and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Electronic supplementary material:
The online version of this chapter (doi:10.1007/978-3-319-13954-8_9) contains supplementary material, which is available to authorized users.
Keywords
CCCSSMnemonic for BHC introductionLife context questions for adultsLife context questions for children and teensFunctional analysis questionsFollow-up consultsPCBH chart review toolChart note locationSOAP note“Deliberation is the work of many men. Action, of one alone.”
Charles de Gaulle
Assuming a basic understanding of the territory of PC, the operational structures necessary for supporting a BHC practice, and the theories, interventions, and measurements for PCBH practice, this chapter gives structure to daily clinical work. This is where deliberation turns into action. Hopefully this “nuts and bolts” content will complement the theoretical material of previous chapters. The goal is to begin to help the reader envision how the BHC orients patients to PCBH services and actually conducts initial and follow-up visits with patients.
Orienting Patients to PCBH Services
A good way to get the word out about BHC services is to create a brochure about the program. It can be placed in the general waiting room and/or exam rooms, where PCPs can give it to patients when making a referral to the BHC. This simple strategy can help greatly with marketing and growing a new service and also helps patients to understand the BHC’s role prior to an initial visit. Figure 9.1 provides suggested content for this type of brochure. We recommend using colored paper to catch attention and perhaps, if one’s computer skills are up to the task, adding a few eye-catching graphics.
Figure 9.1
Content for a flier introducing BHC services
Initial Consults
As mentioned in Chapter 4, the BHC provides two basic services: brief consultative interventions and pathway-related services. Brief interventions serve at least one of three purposes: preparation for a PCP appointment (PCP-prep), medication assistance, or care augmentation. Initial consults are always brief consultative interventions and may be pathway related as well. The descriptor “initial consult” may seem simple to define; yet in reality, it can be a bit fuzzy. Is the first BHC contact with a patient for marital problems considered an initial consult if the BHC has previously seen him for obesity? What about the patient seen one year earlier for headaches who is now seeing the BHC again for headaches? This is more than an issue of semantics, because the structure of an initial consult varies from that of a follow-up. Details of the differences between the two will hopefully become clear as this chapter progresses, but the most significant difference is that the initial consult includes both a functional assessment and an intervention, while a follow-up includes only the latter. Thus, determining which category a visit falls into has ramifications for the focus of the visit and the amount of time required. We will come back to this issue in a few pages, after first providing a more complete picture of the content of initial consultations.
The initial consult involves an introduction, questions about the patient’s life context, a functional analysis of the target problem for the consult, and, of course, charting and feedback to the team. The amount of time available for the initial visit determines how much detail the BHC goes into, but each component is addressed regardless of the visit length. If the visit lasts the usual 30 minutes, then completion of an outcome measure is also included; shorter visits include this when able. Figure 9.2 provides an overview of the initial consult.
Figure 9.2
Components of a BHC initial visit
The Initial Consult Introduction
Each initial consult begins with an introduction to the BHC service to ensure the patient understands the BHC’s role and what to expect from the visit. This is particularly important given the differences between a BHC visit and what patients might have experienced with more traditional MH visits. Introductions actually come first from the PCP, when she refers the patient, meaning that if the BHC has been effective in teaching PCPs how to refer, all involved may be spared from misunderstandings (see Chapter 10 for suggestions on training PCPs to refer patients). Table 9.1 provides a mnemonic device that BHCs can use to remember the critical elements of the BHC introduction to patients in initial visits. Key components include a summary of the BHC’s credentials (C), an explanation of her role as a consultant (C), the practice of charting to the medical record so that team support is possible (C), the length and structure of the visit (S), and the possibility that this may involve a single visit only (S). Depending on the referral issue, the BHC may include mention of his role as a mandated reporter. Figure 9.3 offers a scripted introduction. Obviously the wording will be modified to fit one’s usual way of speaking, but the key components of the script should be maintained.
