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Beyond the elevator pitch: shifting from fact-sharing to storytelling to promote integration

Posted By Katie Snow, Monday, May 6, 2019

I think about elevator pitches a fair amount, maybe more than would be considered healthy.  I can’t help it. Every time I think I have finally explained the role of the mental health provider on the health care team to anyone who could possibly care, another person says, “I guess I still don’t really understand what you do.” So, after approximately the 1,000,000,000,000th time repeating something like this,

I am a licensed mental health provider and I work here in the clinic as a part of the health care team. I am here to help you address stress or mental health challenges that impact patient health. I am also here as a resource for you—to consult about psychosocially complex patients, to come into rooms to continue conversations with struggling patients so you can move onto the next patient and to be an expert on additional resources and next steps for these patients.”

I realized I needed a new approach.  Which was a bummer, because I really had the whole who/what/how fact delivery structure figured out.

It became obvious that for busy medical providers the facts of the standard elevator pitch were too easily lost in the daily blitz of patient care.  BHCs want to be brief and to the point when describing their role whether the intention is to orient new folks to integrated care, increase referrals or more fully engage hesitant providers. However, we risk under-engaging our key audience when we focus solely on listing facts, skipping over the work of emotionally engaging providers with our, and their, stories.

There is nothing inherently wrong with the above pitch.  It may even be a great starting point.  The statements are all accurate and easy to understand.  Unfortunately, it does not connect behavioral health care to that provider’s emotional context (anything from whether she got a good night’s sleep last night to her daily experience caring for her patients or simply her hopes for making it through that clinic day without running too behind).  It is eminently forgettable. We can walk away from an interaction like this having shared almost nothing with each other. The facts-only approach can keep an integrated care practice stuck in the early, low-referral volume, low-provider engagement phase indefinitely—a common frustration for BHCs wondering why they aren’t feeling like a part of the team.    In other words, emotion matters in learning, and the most effective way to connect with emotion is to engage in storytelling—adding a why to who, what and how.

I imagine many of you have sensed this in the course of your work and, like me, struggled to put it into words. A leadership learning collaborative put on by an organization called Primary Care Progress (PCP) helped me with this recently.  In the approximately 30 hours I spent last fall taking part in PCP’s Relational Leadership Institute (RLI) I found a new enthusiasm for engaging more deeply with providers’ stories and sharing my own, and recognized a reproducible framework for storytelling in the RLI concepts  “Story of Self” and “Story of Us”.  To summarize the Story of Self/Story of Us idea using wording from the course itself: “A good story is drawn from the series of choice points that structure the “plot” of your life: the challenges you faced, choices you made, and outcomes you experienced.”  To utilize this format when engaging with a provider I could say:

“In my career as a mental health provider before working in this clinic I noticed how disconnected my role felt from my clients’ physical health care even though I  knew it could be helpful to work more closely with their medical providers (challenge).  That’s one of the reasons I came to work here in this clinic (choice). That was really affirmed today when I saw how useful Cindy found her appointment with you—she told me she felt really valued when you took the time to listen to her and then made the effort to bring me in to figure out a plan.  It was incredible how ready she was to take next steps toward action to feel better by the time you brought me into the room (outcome).”

The words above still share who, what and how, albeit less explicitly.  However, they go farther and provide context (Cindy’s story) as well as an emotional connection (they, as a provider, were helpful to a patient that they care about) and a little of your story.  NOW, there is a face and feeling to associate with what you do that they are likely to carry with them and remember as they encounter similarly challenged patients and offer to engage you in their care. Over time, BHCs become collectors of these stories. Stories of witnessing meaningful, team-based healthcare in action that we can share (remember, providers don’t know what goes on once you go into the exam room or a follow up patient appointment unless you tell them—or write extremely vivid notes that someone actually reads).   As a part of integrated teams, siloed medical providers no longer exist and they have increased opportunities to see and hear their—our—impact reflected back to them.  Opportunities for connection, meaning and remembering.  This becomes the “story of us”, the challenges, choices and outcomes that are your team’s identity.

It doesn’t stop with the pitch--you can take this even further as you get to know providers’ personal stories; learning about what inspired them to pursue a career in healthcare and helping them link their why to the care you see and help them provide.  When the team recognizes that your presence can allow them to engage patients in meaningful and incredibly helpful ways that connect them back to their own values you will see your patient volume and job satisfaction increase.  At this point, you will know you have stepped into the realm of storytelling with your elevator pitch.

Katie Snow, LCSW is a Behavioral Health Consultant and Clinical Supervisor for Women’s Healthcare Associates, a group of OB/Gyn clinics in the Portland, Oregon metro area. Katie started out as a BHC in 2014, with 16 years of experience working in varied community mental health settings and 0 years’ experience working in integrated care. That number would have stayed at 0 without the incredible support of the LifeWorks Northwest Integrated Medical Services team and the genuine trust and support of the staff and providers of Women’s Healthcare Associates.

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In Search of the Briefest Family Caregiver Eval

Posted By Barry J. Jacobs, Tuesday, April 23, 2019

As befits his majestic name, Brian Duke threw down the gauntlet.

 

“If you really want to help health systems do a better job of supporting family caregivers,” said the former Secretary of the Pennsylvania Department of Aging and the current System Director of Senior Services for Main Line Health in suburban Philadelphia, “then you better come up with a very short assessment tool. Three or four questions, tops.”

 

Three or four questions? To capture the complexity of caregiving family relationships? I knew that the 2006 National Consensus Report on Family Caregiver Assessment called for 7 domains of comprehensive caregiver assessment: context; caregiver’s perceptions of care receiver’s health; caregiver’s values; well-being of caregiver; skills needed to provide care; and potential resources. (See https://www.caregiver.org/national-consensus-report-caregiver-assessment-volumes-1-2)

 

But, as if anticipating my argument, Duke added, “How can I ask primary care providers to add a lengthy caregiver assessment tool to the list of 30 or so other health assessments that they’re expected to conduct?”

 

I’d worked in family medicine for 24 years and understood his point. Primary care providers are overwhelmed with competing priorities for patients, let alone their family members. Identifying a few useful screening questions and then convincing those providers to incorporate them into their routine line of questions would be monumental tasks.

 

“Let me see what I can do,” I replied to Duke, accepting his challenge. “I’ll get back to you.”

*                                    *                                        *

From the earliest days of the subspecialty of family medicine, there was an aspirational goal of understanding patients in the sociocultural contexts of their families. In 1978, family physician Gabriel Smilkstein developed the Family APGAR, a 5-question assessment of adaptability, partnership, growth, affection and resolve intended to help primary care clinicians quickly determine whether patients’ families were “Highly Functional,” “Moderately Dysfunctional” or “Dysfunctional.” The instrument never had strong psychometric evidence or widespread clinical use outside of academic circles and has been mostly forgotten in the annals of the field. However, a 2016 Japanese study breathed new life into the Family APGAR when it found that one of its questions has real utility: “Applying the simple Resolve item—'Are you satisfied with the way you and your family share time together?’--might be the most efficient way to assess whether patients have family issues” (Takenaka & Ban, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858843/)

 

 Among researchers in family caregiving and at local Area Agencies of Aging (AAAs) around the country, the most commonly used assessment of family caregivers has long been the Zarit Caregiver Burden Scale. Unlike the broad-based Family APGAR, it is narrowly focused on a family member’s degree of “burden” or stress handling caregiving duties. Originally published in a 22-item form, its creator Steven Zarit realized early on that it would have to be available in shorter formats to be adopted by healthcare practitioners and he devised 12-, 6- and 4-item versions. While the 12-item form is frequently used by AAAs, the penetration into healthcare of any of its versions has been limited to geriatrician’s practices and a few specialty and palliative care programs.

