Collaborative Care
In the clinic where I am currently working things are done a bit differently. There are really no 15 minute appointments, we see people for same day crisis appointments and sometimes patients come to the clinic to sit in the waiting room and calm themselves. What I am starting to appreciate the most is the way we collaborate within the office.
In recent weeks I have joined forces with another PMHNP to work on several cases. This is not the kind of collaboration where we simply run a case by eachother or debrief after, though that happens all the time as well, these are cases where we cocoon the patient and really try to stabilize quickly and support fully. Cases where we each see the patient separately and sometimes see them together. Cases where one of us manages medication and the other provides an added layer of psychotherapy, or even cases where one provider meets with a child or adolescent and the other meets with the parents. Sometimes these are cases where a recreation therapist or health coach are involved as well. These are the complex cases, where in other models of care the patient would be hospitalized. The cases are intense but the benefits and outcomes are often far better.
Consider the benefits of this approach to care.
-The patient has a back up provider they are familiar with if the primary person is not available. When a patient presents in crisis is not an ideal time to build rapport for the first time so this is a good way to have a safety in place for the most complex cases.
-While only 1 provider is the prescriber both provide input and monitoring so there is less risk of medication error or even polypharmacy.
-The providers have the opportunity to learn from eachother and try out new techniques or practices.
-There is always collateral information available and the provders can compare notes about how the patient presents for each of them or what observations they make.
-There is a larger support system available to the patient.
-At times the patient is more comfortable sharing certain things with one provider so having a second person sometimes sheds light on addional factors.
-We are keeping patients out of the hospital by seeing them more often when necessary, sometimes providing an intensive program similar to an IOP but on an individual basis.
Of course this model of care has its challenges as well.
-The intensity of cases can be exhausting and without good support burnout could be a factor.
-Insurance carriers sometimes do not see the need for this level of care. To this I suggest a hospital stay is not less expensive.
-The frequency of visits can be challenging to the individual and their family.
-Two providers both seeing a patient can take up slots in schedules that are already hectic and in areas of care where wait times to see providers can already be long.
Mostly, I think the challenges are because of the broken system we are all operating in. A system where dollars and cents matter more than patients truly improving. A system where insurance audits make sure that boxes are checked but fail to ask the patient about their experience with the care they are getting. A system where the reimbursement for some of the most vulnerable patients is not enough to keep community clinics open and running smoothly.
What I’m certain of is the way I feel about the job I’m doing and the care I provide is very different than what I would experience in a more traditional setting. The medical model where how many people you see is constantly tracked. The model where appointments are 15 minutes and take place every few months. The model where providers who know their patients are the exception and not the norm. When I arrive home from work I am tired but I know that I did the best I could. I was safe. My patients have a team of providers working on the best plans when conplexity increases. And most of all I am keeping people out of hospitals that are overcrowded, under staffed and not always healing environments when it is safe to do so.