Vox Medicus

This section of DOC-Line is devoted to editorials from members of the Medical Staff. If you wish to submit an editorial contact Matt Miller (matthew.miller@wchn.org)

In this edition Dr. Charles Herrick, Chairman Department of Psychiatry talks about Primary Care Providers, new screening burdens, and the value of Integrated Behavioral Health.

A man walks into a bar...

While this may be the beginning of many a joke, it’s not funny when it comes to the increasing demands being made on primary care providers (PCPs) by many of their patients. Primary care offices often feel like the local “Cheers”, managing their patients’ social and psychological distresses as bartenders do, although providing a lending ear and medication instead of a drink to ease the pain. And now CMS has instituted the PHQ-9 as a depression screening metric.

Add another daunting metric to the ever growing “quality metrics”, in addition to the patient satisfaction and productivity requirements and the bartender’s job is looking pretty attractive; and the only paperwork they have to complete at the end of the night is the bar tab.

Depression screening feels like opening Pandora’s Box. Not only you have to screen for it but CMS also requires referrals and tracking improvements in the score. How do you have a brief conversation with a patient who screens positive much less ensure a proper referral is made and followed-up on? Most PCPs don’t have the time or capability to deliver. So, how do we address the problems of proper assessment, referral, and follow-up for the behavioral health issues of patients presenting to primary care offices?

Western Connecticut Health Network Department of Psychiatry has placed a Licensed Clinical Social Worker (LCSW) in the primary care office in Newtown and soon in Southbury. We hope to branch out to Brookfield and Danbury next year. This is not just a licensed clinician co-located in the PCP’s office receiving referrals, but rather someone truly integrated with the medical team to address behavioral health problems simultaneously with medical problems. Most chronic medical conditions are driven by social factors and sustained by psychological ones. Having a clinician who understands both the social and psychological determinants of health as well as a working knowledge of linking patients up to outside therapists, social services and psychiatrists will go a long way toward addressing all the quality, patient satisfaction, and productivity concerns primary care offices are facing.

Access and follow-up have long been a problem for psychiatry. The vast majority of behavioral health clinicians in private practice are selective in the insurance plans they choose to accept, if any at all. When we hire clinicians who accept all insurances, they fill up quickly, and crowd out referrals coming from the PCPs. Finally, when a referral is made, there are a host of reasons why patients don’t follow up. They may not like the clinician; or they don’t want the service but don’t tell the provider; and finally, they don’t have the time or money; and so making a referral can be a crap-shoot.

An embedded LCSW can help with all these issues, linking up patients with the right clinicians who take their insurance and following up to see if they have connected, as well as providing brief care until the connection is made. In addition should the patient need a psychiatrist, one can be consulted and managed by the primary care office and the LCSW who has immediate access to the psychiatrist via phone. This leads to two benefits: patients’ appointments and costs do not increase exponentially, and psychiatry time becomes more accessible to more patients. Soon the network will expand access through the implementation of a telepsychiatry program.

By way of example a bearded, pony-tailed tattooed biker dude in his mid-50s with chronic pain and anxiety issues presents to the office for a refill of his medications. The staff, who are very familiar with him, suggest that the social worker be accompanied by another staff member. She declines, tells them all is well, reviews his record, including Soarian, discovering multiple ED visits for complaints of pain where he received additional opiates. She gently confronts him, informing him he will no longer receive opiates from the ED and they will work on alternative treatments to manage his pain and anxiety. He accepts her recommendations. It is easy in situations like this to take the path of least resistance, give the man what he wants and get him out of the office as quickly as possible, knowing full well a problem is being perpetuated. Now you have the staff to address problems such as these. Integrated care needs to happen now if we are going to effectively manage our patients, keep them healthy and happy, and keep them out of the ED and the hospital. Embrace integrative behavioral health care and stop feeling like a glorified bartender!