 

In a December 2018 article, Liew and Yap claim to have devised a reliable and valid 3-item screener of dementia caregiver burden on the basis of a factor analysis of Zarit’s 12-item form (https://www.jamda.com/article/S1525-8610(18)30637-6/fulltext#appsec1). The three items are:

+ Are you afraid what the future holds for your relative?

+ Do you feel your health has suffered because of your involvement with your relative?

+Do you feel you have lost control of your life since your relative's illness?

 

According to the authors, “this study has procured a highly accessible tool to screen for caregiver burden, which can have a wider health system effect of expanding the reach of caregiver-focused interventions to clinical and social services.” But it was validated on a small number of dementia caregivers (n=179) on the island of Singapore and has yet to be tested in American healthcare settings.

 

Would Brian Duke be satisfied with these suggestions? He is an exacting man who would demand screening questions of greater evidence and track record.

 

I turned to my friend and family caregiver researcher guru Bill Haley of the University of South Florida for suggestions about the ideal family caregiver screener in healthcare settings. He at first recommended the Preparedness for Caregiving Scale (8 items). But when I pressed him for something shorter, he quickly pointed me to the single question used in the most famous family caregiver study of all time--the 1999 Journal of the American Medical Association article by Richard Schulz and Scott Beach on the relationship between caregiver strain and mortality:

+ How much of a mental or emotional strain is it on you to either provide the help directly, or to arrange for help to be provided for this activity?

 

Haley said this question has high reliability and validity for identifying caregivers who are highly stressed and at significant risk for depression. That would certainly be a good start for risk stratifying patients’ family members who require a more comprehensive evaluation and more intensive support services.

*                                  *                                  *

            I’m still on my search. There is more and newer research to review, more questions to consider, more old friends’ expertise to tap. We need quick and efficient ways of assessing family caregivers to better address their needs and improve the clinical outcomes of their loved ones with chronic illnesses and functional deficits. Brian Duke and American healthcare are waiting.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and Principal at Health Management Associates, a national healthcare consulting firm. He is the author of The Emotional Survival Guide for Caregivers (2006) and co-author of AARP Meditations for Caregivers (2016).

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The Art and Science of Measuring Integration

Posted By Matthew P. Martin, Thursday, April 4, 2019

What do the US, Myanmar, and Liberia all have in common? They are the only countries in the world who do not commonly use the metric system of measurement. Instead of kilos, liters, and meters, we measure in pounds, gallons, and yards (i.e., the English system). No big deal, right? Well, consider that in May 1999 the $123 million Mars Climate Orbiter was lost when it veered off course and burned up in the Martian atmosphere. A week later, NASA revealed the cause: One part of the orbiter’s navigation system was speaking in English units and another in metric. The lesson seems clear: use wisdom when choosing a measuring stick.

 

In the fields of science and medicine, we have an objective measurement system based on a universal physical constant (speed of light). In the field of integrated health care delivery, there is no objective system of measurement, no gold standard to follow. All of the measuring tools we use today are rooted in certain values and beliefs about what makes integrated care work. They are the products of fallible humans striving to do the best they can with what they have. Yes, some of these beliefs are supported by evidence or widely practiced; but none of them can lay claim to be the only road to Rome.

 

That said, how do you measure integration? What stick(s) are in your tool bag for evaluating your integrated care service? There are several benefits for implementing a regular system of collecting and analyzing data points that reflect upon your service. First, that data can indicate successes and gaps in your service. Are you reaching enough patients? Do all the medical providers participate in your service? Second, you can demonstrate value to stakeholders (e.g., funders, payers, decision-makers). Are you seeking a grant? Data from your measurement system will strengthen your position. Third, data can reveal the individual performance of clinicians and staff. Are you a manager or supervisor? What data do you need to evaluate your subordinates? Fourth, you can advance the science of integration by measuring your service and reporting your results.

 

If you’re like most of us in this field, then research and evaluation training is something you have had to pick up along the way in your career. I have learned that developing a culture of quality improvement in your clinic really helps to generate energy and support for measuring an integrated care service. Seek out champions among your colleagues who are also interested in data collection and analysis. Also, find ways to make your measurement a regular part of the clinic workflow. Identify data points that you are already collecting and then imagine new ones that want to collect in the future. Finally, remember that you cannot measure everything and not everything should be measured. Start small with your plan, stick with it, and grow over time.

 

What should you measure? I recommend using the RE-AIM framework to guide your decision-making process on data points. For example, if you want to know if your integrated care service is reaching the target patient population, then you may want to count the number of patients screened, the number of positive screenings, and the number who needed treatment actually receiving that treatment. If you want to determine the effectiveness of your service, then consider measuring patient outcomes like symptom reduction (e.g., PHQ-9, GAD-7), functional improvement, quality of life, and care utilization (e.g., number of visits, hospital admissions). If you want to measure how often your medical providers are engaging in the integrated care model, then look at measuring the number of same-day referrals (e.g., warm handoffs), formal referrals, the number of clinicians who referred last month, and the number of team huddles or meetings with a behavioral health provider. There are many other operational and financial data points you can measure.

 

Remember to be judicious and pragmatic when choosing the right data points for your organization. Once you start analyzing your data, look for care gaps and prioritize the gaps that are most important for addressing first. Once you choose the most important gaps, then describe how clinical practice will change using tools like a process map. Then, engage your team in making the change and continuing your measurement plan. At that point, you can repeat the cycle over and over. Your measurement plan will likely change over time, especially as new policies and practices emerge. But you and your team will be ready to craft new sticks for new metrics.

 

Reference

Gold, S. B., & Green, L. A. (Eds.). (2018). Integrated Behavioral Health in Primary Care: Your Patients Are Waiting. Springer. 

Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. Dr. Martin conducts research on integrated care measurement, medical workforce development, and population health strategies in primary care. He serves as the Director of the ASU Project ECHO hub for behavioral health didactic training and teleconsultation. 

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Research Review: The Latest and Greatest

Posted By Matthew P. Martin, Tuesday, March 26, 2019

Welcome to the March 2019 research review, where I review some of the latest research findings and developments in the field of integrated behavioral health. Per usual, I include links to the articles in the headings and then snippets from the abstract below the heading.

