Bob Van Oosterhout

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Article written for MidWest Clinicians Network Newsletter, Spring 2008

Behavioral Health and Primary Care Integration under One Roof:
Advantages of Working down the Hall

I've been doing counseling for thirty years and have always placed high value on communication with medical providers. But, because of time limitations and difficulty reaching people, it was limited to an occasional phone call, letter, or more often, voice mail message. Getting releases and playing phone tag could delay communication for weeks.

When confronted with medical concerns, I would suggest that a client contact a physician but too often they would get too busy or simply forget. Even when I worked in a hospital, the medical providers were in another wing and we rarely communicated or collaborated about patients outside of formal meetings.

It is a whole different world when counseling takes place down the hall from primary care. Being onsite with an informal network of co-workers I know, trust, and see on a regular basis has brought the effectiveness and quality of care to whole new levels.

Working down the hall makes it possible for brief informal updates about patient concerns, creates increased opportunities for collaboration, and makes it possible to provide immediate intervention or appointments when needed. We respond right away when there is a mental health crisis in a treatment room and medical providers are available when serious physical symptoms become evident in the counseling office.

Recently during a counseling session a woman who tends to ignore her own health while caring for her ill husband complained that she was feeling tired and nauseous with chest pain and abdominal discomfort. Instead of encouraging her to call her doctor for an appointment and hope she followed through, I walked with her to Urgent Care where she was examined immediately. She was transferred to a hospital where she had emergency surgery the next day.

Primary Care providers come to our door when there is a mental health crisis in their unit. The most common issues involve panic attacks, suicidal risk, or agitation. We are also called when a patient seems hesitant to make a much needed counseling appointment. A brief intervention usually calms the immediate crisis and helps patients understand their symptoms and concerns while providing a plan for insuring safety and management of short-term issues. They leave with a sense of relief, new understanding, optimism, and a follow-up appointment. I would estimate that at least thirty to forty percent of patients who providers recommend for counseling fail to schedule or show up for the first appointment. The percentage of those who keep appointments after I see them in Urgent Care or the medical suites is near 100%.

One of our medical providers saw a patient who was in severe pain with irritable bowel syndrome. He had not been following his diet or taking medication, was suicidal and in deep distress about a recent loss and severe financial stress. I was able to help him to let go of some built up tension, identify reasons for hope, and understand the mourning process. Our dietician was available and she provided a list of foods he could eat along with a plan to manage his diet. We walked back down the hall to his medical provider who prescribed appropriate medication, which he agreed to take. A few weeks later, he was pain free, working on a regular basis and feeling optimistic about the future. It could take that long just to get appointments and evaluations coordinated when I worked in a stand-alone counseling center.

A client, who had recovered from panic attacks and was doing well, reported increased anxiety when she began to exercise at a local gym. I spoke with a physical therapist who I often see in the lunchroom and asked if I could bring her in to watch what was happening while she worked out. It became immediately clear that she was building tension as she exercised by pushing herself too hard. The increased tension caused her anxiety. I showed her how to eliminate the pattern of tension she had developed and the anxiety disappeared.

A middle-aged woman told me her husband was having a severe reaction to his medication but refused to call his doctor. He continued to work as a truck driver even though he had fainted was feeling dizzy. She agreed that he would be likely to discuss his problem if a nurse called and asked how the new medication was working. A brief conversation with a medical assistant after the session led to resolution of a potentially life-threatening situation.

I work with a lot of people who suffer from chronic pain or struggle with Post Traumatic Stress. Treatment is much easier and more effective when all providers are on the same page. I have taught medical staff how to deal with patients who are having severe flashbacks from PTSD and let them know what to expect before they see someone who may be particularly vulnerable or at risk for medication abuse.

Medical providers help me learn to monitor side effects and medication compliance more effectively while the information I give them provides a clearer picture of what's been happening between medical visits. When a referral is made in either direction, a brief consult gives each of us a better understanding of needs and concerns before the first appointment. These conversations usually last one to five minutes and take place between appointments or when one of us walks by the other's open door.

I don't hesitate to call a provider or leave a counseling session for a brief consult when there is an immediate health concern. If a client brings up concerns about medications, I can pick up the phone and a new prescription can often be ready before the end of our session. Since we have a pharmacy on site, the client leaves the building with new medication in hand.

Another advantage to doing counseling in a primary care setting is access to medical information. It is surprising how little some patient's recall from medical visits. I have provided reassurance to a lot of clients by picking up the phone or walking down the hall to clarify an issue or concern. Information about side effects of medications or the implications of new symptoms are available whenever I need them.

We have begun the transition to electronic medical records and plan to design systems for streamlining communication between behavioral health and primary care providers. Specifically we want to design brief reports that track symptom and compliance data that can be collected at counseling sessions between medical appointments. We also want to create summaries of interventions and progress in counseling to quickly update providers before medical visits. Although these will likely be very helpful tools, they will be no substitute for the informal network of trust and communication that we have established simply by working together in the same building. The integration of Behavioral Health and Primary Care has tremendous potential for improving patient care and it works most effectively when all services are under one roof.

Bob Van Oosterhout, MA, LLP, LMSW