Table 9.1
A mnemonic for critical elements of the BHC introduction in initial visits
C | Credentials |
C | Consultant role |
C | Chart to medical record |
S | Structure of visit |
S | Single visit possibility |
Figure 9.3
A behavioral health consultant’s introduction
Some BHCs may delegate explanation of BHC services to the BHA when one is available. In such cases, occasional checks should be done to assure that the BHA is staying close to the script. Some BHAs may rush through and omit parts on busy days or gradually truncate the introduction, as a service grows busier. Figure 9.4 displays a script that may be used by a BHA. Again, the wording may be changed to fit one’s usual speaking style, but the key components should be maintained.
Figure 9.4
A behavioral health assistant’s introduction of BHC services
Answering Patient Questions About BHC Services
Most patients are pleased with the availability of BHC services and have no questions, but some will. Patients sometimes ask why the PCP recommended a visit with the BHC. Sometimes this reflects a patient’s sense of stigma about seeing a behavioral health provider, but other times it is simply a matter of the PCP and patient not having clearly decided on a focus for the BHC consult. Over time, PCPs often improve their communication about a target problem, but in a new BHC service, this skill may be lacking. Regardless, the BHC should know clearly why the PCP made the referral and be able to explain that to the patient in a way that destigmatizes it. Framing the referral as a routine part of care in the clinic, done to help the PCP provide the best care, can help reduce stigma.
Less commonly, patients may express concern about information being relayed to the PCP or placed in the medical chart. To reassure patients without misleading them, a BHC can explain that her goal is simply to tell the provider what he needs to know in order to best help the patient. Regarding charting concerns, try to assure the patient that only information necessary for coordinating care will be documented and explain that the majority of BHC notation is devoted to planning and recommendations. Sometimes important issues can be conveyed to the PCP without putting them in a chart note, but it is best not to make this promise (if it is important enough to tell the PCP, it should probably be noted in the chart).
Introducing and Completing Behavioral Health Measures
At both initial and follow-up BHC visits, the BHC usually asks patients to complete a routine self-report measure. This may be accomplished in the waiting room after checking in or at the beginning of the visit (immediately following the BHC introduction in initial visits and after a brief greeting in follow-up visits). Patients usually accept this, though sometimes it helps to explain this as the BHC’s version of vitals obtained before medical visits (e.g., blood pressure, weight). In larger clinics where the ratio of BHC hours to PCP hours is leaner, a BHA might complete the appropriate assessments prior to the visit. Whether done by the BHA or the BHC, the measures are best scored prior to or in the first few minutes of the visit so that results may be shared with the patient. In the initial consult, health-related quality of life scores help inform the design of the intervention and, for patients who return for follow-up, they provide a way to assess change.
Life Context Questions
Because of the relatively short time allotted for initial visits, the BHC needs to limit questions to those that are most essential. We provide two question lists to help BHCs focus on key areas: Life Context Questions and Functional Analysis Questions. Asking Life Context Questions first often helps build rapport between the patient and the BHC. Overtime, the BHC may mix the Life Context and Functional Analysis Questions, but when first starting with brief visits, we recommend systematic use of the lists to promote efficiency.
The Life Context Questions help the BHC to obtain a quick understanding of the patient’s life situation. Knowing a little about patient resources (or the lack thereof) helps the BHC begin to formulate and prioritize possible interventions even within the first 5 or 10 minutes of the initial interview. For example, the BHC may learn that a patient referred for weight gain has a good relationship with her spouse, but detests exercise. An astute BHC will tuck this information away and perhaps circle back to it at the end of the visit by suggesting the patient go for walks with her spouse to make the exercise more palatable.
Sometimes, PCPs convey a brief summary of this information to the BHC during a warm handoff, and/or it may be available in the chart. However, neither the chart nor the PCP will have much information about patients that are new to the clinic. In either case, the interview can not only inform the BHC’s intervention but also build on what is known about the patient’s life context. This helps the team form a more holistic understanding of the patient.
