It’s important to note that IBHP is not endorsing any particular model nor method of integrated behavioral care; we are simply summarizing some generally accepted procedural protocols. The goal of the integrated program should be the optimal treatment of clients’ mental and physical health through staff collaboration. Policies and procedures should flow from that principle. Adherence to a particular model or procedure should be strengthened, modified or abandoned depending on how well that goal is being achieved.
As an example of integrated behavioral procedures, passages from the “Primary Care Behavioral Health Care Services Practice Manual 2.0” developed by the U.S. Air Force Medical Operations Agency, 2002, are presented in modified form below, along with other material developed by IBHP and others.
ACCESSING THE BEHAVIORAL HEALTH COUNSELOR
There are several ways that clients commonly access behavioral health services:
- written referral from the primary care provider, usually for services at a future date (the most common way);
- verbal or on-demand referral from the primary care provider. [When opportunities present themselves, a “warm hand-off” (see below) can be made by the primary care provider];
- phone triage by a primary care provider or nurse; or
- as a result of pre-screening, established client contract or primary behavioral health protocols.
In general, everyone receiving behavioral health services will be established clients of the clinic’s primary care providers and not self-referred, though there are some clinics do allow self-referral directly to the behavioral program.
In cases involving primary care provider referral, the provider may directly schedule a behavioral service appointment or simply advise the client to schedule it. In either case, the usual procedure is for the provider to complete a referral form to be read by the counselors. Often counselors use this same form to provide written feedback to the provider about the assessment findings and client’s treatment plan once an initial visit has taken place. Counselors should, of course, make every effort to see clients in crisis as soon as possible. It’s a good idea for clinics to have procedures and policies in place for handling crisis situations.
Even if no crisis is present, literature emphasizes that the behavioral health counselors should see referred clients for a triage visit as soon as possible. At most integrated clinics, counselors carry pagers or walkie talkies so that they can be reached at all times if needed.
After an initial assessment, the counselor and primary care provider can then decide whether the client can be best served in primary care or, should be referred to specialty mental health services (if they have a serious mental disorder requiring more extended or intensive services). Often, the counselor and provider will find it useful to discuss a referral in terms of questions to be addressed and projected outcomes prior to the first consultation visit with a client.
Warm Hand-Off Referrals By the Primary Care Provider To the Behavioralist
Kirk Strosahl, an expert in integrated care, is a leading proponent of the “warm hand-off” by which the primary care provider directly introduces the client to the behavioral health provider at the time of the client’s medical visit. The reason behind the “warm hand-off” is both to establish an initial face-to-face contact between the client and the behavioral counselor and to confer the trust and rapport the client has developed with the provider to the behavioral counselor. Many clinicians report that this face-to-face introduction helps ensure that the next appointment will be kept.
Ideally, behavioral counselors would like to offer a complete counseling session at the time of the hand-off, but the client’s and/or the behavioral counselor’s schedule may preclude immediate treatment in nonemergencies. Moreover, some states do not allow government-provided reimbursement for two services provided on the same day.
To minimize the possibility of stigma attached to behavioral health services, the primary care provider is advised to use neutral terms that everyone can relate to rather than couch the introduction in strictly mental health terminology.
The following two examples of possible ‘warm hand off’ (primary care provider to behavioral health consultant) scripts and procedures are provided courtesy of Elizabeth Morrison, LCSW, Golden Valley Health Centers as detailed in her behavioral care operations manual. They are included here not as an endorsement by IBHP, but simply as an example of how one clinic handles referrals between primary and behavioral providers.
PCP’s have their own style of communicating, and will have different relationships with different patients; these and other factors (especially cultural considerations) will make each ‘warm hand off’ to best help the patient overcome any barriers to seeing a BHC. However, some general principles can be articulated:
- The referral to a BHC should be as directive as a PCP would normally make a referral to any other service. There should not be a discernable difference in content or tone between a referral to a BHC and a referral to a cardiologist. Patients will pick up the importance a provider implies regarding a referral, and respond accordingly.
