Jamie: My background has always been in integrated care. From training through licensing, I lived, ate, and breathed integrated care! Coming from a rural community with limited healthcare services, behavioral health and physical health existing in the same space has always just made sense to me. But after a few years of my focus being on behavioral health integration in primary care, I became really curious about how these models of care were being implemented into completely different settings, like in allergist offices, pediatric obesity clinics, and complex care settings, for example. Again, this wasn’t surprising to me and just seemed like a common-sense way to improve patient care outcomes, as well as provider satisfaction. But I will never forget the day I saw a job posting for the role I have now! On one hand, I thought to myself, “Behavioral health integration at the dentist?! How is that going to work?” And on the other hand, I thought, “I’ve got to get in on this!”

Lisa: Oh, I am so glad I am not alone in my curiosity about integrating behavioral health care into oral health care! To be honest, when I first heard about integrating behavioral health into oral health I just wasn’t sure how it would work. At first I thought, well that would be helpful because personally I experience a lot of tension around going to the dentist. I am always up for someone talking to me and helping me feel more relaxed, so that was my initial take on the role of behavioral health in oral health. I thought, when I sit down and feel nervous about my procedure, or about what the dentist is going to say, a behavioral health person could help me manage that stress. But then I learned there was so much more and so many other reasons why behavioral health should be connected and integrated into oral health.

Jamie: Absolutely! At UNC we have done dentistry education without behavioral health for more than 50 years…so I don’t think you’re alone in feeling slight hesitation at the sound of “behavioral health in dentistry.” Changing the way teams are developed and work together, as well as the way patient care is viewed and delivered, is NO small feat. I had a dental colleague put this simply for me one day. He said to me that dentists are incredibly technically skilled professionals. For that reason, they historically have looked at patients and their needs with a 2mm point of view. They are using magnification tools to zoom in on that particular cavity, or that crown. As a behavioral health clinician, I am asking them to back that view up to about a 100-yard view of the patient and ask about their life, their health behaviors, and their own perspectives on their care. This is uncomfortable for most dental providers to think about in the beginning. But as I attend more morning huddles, discuss more patient cases with providers, and meet with more patients in the operatories, I see our dental providers — both learners and faculty — gain a greater understanding of how expanding their care to be more person-centered improves the patient’s experience, as well as theirs.

Lisa: That is very cool, Jamie. I am just fascinated with this whole movement of really connecting ALL of the parts of the body and mind. As an integration specialist, I really have always believed and advocated for whole-person care, but it took a bit of self-education and talking to others in the oral health field to understand the connection between the mouth, the body, and the mind more fully. It is almost a little embarrassing to say, but it also shows how entrenched everyone still can be in their silos, even if there is some overlap with those silos. It is exciting to hear about the work being done at the training level to tear these silos down and create a total culture shift.

I know Greene County Healthcare has been working with Medical Family Therapists in their dental clinics for a while now. In fact, the NC Oral Health Collaborative wrote a piece about the work of one of the MedFTs from Greene County and it was wonderful to hear the great work being done.

While I do think those in training right now — including behavioral health, dentists, and primary care providers — are getting more exposure to whole-person care, I think it is important to share with those currently practicing all of the many reasons that oral health and behavioral health intersect.

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Jamie: When I explain the “why” behind integrating behavioral health into dentistry, I like to focus on specific patient presentations that dental providers will see in the dental chair. What we are seeing, especially in NC with the rise of the opioid epidemic, is that substance use and behavioral health can impact everyone, across all socioeconomic levels. So, regardless of where a dentist is practicing, if they came to me and said that they aren’t seeing behavioral health issues in their practice, or these issues are not impacting their patients’ care, I would kindly argue that they just simply aren’t paying attention. The mouth is the messenger for all sorts of things happening in the body, so if you aren’t receiving those messages, then you’re doing something wrong.

Some of the most commonly used substances in our state include cannabis, opioids, and methamphetamines. Cannabis can lead to increased risk of oral cancer and gum disease, use of opioids is associated with tooth loss and decay, and methamphetamine use can cause teeth grinding, tooth wear, and rampant decay. With that being said, poor oral health can also have an impact on substance use. Untreated oral pain can exacerbate factors that lead to substance misuse, or impede recovery from a substance use disorder. As for opioid prescribing patterns, oral health providers have been among the top prescribers of opioids in recent years, including for individuals 10-19 years old (this often happens after wisdom teeth removal). Another example of this is when we see people who are seeking care for oral health problems in emergency rooms being prescribed pain medications instead of receiving comprehensive oral care. Interestingly enough, we have actually seen a very rapid increase in recent years of dentists working in emergency rooms, with the goal being to provide more comprehensive urgent dental treatment in the ER setting.

