Working with Medical Professionals: Enhancing Your Practiceby Nancy Breen Ruddy, Ph.D..
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Course Outline Introduction Learning Objectives Primary Care Behavioral Health What is Primary Care? Patient centered medical home and mental healthcare Prevalence of behavioral health issues in primary care The Costs of Untreated Mental Health Disorders The Case for Collaboration and Integrated Services The status quo – and the problems it causes Barriers to mental health referral The Benefits of Collaboration How collaboration can improve patient care How collaboration can improve professional satisfaction How collaboration can help mental health professionals build a practice Barriers to Collaboration Confidentiality Time constraints Devaluation of mental health input by medical professionals Overcoming Barriers to Collaboration Routine collaboration and practice and clinical strategies Initial collaboration: Creating opportunities Establishing a collaborative relationship Other strategies for building a collaborative relationship Making collaboration part of routine practice Intensive Collaboration What types of patients need intense collaboration? Difficult patients for primary care providers Intensive Collaboration: Strategies and Techniques Pre-referral collaboration Post-referral intensive collaboration strategies Collaboration of Mental Health Services into Primary Care Integration of mental health services into primary care References
INTRODUCTION AND OVERVIEW
Mental health professionals increasingly realize that they must begin to interface more effectively with the medical community. Yet, many do not know how or where to begin this process. This continuing education program serves as a “how to” collaborate with medical professionals.
The goal of this continuing education program is to help mental health professionals learn how to build and maintain successful working relationships with other healthcare providers. There is a specific focus on building such relationships with primary care medical professionals. Towards this end, the program reviews models of collaborative care and the research literature on the prevalence of mental health issues in primary care, quality of care issues in primary care mental health, and the evolution of various models of care delivery. It will outline the collaborative relationship primary care medical professionals typically have with medical specialists, in contrast to the poor communication and collaboration that often plague the primary care/mental health professional referral model. The program will offer an analysis of the impact of this fragmentation on patient care, with case examples to illustrate common issues. The benefits of, and barriers to, collaborative relationships with other healthcare professionals will be reviewed, including how collaboration can facilitate referral network development. Other healthcare professionals’ and patients’ perspectives on collaborative care will be illustrated via their comments regarding experiences with such care.
After discussing the benefits of a paradigm shift towards shared care, the focus will shift to “how to” collaborate. This portion of the program will outline pragmatic, time efficient strategies to initiate contact with medical professionals and collaborative techniques to make collaboration a routine part of clinical care. The goal is to help psychotherapists integrate collaboration with other healthcare professionals into all clinical care, not just care of patients with specific health issues. The program will offer practice management strategies such as forms, collaboration tracking systems, and communication tools to streamline communication and collaboration. Emphasis will be placed on the importance of whole person assessment in psychological practice, and the knowledge and skills that all psychotherapists need to understand the interplay of physical and mental health. Case examples will illustrate routine collaboration.
The next section will focus on intensive collaborative strategies and skills for use with patients with complex medical and psychological issues, including patients with poorly managed chronic medical illness, somatization and personality disorder. The program will discuss the literature regarding the medical profession’s struggle with challenging clinical encounters, and how these struggles often result in frustration for the medical professional and poor outcomes for patients. It will outline specific techniques psychotherapists can employ to help medical professionals increase their success and satisfaction in these encounters. These techniques are culled from various theoretical orientations, including cognitive behavioral techniques, family therapy techniques, and mind/body strategies. They also include collaboration strategies to improve care and enhance support for both medical and mental health professionals. Case examples will illustrate the use of these strategies.
Learning Objectives
Describe three reasons that mental health professionals should collaborate with primary care professionals.
Explain three practice strategies that facilitate collaboration with primary care professionals.
Discuss how to identify patients in need of intensive collaboration.
Explain two consultation or psychotherapy strategies to optimize care for complex patients. Primary Care Behavioral Health
What is Primary Care?
Primary Care is made up of three disciplines: Internal Medicine, Pediatrics, and Family Medicine. Internal Medicine providers treat only adults, pediatric providers treat only children and adolescents, and Family Medicine providers treat all ages, including well woman care and obstetrics. Some consider Obstetrics and Gynecology as part of primary care, as well, since many women get most all of their care from their OB/GYN. It should be noted that the word “providers” is used, rather than “physician.” “Midlevel providers,” such as nurse practitioners and physician assistants, work in collaborative relationships with physicians providing this critical front line care.
The term “primary care” connotes much more than just “who” provides the care. The primary care setting is the first place most people turn when they have a troubling symptom, be it physical or psychological. Primary care providers often know patients very well from working with them over many years. They often provide care to more than one family member, helping them put the patient into context.
Primary care is intended to be comprehensive and preventative medical care. Its goals include helping patients find the right care and coordinating all of the patient’s health care providers to optimize health (Ruddy, Borresen & Gunn, 2008). In this role, primary care providers assess and treat to the best of their abilities. When they are unsure of the correct diagnosis or treatment, or the treatment falls outside their expertise, they refer the patient to a specialist. They may help the patient to select the right specialist, and to understand their treatment options based on the specialist’s recommendations. When patients must work with multiple specialists, primary care providers often help the patient understand his or her condition and help the patient make treatment decisions. Unfortunately, specialists do not always agree on the best course of action, in part because they focus primarily on the part of the body or organ system in which they specialize. In these cases, the primary care provider may play a critical role to help the patient synthesize the information and make treatment decisions.
