Brigham and Women's Advanced Primary Care Associates, located in South Huntington, MA, has been increasingly successful in implementing its integrated behavioral health model. Four after the clinic team first began integrating behavioral health into daily practice functions, the clinic director, Stuart Pollack, MD, credits the strong culture and multidisciplinary model at the practice for their continued success. Each step within the practice workflow has been thoughtfully designed by the clinical team.
The practice consists of three physician-led teams, each of which includes a physician, a physician assistant, two medical assistants, a licensed practical nurse, and a social worker who specializes in behavioral health. In addition to the core clinical members, the three teams share a pharmacist, a nutritionist, a nurse care manager, and a consulting psychiatrist.
The medical assistants play an integral role in/by streamlining and strengthening workflows. Using PHQ-2 and PHQ-9 screening tools, the medical assistants determine whether a patient requires behavioral health services. Medical assistants administer the questionnaires at the beginning of each patient visit. After the medical assistant completes the patient intake activities, he or she meets with the physician for a brief, in-person hand-off. During this hand-off, the physician and medical assistant determine whether the behavioral health social worker should become involved in the patient's care. If so, the social worker will see the patient after the physician portion of the visit.
The team's social worker maintains continuity of care by checking in with patients after their initial visit and between visits. The social worker reports back to the consulting psychiatrist and primary care physician regarding each patient's care. The three teams in the practice together require approximately six hours per week of the consulting psychiatrist's time. The psychiatrist attends practice meetings and is considered to be an integral member of the team. Through a multidisciplinary approach and an engaged staff, Brigham and Women's Advanced Primary Care Associates has mobilized its collective intelligence to develop a successful embedded behavioral health model that is able to provide the best care to patients.
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