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INTEGRATED BEHAVIORAL HEALTH SERVICES

Featuring Yogman Pediatrics

This is one in a series of stories about strategies primary care practices are using to increase patient engagement. MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care, as we have recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts with the support of CRICO.

One of the key strategies we discovered is having mental health services embedded and integrated into the practice.

Many medical conditions are greatly affected by patients’ behavioral choices and mental health issues and primary care teams must often address common mental health disorders, such as depression, anxiety and substance abuse. In addition, behavioral and lifestyle issues, such as smoking or lack of exercise and poor sleep, affect many aspects of health.

By bringing medical and behavioral health services together within primary care and practicing “warm hand-offs,” the clinical team is able to ensure appropriate engagement on both the mental and general health needs of the patient – and integrate the two.

One practice that has successfully integrated mental health services is Yogman Pediatrics in Cambridge, Massachusetts. We spoke with Susan Betjemann, the social worker embedded in the practice, to learn more about their successful program:

Q: What are the nuts and bolts of the work that you do and why is it unique to be doing it in this setting?

I am a clinical social worker, trained in behavioral health as a therapist for kids and families. Being integrated into the practice essentially means I am fully part of the practice. The warm hand-off is critical because, when primary care doctors are talking with patients about seeking behavioral healthcare or making a referral or a recommendation, the rate of follow-up is low. It’s also really hard for people to track because finding the right therapist is really challenging. So, by handing them off to me, whether it’s going to be me who will see the patient in an ongoing way, or even if I’m just working with the family to make a referral and help them figure out who is going to be the right fit for them, it gives the doctor more of an opportunity to follow-up in that process.

Q: Is it literally that the doctor sees a patient and walks them down the hall and you speak with them right then and there if you’re available?

Yes, so what will happen is they’ll have a well visit, or even a sick visit with a kid. Part of my position is meant for non-clinical time, so I’m often available to meet with the patient on the spot. If that’s the case, they will truly just walk them into my office, give me a brief introduction, and I’ll either have the patient come back at the end of their visit or we’ll meet briefly and plan to have a phone call or a follow-up visit.

Q: You don’t launch into a therapy session at that moment, do you?

It does depend. A simple introduction is usually the intention. But as a therapist, it’s quite interesting because people feel so comfortable in the office and comfortable with their PCP that they’ll launch right into talking about what’s going on for their child or themselves. There are times when you have to kind of pump the brakes a little bit and say, OK, let’s make a time to follow-up on this. But it’s really helpful because it immediately gives me a sense of what’s going on for the patient and how I can be most useful and helpful. And sometimes there are things where the parent is looking for kind of quick, simple advice on something and we talk for maybe 10 or 15 minutes and that’s it, that’s the whole intervention.

Q: What are some examples of the kinds of things people come to you for?

The most common for individual therapeutic services are anxiety and depression. That’s typically what’s coming in. I do see a lot of parents around parenting issues. I like to focus on preventative work, if possible. Challenging behaviors in early childhood is a specialty area that fits with my background and my previous work and I really enjoy meeting with families around that. I’m trained in a specific intervention called “Triple P” that focuses on working with children with challenging behaviors. That stands for “Positive Parenting Program.” It’s evidence-based brief intervention for parents of kids who have challenging behaviors. We also try to apply Dr. Berry Brazelton’s approach of taking a strength perspective in working with families. We’re also working toward de-stigmatizing behavioral health. So, having folks come to me right here in the practice and the pediatrician is just handing them off, we can explain that this is no different than coming to see your doctor, that this is a different part of care, but just as important.

Q: Do you get any more extreme cases?

Certainly, but those are the ones where we might hand off to external resources. Most of the kids I see for therapy or families I work with more intensively, it’s on a short-term basis. If it feels like it’s going to be a more long-term issue or if it’s something that’s going to need more attention, then we’ll refer out. There are providers that we know in the community who we have good relationships with that I can refer them on to. For example, eating disorders, ADHD, oppositional defiance disorder in some cases, these are things I will typically refer out.  

Q: And is another one of the benefits of being integrated that you can more easily loop back to the primary care doctor?

Yes, the PCPs here are very attached to the families, and vice versa, and they like to be kept in the loop, of course, on their patients. That communication varies. If I’m not going to have a chance to see one of the pediatricians, I can send them a message through our medical record system. But oftentimes, the updates take place in person – we just find time and chat. And I really benefit from their knowledge of the family, what they know of the family dynamics, the history, the documentation that they have, it’s critical to my work.

Q: Can you give us some perspective on this term “patient engagement”? What does that mean to you?

It’s a tough term to get an operational definition. I’ve always thought of it as the patient being an active participant in their healthcare. That’s our model within the practice as well – that we’re all kind of partners in this and that the family is, of course, a critical part of that. So, it’s really the work we do together to figure out where we go from here. If the child is having a well visit and has been walked over to me because they’ve been experiencing some increases in anxiety or something like that, then it’s a collaborative decision between myself, the family or the patient, and the doctor as to where we go now.

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