Primary care providers play this central role for patients with mental health issues, as well. They try to help patients to the best of their ability, and refer to mental health professionals when they do not feel they can optimally care for the patient. From the primary care providers’ perspective, psychotherapists are essentially a type of “specialist.” The following vignette illustrates a typical primary care encounter that has a mental health substrate:
This vignette is typical in a number of ways. First, the patient’s presenting concern was a somatic symptom commonly associated with stress. Second, the patient did not disclose life stressors until specifically asked about them. Third, the patient had little to no interest in seeing a mental health professional. Fourth, the physician experienced some internal struggle about delving into psychosocial issues for fear of what he would find and then feel compelled to deal with. Yet, he knew he would not be doing his job if he didn’t “go there” to assess and address underlying psychosocial issues. Fifth, the physician realized he couldn’t “fix” her problem. Rather he focused on giving her some reassurance and some concrete things she could do to help herself cope (seeking support). Sixth, the physician used continuity of care – a follow up appointment in a week, to manage Sandra’s concerns without spending an enormous amount of time that was not allotted in his schedule on this day. Seventh, he ruled out suicidality and homocidality. Finally, he attempted to support Sandra by emphasizing his availability.
Not all primary care providers are as astute and skilled as Dr. Kingston. There are many who would have simply ordered the tests, provided some reassurance but not delved into her psychosocial situation. There are many reasons for this – lack of training, time, and interest for some. One of the biggest reasons primary care providers avoid psychosocial issues is the reality that they do not feel able to help patients with stress themselves, AND feel unable to easily connect the patient to a mental health specialist. Because the process of referring patients for mental health care tends to be more difficult than referrals to medical specialists, primary care providers do not have the same level of “back up” on complex psychosocial issues that they do on complex medical issues. Also, the post-referral communication between mental health professionals and primary care providers tends to be problematic. The sources of these difficulties will be discussed in more detail later.
Patient Centered Medical Home and Mental Health Care
Over the last two decades the concept of the “patient centered medical home” has gained prominence. Some mental health professionals take umbrage at the term, preferring “health care home.” We will use the “medical home” term because it has been in use since 1967 (American Academy of Pediatrics, 1967), and because the term has gained traction in the health care reform debate in a way that “healthcare home” has not. The concept was defined by the American Academy of Pediatrics, American Association for Family Practice, the American College of Physicians and American Osteopathic Association in 2007 to include the following elements: An ongoing relationship with a personal physician who provides continuous and comprehensive care.
Multi-disciplinary care teams that share responsibility for patient’s ongoing needs.
Whole person health care
Coordination and/or integration of care across all levels of healthcare provision (e.g. inpatient, outpatient, specialty care, primary care)
Use of practice management systems such as patient registries, electronic health records, and health information exchanges to improve access to care and care provision.
How is this relevant to mental health professionals? Basically, to be successful, a medical home must integrate behavioral health into primary care practice. In some settings this entails having mental health professionals on site to provide services as part of a care team. However, this level of integration is not feasible in all settings, and current reimbursement structures preclude true integration in most private healthcare settings (Bachman, Pincus, Houtsinger, 2006; Goldberg, 1999, Kausch, Mauch, & Smith, 2008). However, even in settings where integration is not currently feasible, the medical home still advances the centrality of behavioral health issues in medical care. Medical professionals who strive to meet the standards of care outlined in the medical home concept will need assistance from mental health professionals because the behavioral health needs far outstrip their expertise and time. But, mental health professionals must learn to work in a way that enhances care, and begin to work as part of a larger care team.
The Prevalence of Mental Health Issues in Primary Care
Most mental health professionals are not aware that the vast majority of mental health care occurs in primary care. In 1978, Regier, Goldberg & Taube declared that “Primary care is the de facto mental health system.” Their work indicated that most people who needed help with emotional issues never darkened the doorstep of a mental health professional. Little has changed in the decades since; consider the findings summarized in Table 1.
These data points show that primary care is the “entrance” to the health care system for both physical and psychic distress. Further, many people, regardless of their current mental health status, do not view the mental health treatment system as a resource they would access.
Mental health issues and treatment are important in primary care not only because they are common. There are four other factors that highlight the centrality of mental health issues in primary care and these are highlighted in Table 2.
The Costs of Untreated Mental Health Disorders
The cost of untreated and undertreated mental health disorders goes far beyond the direct health implications. Aside from the cost of treating these disorders, one must consider the disability costs, impact on productivity, and impact on the productivity of family members affected by a loved one’s mental illness or addiction. The following statistics are from Hertz & Baker 2002, Loeppke, Taitel, Haufle, Parry, Kessler & Jinnett, 2009, and Edington & Burton, 2003.
As noted earlier, chronically ill patients with co-morbid depression tend to seek more, and costlier, treatment. It has been estimated that untreated mental disorders in medical patients with chronic illness cost commercial and Medicare purchasers alone between $130 billion and $350 billion annually in additional health related, mostly general medical, expenses. This is in addition to the direct care costs of mental health and substance abuse treatment costs. Direct care costs totaled $104 billion in 2001, representing 7.6% of total healthcare spending in the United States.
Unlike other medical conditions, the indirect costs associated with mental illness and substance abuse disorders commonly meet or exceed the direct treatment costs. Approximately 217 million days of work are lost annually due to productivity decline related to mental illness and substance abuse disorders, costing US employers $17 billion each year.
Mental illness and substance abuse disorders are represented in the top five causes of disability among people age 15-44 in the United States and Canada. Combined as a group, mental illness and substance abuse disorders are the fifth leading cause of short-term disability and the third leading cause of long-term disability for employers in the United States. Employees on disability for mental health issues have 44% more lost time than employees who had no depression treatment during their disability leave. On average, a disability leave for depression costs employers $3,408 more per case than other sources of disability.
The Case for Collaboration and Integrated Services
The Status Quo – and the Problems it Causes
People who need psychotherapy and mental health treatment are often very ambivalent about initiating treatment. In the primary care setting, patients often present their distress in a somatic symptom, and may or may not have insight that emotional issues or stress are causing or exacerbating their symptoms (Goldberg & Bridges, 1988). These situations are a tall order for a primary care provider. In order to successfully treat the patient the primary care provider must address issues outlined in Table 3.
