What If We Include Primary
Care Behavioral Health?
It seems
logical to me that we would all need psychological help at some point in our
lives, if we have ever raised children, experienced divorce, sickness, loss of
family members, had a change in job, or moved - we have experienced stress. If
merely hearing some bad news can cause the body to leak fluid from our eyes,
cause our face to swell, our chest to feel heavy with pressure, making it hard
to breath, we might choke or vomit. How can we not believe that stress has
physical ramifications? Couldn’t we expect that prolonged stress might have
deeper long term damage? It’s also
logical to me that a chemical pill might ease my pain and provide some relief
but I still need to figure out how to move forward in my life. In the case of acute
crisis, help might include focusing on the present, “I am safe here and now, in
this room, in this place”. Healing might include focusing on breathing; count
to 3 when I inhale and count to 4 when I exhale. It might be approaching life
in smaller pieces - focusing on minute to minute, or hour by hour, rather than
day by day. It might include helping to recognize that we all behave
differently under stress, and that our thoughts and emotions do not define who
we are.
Some
patients get sick from having unhealthy behaviors, others stay sick because
they can’t or won’t follow recommendations from their providers. Primary Care Behavioral
Health (PCBH) in the clinic can investigate what is preventing patients from
improving. PCBH can go into an office visit after the MD has completed his
assessment to help draft a plan of care that takes into consideration a
patient’s attitudes, beliefs and behaviors. PCBH investigates the patients
coping ability, relationships, support, motivations, and ambitions. They use
several assessment tools to maximize their time, so they can identify the roots
of dysfunction and offer tools for dealing with them. They investigate ways of
motivating patients to want to be healthy and they can assist a member in accepting
Mental Health services more quickly. They may be able to increase the patient’s
willingness to take responsibility for their health, and work with the provider
toward optimal health. Patricia Robinson & Jeffrey Reiter in their book - Behavioral
Consultation and Primary Care: A Guide to Integrating Services - report that “up to 70% of Primary Care
medical appointments are for problems stemming from psychosocial issues
(Gatchel & Oordt, 2003).” They go on to say that “the use of psychotropic
medications has gone up dramatically since the mid-1980s amongst all
prescribers, and psychotropic medications are now among the most widely
prescribed medications in the USA (Pincus et al.,1998).” The antipsychotic drug
Abilify has the highest sales of any drug in America according to WebMD.
Another benefit of PCBH is that their visits in a medical visit, not mental health visit, decreases the stigma of mental health services. Mental health has a large percentage of no show appointments and PCPs are often seeing patients for depression, anxiety and copying issues, when these patients might be better served by mental health.
Another benefit of PCBH is that their visits in a medical visit, not mental health visit, decreases the stigma of mental health services. Mental health has a large percentage of no show appointments and PCPs are often seeing patients for depression, anxiety and copying issues, when these patients might be better served by mental health.
Life is a
team sport and we all need a little help now and then. Hopefully when I’m down
I have friends, family, or spiritual support to help me through this
challenging period. PCBH can help define strengths and amplify them, problem
solve challenges to deal with them, help me move forward toward a more fluid
existence. Remember how it feels to be in love? My husband felt light as a
feather, 20 years younger, stronger than a horse, his vision was clearer,
hearing more acute, and sense of smell more vibrant; all because I said, “I
love you, and I want to be with you”, simple little words. Let yourself feel
the value of a smile, a “Good Job!” We all need to be reminded occasionally
that challenging days will pass, and the sun will shine again. Help me to
understand that others have been through similar pain and challenges, and
survived.
If we understand the power of emotions and our
psyche on health, then it makes sense to me that we need to listen and assess
this to achieve Optimal health. When, I worked in the hospital, we expected the
primary care provider in the clinic to manage the patients overall health and
adjust the plan of care. As a Home
Health nurse, I averaged about 45 minutes per visit, 15 minutes to assess how
my patient was feeling today, 15 minutes to evaluate their overall health and
assess changes, and the last 15 minutes teaching and updating the plan of care.
Primary care physicians have only 15-30
minutes total per visit with patients to manage their care, and they have the
added disadvantage of seeing their patients out of their natural surroundings
and up to 32 patients a day. I can’t understand how a primary care provider can
review and assess response to medications, assess overall health, coping
ability, diet, bodily functions, answer questions, and chart in a total of 15-30
minutes. Sadly, most providers will admit they can’t finish in 15 minutes so
they focus on the top 2 questions, scan the information they have, make a
rushed decision and chart after hours on most of their patients. Most of the
primary care providers I know are spending at least 1-2 additional hours per
day, charting on their own time, after hours or on their days off. Often they
accept this as a requirement of the job. It’s a no win situation and it isn’t
cost effective. I question if to make sure they aren’t missing anything,
providers are ordering additional diagnostic tests including MRIs and CT scans.
If providers had more time with patients, they might feel more comfortable
watching and waiting to see if patients improve in a few days. If health care
is our highest cost expense in the US shouldn’t we be able to expect more as
providers and as patients? To put this into perspective, we value our property
so much that we pay taxes to have fire and police protection available when
needed for as long as it takes to get the job done. Property is replaceable, the human body = one
per person for life!
Primary Care
Behavioral Health is partially designed to address this issue of not enough
time to thoroughly evaluate patients. If the problem is at least partially
stress induced wouldn’t it make sense to try to remove or treat the stress
variable and see if the physical symptoms resolve? Optimal Health Care involves
a team approach; no single provider can meet the needs of all of our patients.
Working with the strengths of each other, we create a win –win situation for
everyone which is more cost effective for the providers, the patient, and the
insurance company.
Nurses
provide an important role, by triaging the background of the patient’s problems
before the office visit. Nurses can organize service providers to increase
efficiency and facilitate comprehensive holistic care for our patients.
For more
information on Primary Care Behavior Health go to:
www.DrArmandoHernandez.com – Thank you to Dr. Hernandez for
your inspiration and resources.
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