Climbing on the playground tower at the Fay J. Lindner Center was a bundle of energy and joy named Joshua. Dressed in swim trunks from his camp day, hair cut short and handsome and a T-shirt covered with Angry Birds stickers, Joshua slid down the pole, gave his mom a quick hug and kiss, and plopped down on the ground by his therapist. Despite knowing that he was going to be asked to do something quite challenging, Joshua looked up at his mom with an expression suggesting he knew he could rise to the occasion.
Joshua is a 12-year old boy diagnosed with ODD, Anxiety-NOS, and an ASD. Even with the “alphabet-soup” with which he is labeled, Joshua is happy and flourishing. He has been coming to the Lindner Center for a little over a year and a half and with hard work and collaborative planning Joshua has been developing the skills to deal with his oppositional behaviors, anxiety, and Autism diagnoses.
Joshua’s case is the perfect example to illustrate the efficacy of integrated care. Collaborative treatment not only marries psychological and medical treatment in a patient-centered way, but also incorporates the patient, family members and friends, and other professionals (such as teachers or camp counselors) to address a patient’s needs. Growing research examining integrated care shows that a coordinated, team-based approach allows a patient to benefit from a full range of expertise and is associated with better treatment outcomes and reduced health-care related costs.
With an integrated care approach to mental illness, the patient is never alone. All team members work with the patient to help control symptoms and build skills. Integrative care balances supporting the patient throughout treatment with maintaining the patient’s personal autonomy and individuality. When done properly, collaborative care recognizes that the patient plays a key role in his or her treatment. Depending on the age and strengths and limitations of the patient this can mean many things. Patients are encouraged to pay attention to their feelings about the treatment process, express and advocate to team members what is important, and potentially gain a full understanding of diagnoses and treatment. Furthermore, patients, family members, and professionals often have different “goals.” When goals are created collectively and include the patient’s input, they are more likely to be achieved and have long standing results. Not only is the patient encouraged to be honest and express his or her feelings and needs, but also the professional team is more likely to “check-in” and understand each patient’s experience and personal goals. Additionally, a patient can contribute to his or her own care by seeking information, attending skills-based and support groups, and following through on plans made with the therapist to practice skills outside of session. For Joshua, this means expressing with the encouragement of his team when he feels high anxiety or the urge to aggress. With practice and praise, Joshua is now better able push himself to engage in more challenging social situations and grow therapeutically, as well as express when he has reached his limits and needs a break.
Also important to integrated care is the role of medical doctors in a patient’s life. Often it is the family doctor who first sees a patient when he or she is experiencing mental health symptoms. Many mental health issues often manifest in somatic or bodily ways and the patient and family do not know where else to go. A family doctor may refer the patient to mental health professionals and other services in the community. In an integrated care approach even after a diagnosis is made and treatment begins, the family doctor is still included in care. Given the doctor’s long standing relationship in a patient’s life, the family doctor is often one of the individuals who knows the patient best. In addition to being a valuable resource of information, a family doctor can work with members of a patient’s team to prescribe and monitor the use of medication and communicate any non-mental health medical considerations that may impact the patient’s life and care. In addition to a family doctor, a medical doctor or nurse who has specialized in psychiatry may be part of a patient’s care, as medication may be used to control some symptoms. In the case with Joshua, he was able to receive psychiatric care in tandem with his psychotherapy at the Lindner Center. Joshua’s psychiatrist was able to consult and collaborate with his therapist and mother to best understand how effectively medications impacted his symptoms. This easy communication enabled Joshua’s doctor to prescribe a regimen that best fit his needs. However, as Joshua’s needs changed, especially with the onset puberty, the medical staff integrated into Joshua’s care also changed. Joshua will soon be seeing a developmental pediatrician who can apply specialized expertise to Joshua’s medical care, both meeting his general medical and psychiatric needs. The flexibility of an integrated approach allows care to appropriately change throughout the patient’s lifespan.
Finally, and perhaps most important to integrated care, are the people who are involved in the patient’s day-to-day life. Family members, friends, teachers, and co-workers are in a good position to offer emotional and logistical support, to note both positive and negative changes in behavior that may be important to treatment, and to help implement real-life applications to the care the patient receives. In Joshua’s case, his mother is a good communicator of any of Joshua’s needs and behavioral changes. This invaluable communication helps inform Joshua’s care team of how treatment is progressing and if it needs be adjusted. Furthermore, Joshua’s therapist sees him only 45 minutes a week and his medical provider even less often. Skills building and symptom management cannot happen effectively if done in isolation and only at Joshua’s appointment times. With his care team, Joshua and his mom make careful plans on how skills can be practiced and how he can intentionally and therapeutically be challenged to reinforce the work done in session. For example, prompting Joshua to communicate about his emotional experience in a specific way or doing a real life application of “exposure” therapy with a camp counselor to address an anxiety trigger while at camp have been two ways Joshua has been able to extend his work to out of session.
While some organizations, such as the Lindner Center, deliver comprehensive and coordinated primary and mental health care, individuals and families can also create integrated care among professionals from different organizations. Sometimes this may just mean communicating needs and starting a conversation with a family doctor, therapist or psychiatrist about the importance of integrated care. As an individual moves forward towards creating a more integrated care plan, here are some things to think about:
- Who should take the lead and who will most often communicate with the patient or patient’s family?
- What consent forms must be filled out so that the different team members can collaborate to create an integrated care approach?
- Who will have access to the patient’s mental health and medical treatment records and who will have the primary responsibility for maintaining and managing these records?
- What are the legal requirements and rules related to sharing mental health and other physical health information across professionals and settings?
- What is the best way to share resources with the different professionals who are part of the patient’s integrated care?
- How does limited time or competing schedules affect effective integrated care and what can be done to overcome these barriers?
For more information about the Fay J. Lindner Center for Autism & Development Disabilities, please visit www.fayjlindnercenter.org.