Life Context Questions for Adults
Remember that patients generally expect to be asked briefly about family, home life, work, and, of course, health behaviors during a PC visit. Most often during PCP visits, this happens in a friendly, straightforward fashion. Effective BHCs mimic that style during a visit. Figure 9.5 provides a list of questions that BHCs may use to both establish rapport and identify strengths and vulnerabilities in the patient’s current life context. These are just the skeleton questions; follow-up questions are asked as needed to obtain more detail. Note that most questions are asked in a closed, rather than open-ended fashion which helps promote efficiency; but the delivery style should be conversational.
Figure 9.5
Life context questions for adults
Life Context Questions for Children and Teens
For children and teens, the life context questions can be adapted, as shown in Figure 9.6. The areas assessed are generally the same. Typically with prepubescent and younger children, questions are mostly asked of the parent(s). For younger adolescents, questions are more evenly split between parent(s) and child, giving both a chance to answer. Older adolescents often answer most questions themselves, but with the parent(s) providing additional detail as needed. These are general rules, of course, and vary depending on the nature of the problem and the parent/child relationship. Even for younger children, showing curiosity about the child’s perspective on family life, sibling relationships, playtime activities, friendships, and school is important. Figure 9.6 offers a list of areas to assess. How questions about these areas are worded will depend on the age of the child and whether the question is asked of the child or parents. As with adults, follow-up questions may be asked for more detail, as indicated.
Figure 9.6
Life context questions for children and teens
As with adults, listen for strengths and resources when assessing the life context of younger patients. Does a child with reported behavior problems at school have a strong relationship with her parents? Does the teenager who is experimenting with drugs have a specific future career goal? As with adults, the BHC can use identified strengths and resources to design interventions for young people and their families.
Curb the Urge
Many life context questions bare some similarity to questions asked in specialty MH where providers often spend an entire hour documenting the client’s psychosocial history. New BHCs often feel an irresistible urge to ask open-ended and follow-up questions regardless of need. However, with the structure provided by the life context questions and the power of practice, the new BHC can learn to curb the urge to “go down rabbit holes,” or lines of questioning that contribute little to the development of a strong intervention. With practice, 5–10 minutes should be enough to get a snapshot of the patient’s life at this point in time—and conceptualize follow-up questions that could be asked later if necessary as a part of the functional analysis. The key is to make every question count. In contrast to a traditional “intake,” where the same long laundry list of questions is asked of every patient, an initial BHC consult asks only the questions needed.
We do want to warn against an understandable mistake that many BHCs make early in their practice: allowing extra time for visits when no one is scheduled afterward. This happens when a BHC is having trouble learning brief visits or is feeling guilty about the brevity. But this can be a problem for a few reasons. For one, a patient who is allowed extra time may come to expect the same in subsequent visits and be upset if that doesn’t happen. In addition, team members will be aware of how long a BHC stays in the room with the door shut. Particularly at the start of a BHC service, PCPs are often reluctant to knock on the BHC’s door. If they find it closed often and for prolonged periods, they may stop trying to access the BHC for same-day visits. Remember also that practice makes perfect. A slow day can turn into a busy day in an instant, and if a BHC has not practiced the skills for a brief visit, he will be overwhelmed when time is of the essence. For practice, time the life context questions; make sure there is enough time left to complete a strong functional analysis and end the visit within 25 minutes. Free time in the clinic can always be used to walk the halls, give feedback to PCPs, and look for other ways to help the team.
Functional Analysis Questions
A second core task in the initial consult is completion of the functional analysis of a target problem. In the PCBH model, this is done in place of the diagnostic assessment used in specialty MH models. Whereas the life context questions help the BHC understand the larger picture of the patient’s life and how the referral issue fits into that, the functional analysis is about taking the general referral issue and narrowing it to a specific problem that can be worked with. When combined with information from the life context questions, the functional analysis questions lead one directly to formation of an intervention. We provide a little background on functional analysis here and suggest that those new to this approach consult other texts such as Clinical Behavior Therapy (Goldfried & Davison, 1994).
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