- Unless a patient has used a diagnostic term themselves (“I feel depressed”; “I had a panic attack”; “I’m addicted”) it is more effective to use general terms like ‘stress’ to refer to behavioral health problems. BHC have the time and the skill to assess patients readiness to identify themselves as having particular problems, and can work with patients on de-stigmatizing these terms when necessary
- Similarly, it is more effective to use general terms such as ‘colleague’ or ‘someone who specializes’ instead of ‘counselor’ or ‘therapist’ or ‘social worker’. For many patients these terms evoke stigma, fear, and misunderstanding, and may keep a patient from seeing the BHC. Skilled BHC’S can identify themselves and intervene to address any of these apparent issues. Along the same lines, a PCP asking or offering a patient ‘counseling’ is less effective than offering them ‘education’ or ‘ideas’ or even ‘support’.
Example 1: It sounds like you might be having a lot of stress right now. I work with someone who specializes in helping with these issues, and I would like you to speak with them today to better help me help you. Is it alright with you if I introduce you to her/him?
Example 2: From some of your answers on this questionnaire, it looks as if you may be feeling down lately. I have a colleague who I work with who can give you some ideas of ways to help with this. Her/His office is just down the hall, is it okay with you if my MA walks you there after we are done so you can talk for a minute?
The following are two sample scripts for referring to a psychiatrist. Both address the major barriers in psychiatric consultation, which are stigma and fear regarding the implications of seeing a psychiatrist, and misunderstanding about the role of a psychiatrist. Because of their history, and an almost archetypical stereotype, patients commonly assume a psychiatrist is a super competent, specialized analyst, who will engage them in intensive therapy. Many patients feel disgruntled, ignored, and even angry by very competent and kind psychiatrists, because they ‘only’ received an assessment and a prescription.
Example 1 (high levels of stigma): We have already tried 3 medications that have not worked for you, and I know that has been frustrating for you. We have a specialist here who is a doctor for anxiety/depression/voices, who may be able to change your medicine and find something that works for you. He/She is right here, and could see you next week. Is that okay?
Example 2 (previous history with mental health services): You have a long history of struggles with this problem, and since you are a new patient to me, I am wondering if you would be willing to see our specialist to make some recommendations about medicine. She/He is just a doctor, so they don’t do counseling; however we do have a counselor that I think could be helpful to you. Is it okay with you for me to make you two appointments, one for medications, and one for counseling? I will follow up with you in two weeks…... “
The following script has been suggested in “Providing Behavioral Health Services in a Community Health Center Setting” developed by the Washington Association of Migrant and Community Health Centers:
Primary Care Provider: [to client] “As part of your overall health care, I’m concerned about (health concern). I have a member of our team who helps me assess these types of problems so that I can provide you with the best care. Together we can develop a plan to deal with this. May I introduce you?”
[The Behavioral Health Counselor is brought in.]
Primary Care Provider: [to client]: “[Client’s name], I’d like you to meet [Behavioral Counselor’s name].”
[to Counselor] “I have a concern about [client’s name] and [problem] and thought you could help.” Note: As discussed in the stigma section, mental health concerns can be described in more neutral terms like stress, sleeplessness, anxiety, etc.]
Behavioral Health Counselor [to client]: “That sounds like the type of thing that may be important to your overall health. I’d be glad to talk with you and see if we can come up with a plan for managing this.”
Warm Hand-Off Training Videos
Dr. Peter Van Houten and the staff at Sierra Family Medical Clinic in Nevada City, California have prepared a series of training videos to demonstrate how primary care providers can introduce patients both to the concept of behavioral health services and to the behavioral health professionals on staff. Known as a "warm hand-off", these introductions are important in framing behavioral health care for the patients and in engaging them in theses services. The "warm hand-off" vignettes can be accessed on youtube. Various scenarios include patients with diabetes, bipolar disorder, depression and insomnia, among other conditions.