As integration becomes more of the norm and less the exception, researchers are investigating model of integration in different arenas and for different populations. For example, two studies in this month’s review looked at integration of services for patients with debilitating conditions like co-morbid mental health and somatic disorder and dementia. I am also seeing more development and information on the practice of integration in community mental health settings, sometimes referred to as bi-directional integration. As is often the case, clinical practice outpaces research and evaluation as care delivery systems create and test new solutions for giving patients the care that they need. Researchers can learn a lot by joining with providers who are working at the leading edge of clinical practice.

 

One final highlight I leave you is the new ambitious framework for state-wide integration of Medi-Cal services in the great state of California. Although not a research study, I include it here because the plan includes major policy recommendations to reach state-wide integration by 2025, including the incorporation of value-based payments into the financing of behavioral health services. Although it remains to be seen whether it becomes adopted by decision-makers in the Golden State, the framework certainly offers much to consider.    

 

IMPLEMENTATION SCIENCE

Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care

 

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

 

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

 

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

 

Augmenting Mental Health in Primary Care: A One-Year Study of Deploying Smartphone Apps in a Multi-Site Primary Care / Behavioral Health Integration Program

 

The objectives of this study were to a) test the feasibility of using mental health applications to augment integrated primary care services; b) solicit feedback from patients and providers to guide implementation, and c) develop a mental health apps toolkit for system-wide dissemination. Our findings indicate mental health apps are applicable and relevant to patients within integrated primary care settings in safety-net health systems. Behavioral health providers perceive the clinical value of using these tools as part of patient care, but require training to increase their comfort-level and confidence applying these tools with patients. To increase provider and patient engagement, mobile apps must be accessible, simple, intuitive and directly relevant to patients’ treatment needs.

 

CLINICAL PRACTICE

Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review

 

Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.

 

Evolving Models of Integrated Behavioral Health and Primary Care

 

Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care.

 

A pilot study of an integrated mental health, social and medical model for diabetes care in an inner‐city setting: Three Dimensions for Diabetes (3DFD)

 

Using a non‐randomized control design, the 3DFD model was offered in two inner‐city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes.

3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [−14 mmol/mol (−1.3%) vs. −6 mmol/mol (−0.6%) respectively, P < 0.001], adjusted for confounding. Total follow‐up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost‐effectiveness ratio was £398 per mmol/mol unit decrease in HbA1c, indicating the 3DFD intervention was more effective and costed more than usual care.

 

Integrated care for adults with dementia and other cognitive disorders

 

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.

 

POLICY

Advancing integrated care in England

Implementing integrated care models requires providers to develop new capabilities, which is challenging with resource constraints and often conflicting policy priorities. Given the current funding and legislative context for the NHS, we assessed effective and practical paths to accelerate the adoption of better integrated, higher-value care. We sought to identify feasible modifications in the NHS’ policies and feasible steps for NHS providers to take based on growing experiences in England and globally with integrated care.

 

Behavioral Health Integration in Medi-Cal: A Blueprint for California

 

This paper puts forth an ambitious framework to transform a fragmented system in California in which Medi-Cal enrollees with complex behavioral and physical health needs often fail to receive needed care that must be coordinated across multiple and disparate service delivery systems. This framework builds on areas of strength within the current structures while addressing the systemic barriers to improving care due to the current organization, financing, and administration of physical health care, mental health care, and SUD care in Medi-Cal.

 

WORKFORCE DEVELOPMENT

As a Pediatrician, I Don’t Know the Second, Third, or Fourth Thing to Do: A Qualitative Study of Pediatric Residents’ Training and Experiences in Behavioral Health

 

Despite a mandated 1-month rotation in developmental-behavioral pediatrics (DBP), pediatric residents report inadequate training in behavioral health care. As a first step in much needed curriculum development in this area, this study sought to assess learner experiences regarding the management of behavioral health problems during residency. Four focus groups were conducted for residents in years 1-3 of training in 2 residency programs in a northeastern state. Transcripts were analyzed and coded by researchers through qualitative classical content analysis. The exploratory analysis revealed 9 key themes: time requirements, rapport building, resources and referrals for behavioral health, psychiatric medications, diagnosis vs. treatment, working with families, the importance of behavioral health, fears of working with a pediatric population, and training issues. These qualitative data further identify gaps in the behavioral health training of pediatric residents and may inform future innovations in training curricula.

 

Ethical considerations for behavioral health professionals in primary care settings.

 

In general, psychology training has been slow to adapt to a changing market and systems. Many of the most common dilemmas encountered in primary care are actually reflective of "cultural" and professional differences between medical and psychological service provision ethics and tradition. Therefore, the commentary we provide may not point the reader to one clear, irrefutable solution to a problem or dilemma; in fact, there are surely many more than we can outline here. However, we share a recommended framework for working through ethical dilemmas in integrated primary care (IPC). (PsycINFO Database Record (c) 2018 APA, all rights reserved)

 

Evidence Brief: Use of Patient Reported Outcome Measures for Measurement-Based Care in Mental Health Shared Decision-Making

 

An evidence brief on measurement based care (MBC) practices in mental health care, specifically in the context of using standardized patient-reported outcome measures in shared decision-making with individual Veterans. Findings from this evidence brief will be used to inform guidance for MBC within the VHA. This rapid review found no studies of the specific VA-recommended approach of using any of 4 recommended patient-reported outcome measures (PROMs) for implementing measurement-based care (MBC) in the context of shared decision-making in mental health. However, we identified other promising approaches to use of PROMs for MBC in mental health.

 

DISSEMINATION

Availability of Integrated Primary Care Services in Community Mental Health Care Settings

 

This study examined the availability of primary care and wellness services in community mental health centers (CMHCs) and outpatient mental health facilities (OMHFs). We used data from the 2016 National Mental Health Services Survey to examine the proportion of facilities that reported offering integrated primary care and wellness services (smoking and tobacco cessation counseling, diet and exercise counseling, and chronic disease and illness management). The study used logistic regression to model the odds that a facility offered integrated primary care as a function of facility characteristics. Across states, 23% of CMHCs and 19% of OMHFs offered integrated primary care. The odds of offering integrated primary care were significantly higher among facilities that reported more quality improvement practices, prohibited smoking, or offered wellness services. Less than one third offered smoking and tobacco cessation counseling or other wellness services. Integrated primary care remains uncommon in CMHCs and OMHFs and is more likely among facilities with certain characteristics.

Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. Dr. Martin conducts research on integrated care measurement, medical workforce development, and population health strategies in primary care. He serves as the Director of the ASU Project ECHO hub for behavioral health didactic training and teleconsultation. 

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How Far Can Integration Go?

Posted By Joan Fleishman, Tuesday, March 19, 2019

 

I walk through an empty cobblestone plaza, once bustling with vendors,  the infectious smell of al pastor tacos, and fresh leather sandals. This plaza has been vacant since the period of time in the early 2000s when Tijuana became violent, even dangerous, and Americans didn’t visit.

I climb the snaking stairwells and tunnels leading me across the border, splashed with worn graffiti in two languages. It was as if these walls themselves were pleading for salvation and cursing the division of these two worlds. As I walk, I join the 90,000 people crossing this land border each day, making it one of the busiest in the world.