Given that the typical primary care encounter is 15 minutes or less, it is a small miracle that these issues are ever dealt with in any way. In fact, a 2005 study by Wang, Bergland, & Olfson indicated that the latency between onset of symptoms and initiation of treatment averages 6-8 years for depressive disorders and 9-23 years for anxiety disorders. Further, research indicates that such issues often receive suboptimal treatment in the primary care setting (Katzelnick, Kobak, Greist, Jefferson, & Henk, 1997; Simon, VonKorff, Wagner & Barlow, 1993). Clearly, the detection and treatment or referral of these issues from primary care is problematic.
Unfortunately, the problems don’t stop there. Even when a primary care medical provider detects emotional issues and has a successful dialogue with the patient about referral, patients often do not want to seek psychotherapy (Brody et al., 1997). Primary care providers often must expend a great deal of time and effort just to get the patient to agree to seek psychotherapy. Once the patient does agree to seek psychotherapy they often encounter numerous systemic access to care barriers as summarized in Table 4.
These very real barriers, coupled with the ambivalence that many patients feel about entering psychotherapy, and the reality that patients suffering from depression or anxiety may find the task of overcoming these barriers daunting, result in poor follow through rates for psychotherapy referrals. This is a source of great frustration to primary care providers, who then must do their best to manage the situation alone. The problems with the status quo don’t stop once a patient has managed to follow through on the referral to a mental health professional. Many mental health professionals do not communicate, or communicate only minimally, with primary care professionals (Chantal, Brazeau, Rovi, Vick & Johnson, 2005). This is in stark contrast with communication by other specialists. Typically, when a primary care provider sends a patient for specialist consultation, the specialist responds with a summary of the consultation, including diagnostic impressions and treatment recommendations. Depending on the situation, the specialist may provide ongoing care to the patient, may begin treatment to be followed by the primary care provider, or may make recommendations for the primary care provider to implement. In essence, there is a general sense that the primary care provider should at least be informed, if not centrally involved, in the care the patient receives post consultation. Primary care providers are very frustrated when they don’t get this level of information from mental health professionals, referring to mental health as a “vacuum” into which their patients simply disappear. It is not difficult to imagine why this lack of communication between mental health and primary care providers is problematic. The primary care provider continues to care for the patient without the input of the mental health provider. They are “left in the dark” about the patient’s mental health diagnosis, treatment plan, treatment progress, and even if the patient has followed through on the referral and/or continues in treatment. By not communicating, mental health professionals essentially separate the mind from the body – exactly what many accuse the medical community of doing.
This lack of communication becomes even more problematic when the patient is taking psychotropic medications prescribed by the primary care provider, has a chronic disease, or whose health is affected by their psychological functioning. While one could argue the last group includes everyone, it is particularly true for patients who have suffered trauma (Brown, Schrag, & Trimble, 2005; Green & Kimmerling, 2004), patients in domestic violence situations (McCauley, Kern, Kolodner, Dill, Schroeder, DeChant, Ryden, Bass & Derogatis, 1995), and patients who tend to express psychological distress somatically. The following case example illustrates a typical referral process, and how the lack of communication can be problematic.
This case is typical in many ways. Brenda sought help in primary care when she was in distress. She initially used a somatic “ticket in the door” to address her distress, but had some insight as to the role of stress in her headaches. Yet, she worried that the headaches might be due to something more serious, and was only somewhat reassured by the benign test results. These worries ultimately became more troubling as she grew more depressed and ruminative.
Brenda’s primary care provider attempted to provide biopsychosocial care. Dr. Hyden was able to see her regularly because she had a physical symptom to “justify” the visits. She provided Brenda with support and information, while attempting to set the stage for a referral to a mental health professional if needed. She gave Brenda psychotropic medication when she felt Brenda’s condition was worsening, in part because she didn’t know what else to do.
Brenda was reluctant to seek psychotherapy. Yet, when her primary care provider communicated that she felt it best that Brenda seek psychotherapy, Brenda did follow through. She met road blocks in this process, which might have completely stopped another patient. If anything, Brenda’s entrance to the mental health system in this scenario may have been optimistic if not unrealistic.
Brenda found a therapist that she felt good about on the first try, and had an initial consultation only a few weeks after starting the search for a therapist. Dr. Jenkins did ask about her general health, but did not focus on the headaches, per se. Dr. Jenkins did not communicate with the primary care provider, even when Brenda had indicated that Dr. Hyden had been the source of the referral and had treated her for the depression. Also, as is often the case, Dr. Jenkins put the responsibility for communicating with Dr. Hyden on Brenda’s shoulders. She coached Brenda to talk to Dr. Hyden about the weight gain, but did not initiate contact herself. Finally, while her focus on the infertility and miscarriage was helpful, it illustrates how many mental health professionals only will talk about health matters that have obvious mental health implications (e.g., miscarriage). Many mental health professionals tend to underestimate how much medical conditions (such as headaches) affect mental health.
How might Brenda’s care have been improved by collaboration and communication between Dr. Hyden and Dr. Jenkins? First, Brenda most likely would have been comforted to know that the two people she was relying on to care for her were working together as a team. Second, Dr. Jenkins likely would have better understood the central role of the headaches and might have focused on them more directly. Third, Dr. Hyden would have learned that Brenda felt only a mild improvement from the antidepressants, and that Brenda felt that the negative side effect of weight gain was greater than the benefit she was obtaining. Dr. Hyden could have tried a trial of another antidepressant, or referred Brenda to a psychiatrist for consultation. If Dr. Jenkins had told Dr. Hyden that Brenda had terminated psychotherapy prematurely, Dr. Hyden could have used her influence to encourage Brenda to continue, or could have further explored why she had stopped attending sessions. At the very least, Dr. Hyden could have monitored Brenda’s situation more closely from that point. This basic, “run of the mill” case might have had a much improved outcome, if only the two professionals had taken the time to communicate.
