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Moving from the "Unexpected Visitor" to the "Curbside Consult"

Posted By Cassidy Freitas, MA, MFTI, Tuesday, April 10, 2012
There is a knock at the door. An unexpected visitor has shown up at your doorstep and you already have guests. You are really wishing they would have called ahead of time, but alas, here they are. This unexpected visit is from someone who is important to you, a relationship that you would like to maintain. You are having an important and private conversation though with the guests you are already hosting, and must decide how to balance these two important relationships that are inconveniently colliding. Now imagine that your home is a primary care setting, the unexpected visitor is a physician in need of your consult, and your present guests are a couple you are seeing in therapy. In a nutshell, this has been a common experience for me as a "co-located” therapist. Let me provide a real life example.

My intake becomes quiet and exhales as he looks down at the tissue he has been nervously shredding into little bits and pieces. His body language changes and I sense him trying to formulate the words he is about to say when there is a knock. He tenses up as we both look at the door, and the moment for him to speak quickly fades away. I excuse myself as I open the door and see a look on my colleague's face that I know all to well. My colleague is a resident physician in our clinic, and the look on her face is "Help."

I turn back to my patient and explain to him that we are experiencing one of those special circumstances where I must make myself available. I step into my colleague’s office and she shares a quick summary of a patient she is currently treating, a new mom being seen with her husband who had become tearful during their visit and expressed some suicidal thoughts. My colleague is concerned and is hoping I can provide some consult on how to effectively and efficiently assess for postpartum mood disorders and this patient's safety. After some thought and a few brief assessment questions, I make the clinical decision to join my colleague in her visit with this patient. I am already feeling uncomfortable about leaving my patient at such a vulnerable moment, but in an effort to be collaborative, these are the clinical judgments that need to be made.

These interactions between behavioral health clinicians (BHCs) and physicians are an integral and special piece of collaborative care. I share the above scenario because it reflects the challenges I had faced in a "co-located” primary care setting. While Hunter and colleagues (2009) reinforce that physicians are more likely to use a BHC who is responsive and easily accessible, and that BHCs working within the primary care setting must make themselves available at all times, my above scenario is not the ideal.

Cassidy Freitas
Constructive, supportive, didactic, opportunistic, and at times inconvenient. For me, all of these words described my experience with the unexpected knock on my door.
 The beauty of co-location is that we as BHCs are available to physicians when needed, and that our presence contributes to the care of the whole person. Specifically, I believe that Medical Family Therapists are particularly well-suited for this position because our training emphasizes two content areas that are underdeveloped within many healthcare environments, 1) a systemic relational perspective of illness and the illness experience, and 2) the inclusion of the relational system around the patient.

While co-location is definitely heading in the right direction, it is clinically not the perfect scenario. At the UCSD Department of Family and Preventive Medicine we are moving in the direction of many other clinics by utilizinga system in which "floating” therapists are available to the physicians when these consults are desired. Our new clinic system, coined T-CARE, follows the mission of the Primary Care Behavioral Health model in that it provides educational and systemic changes that improve the primary care system’s ability to provide care (Robinson & Reiter, 2006).

Constructive, supportive, didactic, opportunistic, and at times inconvenient. For me, all of these words described my experience with the unexpected knock on my door. As a "co-located” BHC I was constantly doing what I could to balance the needs of my patients, the physicians, and the physician’s patients that were driving these unexpected consults. While our clinic moves from co-location to collaborative integration, I am becoming more aware of the marked distinctions that exist between these two models. The exchanges and consults that are so central to collaborative care are still occurring, but the unexpected visitor is no longer knocking on my door when the circumstance is clinically inopportune.

Above all, I believe that these exchanges have allowed me to build key relationships with the primary care staff in my clinic (convenient or not), and in the end, I wholeheartedly believe that these connections and interactions are at the heart of collaborative care.

Now I must ask, what has your experience been of the curbside consult? How do these interactions take place at your clinic? And have you ever had to make a tough clinical decision such as the one I described above?

 

References

Hunter, C.L., Goodie, J. L., Oordt, M.S., & Dobmeyer, A.C. (2009). Building an Integrated Primary Care Service. Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention (pp. 11-20). Washington, DC: American Psychological Association.

Robinson, P. & Reiter, J. (2006). A mission and a job description. In 1st edition, Behavioral consultation and primary care: A guide to integrating services (pp. 29-58). New York: Springer-Verlag.

 

Cassidy Freitas is an MFT Intern practicing at the UCSD Department of Family and Preventive Medicine. She is a recent graduate from the University of San Diego, and is in the process of pursuing MFT doctoral programs.

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Peter Y. Fifield says...
Posted Wednesday, April 11, 2012
Cassidy, This post is wonderful in how it sheds light on the love/hate relationship with this thing we call integrated care. I really enjoy the idea of having a "floating therapist" ready for warm welcomes and have been toying with that idea for a while now; still unsure on how to make it work in our non-academic, FQHC setting and have that position somewhat financially viable.

One thing we do that has taken some of the startle out of the interruption when a PCP is in need of a BHS is that we use a silent pager system where the PCP hits the page button and a pager [located on my hip] vibrates. This silent signal lets me know I'm needed [and by whom for the screen on the pager indicates what PCP paged me]. In this case the patient would be able to continue expressing that hard to come by emotions without the intrusive audible knock on the door. When the time "feels right" I can explain that I was paged and dismiss myself. I agree, the process in general is not ideal but this, for us, has been a very practical, inexpensive and easy to implement work-around that has reduced at least some of the offensiveness that comes with even a quite knock on the door.

Wonderful post, thank you for your contributions.
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