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The Case of Gina - How Integrated Med/Psych Care Actually Works
Published Tuesday 04 of November, 2014
NHMH’s goal is to ensure that patients in primary care have both their medical and behavioral-emotional conditions addressed together in a coordinated fashion, which is what most patients/consumers seek. The collaborative care model is the most successful example of integrating behavioral health services into primary care. Here’s what integrated care actually looks like for you, the patient:
Gina is a 54 year old single female, non-smoker who weighs 285 lbs, and lives alone in as subsidized housing. She has been a patient at Clinic A for many years and comes in at least once a month. She wears clothes from second hand stores including poorly fitting shoes and frequently unmatched socks. Her problem list includes obesity, diabetes, high blood pressure, arthritis of the knees and hips, and depression.
Gina’s primary care team has had a difficult time engaging her in care and helping her reduce her blood pressure. She has trouble walking because of her arthritis and her weight. She says that she cooks for herself in her apartment and denies having a sweet tooth. She has been offered a referral to the nutritionist, but says she knows what to eat. She claims to monitor her blood sugar at home, but seldom brings in any record of the readings. When asked what numbers she gets, she waives her hand dismissively saying, “Oh, after I eat it always goes over 200 or so.”
Gina has a superficial jovial appearance and generally deflects suggestions for behavioral change with comments like, “Oh, we tried that once, but it didn’t do anything.” She has been on a moderate dose of an antidepressant for years, which she doesn’t want to stop, and her questionnaire screen for depression is consistently over 12 (a score of 10 or more suggests a high likelihood of major depression), is hard to interpret because of her jovial affect and humorous acceptance of her symptoms. She has never followed through on referrals to psychiatry despite the care team’s best efforts, stating that she doesn’t have coverage, the psychiatrists are too far away, they don’t know what they’re doing, and she doesn’t really need help.
The primary care team is concerned because her risk of a cardiac event is very high, and they are frustrated because of her poor blood sugar control and elevated blood pressure are preventing them from meeting the clinic’s quality of care standards.
Collaborative Care Introduced:
Because of a change in public transportation, Gina is forced to transfer her care to Clinic B where the doctors have integrated behavioral health care into the primary care setting using the Collaborative Care Model. The team consists of a social worker present in the clinic daily, as well as a Masters-level therapist who is on-site several half days weekly and who works in close association with a psychiatrist who is off-site but consults by telephone.
On Gina’s second visit to the new clinic, the social worker spots her during a care team meeting and encourages the physician to bring Gina to her office after the visit, to introduce them. In the initial conversation, the social worker is able to schedule Gina to come back and spend an hour with her in the clinic the following week. During that conversation, and several others that follow over the next month, the social worker discovers that Gina was sexually abused as an adolescent. She is able to connect Gina to a specialized counseling resource for her in the community. The social worker also introduces Gina to the female therapist at the clinic, and Gina keeps the appointment. In that encounter, the therapist, in collaboration with a consulting psychiatrist, suggests a minor change in Gina’s medications, which the primary care team makes, and sets up a series of behavioral therapy sessions that focus on her depression.
The primary care team continues to work with Gina on her diabetes management, cardiac risk factors, and depression, while the behavioral health team provides talk therapy interventions. All members of the integrated care team are able to view each other’s documentation in the electronic health records. Over the course of the next year, Gina’s engagement in managing her diabetes gradually improves. Her blood pressure, which had been consistently over 140/90, starts to come down closer to the target of 130/80. She begins walking daily, and starts losing weight. The care team notices that the depression questionnaire screen scores begin to come down slowly.
Gina’s untreated depression and her underlying post-traumatic condition resulting from child sexual abuse were barriers to the care team’s effort to engage her in behavioral essential for the effective management of diabetes. Her health was not improving and much of the care team’s effort was unproductive. The behavioral health team’s intervention reduced that barrier, and allowed Gina’s care team’s efforts, along with hers, to have their intended outcome.
This is the kind of collaborative physical-behavioral care we should all be receiving in primary care. If you are not, TELL your doctor you would like to see him/her begin collaborative care as soon as possible. To make integrated care a reality, doctors need to hear from their patients!
Source: Safety Net Medical Home Initiative. Ratzliff A. Organized, Evidence-Based Care Supplement:
Behavioral Health Integration. Phillips KE, Holt BS, eds. Seattle, WA: Qualis Health, MacColl Center for Health Care Innovation at the Group Health Research Institute, and the University of Washington’s AIMS Center; 2014.
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Florence C. Fee, J.D., M.A.
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