and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Keywords
Biomedical providerBiopsychosocial model“DIY” providerPsychiatric emergenciesTriageCare algorithmDisruptive patients“But that’s the challenge—to change the system more than it changes you.”
Michael Pollan
Reflecting on our time in specialty MH, we both can recall many difficult situations. Every MH provider has gone to bed worried about a possibly suicidal patient, felt frustrated with patients who demand a lot of time without ever seeming to improve, or struggled through a conflict with a colleague. Indeed, every job comes with its own stresses, and BHC work is no different. However, the BHC who has worked only in specialty MH will face some very different challenges in PC. In some cases, problems occur that are unique to the PC setting, while in other cases the PC work will require a different approach to a problem that might also be encountered in MH. These challenges occur across the board with PCPs, patients, and the PC system itself.
This chapter discusses the most common of these challenges. We start with problems the BHC may encounter when attempting to form strong working relationships with some PCPs. Following that, we describe a number of situations where interactions with patients may be stressful. Examples include patients who have psychiatric emergencies in the busy PC setting, patients who do not improve, and patients who ask for more than the BHC can or should provide. In the last section, we talk about several issues related to systems that can frustrate and puzzle both new and experienced BHCs.
We certainly do not have all the answers for these problems, and indeed we often still struggle with them in our own clinics. What this chapter hopefully does offer readers is at least an improved awareness of challenges they may face, along with some suggestions for addressing them. Sometimes these suggestions will help and sometimes they won’t, but a word of encouragement to BHCs: you can change the system more than it changes you.
Puzzling Moments with Providers
Upon arriving in PC, most BHCs make a concerted effort to meet and make relationships with all of the PCPs in the clinic. Most will be friendly and helpful and very willing to start making referrals. Inevitably, however, there will be some who the BHC simply cannot wring referrals out of. Curiously, these PCPs are often polar opposites of each other. Some may have little interest in psychosocial issues, simply writing a prescription or referring to specialty care anything that smacks of emotion. Others may be overly interested in the psychosocial piece, preferring to handle everything themselves. These types of providers can be both interesting and challenging for a BHC to figure out.
The “Biomedical Provider”
When George Engel introduced the biopsychosocial model in 1977 (Engel, 1977), it was hailed as a revolutionary idea that would change medicine. Whereas the prevailing biomedical model of earlier times emphasized linear, cause-and-effect thinking, and a singular focus on disease, the biopsychosocial model introduced the notion that psychosocial factors are also important for medicine to study. Engel believed medicine would never fully understand and treat medical problems by focusing solely on biology, because factors such as culture, family, community, environment, personality, and emotion also influence health significantly.
Within a fairly short time, the medical community became familiar with the biopsychosocial concept and began teaching it in medical schools. However, despite this change, studies suggest the biomedical model continues to influence physician communication styles and to exert a negative impact on patient outcomes (Barry, Stevenson, Britten, Barber & Bradley, 2001). For purposes of discussion, we refer to PCPs who are influenced in such a way as biomedical providers. The BHC may have fewer opportunities to influence biomedical providers because they may be less likely to refer patients. Further, they may be less interested in BHC recommendations. Biomedical providers may seem to favor psychiatric consultation over a consultation with the BHC and may be reluctant to screen patients for behavioral problems. Their chart notes may show scant mention of the patient’s psychosocial history, which they often rely on an RN or other staff person to obtain. Following a disease model, if they do enlist the help of a BHC, the questions they are most likely to ask are, “What’s the diagnosis?” and “What medication do you recommend?” All of this may leave the BHC feeling underappreciated, not to mention perplexed about how to reach their distant biomedical colleague.
Strategies for Bridging the Gap
The good news (if it can be classified as such), in terms of improving this situation, is that the presence of behavioral issues is so widespread in PC that no one can avoid them completely. All PCPs feel the weight of them, regardless of orientation or interest. That reality opens the door to opportunities for a BHC. Most biomedical providers do include some psychological and social aspects of care in their work, and, as such, they may be amenable to influence if the right strategies are used. If a BHC can prove his value to patients and take some work off of the PCP’s shoulders, a solid working relationship is possible. Biomedical providers can actually produce a bountiful harvest of referrals, if for no other reason than they prefer to have someone else handle their patients’ behavioral issues! Strategies for bridging the gap with these providers include conducting group visits, posting metrics on PCP utilization of the BHC service, demonstrating value to the PCP, making BHC referrals a routine part of care for certain conditions, and using routine screenings to identify behavioral problems. We discuss these below.