The Benefits of Collaboration Brenda’s case illustrates many ways that collaborative care can improve treatment. These benefits to clinical care include, but are not limited to elements listed in Table 5.
Collaboration creates teamwork between healthcare professionals that can be very reassuring to patients. Collaboration can also be helpful to mental health and primary care providers themselves. These benefits are summarized in Table 6.
Barriers to Collaboration
Even though most patients want their mental health professional and primary care provider to collaborate, this does not occur commonly. So why isn’t collaboration the norm in mental health? There are many reasons, most of them based in how mental health and medicine traditionally have had separate training, separate treatment and research systems, separate reimbursement structures, and very different cultures (Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). The three most commonly cited barriers are concerns about confidentiality, time constraints, and a perception that medical professionals do not value mental health input (APA survey, 2006).
Confidentiality: Many mental health professionals fear that patients themselves will be offended or put off by the request for a release of information to the primary care provider. Confidentiality is a cornerstone of mental health treatment and culture. Mental health professionals fear that patients will not feel comfortable disclosing sensitive information if that information might be shared with others. Others express concern as to how mental health information will be used in medical settings, secondary to perceptions that medical professionals are less sensitive about privacy concerns or may use the information in an insensitive manner. These provider beliefs continue, despite research that shows that team care results in improved outcomes, particularly in chronic disease management (Wagner, 2000).
Time Constraints: Busy schedules are both a perceived and real barrier, particularly in light of the reality that neither party receives reimbursement for time spent collaborating. Unfortunately, busy medical and mental health professionals can be very difficult to reach, expanding the time it takes to make collaboration happen. Yet, those professionals who take the time to develop an ongoing relationship report that they feel the time is well spent. A 5 – 10 minute consultation can save enormous time and frustration in patient care encounters, providing much needed contextual factors in treatment and ensuring that both providers are on the same page. Devaluation of mental health input by medical professionals: Mental health professionals also express concern that their input is not valued by medical professionals. In the 2006 APA survey, one respondent expressed this common concern by stating, “Most physicians seem very impatient when they are contacted by phone, even though I keep the contact short, organized and try to speak their language.” (Ruddy, Borresen & Gunn, p. 33). Clearly, medical professionals fall along a continuum of interest in the interplay of mental health and physical health, and in the level of respect they have towards mental health professionals. Yet, many mental health providers would be surprised to learn that a survey of family physicians indicated that 13.5% already have mental health professionals providing services in their office, and an additional 60.2% indicated they value collaborative care to the point they would consider having an in house mental health professional (Chantal, Brazeau, Rovi, Yick, & Johnson, 2005). A significant percentage of primary care providers so value mental health input they either have, or are interested in having, a mental health professional as part of their team.
Routine Collaboration Practice and Clinical Strategies
Establishing professional relationships with specific primary care professionals greatly mitigates most of the barriers to collaboration. It is easier for a mental health professional to trust that sensitive information will be managed appropriately when they know the medical provider from previous collaboration. Established collaborators know the best methods and times to reach one another for consultation, reducing the time barriers. Finally, a medical professional who engages in an ongoing collaborative relationship obviously values the input of the mental health professional, and likely will encourage patients to seek services from the mental health professional(s) who they know.
So, how does a mental health professional go about contacting primary care professionals to set the stage for collaboration? This section reviews specific strategies for creating and maintaining collaborative relationships. A more specific review of these strategies, including forms that facilitate collaboration, can be found in The Collaborative Psychotherapist (Ruddy et al., 2008).
Initiating Collaboration: Creating Opportunities
The easiest way to begin to establish collaborative relationships is to reach out to the primary care providers of current and recent patients. Phone contact may seem the most direct, but calls can be frustrating because it can be so hard to connect. Also, in many primary care offices, front desk staff view themselves as “protectors” of the providers’ time and may make direct contact a challenge. Unfortunately, this combination can make even the most motivated mental health professional throw up their hands, or at least feel highly unwelcome. The first time you attempt to contact a potential partner in collaboration, send a letter of introduction that very briefly reviews information about the patient you share including diagnosis, length and course of treatment and the anticipated termination date. Indicate a desire to collaborate, and that you will contact the provider by phone in short order. Ask them to notify the front desk that you will be calling so they can put the call through. Also, ask that they leave you a voice mail if there is a specific time or alternate phone number (e.g., the office’s “private line”) that would facilitate connecting. It is critical that the letter is no more than one page.
A few days after the provider would have received the letter, place a phone call. Do not take it personally if the provider is not anticipating your call or does not remember your letter. While all incoming patient care documentation is reviewed by a provider before it is filed, the incoming documentation in a primary care office is voluminous. Each primary care provider has primary responsibility for literally hundreds (and in very busy practices, thousands) of patients. It is not realistic to expect the provider to remember every paper they review. So, why bother with a letter? It increases the likelihood that the call will be productive. If the patient regularly visits the provider, or if the provider had concerns about the patient or initiated the referral, they are much more likely to remember the specifics.
Just getting through to the primary care provider can be a struggle. There are a few strategies that can help and these can be seen in Table 7.
Follow up the phone call with a brief note thanking the medical professional for their time, documenting the patient information that was discussed in the call, and reviewing the level of collaboration that will follow. Again, include business cards with this letter to facilitate further referrals.
