter’s post discharge follow up appointment. Due to our integrated services, the appointments could occur back to back. Ms. Perez expressed improved mood, but described multiple stressors leading to anxiety and depressed mood and agreed to a trial on an SSRI. Her time at the practice concluded with a brief meeting with Dr. Stern about sleep training and a meeting with Ms. Scott to construct a plan to allow her to access resources that could alleviate some financial stressors. Finally, Dr. Gee met with her and modeled ways to set limits with her child, as well as reinforced the importance of all of the plans created by the team.
Although it is too soon to know whether our efforts will benefit Ms. Perez and her children in the long term, it is clear that this family has been helped in a way that could only be achieved with collaborative care in an integrated setting. She has improved communication with her parents and husband and as a result has mobilized familial support to help her overcome significant financial, housing, and emotional stressors. She continues to take her medication and keep her appointments. As a result Ms. Perez continues to report improved emotional stability.
The Pediatric Behavioral Health Integration Program (BHIP) integrates universal mental health screening, assessment, treatment, consultation, and referral as needed within all Montefiore Medical Group sites serving pediatric patients. All BHIP team members are housed at the site, share the same EMR, and provide these services. Depending on the size and needs of the site, BHIP team members may include Healthy Steps Specialists (LCSWs or early childhood psychologists), child and adolescent psychologists and/or child and adolescent psychiatrists.
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