Promote Group Visits
Group visits, discussed in Chapter 12, can provide a good avenue for connecting with a biomedical provider. Groups can be especially attractive to biomedical providers because they help patients work out problems that otherwise might be raised during individual visits with the PCP. Having a group to refer patients to takes the pressure off during individual visits; a PCP can simply refer the patient to the group for discussion of psychosocial issues. The BHC struggling to obtain referrals from a biomedical provider may also find group visits to be a boon, as patients who might otherwise never have been referred have the opportunity to get familiar with the BHC. Patients from groups will also sometimes initiate an individual visit with the BHC outside of the group, resulting (hopefully!) in positive feedback to the PCP about the BHC visit.
Groups can be especially helpful if conducted by the BHC and PCP together. Simply organizing and planning a group allow for personal interaction between the BHC and the PCP that might not have occurred otherwise. Participating in a group also gives a PCP the opportunity to learn what a BHC has to offer. If present during the group visit, the PCP can see how positively patients respond to psychosocial interventions and how much they appreciate the attention to that part of their health. Group visits may also demystify the work of the BHC, and the PCP may discover psychosocial interventions he can use during his own patient visits.
Despite all this, convincing a biomedical provider to co-lead a group visit can be a challenge. The time needed for planning is a definite deterrent, and sometimes the logistics of scheduling, billing, and other realities simply do not work out. Many PCPs (biomedical or otherwise) are also not comfortable working in a group context, as it likely was not part of their training. Some may also express concern that a successful group would make the PCP a magnet for other patients with MH problems. Yet, even a biomedically oriented PCP will often warm to group visits after trying one, so searching for ways to get a foot in the door is never a bad idea. Running a group first with a different PCP, then discussing the experience at a clinic provider meeting, may start to break down resistance.
Let the Numbers Do the Talking
Review of clinical metrics is a common occurrence in PC. Many clinics distribute reports at monthly provider meetings showing PCP performance on various measures; often these are even posted publicly (e.g., in a break room). Common metrics include the percentage of older patients on a panel who have completed a colon cancer screening, the percentage of diabetic patients with appropriate blood glucose, or any number of other outcomes of interest. The goal is to promote discussion of what is working (and what is not) and to help PCPs be aware of how their patients are doing; of course the process also promotes a bit of competition among PCPs and a bit of pressure to keep one’s numbers respectable.
Metrics on PCP utilization of the BHC service can be used in a similar fashion. Reporting these regularly, perhaps at a provider meeting or just via a report left on each PCP’s desk, can have a helpful effect on referrals. Metrics to report could include the number of BHC referrals from each PCP, the percentage of each PCP’s panel that has been seen by the BHC, the five most common problems referred by each PCP, and/or any other metrics of interest. The best strategy is for the BHC to announce at a provider meeting that she plans to start reporting some BHC outcomes and to ask for input about which metrics the PCPs would be interested in. Metrics on PCP utilization of the service can be included along with others to soften the presentation. Just as with other regular clinic metrics, this practice can provoke helpful discussions about the BHC service and exert subtle pressure on a biomedical provider to catch up to the utilization patterns of her PCP colleagues.
Demonstrate Value
A strong BHC service can be of tremendous value to a PCP. As discussed throughout this book, the primary customer for the BHC is actually the PCP. The goal is to help the PCP be more efficient and effective in dealing with behavioral issues encountered in PC. There are many ways a BHC can accomplish this. The most obvious is through direct patient care. However, a BHC can also help by taking tasks off the plate of the PCP. For example, a BHC may take care of a call from a distressed patient, help a patient request a letter summarizing his MH treatment (e.g., for a legal issue or a disability application), or review records from outside MH specialists, creating a summary for the PCP in the patient’s chart.
Helping with tasks such as these can be of great value for a time-strapped PCP, yet a BHC can generally only help with patients she has seen. For example, the BHC could not write a letter for a patient she has never seen. Thus, as a biomedical provider sees her colleagues getting help like this from the BHC, she might start to think more seriously about engaging the BHC in care so she too can benefit from what the BHC has to offer.
Develop Reminders and Registries to Increase Referrals
PC clinics are increasingly using computerized reminder systems and patient registries to guide the care of chronic conditions. These systems help increase the use of evidence-based interventions and promote comprehensive care (Bodenheimer, Wagner & Grumbach, 2002a, 2002b). As such, they have the potential to be effective vehicles for increasing BHC referrals from a biomedical provider. Consider the reminder system feature of many EHRs. Prompts can sometimes be built into an EHR so that if a PCP enters, for example, a diagnosis of depression or a patient BMI over 30, a reminder pops up recommending a referral to the BHC. The simple presence of a reminder does not guarantee a referral will be made, but it at least nudges the biomedical provider.
Similarly, many clinics use computer registries to track care for patients with chronic conditions, especially diabetes, and providers are often graded on how their patients are performing on various indices. Registries, particularly when integrated into an EHR, offer an excellent opportunity for increasing work with a biomedical provider. If a BHC referral is included in the registry’s list of routine care components, it can greatly improve the likelihood of a referral from a biomedical provider.
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