It is imperative that you follow up with the primary care professional in the way that was discussed during the call. For many clinical presentations, a letter at termination is sufficient. This is true for situational stressors (e.g., divorce, job loss, etc) and when the patient does not have any ongoing health concerns or does not take psychotropic medication. Regular updates should occur for patients who obtain psychotropic medications from the primary care professional, or who have chronic health concerns. When and how more intensive collaboration occurs will be reviewed in a later section.
Establishing a Collaborative Relationship
Simply collaborating on one patient is unlikely to establish a collaborative relationship, particularly when little follow up is needed. There are a number of strategies you can use to assess the medical professional’s interest in collaboration, and to create other opportunities for establishing an ongoing relationship with them. These can be summarized as follows in Table 8 and are discussed in more detail subsequently.
First, try to get a sense of how interested the medical professional is in establishing a relationship. If they never refer to you again and want only notification of termination, they may not be terribly psychosocially oriented, or may already have a mental health professional to whom they refer. Use your sense of how receptive they were to the initial call to gage interest in collaboration. If you see that you get more referrals from that provider, the sharing of multiple patients creates the opportunity for greater collaboration. Also, if you share a particularly challenging patient situation and communicate often it is likely a relationship will develop.
Try to focus on medical professionals who regularly refer for mental health services, appear to value and focus on mental health and psychosocial concerns in their practice, and want to collaborate. All three of these characteristic fall on a continuum, and the trick is to assess these characteristics and adapt your collaboration style to the needs of the primary care provider. Some primary care providers don’t like managing mental health issues, but recognize they are important. These providers tend to make a lot of referrals (rather than trying to manage the situation themselves), but may not want to collaborate extensively. Connect with these providers by emphasizing your availability and willingness to inform them of the care and involve them directly only when necessary. Some primary care providers enjoy psychosocial aspects of care, and may have even chosen primary care because of the centrality of psychosocial issues. They may make a lot of referrals, or may try to manage situations on their own. These providers sometimes struggle to “let go” of patients whose needs exceed their training, and may realize the problem too late. Connect with these providers by offering to provide pre-referral consultation to help them manage situations and to determine when a referral is necessary. Also, they are likely to want more information from you regarding the mental health care, and may want more direct involvement. Some of these providers even specialize in helping very complex, challenging patients. It can work very well to establish a relationship with such a primary care professional by providing intensive collaboration such as that described in the “intense collaboration” section to follow. At the other end of the continuum there are primary care providers who basically choose to ignore psychosocial issues. These providers are simply not good candidates for establishing a collaborative relationship. They are unlikely to generate referrals or to want to collaborate. To be fair, the mental health professional who largely ignores health issues and collaboration with medical professionals is far more common than the primary care professional who ignores psychosocial issues and collaboration with mental health professionals!
When you have identified a primary care professional who seems interested in collaborating, ask if they would like to meet in person to discuss working together more in the future. Offer to bring lunch to their office. Depending on the size of the office consider bringing lunch for all of the providers and support staff, since it is an opportunity to network with all of them. Recognize that support staff often facilitates referrals and having a personal connection with them may be beneficial. It is common sense that providers are going to be more comfortable referring to a mental health provider they’ve met, especially given the reality that personality and social skills are so much of what facilitates a connection in the early stages of psychotherapy.
During this meeting ask the providers if they have any other challenging patients they would like to discuss. With both providers and support providers describe your practice (focus, philosophy, hours, insurances etc.). Don’t be surprised if the support staff suggests patients to discuss because they are often aware of which patients wreak havoc in the office. Also, expect that people will come in and out at their leisure while you’re there. Primary care offices tend to be very fluid places, even chaotic compared to mental health settings. So, while you may bring lunch at noon, the support staff may come in shortly thereafter, with providers coming in around 12:30 as they finish their morning session. Some people may come in, grab food and leave, others will spend some time. Clearly you will spend time with the provider with whom you’ve shared patients. They may be able to encourage their colleagues to give you some time, also. Within a given practice different providers may have very different styles regarding psychosocial issues and collaboration, so don’t be surprised when the practice partner of a great collaboration partner won’t give you the time of day. However, because most primary care professionals do try to provide biopsychosocial care, it is unlikely that all of the providers in an office will be disinterested.
Building a collaboration network via shared patient contacts takes time. Anticipate spending about thirty minutes per new patient to initiate contact and determine the medical provider’s interest in collaboration. Following through from that point can take very little time, if collaboration is part of your routine. However, each new referral is an opportunity to find a partner in collaboration. The thirty minute investment is a small price to pay to slowly build a cadre of teammates in clinical care who will refer to you, and work in tandem with you to provide optimal care for shared patients.
Other Strategies for Building a Collaboration Network
Another factor to consider as you seek potential partners in collaboration is simple geography. If you are in an office park look at the directories of all of the buildings for both primary care and specialists who might need to refer patients. Make a list of all of the primary care offices in a ten mile radius of your office (more in rural areas). Patients generally want to seek care close to home, so the geography matters. Again, start with a letter of introduction and follow up with a phone call. When you don’t share any patients with any medical providers in a given practice it might be more productive to call the office manager rather than one of the providers. The office manager has a sense of the providers in the practice and may be able to advise you if the providers are likely to be interested in establishing a relationship with a mental health professional. Emphasize that your office is close by, which insurances you take, and your willingness to collaborate. Non-primary care specialties most likely to need to collaborate with mental health professionals are endocrinology (diabetes), cardiology (post cardiac care depression, anxiety disorders and lifestyle modifications), infertility centers (depression and marital stress), pain centers (depression and pain management) and pediatric chronic disease specialists (cystic fibrosis, etc.). Often, cancer centers, infertility centers and pediatric chronic disease centers have mental health professionals on staff, but this is not always the case. If the office manager or medical professional seems interested, offer to visit the office to discuss opportunities for further collaboration. Keep in mind that specialists fall along the same continuums as primary care providers in their interest level and skill in dealing with psychosocial issues and collaboration. Assess these factors and adapt your approach to specialists in the same way as you would for a primary care provider.
