Specialty provider reaches entirely new population in pediatric offices

One of the initiatives that has most energized the clinical and administrative staff at Gosnold on Cape Cod shatters many stereotypes about a specialty addiction service provider. The effort takes place in a medical setting, focuses more on prevention than on treatment, and achieves true teamwork with physicians who welcome and even depend on the addiction treatment organization's expertise.

“We have the potential to demonstrate to the medical profession that mind care has a tremendous impact on body care,” says Gosnold's CEO emeritus, Ray Tamasi. “Doing this work together enhances the overall health of the family and the community.”

Under the initiative, Gosnold has been providing on-site behavioral health services, delivered in a doctor's office and generally with family, physician, and Gosnold clinician all present, at pediatric practice locations of Briarpatch Pediatrics. A newly awarded grant from the Lynch Foundation will allow this work to expand significantly at the practice's pediatric offices across Cape Cod and Nantucket.

Tamasi estimates that only around 5 to 8% of the young patients who have received consultation through this cooperative effort have been evaluated as requiring specialty services beyond what can be delivered in the doctor's office setting. He considers this type of work extremely beneficial as care delivery systems move toward a patient-centered medical home model.

“I see this as a great opportunity for behavioral health organizations,” says Tamasi, whose present role at Gosnold involves exploring long-term innovations and partnerships.

Clinician at the ready

Catherine Dotolo, LICSW, is Gosnold's director of primary care integration and the clinician on the front lines of this innovative project. She cites as the most exciting aspect of this work the fact that this is a prevention initiative.

“There's so much of mental health work that can be captured at an earlier stage,” says Dotolo. “It's unfortunate that these illnesses progress to high acuity levels.”

She appreciates the opportunity to offer young patients and their families a wealth of information in a largely non-threatening setting—the same place where young children have gone for years and get stickers or books to take home, a far cry from the intimidating presence that a private psychiatrist's or counselor's office would exhibit.

“I may be able to tell them, 'This pain in your belly is called anxiety. Does this run in your family?'” says Dotolo. Teaching the young people useful self-management techniques becomes an important component of her services.

She adds, “We destroy the notion that mental health is something to be avoided.” The patients and families express a great preference for seeing the clinician in the medical office as opposed to a specialty setting.

Dotolo says that a behavioral health clinician working in a medical setting needs to remember some key differences in practice culture. “Pediatrics is a fun place to work,” she says. “You have to have a dynamic and adaptable personality type.”

Cultural competence becomes a critical component as well. “You have to understand culturally what it is to be a 13-year-old in today's society,” Dotolo says. It's not the same as it was a generation or two ago.

Strong interpersonal skills and a consistent team orientation are high on Tamasi's list of prerequisites for this role. “It's not for everyone,” he says of working in the medical setting. “The counselor doesn't own the patient here.”

A motivated practice

Tamasi says Gosnold originally was able to launch the initiative with its own funding after finding a couple of receptive, forward-thinking doctors in the pediatric group. From Gosnold's perspective, the challenge it was seeking to address involved, “How do we do behavioral health in a way that starts closing the door on new users [of services]?” Tamasi says. “How do we start going to where the patients are?”

These doctors didn't need a lot of convincing that they had to do a better job identifying potential problems in their young patients and having them addressed early. “When we found something in the past, we didn't know what to do with it,” says Briarpatch's Leif Norenberg, MD. “Now we don't feel helpless, worthless, hopeless.”

When Norenberg discovers during a patient visit an issue that could merit a discussion with Dotolo, he tells the patient and family that he would like to call in the person he refers to as a life coach. “It's such a benign, non-offensive thing,” he says. “They go for it.”

He also appreciates the opportunity to hear directly how a behavioral health clinician interacts with a patient. “In the past, I never knew what the counselor was doing with patients,” he says.

That is, if the patient ever got to the counselor at all. Most patients and families who receive a passive referral never follow through to make the appointment, says Norenberg. That is not a concern with the warm handoffs that take place under this initiative.

“We started to see a fluid exchange between the disciplines,” says Tamasi. In the past, pediatric patients might receive a brochure about behavioral health services available in the communuty, and maybe 10% ever would place a call, he says.

Financial barriers

The grant funding also allows the Gosnold clinician to spend more of her allotted time with the patient and family, avoiding the need for documentation requirements that take time away from hands-on care, says Norenberg.

Tamasi realizes, however, that for cooperative arrangements such as this to advance the field in a significant way, payment systems that still focus on siloed services and crisis care need to evolve along with them.

“Clearly, a barrier is the way services are paid for,” Tamasi says. The health care community needs a better grasp of data that demonstrate that the costs of treating common medical illnesses soar when a patient's co-occurring substance use and mental health issues are not addressed at the same time.