As for mental health, one of the most interesting things I’ve learned since being in this setting is the significant impact of dry mouth on overall oral health. As you know, anti-depressants and anti-psychotics often cause xerostomia, or dry mouth. Saliva acts as a protective coating on the teeth, and when it is in scarce supply, the teeth and more susceptible to caries and decay. I’ve seen patients here who are high in socioeconomic status start a new anti-depressant medication and come in for their six-month cleaning with significant changes in their oral health. There is also ample evidence in the mouth for eating disorders (tooth erosion), bipolar disorder and OCD (patients get overzealous with brushing and flossing), and trauma or anxiety (habitual teeth grinding and clenching, TMJ disorders). There is also a lot of evidence that poor oral health can exacerbate cognitive decline and functioning, which was a new concept to me! The last connection I’ll mention won’t be a surprise to any behavioral health clinician. When patients experience tooth loss or poor oral health, they see multiple impacts on their quality of life. Their self-esteem is low, their relationships are impacted, it can be difficult to find employment, this list goes on and on.

Lisa: I have to be honest, before talking to you and doing my own research, I just had no idea about so many of these connections. Even though these connections are evident, I would imagine that whenever a new workflow or paradigm shift happens in healthcare, it can feel overwhelming to those practicing because of all that they juggle already to keep their operation flowing smoothly. Is there a framework that can help providers figure out where to start their change process to address some of these issues you’ve talked about?

Jamie: I really like this example framework below developed by the Center of Excellence for Integrated Health Solutions/National Council for Behavioral Health. This framework shows how even minimal integration — such as staff education or screening for needs — can be a big step towards improving patient care outcomes. I’m curious though…as an integration specialist, what are your thoughts on this framework?

Lisa: Well, change for practices, in my opinion, is not a lot different than change for people. We have to figure out where we are, start small, and evaluate the changes to keep moving forward. This framework reminds me of other integration continuum charts that can help providers figure out what part of the puzzle they can put into place in their practices. Even if a dentist is practicing in private practice with no behavioral health professional on site or nearby, and even if a behavioral health clinician is practicing in a traditional private practice, steps can be taken to help heighten the coordination and awareness of the relationship between oral health and behavioral health so that patients start feeling better both physically, orally, and mentally more quickly.

For example, oral health providers can receive mental health first aid training while behavioral health clinicians can receive training on oral health issues. On another deeper level of involvement, oral health providers could receive more intensive training about interventions such as motivational interviewing to help patients with brief interventions if it was clinically appropriate in their appointments, and behavioral health providers can include oral health questions about hygiene and utilization in their biopsychosocial assessments. Integrating behavioral health into oral health can certainly go as far as bringing in a behavioral health clinician into the dentist office, but I think it is a mistake to think that it has to be all or nothing. How would you encourage clinics to get started, Jamie?

Jamie: I agree with you completely on that! Students often ask me what they are supposed to do “in the real world,” meaning if they start their professional career in a setting where they do not have a behavioral health clinician on their team. There really is no wrong way to get started! Maybe I’m thinking a lot like a social worker, but I would say the key is to seek resources, resources, resources. If you are not the expert on your team, it is always good to acknowledge that and stay in your lane. Locate your local experts, or resources, like your local LME-MCO, Mobile Crisis Unit, Crisis Lines, Department of Social Services, 211, etc. Keep a flyer or binder of those resources at the front desk. Ask a staff member to be responsible for connecting with those organizations, learning about what they do, and periodically updating them if needed. North Carolina is fortunate in that it now has an easy-to-use, integrated, state-wide resource network called NCCARE360 that serves as an electronic one-stop-shop for all of the resources available within the local community. This way, you feel confident as a provider knowing that if you ask a patient a question about their behavioral or emotional health, or if a patient brings this up on their own, you know who to direct them to. No matter what type of healthcare you are providing, patients should be assured that there is no wrong door for accessing care and support.

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What often makes children’s resilience possible is the involvement of at least one caring and available adult. That caring adult can be a caregiver in the family, a family friend, a teacher, a youth group leader, a healthcare provider/therapist, or coach. This past year, as children watched for clues on how to handle all of the changes that were happening, the adults they normally turned to were likely trying to manage the chaos themselves. These adults, despite their best efforts, could very well have been emotionally unavailable due to their own stress, and quite possibly physically unavailable. We will not know the long-term impacts that this period of time has had on our children for a while; however, we do know that as the fog clears, it will be everyone’s responsibility to help ensure that resources are available for healing and recovery.