I don’t know what to expect from today. I’m joining Boarder Dreamers, a grassroots group of medical providers, to provide a mobile medical clinic to migrants at the shelters. Current US policies restrict access to asylum and slow migration, which leaves many people trapped in uncertainty in border towns like Tijuana.

***

First Stop: Enclave Carocol

We gather in the back of the soup kitchen turned clinic. We are a motley crew of medical providers and students, behavioral health providers, nurses, and legal advocates. Our mission today: Assess and address the biopsychosocial needs of migrants from Central and South America at the shelters and camps we will visit. They are awaiting their number to be called to begin the asylum process.

The clinic in Enclave is sparse. Light shines down from an exposed bulb hanging from the ceiling.  There are two corners of the large open room where colorful, old bed sheets are hung to create exam rooms. There is a 1970s exam table and shelves full of medical equipment. A bowl of shiny red apples and a 5-gallon water jug sit on a bare table. Hanging crookedly on the water jug a sign reads, “potable”.

We step back outside into the sun and brisk January air. We organize into small teams.  The behavioral health team, made up of myself, another psychologist, and two social workers, are going with the physician assistants and their students. They are equipped with a large duffle bag of medications and supplies. The students are in scrubs and around their necks hang polished stethoscopes. Their eyes are bright and wide.

***

 Second Stop: El Templo aka Little Haiti

Our Uber driver doesn’t actually take us to the Templo. The road is completely washed out and we walk the last ¼ mile on foot. The “road” looks more like a landfill, and what is later explained to us is that the residents throw their trash where the road used to be to help when the road washes out. Ah…yes, of course! Why didn’t I know that?! We walk up this “road”, flanked by horses, chickens, and the largest pigs I have ever seen (which is saying A LOT because I grew up on a farm).  There is wood smoke and Ranchera music in the air.  We are definitely in Mexico.

We see 63 patients at the Templo. Old and young. Haitians who left Haiti by boat after the earthquake and have spent the last few years living in Venezuela and Chile. They tell us they started their journey 5 weeks ago, on foot, to Tijuana. They have only been there a few days.

The medical providers treat scabies and lice, foot sores, and abscesses. They do pregnancy tests and hand out calamine lotion. But what is clear, is that they cannot treat everything our patients are struggling with. Hanging in the air, there is a weariness, an exhaustion, and a vigilance. We see it in their eyes. And we feel it in our hearts.

The statistics of immigration into North America are astonishing.  It is estimated that 500,000 people make the journey to Mexico every year. Many don’t make it. There is a high incidence of violence and sexual assault.  We listen as a mother and her 10-year-old son recount a night on their journey where they witnessed a horrifying event. The exposure to trauma is a given on this journey.

The behavioral health professionals gather. What can we do for these people, these families who have traveled so far, and have experienced unspeakable things? How can we help?  Their journey is not yet over. We ask ourselves, “What does mental health first aid in a migrant shelter look like?”

A few of us lead an art project for the children who are eager to use the colored pencils we brought and learn a few words in English. They are happy to draw and talk and laugh. They ask us questions and draw pictures of worlds in their imagination. We offer any child who wants to talk with one of us about their picture a few minutes of undivided attention.

The rest of us, with the help of our Haitian-Creole translator, facilitate a “charla” (a chat) for the men at the shelter. We discuss anxiety and depression. We normalize the anger and powerlessness.  We discuss the fear they have about the asylum process. For some they fear being separated from their wives and children. Those who don’t have a wife or children they fear they will not be granted a number, which would allow them to be called for a Credible Fear interview, the first step in seeking asylum in the US. The men agree, all they want is to work, to provide for their families, and keep their children safe. Lastly, we talk about resiliency, which of all the people I have met in my humanitarian work, these men truly embody.

***

 Third Stop: YMCA Youth Shelter

We arrive at the shelter housing unaccompanied minors. There are roughly 25 teens here. Some have been here for months. There is no formal asylum process for unaccompanied minors and they are often at the border for many months before they can cross. Today they are eager to be seen by the doctors.

I am setting up the table for the mental health consults and I start to realize that the way this clinic has been functioning behavioral health and physical health have been viewed as separate. We are asked to set up in separate spaces and do separate things. But I want to do something different. I suggest that the physician, who came with us to the youth shelter, and I see patients together. She is agreeable. So, as the nurse triages the patients, the physician and I set up three chairs in a triangle.

At first, it’s clunky. Who interviews the patient first? When does the physical exam happen? With our limited time and attention to urgent needs, what is most important to ask about or address? The teens have various physical complaints; stomach aches, tooth aches, swollen glands. A 15-year-old is 3 months pregnant. She has had no prenatal care, no prenatal vitamins. No one is sleeping well, a few are having panic attacks, one expresses passive suicidal ideation.

It becomes clear that most of what they are experiencing are reactions to stress, trauma, separation; the psychological toll of migration. We can only offer a kernel of what they truly need, but what we can offer is an opportunity to be heard, to be cared for, to have someone to talk to, tell their story to, and acknowledge their journey.

The sun is beginning to get lower in the sky and I know we need to speed things up. Instead of me seeing all the patients I suggest we try using a Warm Hand Off when the physician thinks the patient would benefit from talking to a behavioral health provider. This works well and is more efficient. She comes and gets one of us on the BH team, introduces us and explains why she thinks it would be a good idea if the patient chatted with us for a bit and then she moves on to her next patient.

In that moment, as we lose daylight and the chill returns to the air, the team gains something, a game changer. They discover how even in a mobile clinic in Tijuana, at a shelter for unaccompanied minors, integration of behavioral and physical health makes sense, saves time, and better meets the patients’ needs.

***

 As I walk back over the border on the worn sidewalks, through the metal detectors, and past the empty plaza, my teammates are a buzz with how we worked together today at the YMCA Youth Shelter and this new model of care. They are excited to try out integrating physical and behavioral health services at other shelters next weekend. They are eager to use Warm Hand Offs to introduce behavioral health to patients they know would benefit from talking with one of us.

Tonight I realize that integration has no borders.  The utility and value of an integrated model of healthcare is not confined inside the clinic walls, but can be deployed anywhere that multidisciplinary teams exist.

So, I really only have one question for you. Where will you take integration next?

Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.

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Integrated Behavioral Health in Ob/Gyn Clinics: Is there anyone else out there?

Posted By Katie Snow, Thursday, March 7, 2019

Join the CFHA Women’s Health Call

Thursday, March 14 at 1:00 pm PST/4 pm EST

One of the first things I noticed when starting out as a BHC in an obstetrics/gynecology clinic was that every template or model for integrated care focused on primary care as the setting for behavioral health integration.   Although much of that information is adaptable to ob/gyn care, the value of a community of behavioral health professionals working in ob/gyn has become apparent to me. The goals of this community would be to share ideas and to develop effective targeted interventions for issues that are unique to women’s healthcare.   

