Five Minute Read

Operating as a behavioral health consultant (BHC) in primary care has always demanded flexibility but never more so than during the pandemic. Things have changed significantly and it’s worthwhile for us to reflect on those changes, not with resistance, but simply with acknowledgment and mindfulness about what those changes mean. So, this is one of my mornings recently.

This morning I had three visits on my schedule, one video visit to start the day followed by a phone visit and an in-person visit. I reserve the last slot of my morning for the rare in person warm handoffs (these days) and/or care management work which has increased significantly during the pandemic as demand for services has increased. In total I aim to have about 5 patient touches per half day. It has taken a lot of work to feel comfortable with this approach given that I am the only BHC in my clinic and I’m only there one half day per week. Yup, just one half day, since my day job is CEO at the Collaborative Family Healthcare Association. So, it really changes what I can do working within the Primary Care Behavioral Health (PCBH) model.

So, my day starts out with some anxiety because I’m never sure if a video visit will work and I’m also not sure whether I can find a room with video capability available since I’m not assigned a room (the pitfalls of being the lone BHC). I schmooze with a medical assistant who kindly offers me a room and cross all my fingers and legs in hopes that the video works in the exam room. Well, the video worked but the audio didn’t, so I quickly switch over to phone for the audio, take a deep breath and get in my BHC zone with the patient. Fortunately I feel sharp today and work through a good 30 minute consult with relative ease despite the technological hiccup.

Then I walk to the resident workroom to take my phone visit and make sure I don’t overstay my time in the exam room. Phone is pretty reliable but the patient on the other end speaks Spanish with a strong Puerto Rican accent so I have to work extra hard to understand. Plus phone audio just has a weird quality to it sometimes, so it is draining in its own way. It also doesn’t help that this patient is really not the best fit for primary care given some significant bipolar depression, but these days finding an outpatient therapist, let alone one that speaks Spanish and can work with bipolar depression is like finding a needle in a haystack located somewhere in the Orion Nebula. I do my best adaptation of CBT on the phone and try to strategize the best visit frequency for this patient given that I could literally see her daily (but clearly can’t).

I fall behind but am sort-of on-time for the in-person visit, which is a breath of fresh air given how much of my work is still remote. By the way, in between visits I say hi to a few of the providers in clinic and give some advice to a first-year family medicine resident on DBT. And I schmooze another medical assistant who has an impressive jug of water she drinks throughout the day. I’m amazed she can handle that much water! Another 30-minute consult goes well and I’m feeling pretty energized having surpassed the logistical hurdles of going from video to phone to in-person. And yes, I’m doing all of this masked and eye-shielded up, which is so much fun. But my day is not done.

I hang out in the resident work room and go through my EHR in-basket which has a running list of people providers want me to see. I call one and schedule them (often I just try to have the consult right then and there, but this one didn’t fit well). I check my schedule to see how far I am booked with follow-ups and try to strategize the best way not to get clogged up and stay available. It’s tough with so much demand but I don’t want to book out further than 3-4 weeks if possible. It’s not pure PCBH, which kind of kills me inside, but it works… mostly. I take a moment to mindfully reflect on the reality that I can only do my best with the demand and strategize about how I will work through the list. I settle on calling patients closer to the time I have an available “warm hand-off slot” versus scheduling further out. I call another patient and leave a message. Then a resident precepting indicates they may need my help with a patient so I stick around past lunch time and try to clear my head and get notes done. The resident doesn’t come back for another 45 minutes. They are a first-year resident, so not very good yet at getting out of rooms and presenting the concept of a BHC to patients so it turns out I’m not needed. Oh well, that’s life as a BHC sometimes.

Time to go to my office, put on my CFHA hat and reflect. Video, phone, in-person. What a world we live in.