If you have an area of specialty that might be of interest to medical providers, contact their local or county professional organization and offer to present on the topic. The topic does not necessarily need to be “health psychology” topics. For example, you might make a presentation to pediatricians focused on attention deficit disorder or learning disabilities. Depression and anxiety management might be appropriate to a family medicine or internal medicine audience. Of course, the presentation should be catered to a medical audience and ideally be very interactive rather than didactic. Co-presenting with a medical colleague with whom you already collaborate is ideal because it creates the opportunity to discuss how sharing care has been beneficial to the medical provider and his or her patients.
If you are actively involved in your own professional organization, reach out to medical providers in your area who might be willing to present on a topic of interest to your mental health colleagues. Any kind of “cross pollinization” between mental health and medical professionals has the potential to create greater collaboration. At the very least it creates opportunities for medical and mental health people to interact.
Making Collaboration Part of Routine Practice
Collaboration starts during clinical consultation with patients. The first step is to integrate questions regarding health, medical care, and personal and family medical history to create a full-person assessment. This is a significant expansion of the interview focus for many mental health professionals. Some mental health professionals may be uncomfortable asking questions about health, fearing that the patient will think they are trying to practice medicine without a license. However, simply gathering a personal and family health history is in no way diagnosing or treating medical conditions. This information is important to set the stage for integrated, holistic care from the very beginning of care. Questions about health assess not only if the person seeking care may have health issues, but also assess if familial health issues are relevant to the presenting concern (e.g., caregiver stress). Basic health information such as chronic medical conditions, troubling physical symptoms, and a medication list can help the mental health professional determine the degree to which health concerns should be a focus. Patients should be asked when they last saw a medical provider, and the date of their most recent comprehensive physical. If they have not had a general physical exam in the last 12 – 24 months they should be encouraged to schedule one. Overall, the goal is both to help patients recognize the interplay between their mental health and overall physical wellness, and to ensure that the mental health professional is aware of all relevant health concerns.
Intake forms should include information about the patient’s medical providers, including the name and number of their primary care provider. Some patients will indicate they do not have a primary care medical provider, and this should be discussed. Obviously, mental health professionals must obtain consent from patients before contacting medical professionals. When patients have an established, comfortable relationship with a primary care professional this is rarely a problem. Preface the request for the release of information with an explanation of the reasons collaboration can enhance care, and clarification about what information will and will not be shared. Explore any concerns the patient may have, while ensuring that the patient does not feel pressured in any way to agree to the release. Again, this dialogue serves multiple functions. It is helpful for a mental health professional to know the patient’s prior experiences with helping professionals. Have they found these interactions helpful or unhelpful? Have there been any critical incidents or breaches of trust that might affect the development of a therapeutic alliance between the mental health professional and the patient? Patients who balk at a request to release information to their primary care provider may have had negative experiences that could be relevant to the development of a working relationship with the therapist. Additionally, this dialogue serves to clarify to the patient what will and will not be shared with the medical professional. All information exchange should occur on a “need to know” basis. In other words, sensitive information irrelevant to the patient’s medical care should not be communicated. When patients express concern about the type of information that will be shared, the mental health professional can reassure them that they will share only that information the patient has approved.
One way to clarify information exchange is to specifically discuss collaboration communications during clinical encounters. For written communication, co-create letters during clinical encounters to reassure an anxious patient regarding the information exchange. This exercise serves a therapeutic purpose as well, because it creates an opportunity to discuss the focus of therapy and review the patient’s progress. Co-creation of a letter might occur something like this (See Table 9):
The resulting letter might be something like that seen in Table 10.
Using in-session time can significantly reduce the amount of time such a letter takes to create. In ongoing cases, or very simple presentations, a form letter can be used. Creation of such form letters further saves time and streamlines communication. The information found in Table 11 is critical to include in letters. Brevity is the key; only exceed one page in very complicated situations.
Communication can occur via letters, scheduled phone consultations, or e-mail, with the appropriate HIPPA protections in place. As electronic health records become more commonplace, they may well facilitate communication and information sharing (Richards, 2009).
Even in the most basic of presentations it is critical that you tell patient’s medical professionals when treatment has terminated. The medical professional needs to know that care has stopped. When the termination is not mutually agreed upon, letting the medical professional know the patient has stopped treatment allows him or her to reach out to the patient and try to understand why they have decided to discontinue therapy. Depending on the situation, they may encourage the patient to return to see you, or another provider. If the patient does not want to continue therapy, or cannot for financial or others reasons, the medical professional can ensure that the patient has some kind of regular follow up and support to help them maintain therapeutic gains. This example of a letter regarding an unplanned termination can be found in Table 12.
When the termination is agreed upon, the medical professional can offer to see the patient some time after therapy has ended to ensure that they feel comfortable with the support of psychotherapy. Also, they can be alerted of “early warning signs” that the patient is having difficulties again. The letter should briefly review the referral issues, length of therapy, primary focus (including any health related issues), status at termination, and “warning signs” of relapse. Table 13 shows a sample letter for a planned termination.