Please join the CFHA Women’s Health call on Thursday, March 14 at 1 pm PST/4 pm EST to discuss how we can pool our knowledge related to behavioral health care related to ob/gyn issues.  There are myriad opportunities for intervention. I will highlight a few here and encourage you to join in our conversation. https://www.cfha.net/events/EventDetails.aspx?id=1201796

 

Perinatal Mood Disorders: Intervention and Prevention

BHCs can play a role in identification and outreach to at-risk perinatal patients: deploying both brief interventions and skillful referrals with benefits to families, providers and payers. BHCs and medical providers frequently receive feedback from women indicating that they would have been unlikely to seek out care for a perinatal mood issue, even a severe one.  Patients tell us that they agreed to a warm handoff or behavioral health appointment out of trust for their ob/gyn provider, and because the care was quick, available onsite, and came with minimal barriers. As a result of earlier intervention, symptoms tend to resolve more quickly.

By sharing ideas and documenting results, we could increase the use of early intervention with potential for real impact with this population.

 

Miscarriage, pregnancy termination, stillbirth, neonatal death and infertility

Being in the right place at the right time is especially important in the many situations involving loss and grief in Ob/Gyn care.   There is a look of surprised relief in many patients’ eyes when I come in for a warm handoff after they have discussed or learned of adverse pregnancy findings or are in the throes of decision making with their medical provider.   BHCs provide space, time and expertise to process these experiences as they occur, in the initial period after a loss or while navigating the uncertainty of a high-risk pregnancy. We are able to provide a gentle touchpoint in the direction of self-care during the immediate crisis as well as monitoring for common complications of this type of grief such as insomnia, isolation, guilt, loss of self-efficacy, hypervigilance, suicidal ideation and ruminative self-doubt. Those with multiple losses or pre-existing mental health challenges may ultimately find a relationship with an ongoing mental health provider most beneficial but I rarely hear from a patient that they feel our time together was wasted.  

Exchanging information on this topic could offer us new ways to help our patients cope at this difficult time.

 

Perimenopause and menopause:

Symptoms of perimenopause and menopause such as weight gain, low libido, insomnia, vasomotor symptoms and depression may result in a referral to behavioral health. The factors contributing to these symptoms tend to be complex: many patients are in their most productive working years, are raising children or teenagers, caring for aging parents, adjusting to an empty nest, contemplating or experiencing divorce or recognizing that they are no longer willing to live within certain societal constraints that they had previously accepted.  Some women use alcohol or marijuana to cope, and need support to decrease or cease use. Some are ready to dive into an ongoing therapeutic relationship and just need help connecting to that care. Others have ventured far enough from their comfort zone just meeting with me in the clinic but are open to ideas about how to improve their quality of life and functioning. Because many patients have a good amount of insight by this point in their lives, they readily soak in some of the “nuggets” offered in brief visits and are often eager to take next steps on their own or with a limited number of follow up visits.

By pooling our knowledge and experience in this area, we can provide additional resources for this group of patients.

 

Pain—menstrual, sexual, chronic pelvic and more

Supporting patients related to their experiences with pain is, of course, a mainstay of integrated behavioral health practices.  When working specifically with female reproductive organ and pelvic pain, there are some additional factors to consider:

There exists a long history of dismissing women’s pain or attributing it to women being excessively dramatic. At the point I meet them, most patients feel that their concerns are being taken seriously by their gynecologist, though it may have taken months or years to be referred there. By some estimates, the average time from initial complaint to a diagnosis of endometriosis is 8 years.  I try to keep this in the forefront of my mind as I assess for and provide education about the role of trauma, depression and lifestyle factors that can contribute to a worsening experience of pain. My hope is to not dismiss or diminish concerns but rather shine a light on the constellation of interventions that tend to improve symptoms.

Many women also struggle with shame and internalization of distressing issues such as painful sexual activity and severe pelvic pain, particularly if a diagnosis has not yet been given to explain these symptoms.   In these situations, patients may feel understandably overwhelmed by too much direct questioning and require an especially sensitive approach – i.e. we need to slow down sometimes! Behavioral health can play a key role of support between or in conjunction with medical provider visits to learn coping strategies, obtain support or connect to ongoing mental health care as helping women address some long-avoided topics.  

What other ideas do you have about supporting women experiencing these challenges?

 

How can we improve the care we provide?

Women discuss a wide variety of issues with their ob/gyn. Many of these are ideal for a warm handoff to a BHC in order to continue the conversation and to provide support and intervention. There will never be a one-size fits all approach to any issue we see in behavioral health. However, for issues like diabetes, hypertension, tobacco use and even depression, we recognize the impact on well-being, can measure severity and evaluate progress, and have a toolbox of evidence-based interventions to use to help.  

The benefit of a community of practice focused on women’s health would be to push forward an evidence-based approach to the areas discussed above.

Join in to talk about needs you see or anticipate in your setting. All are welcome, even those just interested in learning more!

 

Join the CFHA Women’s Health call on Thursday, March 14 at 1 pm PST/4pm EST

Additional note:  I was thrilled to read the February 2019 US Preventive Services Task Force (USPSTF) findings regarding prevention of perinatal depression.  The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for persons at increased risk. They also highlight the potentially promising role of “embedded behavioral health specialists” in improving health system delivery of these interventions.  To read more: (https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-preventive-interventions )

Katie Snow, LCSW is a Behavioral Health Consultant and Clinical Supervisor for Women’s Healthcare Associates, a group of OB/Gyn clinics in the Portland, Oregon metro area. Katie started out as a BHC in 2014, with 16 years of experience working in varied community mental health settings and 0 years’ experience working in integrated care. That number would have stayed at 0 without the incredible support of the LifeWorks Northwest Integrated Medical Services team and the genuine trust and support of the staff and providers of Women’s Healthcare Associates.

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Training the Ground Troops of Family-Engaged Care

Posted By Barry J. Jacobs, Wednesday, February 20, 2019

 Around the long mahogany board room table, the 40 middle-age nurse and social work care managers of this large Medicare ACO regarded me with a mixture of inquisitive and impassive looks. I was supposed to deliver the good news on how strategies for supporting family caregivers are becoming more sophisticated. I started off by asking how many of them had been caregivers in their own families. Everyone raised their hands. One woman shared her story of growing up with a grandmother who’d had a stroke. Another revealed she had a father with dementia.

They talked about how trying these personal experiences were. I then asked how many of them used formal, structured means of engaging and assessing the family members of the geriatric patients with whom they worked professionally. Not a hand went up.

 

Medical family therapists and physicians and nurses with family systems training--the heart and soul of CFHA--are not the frontline ground troops of family-engaged healthcare. Care managers are--or should be. Mostly seasoned female nurses with big overflowing hearts and steel-trap minds for details, they sit in back offices in primary care clinics, in healthcare insurer cube farms, and at hospital unit desks, making dozens of phone calls daily to smooth out care transitions, coordinate communication among disparate providers, and better address patients’ social determinants of health. They have learned ways of supporting patients who have housing, transportation and food insecurity challenges. But even though they work with the family members of those patients every day, they don’t know—and often don’t know they don’t know—about the latest methods for engaging families as partners in healthcare and social service delivery.

