Emma Ansara is a family nurse practitioner providing primary care to patients across the age spectrum at Western Maine Family Health Center in Livermore Falls, ME. She is the clinical lead for a MeHAF-funded Integration Initiative implementation grant at HealthReach Community Health Centers in which LCSWs are embedded in the primary care setting to provide behavioral health support and limited mental health counseling. HealthReach Community Health Centers is a network of 11 federally qualified health centers serving people in more than 80 towns and cities in western and central Maine. (The patient names have been changed to protect their privacy.)
I recently met a new patient in the final visit slot of the morning. When I walked in the office, I was surprised to see Veronica, as the week before she had accompanied a well known patient, her new husband, Don at his annual check of chronic health conditions.
As a young man, Don had undergone major cardiac surgery after years of a non-specific diagnosis of gastroesophageal reflux disease (GERD). Subsequent limitations on activity had lead to a lengthy disability and job retraining that had left him frustrated and depressed. At his recent visit we spent most of the time discussing his mood. While he did not opt to pursue treatment for his depression with counseling or medications, using the PHQ screening tool, we discussed viable options and a plan for managing and monitoring his depressive symptoms.
As I started my visit with Veronica, she interrupted and said, "I know this visit is supposed to be about me, but I wanted to thank you for seeing my husband last week. I came to that visit ready to pipe up about Don's symptoms, and I could keep my mouth zipped. You really asked all the right questions, and I know we both appreciated the depression screen and how that helped us to better understand where his symptoms are or could be."
The opportunity to contribute to this blog and the timing of this visit got me thinking about the ways in which my practice has changed since becoming involved in HealthReach's Behavioral Health Integration Project. I have had the good fortune to be involved from the beginning of the project through its transition from theory and planning to implementation and involvement in daily patient successes (dare I say transformations?). Much of the research and discussion of the value of integration focuses on the outcomes experienced by patients, as it should. However, there are several ways in which my own practice has changed as the result of our Integration project. In some ways the changes are obvious; there's a new provider sitting in our primary care offices. In other ways the changes are more subtle and bring into relief some of the limitations of the previous care we were providing.
As the result of collaborating across disciplines, attending years of MeHAF Integration Learning Community meetings, and having my interest and attention more greatly attuned to mental health care in the ambulatory setting, I now use a handful of mental health screening tools regularly (PHQ 9 and GAD 7 the most). And I don't find myself using them because Medicare has recently said they would reimburse for depression screening or I am trying to earn blue ribbons through a quality care initiative. Right before our terrific social worker joined our team, I found myself starting to use the tools regularly because I thought, this is our common language. Little did I realize how EXTREMELY useful I would find them and that patients would feel the same way. I now use those tools regularly for screening, but also for symptom management. And this is what I've found: patients respond very positively and they don't feel the questions are intrusive or stiff, or cookie-cutterish. Rather, patients indicate that the questions help them articulate what they are feeling.
My increasing use of these tools means I now turn a more critical eye to the management of my depressed or anxious patients. Are the medications they are taking the right ones- should the SSRI be tapered, increased, changed? The screener is an opener to revisit the diagnosis of depression that has been sitting untouched on the problem list for years. Where before I might have felt that such questions were intrusive (or took too much time?), now I feel comfortable "going there," and patients respond to that comfort with statements like, "Please go ahead, I appreciate your concern."
The other profound change that has resulted from our efforts at better integrating primary care and mental health has been my expanding and more nuanced understanding of the mental health world. While we often discuss the difference in cultures, the reality is the two systems of care are extremely siloed, have arisen out of different reimbursement and payment patterns, and in fact speak at times two totally different languages. My commitment to improving integration for our patients is not limited to integration in our office, but also to engagement with the mental health community as a whole.
Little by little, and with the assistance of our behavioral health consultants, I am gradually learning more about this foreign land, and now am able to make referrals and leverage services that were previously unknown to me. When making referrals to mental health agencies, I now consistently encourage patients to consider case management and invite case managers into the primary care office. I make referrals for psychological and developmental pediatric evaluations where as before I simply placed them on a list for the pediatric psychiatrist where they sat for 6+ months. I now consider the state of Maine as my catchment area and, again thanks to support from the behavioral health consultants and our referral staff, I am able to better connect patient with more timely services.
I can imagine that a seasoned mental health professional looks at this list and thinks, "Goodness, does Emma not know anything at all!?" While I can offer my apologies for ignorance, and want to acknowledge that there is likely a huge variety of knowledge and practice among PC providers, I also want to illustrate in a very concrete fashion the benefits of the integration effort at HealthReach. In this day and age, when there is a shift occurring from being a culture who believes that there is a pill to cure everything, to learning that perhaps there is little benefit to the pill or indeed that they might cause harm, it has been profoundly grounding and meaningful to have additional resources, knowledge pools and networks to leverage. I would venture to say that my work in this arena has helped me to move closer to the ideal of practice that I held close to my heart when I entered nursing. Thank you to all who have supported and continued to support these efforts.
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