Making collaboration routine helps you develop and maintain collaborative relationships with medical professionals in a time efficient and effective manner. Most mental health professionals find that these types of letters and communications take very little time but have great benefit. It simply makes sense that patients benefit when their medical and mental health professionals are on the same page, and are aware of what the other is doing for the patient’s benefit. Each of the examples here are pretty typical mental health presentations – and each letter illustrates how simple information exchange can improve care. Ms. Frank was worried that her doctor would be mad at her because she wasn’t effectively managing her diabetes, and the therapist’s letter gave her a way to express her concern indirectly to her doctor. Mr. Simpson had a very frightening physical symptom secondary to anxiety – the teamwork between his therapist and medical professional helped him differentiate palpitations from a heart attack, and helped him commit to more proactively managing his anxiety. While cost reduction benefit research is a bit murky, Mr. Simpson’s case is the kind of anecdotal evidence that mental health professionals cite as how collaboration may reduce overall healthcare costs. Six psychotherapy sessions are much cheaper than multiple trips to the emergency department and the ensuing workups. Further, if Mr. Simpson’s anxiety difficulties return, referral back to the therapist should be relatively easy.
Intensive Collaboration
Occasionally, letters simply don’t allow for the kind of give and take discussion and sharing of ideas that facilitate optimal care in complex clinical situations. This section reviews the types of presentations that necessitate more intensive collaboration, and strategies and techniques for collaboration and consultation in these complex situations.
Clinical Presentations that Need Intensive Collaboration
There is hefty medical literature outlining the various characteristics of “challenging” patients (Krutitzky, 1996; Murtagh, 1991; Nyman, 1991). More recently, literature has focused on “patient complexity” and attempts to create a vocabulary and set of strategies for providing complex patients with optimal primary care (Peek, Baird, & Coleman, 2009). Unfortunately, medical professionals get little training in strategies to help them be more effective with patients with complex problems who don’t respond well to typical care. They are trained to interview a patient, create a differential diagnosis, order tests or treatments that will help them rule out or rule in various diagnoses, convey this plan to the patient who will then enact the plan and get better. At least, that is how it is supposed to work. This model breaks down in any number of situations. The following is not an exhaustive list, but gives the reader the general sense of the types of situations and patients that stymie medical professionals (See Table 14).
While this is not an exhaustive list, it does encompass most of the types of patients that are frustrating for primary care professionals. Of course, a review of the list reveals that these are the same patients that are frustrating to mental health professionals. Their complexity, chronicity, and the high level of skill necessary for optimal care make them a challenge under the best of circumstances. A team approach to these patients lessens the burden for any one person, creates an ally in providing care, and can create a genuine bond between providers as they help each other help someone truly in need.
Intensive Collaboration: Strategies and Techniques
How does intensive collaboration differ from routine collaboration? In short, intensive collaboration necessitates a team approach, where the medical and mental health professional consult each other as they plan and implement care to ensure not only that the other knows what they are doing, but also that the approaches being used complement each other. In contrast, in routine collaboration most of the communication is simply to inform the other party what has occurred in treatment. Obviously there is a continuum of collaboration, but this sense of shared, team care is the critical difference between the two approaches. Pre-referral Collaboration: In an established collaborative relationship the medical professional may occasionally ask for assistance before they make a mental health referral. This is common when the patient can’t or won’t seek psychotherapy, or when the medical professional is attempting to determine if a psychotherapy referral is appropriate. Sometimes medical professionals struggle with a patient and simply need the input of a professional who understands behavior, relationship patterns, and behavior change strategies. In these consultations try to clarify the exact consultation question. Recognize that medical professionals sometimes just want empathy for the difficulties of caring for a particularly difficult patient and acknowledgement that they are doing a good job. Unsolicited suggestions can be perceived as criticism, so tread carefully. These dialogues illustrate these challenges as displayed in Table 15.
In the first dialogue the Dr. Howe offers some empathy, but quickly addresses the likelihood the psychotherapy referral is going to fail. Since this is the reason for Dr. Jenkins’ call, this statement (although likely true) puts Dr. Jenkins a bit on the defensive and questions the very reason for the call. Also, Dr. Howe jumps into offering strategy without hearing more about the patient. Again, this could make Dr. Jenkins feel defensive or criticized. Finally, Dr. Howe doesn’t seem to want to continue to dialogue when it is clear that the phone call is not going to yield a referral in the near future. Dr. Jenkins could interpret this to mean that Dr. Howe only wants to help him when he can get a referral out of the situation.
In contrast, Dr. Ryan offers multiple empathic statements about how frustrating and disruptive this patient can be. He seeks more information about the medical professional/patient interaction to see if he can discern a pattern. Then, he non-judgmentally describes the pattern. This review of the pattern both establishes that he understands the situation, and that the situation is a two-sided interaction in which Dr. Jenkins has a role. He asks if Dr. Jenkins is seeking ideas and strategies before he offers them, and clarifies that he may not have an easy solution. Both strategies are paired with a rationale, and empathy for how challenging it can be to break a pattern. Dr. Ryan then addresses the desire for a referral, and the reality that this patient is probably not going to follow through right now. He emphasizes his willingness to provide further consultation, even in the absence of a referral, and offers a strategy that might facilitate the referral. This dialogue illustrates a few “cardinal rules” of pre-referral collaboration as can be seen in Table 16.
Post-Referral Intensive Collaboration Strategies
The need for intensive collaboration may not be obvious at the time of referral, or you may not have an established relationship with the patient’s provider before you begin to work with them. This is one reason that some level of collaboration with all patients from the very beginning of care is a good idea. It allows you to get the primary care professional’s perspective, which may indicate that the patient has complex issues. Also, it sets the precedent for ongoing collaboration as your normal practice, so the patient does not interpret the collaboration as something outside the norm. Primary care professionals are likely to welcome collaboration regarding their challenging patients. They may not know exactly how you will be able to be helpful, but they likely are seeking assistance.
Just as with routine collaboration, begin by talking with the patient’s medical professional to determine the frequency and methodology of communication. If you sense that the patient will need intensive collaboration but the medical professional does not engage at the outset, use your judgment as to how much to push the medical professional. In the context of an established relationship you can explain why you anticipate that regular communication will be helpful. Without an established relationship it is likely best to mention that you have needed to communicate more for patients like this in the past, but take a “wait and see” attitude. Primary care medical providers tend to be very pragmatic, so will accept greater communication when it becomes clear to them how it can help them provide better care and more optimally manage a challenging patient.