 

So, what are those methods? They loosely fit into three buckets:

 

Intentionally engage family caregivers: The care managers at the ACO training were quick to point out that they interacted with patients’ family members all the time. But they admitted that these relationships developed somewhat haphazardly. If the family members picked up the phone call for the patient when the nurse called or were present in the home when the nurse stopped by, then some conversation and coordination ensued. In many cases, though, this never happened and family members of great importance to a patient’s treatment course were never meaningfully engaged.

 

This wasn’t due to malicious disregard. Everyone pays lip service to the importance of family. But most of the care managers around the table never received training about intentionally engaging patients’ family members and still practice with the patient solely in their sights. In my opinion, this has only been reinforced in recent years by the increasing emphasis on “patient- or person-centered care.” “Family-centered care” is looked at askance as almost an antithetical heresy. That’s one reason I now push the term “person-centered, family-engaged care” to indicate that including families in our scope of practice won’t violate our duty to individual patients.

 

An intentional approach to engaging family caregivers requires reaching out to patients’ family members as a normative protocol at the outset of patients’ treatments. It is about acknowledging and valuing their potential contributions to patients’ well-being through the hands-on help and emotional support they give. For example, at Dignity Health System in Santa Barbara County, California, caregiver navigators show up at patients’ homes to meet family members—not patients—to establish relationships with them and give them educational materials and caregiver support gift baskets.   Those navigators may then arrange for community health workers to connect with the family members—not the patients--to better support their needs. For more about these kinds of family-facing strategies, see this May 2018 Washington Post article.

 

Assess family members formally: The care managers at the training also contended that they used their clinical instincts to gain a sense of how their patients’ families functioned and whether they could be relied upon to assist with patients’ care. But as far back as 2006, the California-based caregiver advocacy organization, Family Caregiver Alliance, devised a National Consensus Development Conference, spearheaded by trail-blazer Lynn Friss Feinberg, to create agreed-upon formal means of assessing family caregivers. That document calls for evaluating family caregivers’ backgrounds, beliefs, values, skills, resources, etc.

 

 In the years since then, healthcare has been exceedingly slow, however, to consider these standards, let along adopt them. It was only in 2019, in the fourth edition of its “Clinical Practice Guidelines for Quality Palliative Care,” that the National Coalition for Hospice and Palliative Care included recommendations for assessing and treating family members (guidelines 4.2.1-4.2.1 and 4.3 on pages 27-28). Few, if any, other national standards for family caregiver assessment exist in any other healthcare sector.

 

 In the training that I’ve done with thousands of mental and physical healthcare professionals over the last decade, I’ve expanded upon the Family Caregiver Alliance’s framework to a 7-point family caregiver assessment that includes family constellation, history, willingness to provide care, ability to provide care, willingness to receive help, meanings derived from caregiving, and stress-level. For more information, see this recent CFHA webinar.

 

 Provide family caregiver support that’s individually tailored and actually helpful: The care managers readily understood that family caregiving is stressful. They spoke of listening supportively to family caregivers’ concerns and referring them to social workers and/or caregiver support groups. These elements of their geriatric practices made me entirely grateful. I’ve learned through my clinical career, though, that not all help is helpful. Unless we really get to know people in the granularity of their life circumstances and idiosyncratic attitudes, we can’t fashion the right support at the right time--thus the need for diving deeply through family caregiver assessment. One-size-fits-all caregiver support groups rarely do. I’ve also learned that family caregivers are proud and are often loath to accept help. That’s what makes the relationship-building we should do with patients’ family members from the outset more essential. It is only when we take the time to establish ourselves as trustworthy guides that we have half a chance of convincing them to utilize the support services we can offer.

 

 After the training, the care managers’ director told me she found my presentation “eye-opening.” Her comment was flattering but also alarming. Little of what I presented should have been brand new to them—and yet the idea of approaching patients’ family members with intention and formal clinical approaches came as a revelation. Person-centered, family-engaged healthcare won’t make any advances unless the ground troops are on board. Those of us in collaborative family healthcare have a lot more to do to supply them with the orientation, tools, inspiration and will.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and Principal at Health Management Associates, a national healthcare consulting firm. He is the author of The Emotional Survival Guide for Caregivers (2006) and co-author of AARP Meditations for Caregivers (2016).

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What Is Your Philosophy of Screening? And Other Terrible Pick-Up Lines.

Posted By Matthew P. Martin, Wednesday, February 6, 2019

The title of this post is a terrible pick-up line, but it reflects my recent musings on how we identify patients in primary care who may benefit from behavioral health services. Health screening is standard practice in primary care. We screen for physical health, mental health, substance use, health behaviors, family functioning, social determinants of health, and more. We assume that the screening tools are accurate and use the data to inform our treatment decisions. We may even assume that patients do not completely understand their own health and that screening can be the first step toward an accurate diagnosis. Screening allows care delivery systems to process high numbers of patients, categorize patient health problems, calculate risk levels, and assign appropriate treatment.

Screening is a ubiquitous practice in healthcare. I have worked in five different primary care systems and each one had a protocol for identifying patients with depression. Other industries use screening as well. Employers screen new employees for drug use and citizenship status; athletic teams screen players for physical prowess and potential ability; banks screen customers for credit worthiness. There seems to be this underlying belief that certain discrete points of data can predict something important about employees, athletes, customers, and patients. Although there is strong evidence that health screening works, it is certainly an imperfect science. For example, many patients with chronic pain symptoms will flag on the PHQ-9 (a depression screening measure) even if they don’t have depression symptoms. Most behavioral health measures rely on self-report and are at risk for false positives (and false negatives too!). Screening data should inform clinical intuition and experience; it is a starting point, not an end point.

It may help to take a step back and think about the functional purpose and rationale of screening. By taking a step back and choosing the target of your screening efforts, you can create a comprehensive strategy that meets multiple needs while efficiently using your resources. In my career, all of my clinical experience has involved universal screening. The purpose of universal screening is to identify as many candidates as possible; in other words, the wider your net, the more fish you catch. The rationale is that universal screening can identify anything on the spectrum: potential, developing, active, and even urgent health problems.  For example, SBIRT (screening, brief intervention, and referral to treatment) is an effective universal screening approach for identifying substance use and assumes that, because there are more risky substance users than those with full blown dependency, a greater number of problems exists with the former sub-population. Another example of universal screening is the recommendation from the United States Preventative Services Task Force for depression screening. They recommend all adults be screened, although they do not specify frequency. The collection of physical vitals data (blood pressure, heart rate, weight) is a universal screening approach too. Imagine seeing a medical provider and not having your blood pressure recorded.

