Of the many obstacles individuals and organizations face in the transition to an integrated model of care – be them systemic, workforce related, or issues with the electronic record – the one that often seems insurmountable to some is The Diagnosis. I feel like it would be appropriate if we made the DONGDONG noise from Law & Order every time we mention The Diagnosis.
At a recent training academy for behaviorists, a participant struggled with the idea that she could stamp a patient with a diagnosis in such a short abbreviated time as related to the brief intervention model that supports integrated care. “It’s such an important process,” she said. “I can’t wrap my mind around how we can just diagnosis someone with something in such a short period and have that diagnosis stuck to that person forever.” Another explained that she works with teens who often go into the military or police academies and is troubled with the idea that her diagnosis could interfere with their futures.
Certainly no one would debate those concerns. Any mental health expert understands the importance of a diagnosis, but also the weight of it in terms of stigma. But like many issues when it comes to an integrated care model, there needs to be considerations and new perspectives to the methods we use.
First off, we need to think about the purpose of the diagnosis. As explained by Suzanne Bailey, Psy.D., a behavioral health consultant (BHC), the diagnosis is gateway to a path of care. It triggers certain interventions, best practices and options for the patient. And, in this model, explained Parinda Khatri, Ph.D., Cherokee Health Systems’ chief clinical officer, the diagnosis is typically a working diagnosis. “We’re not issuing a life sentence,” she said. “Diagnoses change all the time, especially in primary care.” Dr. Khatri explained that we are presented with an array of signs, symptoms, observations, and other data that we start with. It is also important to understand that a BHC rarely – if ever – walks into an exam room cold, devoid of any information at all. “The patient record is rich with information and data,” she said. BHCs will take time to briefly review the patient’s record looking at recent screenings, the doctors’ notes, and any history that can be quickly gleaned. “It’s not unusual that I walk into the room with a working diagnosis already in mind,” Dr. Khatri said.
In the case of the teens who’s futures can be impacted with a diagnosis it is clear that the issuing of a diagnosis is no less important in primary care than it is traditional mental health. It is important to remember that a patient presents with a diagnosis already; the mental health expert only uncovers it and labels it. It is like the fable of the boy watching a great sculptor carve out a noble statesman from a block of marble. “Hey mister, how’d you know that guy was in there?” the lad asks. Granted, it can often take a great deal of time to appropriately identify and label a syndrome or disorder, as it can with a primary care diagnosis. If a youth presents with a spectrum of symptoms, complaints and reports from others that might indicate some sort of severe disorder, number one it is our job as a mental health expert to appropriately process that information and objectively diagnosis it. Number two, we understand that we may need more time to do this, so a referral to a more structured, traditional setting would be an appropriate intervention in the case where you suspect there are heavier issues in play. In the meantime, for the services you need to provide in the integrated setting, you can issue a working diagnosis knowing that on the plan of care you are going to build a referral to specialty care for a more thorough assessment if you deem it necessary. It would be rare even in a traditional setting for a therapist to level a “life sentence” diagnosis on the first visit anyway. Often we will “rule out” several other options before settling on a diagnosis.
“True, but we all know the stigma related to a diagnosis and that people will see it and even if it was discharged, still think of that person as having it,” said one of the other participants. We can debate about the legitimacy of that statement, some scholars will support it, while others will present data to dismiss or negate it. The fact remains that the process of diagnosing is important. That is why at Cherokee Health Systems we use highly skilled, well-trained individuals in the role of the behaviorist; they are typically psychologist level providers. However, well-seasoned, highly skilled social workers can – and do – function effectively in this role. It is difficult – and dare we say unfair – to throw a brand new professional in this role and ask them to depend on their limited experiences and training to process all of this in the fast paced world of primary care. It is also important to remember that you are not operating in isolation; you are part of a larger, dynamic team. You have a physician, team of nurses, clinical supervisor, and consulting psychiatrist with which to consult; and most importantly – the patient. You are part of a behavioral enhanced patient centered medical home model.
Through this peep hole of The Diagnosis, you can see the inner workings of an effective, efficient integrated care model. You see the communication channels, the importance of a robust EMR, the workforce development and construction of an integrated team, the screening mechanisms, patient flow and cohesion of an overall plan of care; and if you look even deeper you can see the back office mechanisms of billing, coding and contract negotiations to support the model. If any one of those facets are missing or broken, the model struggles.