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Unlocking the Layers: Behavioral Health Integration with a High Utilizing Population

Posted By Audrey Martin, Wednesday, February 11, 2015


In my work with patients who are frequently hospitalized, I am often reminded of the process of peeling layers off of an onion. Patients are intricate people, with layer upon layer of life experiences often unseen by the health care system. Just as it takes time and patience to get to the needed layer of an onion, engaging the complex physical and behavioral health needs of a patient requires time and a supportive atmosphere so the patient can feel comfortable letting our team into their lives and layers. The Care Connections Clinic of Lancaster General Health is an interdisciplinary team approach to caring for high utilizing patients, as a transitional high intensity intervention that includes temporary assumption of primary care services.

Patients are selected for participation in the Care Connections Program based on data analysis of hospital utilization records or by recommendations from the larger healthcare community for patients that meet utilization criteria. Our team is made up of patient care navigators (LPN, EMT, or Paramedic), nurses, social workers, behavioral health clinicians, administrative leadership, CRNP, and physicians. Through our team approach we seek to foster relationships of trust and security in which the patient can let go of layers of masked behaviors, emotions, maladaptive thought patterns, and hidden psychosocial stressors which often contribute to poor health outcomes and frequent hospital utilization. The Care Connections Clinic models and continues to improve the integration of behavioral health as an equal partner in the interdisciplinary high-risk team. The following case study illustrates how this integration impacts patient care and outcomes.

Case Study

Mr. Worthington is a 40 year old Caucasian male, who joined the Care Connections program after the patients primary care physician noticed the patient had several hospital visits related to altered mental status and uncontrolled diabetes and sent a recommendation for the patients enrollment to the Care Connections team. The patients data related to hospitalizations was reviewed by the Care Connections team, and was found to meet criteria for the program.

His initial encounter with our team was scheduled urgently to address access to medications after hospital discharge because he didn’t have medical insurance. The patient came in with his wife. He was social and talkative, but had clearly impaired memory and cognitive function such that he could not give a reliable history. His wife was tearful and reported being completely overwhelmed caring for the patient with his cognitive impairment. The patient had brittle insulin-dependent diabetes and a history of long-standing prescription opiate use for chronic pain, but there was no clear etiology of his altered mental status.

He was social and talkative, but had clearly impaired memory and cognitive function


At his first visit in the office, the patient had a brief behavioral health evaluation by our Licensed Clinical Social Worker and was referred for neuropsychiatric testing. A few days later, the patient had a more extensive psychosocial intake evaluation with the same team member, which revealed inconsistency in the patient’s social history, raising concerns about possible psychiatric contributions to his overall clinical picture. A recommendation was made for psychiatric evaluation after the neuropsychiatric evaluation.

These consultant evaluations were delayed due to insurance access barriers and the patient had several more visits with our team focused primarily on other acute medical concerns such as dysphagia and weight loss and pain management. These issues seemed to stabilize and his cognitive function seemed to improve, but the patient became progressively more depressed. Behavioral health assessed the patient again and, at this follow-up visit, the patient’s spouse shared that he had a history of high risk behaviors such as overspending to the point of accruing overwhelming credit card debt, sleep disturbances, weight changes, and weeks at a time of “high moods” followed by weeks of “low moods.”

As the behavioral health provider and primary care doctor met to discuss findings, underlying bipolar disorder was strongly suspected and the patient was started on a mood stabilizing agent. The patient was monitored over the next few days, and it became apparent that he would require more intensive and immediate psychiatric monitoring for stabilization. With the team’s holistic medical and behavioral assessment, a case was made to the inpatient behavioral health team to admit the patient for stabilization. The Care Connections behavioral health provider was able to coordinate with the inpatient treatment team and participate in the patient’s family meeting on the inpatient unit. A clear plan for discharge was developed and the Care Connections team will continue to monitor the patient’s progress. Since receiving a clear explanation of the potential for a mood disorder, the patient and patient’s family now have a set of tools to help maintain overall behavioral wellness.

Today, the patient is stable enough to engage with our team in taking better care of his diabetes and addressing his chronic pain.  It is not yet completely clear if his altered mental status is the result of multiple medical issues, mood disorder symptoms, or a combination of both.  For our team, this case stands out as a victory for collaborative, interdisciplinary care.  In particular, the integration of behavioral health into the care team helped us peel away some of the layers of medical and psychosocial complexity in a way that brought clarity and prioritization to the care plan and moved this patient forward quickly in the direction of true wellness.

The patient and family now have a set of tools


Key Learnings

Here is what weve learned while developing an integrated behavioral health and physical health treatment team:-     Normalizing Behavioral Health Treatment and Minimizing Stigma: The behavioral health provider is an equal voice on the treatment team of physicians, nurse practitioners, case managers, a social service liaison, and patient care navigators.  The patients see the behavioral health provider, just like they would see any other member on the team. In doing so, the stigma often associated with behavioral health treatment is reduced and behavioral health concerns are treated collaboratively, similar to any other chronic disease.

-     Interdisciplinary Learning: A great value of a full-integration behavioral health model is the collaborative learning implicit in the daily interaction of team members from different disciplines. The behavioral health provider will learn from the other team members about physical ailments and their management. Likewise, the medical team can learn from the behavioral health provider skills such as motivational interviewing techniques and trauma-informed care practices that enhance their effectiveness in patient interactions.

-     A full view of the patient for promoting wellness : A team-based approach to patients that includes bio-psycho-social-spiritual assessments into the normal workflow of patient evaluation gives the care team a more comprehensive understanding of the patients life and situation.  This deeper understanding can prioritize or target interventions or recommendations for maximum effectiveness.

-     Flexibility in redefining workflow- The Care Connections program continues to evaluate and refine the process of screening and stratifying behavioral health needs into a standardized work flow. For example, not all patients may need an exhaustive behavioral health assessment done by a specialist on the team. We continue to work on developing front-line screening tools and criteria which trigger different levels of behavioral health intervention.


Overall, the Care Connections team has demonstrated the benefits of integrating behavioral health with physical health treatment for greater holistic care. The interdisciplinary team at Care Connections works in concert to promote a patient-centered, strength-based approach, encouraging greater patient security and enhanced engagement with the healthcare system. As the team takes time to meet the patient “where the patient is,” we begin to uncover layers of understanding previously hidden from the healthcare team.  Our goal is to help patients find health and healing in the deepest layers of their lives and become advocates for health and wellness for themselves and others.

**Please note, names and identifying information for this case study have been altered to protect patient confidentiality.


Audrey Martin, LCSW is the licensed clinical counselor at Lancaster General Health’s Care Connections Clinic. Audrey provides patient assessments and individual/family counseling surrounding adjustment to illness and psychosocial barriers to health at the Care Connections Clinic. Audrey was involved in the initial pilot program for high utilizing patients at LGH for 2 years prior to the development of the Care Connections Clinic in 2013.

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