Universal screening is pretty, well, universal in healthcare. There is another approach that has gained some recent attention that you may not know about. Although there is no official term for it, let’s call it focused case identification (FCI), a population health management strategy. This approach includes tools like patient registries, risk calculation, and non-clinical data. The purpose of FCI is to identify patients who would benefit most from a service based on an algorithm or risk score. The rationale is that, in a healthcare system of limited resources, our sickest patients are most likely to be high utilizers of care and have the worst outcomes.1,2 By determining risk level and focusing our resources on this segment of the patient population, we can get the biggest bang for our buck. There are four recommendations to follow when taking this approach: first, focus your case-finding efforts on patients with chronic medical conditions and high health care costs; second, deploy treatment resources in a fully integrated fashion; third, use only highly trained clinicians and evidence-based treatments; fourth, escalate care when appropriate using care management and coordination strategies.3 The assumption is that a focused case identification approach would reach the Triple Aim faster compared to universal screening.

So, what should your clinic do? Well, first let me say that I may be creating a false dichotomy here, a straw man so to speak. This comparison of two case identification approaches is just meant to highlight the strengths and limitations of each model. On the one hand, universal screening is a fairly straightforward and low technology-based strategy (you could do it all with paper surveys) that can create false positives and negatives. On the other hand, a FCI model can identify your sickest patients and efficiently use resources, but it requires significant expertise and sophisticated health information technology for maximum benefit (e.g., care management software, risk calculation tools). I can see hospitals using the FCI model because they have access to the knowledge and technology it requires, but a small clinic in rural New York? Not so much.

Here are some thoughts about moving forward. First, combine both case identification approaches into a comprehensive strategy. Clinics can’t focus on patients with chronic health problems and comorbidities unless they first screen for those issues. That usually requires a universal approach. Perhaps the solution is to only universally screen all patients with chronic health conditions like diabetes and congestive health failure, but not the entire patient panel. Second, clinics need access to knowledge and technology that make FIC possible. Payers, both private and public, can create knowledge networks that clinics can easily join to learn more. Some clinics may need practice facilitators to accelerate their transformation process. Finally, policymakers should create rules requiring EMR vendors to develop easy to use and affordable population health management tools, making FIC more likely to happen. So, perhaps instead of using “What is your philosophy of screening” as a pick-up line, maybe a better line is “What is your value-based case identification model?”

 

1. Cogan, S. (2014). What is population health management? Health Management Technology, 35(5), 18.

2. Zander, K. (2019). Population Health Management: Coming of Age. Professional case management, 24(1), 26-38.

3. Kathol, R. G., & Rollman, B. L. (2014). Value-based financially sustainable behavioral health components in patient-centered medical homes. The Annals of Family Medicine, 12(2), 172-175.

Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. Dr. Martin conducts research on integrated care measurement, medical workforce development, and population health strategies in primary care. He serves as the Director of the ASU Project ECHO hub for behavioral health didactic training and teleconsultation

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The Unspoken Role of the Behavioral Health Consultant: 6 Tips for Navigating Colleague Mental Health Needs

Posted By Katie Snow, Wednesday, January 23, 2019

This post was inspired by a recent CFHA listserv discussion. If you are reading this and not a CFHA member, the listerv is one of the many amazing benefits of CFHA membership!

It usually looks something like this:

A face I know well pops into my office door—another staff member in the clinic where I spend my days as a behavioral health consultant. This face lacks the bright “just popping in to say hi” or frazzled “we need you right now a patient is in crisis” look.  It is more cautious, mingled with a sad or hopeful furrowed brow.

A voice soon follows, starting with an attempt at an upbeat, “can I ask you a question?” and a pause and then, in a softer, sometimes shakier voice, “it isn’t about work….”

The words that follow vary, but there are consistencies. They, or someone they love, are struggling with a mental health or substance use issue. They have tried to get help but have run into problems accessing or using that help.  I am the only person they know personally who has the “inside scoop” on the fractured, difficult to navigate mental health and addictions care in our community and they are desperate to access it.  They want the name of a good therapist.

The above scenario was one of the most surprising aspects of my new role when I began working as a behavioral health consultant.  I was accustomed to exclusively working with other mental health providers, not being the lone mental health provider in my workplace.  I was also used to an almost reverent relationship to the ethical guidelines ground into mental health professionals in graduate school and practicums: in particular, the expectation that we keep our personal lives very separate from work and that we do not engage in dual relationships.  This makes sense, particularly since we know how to access mental health care for ourselves and our families (not that we always do this, but that is a topic for another day).  I quickly learned that boundaries look very different in the medical setting. The medical staff and providers may agree with and support our boundaries once we make them clear, but dual relationships tend not to be front and center for them in the same way they are for mental health professionals.  

The request for referrals often came with additional information about personal or family problems. In my setting, where staff and providers are also patients in our clinic, sometimes these conversations occurred in the context of a scheduled behavioral health appointment because the staff member was referred to me by their provider (and, initially lacking other protocols or knowledge of how to handle this, I saw them).  In either scenario, I soon found myself to be the holder of a great deal of both information and concern about my co-workers.  I felt honored to be considered worthy of the trust implicit to their request, hopeful I could help, and overwhelmed at the prospect of managing all of these concerns in addition to my patient load.  If I am honest, I also felt a sense of loss.  We BHCs want and need collegial relationships as much as anyone.  It changes the power dynamic to see someone as a patient or know personal details of others’ lives without a friendship to contextualize that information.  It immediately requires a more mindful approach to that relationship.  It means we are working even when we are taking a break, needing to always hold this power in balance with the joking and fun-having that is a part of a healthy workplace.

My response to this situation has been multi-faceted. I certainly do not have all the answers, but I will share some advice and information on where I am currently landing:

1.     Seek Supervision: My supervisor had experience with this issue in a different group of clinics. It was applicable to my clinics and eventually helped me to formulate a practice standard for the team I supervise. In the interim, it gave me a place to process what I was experiencing and gain support and ideas.

2.     Talk to Human Resources: I recommend having a conversation with HR prior to encountering this situation if possible. Your clinic’s HR director probably has an opinion about the best steps to take when a colleague comes to you with a mental health or substance use problem.  Their stake in employee well-being is significant and they very likely have resources that you will find useful. They may also want you to direct employees with significant issues applicable to work performance directly to HR.

3.     Know employer-sponsored resources:  See item #2 above. HR will likely give you information on an Employee Assistance Program, possibly a physician/provider specific counseling resource and services covered by the employer-sponsored health insurance plan. Keep an easy to access, updated list of these resources as many employees are unaware of them. This list is always my go-to and can quickly reroute a conversation that would otherwise become much more in-depth.

4.     Refer internally but offsite if needed and possible:  For my team, it has made sense to create a practice standard that asks that employees seek behavioral health care from a BHC at another physical location within the company when referred. Again, this may not be relevant for all, depending on whether employees are also clinic patients. Because most of my colleagues are accessing healthcare within our clinic, it makes sense that behavioral health be available to them as a part of their care. In my group of clinics we have the luxury of being a group of 5 BHCs. We are spread across a large geographic area but it is possible to have a colleague simply access care from a BHC at another location.

