3RNet Blog

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This post comes to us from a Rhode Island Provider, Dr. Nelly Burdette.

Three years ago, I pitched my ideas around behavioral health integration to Providence Community Health Center Inc.’s (PCHC) newly hired Medical Director, Dr. Andrew Saal. Given that PCHC’s patients are served in the largest urban, multi-site, multi-lingual health centers, there are many barriers to health and care that can impact behavioral health. Addressing long wait lists for specialty mental health in the community, and the necessity for a centralized, systematic approach in managing not only basic behavioral health needs within primary care, but also population health, a new IBH Department was born. 

I wrote my ideal job description that outlined the direction of the department of integrated behavioral health and within six months, PCHC created a job for me. Today, the Department of Integrated Behavioral Health has hired and trained five LICSWs serving as IBH providers across six sites, and five bilingual behavioral health community advocates paired with each IBH provider to assist with social services and resources. Students have also expressed interest in collaborating, and we will soon have psychiatry and social work students rotating through our clinics.

Integrated behavioral health serves as a critical component of our fully integrated health centers at PCHC. The medical assistants facilitate universal screening for depression, anxiety and substance use that then generates  a warm hand-off (or brief meet and greet) with an IBH provider and/or community advocate on the same day as the medical visit. IBH providers meet with patients to assist with brief evidence-based interventions (averaging 3-6 visits per episode of care) within the context of mild-moderate mental health or lifestyle management issues surrounding chronic disease management. This year we are adding co-led group visits for management of patients with diabetes and depression, as well as groups that incorporate yoga for chronic disease. Nurse Care Management (NCM) is integrated for the high-risk, high utilizer population and provides home visits, frequent phone contact within the context of reducing inappropriate healthcare utilization and promoting healthy management of chronic disease. Most of our PCPs will say that they can’t imagine working without the integrated care and as Dr. Cesar Mora, one of our family medicine doctors’ states, “Having IBH right next to me is amazing. More than 50% of my patients could use the services and we have a system to get their needs met right away now.” 

PCHC has been at the forefront of integrated care innovation, responsive to the community it serves and able to flex internally to allow for growth and change as behavioral health becomes more clearly intertwined with physical health. It couldn’t be a better place to work for those looking to push the limits of where physical health and behavioral health connect.

Dr. Nelly Burdette is a clinical health psychologist with over 10 years of experience in creating, training and leading integrated care departments within primary care and community mental health settings. In addition to leadership, management, supervision and clinical roles, she also serves as the lead practice facilitator within integrated care to the  Care Transformation Collaborative of RI, a multi-disciplinary non-profit convened by the Office of the Health Commissioner in order to transform primary care in the State. 

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