Dr. Lisa Bisgard screens all of her teenage patients for depression and substance abuse at their annual checkups. But until recently, the Orchards Kaiser Permanente pediatrician didn’t have a consistent way of handling those patients who had positive screenings.
Sometimes Bisgard would refer the teen to Kaiser’s mental health services. The problem with referrals, though, is it’s up to the patient to follow through and actually make the appointment. Other times, Bisgard would handle the diagnoses herself, prescribing medication and monitoring the patients.
“The problem is, we have no training in it,” Bisgard said. “When I completed training 15 years ago, I treated medical issues, not mental health issues. … The practice of medicine has changed so much.”
But now, Bisgard has another option: an in-office behavioral health consultant. Kaiser Permanente has hired 16 behavioral health consultants and embedded them in primary care clinics across the metro area. Kaiser’s Cascade Park, Salmon Creek and Orchards medical offices now all have consultants.
The consultants provide a warm handoff for primary care providers. Bisgard can walk her patient down the hall to meet with the behavioral health consultant in her office, Diana Nulliner, so the patient makes that connection before leaving. Or, if Nulliner isn’t available, Bisgard can get the patient on her calendar, ensuring the patient leaves the office with an appointment.
“I have a direct line to someone,” Bisgard said.
The behavioral health consultant model of care is gaining traction with Clark County providers. The Vancouver Clinic recently created a mental health department and hired its first psychiatrist, Dr. Arundhati Undurti, who hopes to work toward the same model within The Vancouver Clinic.
Familiar setting
As a behavioral health consultant, Nulliner meets with patients in her office within the family practice unit. That way, patients stay in a familiar setting, rather than being ushered off to a separate mental health office.
Nulliner meets with patients for 20 to 30 minutes between one and five times and works to help them manage and reduce whatever symptoms brought them to the doctor’s office. Nulliner sees patients experiencing anxiety, depression, anger issues, grief, chronic pain, stress, relationship problems and sleep issues, among others.
After those visits, Nulliner then makes the call as to whether the patient needs to be referred to mental health services or if he or she can manage symptoms without additional treatment.
Recently, one of Bisgard’s patients screened high for depression. She prescribed medication to the teen but also connected her with Nulliner. The teen was experiencing anxiety about being left home alone. Nulliner worked with the teen to come up with coping skills that the teen uses to manage her symptoms.
After just one visit with Nulliner, the patient was doing much better, Bisgard said. That intervention, she said, may mean the patient won’t need medication after all.
Consultant interventions may also mean patients aren’t being referred to a higher level of care within the mental health system — an area that is already stressed — if those services aren’t necessary, Nulliner said. The goal within Kaiser is to reduce mental health referrals by 30 percent over the next year — an obtainable goal, she said.
At Vancouver Clinic
The Vancouver Clinic is also expanding its mental health services. The clinic has for years had three mental health nurse practitioners — two in pediatrics and one who works with adults — in its medical offices. But this year, The Vancouver Clinic hired Undurti and created a department dedicated to mental health services.
“They felt that without a significant mental health component, they were unable to provide all of the medical care for patients,” Undurti said.
The mental health providers at The Vancouver Clinic are dispersed at different clinics; Undurti works out of the Salmon Creek office. Having the mental health providers embedded with family medicine allows mental health providers to better communicate with primary care providers, Undurti said.
Eventually, Undurti would like to see The Vancouver Clinic implement the collaborative care model that Kaiser recently launched, adding behavioral health consultants who can help triage patients before referring them to mental health services.
Until then, if a Vancouver Clinic patients needs mental health services they’re either referred to one of the four mental health providers or an outside provider, which can be difficult to find, Undurti said. In addition to adding consultants, Undurti hopes to embed mental health providers in additional departments, such as obstetrics and oncology, and add therapists to the department.
“I think a lot of patients’ mental health needs go unmet,” Undurti said. “This is a way for us to start to address meeting mental health needs.”