5.     Except it isn’t always simple:  Even with all of the above options, sometimes people just need help right away or can’t get it any other way.  Maybe they work 8-5 Monday-Friday and there aren’t appointments available to them when they can attend. Or there is a 3 week wait for a new appointment and that is too long.  Sometimes resources are too far away to be realistic. Often the person assigns so much shame or stigma to accessing mental health/addictions care that they will not access them without support.  So, I try to be flexible within our practice standard, recognizing the key role behavioral health plays in filling gaps in mental health/addictions care.  At times, that has meant that I have been flexible and seen an employee for a few visits as a bridge, a warm-up to accessing care, or for stabilization.  At other times it has meant I have looked around for therapists meeting their needs for appointment time, insurance accepted and location and passed these referrals on to them.

6.     State your boundaries and check for understanding:  When I have ended up seeing a colleague for an appointment or having more extended conversations, I have gotten better at defining my role and boundaries upfront. I tell colleagues that taking someone on as a patient or having specific information about their situation can change our relationship and I try to provide some clarity about what this means. I am very, very clear about my mandated reporting responsibility.  I share my priority for finding them ongoing care. And then I listen.

 

Maybe it’s the new year, but while writing this post I spent a lot of time reflecting on our role as BHCs. It left me feeling more than a little bit grateful to the many folks out there who have and are contributing to the development of this field.  With all its complexity, integrated behavioral health truly has the potential to be one of the answers to the national conversation about how to increase access and decrease stigma surrounding access to mental health and addictions care.   Thanks to all of you for being a part of this movement. And Happy New Year!

Katie Snow, LCSW is a Behavioral Health Consultant and Clinical Supervisor for Women’s Healthcare Associates, a group of OB/Gyn clinics in the Portland, Oregon metro area. Katie started out as a BHC in 2014, with 16 years of experience working in varied community mental health settings and 0 years’ experience working in integrated care. That number would have stayed at 0 without the incredible support of the LifeWorks Northwest Integrated Medical Services team and the genuine trust and support of the staff and providers of Women’s Healthcare Associates.

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Assume Trauma Until Proven Otherwise

Posted By Joan Fleishman, Tuesday, January 8, 2019

I decided to write a piece in response to the CFHA listserv discussion on detecting and addressing trauma in primary care.

As I watched the messages from my colleagues trickle in about how to address medical providers’ unease discussing trauma with their patients I paused and knew my contribution would be forthcoming.  I have done a significant amount of work in my clinics to promote, train, and implement Trauma Informed Care (TIC) across our clinical system. The questions that were being asked on the listserv were real. They are the questions that my colleagues and I grapple with. How do we to address trauma in primary care? How do we prepare and support medical providers to do this work?

Why are we so uncomfortable with topics like trauma, with intimate partner violence, with suicidal ideation? The answer is complex and simple at the same time, these are not easy topics to talk about.  Partially because they are sensitive, partially because they carry stigma, and partially because they are so prevalent that those having the conversations may be personally affected by them. Regardless of these factors, there is growing evidence for trauma informed care in medical settings. This work has been supported by agencies like SAMHSA, HRSA, and National Council for Behavioral Health.

I recently was asked to teach TIC to 3rd year medical students. In fact, one of our learning objectives was, “develop comfort in addressing a trauma disclosure with a patient.”

The first question I get in the class is should we be screening for trauma or PTSD. The listserv discussion included thoughts on universal screening for ACEs and PTSD in primary care patients. Although I think that screening is appropriate for some sub-populations served in a primary care setting, I have not yet seen robust evidence that this type of screening in a general primary care population leads to improved outcomes. As mentioned in the listserv discussion the USPSTF has not yet issued a guideline for screening for trauma or PTSD.

In the listserv discussion, there was a call for medical providers to provide validation, empathy, and sensitivity to patients with a history of trauma as an intervention that seems feasible and realistic for primary care providers to implement. It was pointed out that these should not just be applied to patients with a history of trauma or PTSD, but to all patients. I endorse this idea and will take it a step farther by suggesting that validation, empathy, and sensitivity should be applied in the context of trauma informed care and a universal precaution approach.

These three qualities (validation, empathy, and sensitivity) fit perfectly into the formal conception of trauma-informed care: fostering safety, autonomy, and trust in the patient-healthcare provider relationship. When operating with the universal precaution approach, direct screening is not necessary.  We approach all patient care, every interaction, with the principles of trauma informed care including safety, trustworthiness & transparency, peer support, collaboration & mutuality, empowerment, voice, choice, and cultural, historical, and gender issues.

Being trauma-informed means that one can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization. It is important to remember that trauma-informed is different than trauma specific or trauma sensitive.

So, what did I teach my 3rd year med students? We discussed how to ask about trauma and how to respond to a trauma disclosure. I introduced the five points below. I hope these can help you in your practice. You may even want to share them with a colleague.

Use a Trauma Education Statement. It is important that we explain why you are asking about trauma in the context of their medical care and that we acknowledge the impact of trauma.

Examples:

“We’ve learned a lot about how abuse, neglect, and chronic stress can lead to health issues like chronic pain...

“What we know about trauma is that people who have been exposed to abuse or have had bad things happen to them are more likely to have certain health problems like chronic pain…”

Inquire about the patient’s experience. I suggest to my students that the first time we bring trauma up we are simply planting a seed. I encourage them to lead with curiosity and compassion. I emphasize that it is important that we let our patients know it is not necessary to gather details for them to be able to help.

Examples:

“I wonder if you have had some experiences like this in your past…”

“I don’t need to know the details of anything that may have happened to you. I wonder if you have experienced emotional, physical or sexual abuse in your past…”

Create safety. Once someone has shared about their experiences it is crucial that we validate their emotions and experiences. We also must act as a container and prevent activation and emotional dysregulation.

Examples:

“You don’t have to share details with me. I want you to know that you can talk with me about these experiences and how they may be affecting you now.”

“I want to acknowledge that these are really hard things to talk about for most people because talking about them can bring up emotions or you might feel like you are reliving what happened to you.”

Addressing a disclosure. This is where my students felt the most unprepared. I encourage them to thank their patient for sharing their story. And I encourage them to connect how knowing the patient’s history can help them provide better care.

Examples:

“Thank you for sharing your story with me because it really helps me understand the whole picture of your health and how you live your day to day.”

“Thank you for telling me this. Given what we know about certain health conditions and trauma, this will help your healthcare team provide better care.”

Preventing and reducing activation. If you begin to notice that your patient is fidgeting, playing with something in their hands, rocking in their chair, avoiding eye contact or seems “checked out” they may be activated or dissociated from retelling their experiences. I teach that in these moments it is ok to interrupt their story. Validate their experiences and emotions and explain that reliving emotions and telling the details of an experience is not necessary for you to help.

Examples:

“I’m actually going to interrupt you because I can see that this is really distressing and hard to talk about and I don’t want you to have to feel the emotions that go with those experiences.”

“This sounds like this was a really significant event in your life. I want you to know that you don’t have to tell that story because you don’t have to relive the emotions that you experienced.”

If you have questions or if you wish to have further conversation about this topic, feel free to contact me at fleishma@ohsu.edu.

Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.

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