Since intensive collaboration entails extensive communication it helps to have multiple means of contacting one another. E-mail can be very helpful in this regard as it is more conducive to idea sharing and dialogue than letters and does not require that both providers be available at the same time as with a phone call. Ensure that your e-mail settings are consistent with HIPPA regulations.
Often the focus of the collaborative contacts is similar to routine collaboration. The focus may include symptom profile (psychological, psychiatric and medical), adherence to medical care, and impact of issues on functioning and relationships. When appropriate, explore the relationship between the medical professional and the patient. This helps you assess if there are medical professional/patient interaction problems and if the medical professional is open to discussing how to improve the relationship or work with the patient differently. You must tread carefully here to ensure that the medical professional doesn’t feel criticized or blamed for problems. Again, starting with empathy for the challenges of caring for complex patients, and recognition of the effort and skill the medical professional has used to this point reduces the likelihood that the medical professional will feel criticized. Patients often complain to mental health professionals about the medical care they receive. Be aware they often complain about the mental health care system and mental health professionals to medical professionals, as well. Be particularly careful about triangulation during intensive collaboration, especially if there is tension or frustration between the medical professional and the patient. If the patient has personality issues they may try to “split” providers. Regular dialogues with the medical professional will help you gage their level of frustration and the degree to which they’re willing to alter how they interact with the patient. These opportunities for a “reality check” on the patient’s reports of their medical encounters also can help steer a dialogue with the patient about their own role in any difficulties, and how they might work with the medical provider differently in the future.
Occasionally it becomes clear that the medical professional is burned out working with a particular patient or that there is a poor working alliance between the medical professional and patient. These circumstances are difficult if you don’t have an established relationship with the medical professional, because they may not be open to discussing the problem and potential solutions. However, when you do have an established relationship you may be able to serve a critical role in either improving the relationship or helping the medical professional and patient realize it is time for a transfer of care to a new medical professional. The latter is rare, but it does occur. Usually, the medical professional and patient are relieved when their conflict or tension is confronted and they can agree to work together differently or part ways. Given the continuum of skill sets medical professionals have regarding complex patients you may encounter situations where the medical professional is “in over their heads.” Gently probe to assess the medical professional’s level of awareness of the problem and their level of commitment to working with this patient. Medical professionals usually are aware when things are not going well and welcome suggestions. Often, if a transfer of care is warranted, both the medical professional and patient want to end their working relationship.
The situation is a bit more difficult when the medical professional is burned out on the patient, but the patient has little to no insight regarding the situation. Even very skilled, compassionate medical professionals can reach a point that they just feel unable to continue working with a particular patient. Also, some offices have specific rules about patient behavior towards staff that may result in a patient with emotional regulation or anger management issues to be dismissed from the practice. Most primary care offices have very specific protocols for patients for whom they prescribe narcotic medications and dismiss patients who do not follow the protocol. When a patient needs to change medical providers because their current provider is unwilling to continue to work with them, therapy can both support the patient through this loss and/or perceived rejection, and help them prepare to work with a new provider more effectively. The medical professional/patient relationship is likely a microcosm of the patient’s relationships with others. As such it can serve as a catalyst for discussion of the patient’s relationship difficulties in other arenas. Although these situations are challenging they highlight how much collaboration can help complex patients, and how a lack of collaboration could be problematic. Finally, consider scheduling a joint appointment with the medical professional and patient. While these appointments can be difficult logistically, the upfront time and effort can save enormous time and frustration. Joint appointments can focus on critical relationship issues between the patient and medical professional, new diagnostic information, treatment decisions and planning, information dissemination to the patient and family, adherence to treatment plan, lifestyle modification, or simply “check-ins” during protracted mental health treatment. Before suggesting a joint appointment to the patient, discuss the idea with the medical professional to ensure he or she is interested in having a joint appointment and to determine what the focus of the appointment should be. Then, suggest the appointment to the patient to see if they are willing. Patients generally welcome the opportunity to meet with their “team” together. Help the patient determine their desired focus for the session, and who they want to include in the meeting. Try to overtly dovetail each participant’s agendas to ensure that all will be addressed during the appointment. Schedule the session as the first appointment during an office session for the medical professional, to ensure that they are able to start on time. Realistically, these sessions almost always occur in the medical setting. Ideally, spend a few minutes alone with the medical professional before the meeting to review the focus of the meeting. Agree on who will “run” the meeting (usually the mental health professional). During the meeting be very mindful of time, and ensure that all tasks that emanate from the meeting are assigned specifically to one person. Document the meeting closely and review your documentation with both the patient and medical professional. Collaboration at the Larger System Level
Integration of Mental Health Services into Primary Care
It is becoming more common, especially within the public health system and military, for mental health professionals to serve an integral role in primary care (Robinson & Reiter, 2007). Definitions and implementation of “integration” vary widely and fall along a continuum ranging from basic co-location of providers, to very structured protocols for team based care (Doherty, McDaniel, & Baird, 1996; Wulsin, Sollner, & Pincus, 2009; Veterans Administration Healthcare Network, 2005). A growing outcome literature examining different models of integration with various populations shows positive trends for integrated care (AHRQ, 2008; Blount, Schoenbaum, Kathol, Rollman, O’Donohue, & Peek, 2007). However, a description of integrated primary care is beyond the scope of this document. The interested reader is referred to Behavioral Consultation and Primary Care: A Guide to Integrating Services (Robinson & Reiter, 2007) and Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention (Hunter, Goodie, Oordt, & Dobmeyer, 2009). References
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