I vividly remember my first meeting with the OB-Gyn and maternal-fetal medicine providers in the early weeks of my role as a behavioral health consultant for a group of women’s health clinics. I wore my favorite shirt. I got up earlier than seemed reasonable (who knew how much doctors love 7 am meetings?). I brought handouts. I told them I was there to help them take care of their patients’ health problems that are impacted by stress or mental health challenges. The referrals started rolling in!
Just kidding. Deafening silence. I had a lot of time to make more handouts.
It turns out that this group of providers are very connected to their patients and, once I got to know them, I understood. They had cared for these women throughout pregnancies and delivered their children. For some, deftly slicing the abdomen and uterus open to do so before neatly stitching them back up; for countless others, theirs were the first hands to touch baby’s slick downy skin on its initial descent into the world. They had met some long term patients after a sudden pain led to an ER visit resulting in a gynecologic surgery that saved that woman’s life. They had seen others through crippling menstrual pain, loss, infertility, menopause, scary diagnoses and more. They weren’t going to suggest their patients talk with just any enthusiastic person in a nice shirt who showed up in the clinic. I had to earn their trust that I could add value to the care they provided.
For those who, like me, enter the integrated care world as a mental health provider not formally trained or experienced in PCBH or another model, working in a medical clinic feels like visiting a distant land with unfamiliar customs and language. At first, the only thing that seemed certain were the skills I had honed over many years working in community mental health. Less certain was how to fit them into a brief model in a way that was valued by patients and providers. The good news is that providers did eventually start to trust me to help care for their patients. In fact, we have had to hire more help. Today I will share some of the tidbits that have helped sustain, grow and institutionalize behavioral health in my particular clinic setting. I hope some are useful and relevant for you. Over the next year my blog posts will focus on some of these topics in more detail and more, so stay tuned!
1. Integration is adaptation, teaching and learning: I learned everything I know about integrated care from colleagues working in primary care settings. Pretty early on, I realized that there were unique aspects to OB/Gyn care that didn’t fit with that model. I also realized that the providers mostly saw me as a co-located mental health provider and I would need to teach them about integrated care (which I was very much still learning). For one thing, I wasn’t working with 3 or 4 providers like my colleagues, it was closer to 25 in my physical location and 125 across the multiple locations for the company. And, instead of diabetes, tobacco use and obesity as the top 3 behavioral health referral problems I was seeing mostly perinatal mood disorders, pregnancy loss and menopause-related insomnia and mood issues. I was also heavily used for crisis situations, a challenge to the brief model. For example, when encountering a family that had just received news of an adverse fetal diagnosis or pregnancy loss, a 20 minute visit didn’t meet the need for connection, support and planning. In most cases, I found ways to adapt the model to work better for this population and setting.
I also had a lot to learn. I have already mentioned the level of care and concern for patients from this group of providers. This care came along with an expectation for patient hand-holding that was not comfortable for a social worker trained to highly value self-determination and self-efficacy, but I found some middle ground. And the acronyms! I had to start spelling out mine (no more CBT, DBT, MI etc.) and start learning theirs (SAB, LARC, IC, NSVD—OMG!). I used Google a lot. Most powerfully, I learned how important a warm handoff can be. Even if it meant leaving a scheduled visit, I learned to prioritize them. It quickly became clear that for many people, coming back for a scheduled appointment was not likely and I came to see that I could do more in a short period of time than I had expected. This comes with the added bonus of being known as the fastest run-walker in the clinic and some mad laptop slinging, type-walking skills.
2. Perfect your elevator pitch (and get used to saying it A LOT): You may be the only mental health provider in your clinic. You may also be the only mental health provider many patients ever speak with. So, by default, you will play ambassador and translator of the mental health and behavioral health worlds in your clinic. Don’t expect providers, staff or patients to immediately understand or remember what you do or how you fit into the big picture. Find a way to describe your role that makes sense to these varied groups and be diligent about communicating what you do. Here’s a typical spiel when I am introducing my role to a patient: “Hi, I’m Katie. I’m a member of the team here and a licensed mental health provider. My job here in the clinic is to learn about any problems that are getting in the way of feeling your best and work with you on some ideas that may help you feel better soon. I often see patients a handful of times, usually somewhere between one and five, to help out with this. I also provide help connecting to resources outside of this clinic, such as longer-term counseling, if you are interested.”
3. Focus on physical symptoms impacting functioning: It is a consistent challenge to deliver useful interventions to patients in a short time frame and, in some situations, it can feel like an impossible task. Most mental health issues have one, if not many, physical symptoms. When overwhelmed, remember to ask about basics such as sleep, energy level/fatigue, nutrition/weight gain, physical activity, rapid heartbeat/shortness of breath, pain, sexual health and the impact of any chronic health conditions. Or, ask some of the providers in your clinic about typical complaints they encounter. A focus on physical symptoms that are causing distress or contributing to or resulting from mental health symptoms will allow you to narrow your focus, provide meaningful brief interventions and help patients feel more hopeful about getting better. I was pleasantly surprised at how easily I could apply my clinical toolkit to these symptoms and have patients experience real results.
4. Save time with brief screening tools: Now that I use them all the time, I can’t believe I ever functioned without constant use of the PHQ-9, GAD-7, Edinburgh Postnatal Depression Scale (EPDS) and the Columbia Suicide Severity Rating Scale (CSSRS). Depending on the presenting issues, I often start with one or more of these to help quickly identify (and quantify) mental health symptoms. It really helps to know upfront if our visit is going to focus on safety due to suicidal ideation or if we will be able to move beyond that topic. Patients also benefit from a brief description of their score, scoring scales and information about how their symptoms relate to a particular mental health issue.
5. Stay updated on relevant community resources: Maybe you have someone else in your clinic who helps with this. More likely, you do not. Even if you don’t consider yourself an expert in this, take some time to get and stay updated on resources in your area that meet the needs of the specific population you serve. Providers and patients really value this expertise. I see a lot of women experiencing anxiety and depression in pregnancy and the post-partum period, so I am constantly on the hunt for affordable, accessible parenting supports, diaper banks and maternal-health aware mental health care. Most of the things that contribute to wellness take place outside of the clinic in the context of families and relationships. Your patient may be more likely to take your input on getting more physically active, starting some breathing exercises or shifting negative thought patterns if they see you as helpful in more concrete areas.
Let me know if you would like to hear more about these, or other topics, from the perspective of a newcomer to integration. Leave any questions or thoughts in the comments!
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.