There is not a single sector of our society that can handle all of the needs of our children on its own. We cannot expect families to manage on their own. We cannot expect school systems to jump in and miraculously fill the entire gap. We cannot expect that regular visits to the pediatrician for sore throats and stomach aches will not be tangled up with the emotional turmoil that trauma can bring. We cannot expect to return to the status quo of how we have previously taken care of children in North Carolina.

It is in these appointments that there is space and some time for patients and their caregivers to ask questions about mood, substance use, stress management, and coping with overall worries about life. It is in these appointments that we can be even more purposeful around our conversation with patients (and each other) around mental health and relational health to help nurture the whole child. Now is the time to capitalize on those valuable patient interactions in primary care offices to help provide additional support to these kids who have been through so much.

At the Center of Excellence for Integrated Care, we have been exploring system and policy changes that can integrate even more behavioral health support for children and adolescents than is already offered. Integrating behavioral health into practices not only helps provide a more robust offering of whole person care, but it also has been shown to help providers feel supported and improve their overall satisfaction with their work. It is time that our protocols and policies provide the support both our providers and our pediatric patients need in the aftermath of this past year. It was needed before now, but now it is undeniable. We look forward to sharing more as our partnerships around this idea evolve!

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COE-Mental-Health-Series-Webinars

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Welcome to the Team

In this story, Ricky Caliendo, LMHC, provides a narrative that describes the experience of integrated care from a patient’s perspective. The names of the patient and doctor are fictitious.

“Another night of lost sleep,” I think to myself as the screeches of a toddler travel into my bedroom. There he is. At the foot of my bed, with that look only a mother could read. It’s time for breakfast. My stream of consciousness continues as I move through the morning routine.

“Breakfast, pack a daycare bag, project for the office, take your medication…what am I missing?…ugh, doctor’s appointment today!”

Attempts at applying eye liner and mascara at a red light should mask the lack of sleep. I adjust the rearview mirror to find my three-year-old son’s face showing intense curiosity.

“You look like a clown, mommy,” he comments through his giggles.

Children are brutally honest and, despite my exhaustion, my mouth cracks a small grin when we lock eyes through the rearview mirror. It’s time for him to go to daycare and for me to push forward.

“Coffee, doctor’s appointment, work, kid, bills, dinner, call with lawyer…” I recite to myself on the way to the doctor’s office.

As I enter my primary doctor’s office, I begin to script my conversation with him.

“Sleep, aches, lack of focus, tightness in chest, diarrhea…ugh, he is just going to think that I’m crazy.”

After checking in and nestling into the waiting area, all of a sudden I am acutely aware of the weight of my recently applied mascara that now feels like it weighs ten pounds. In the exhausting fight to keep my eyes open, I notice a new poster in the waiting room.

We have a new member of the team! Carly Johnson, LCSW, is our new behavioral health clinician and works diligently alongside our doctors to serve your whole-person health needs!

“Okay, Carly, welcome to the team,” I say sarcastically in my head. With just a moment to be still, I feel the weight of my eyes again, and began to nod off to sleep.

“PAMELA? Is there a Pamela here?” exclaims a staff member.

Waking up, embarrassingly, I pull my head up to see Carly’s picture staring at me and I gather myself for the appointment.

Blood pressure. Temperature. Medication list. Paperwork. Hold on, I know this routine. But what is this new paperwork? My medical doctor is asking me about my sleep, mood, motivation, and whether I enjoy things anymore? I complete the questionnaire and interestingly the score does seem higher rather than lower. I am curious about what the score means.

Dr. Haffner enters the exam room in his white coat and I think to myself, “How do they always keep those coats so white? I can barely keep my boy’s church clothes clean.”

Lost in my preoccupation about his coat, I look up and recognize that Dr. Haffner is awaiting an answer to a question that was completely lost in my daydreaming.

“I’m sorry Doc, but I’ve been feeling a little out of it lately,” I say in response to the unknown question. It turns out he asked the fairly typical doctor question about what has brought me in today.

I recite the symptoms list as gracefully as it has been in my head. “I did it!” I silently reassure myself.

Dr. Haffner validates my feelings about my symptoms and discusses some of the paperwork that was completed prior to him coming into the exam room. He indicates that he is concerned about my lack of sleep, low motivation, high levels of stress, and complaints about stomach aches. He reassures me that he will order some blood tests. But, while we’re waiting on those results, he wants me to meet a new member of the team. I instantly find myself nervous and excited at the same time.

A woman in her 40s, dressed in business casual attire, enters the exam room offering a big, warm smile. She introduces herself to me…although I acknowledge her name before she’s able to get it out…Carly.

Dr. Haffner and Carly explain the clinic’s approach to whole-person care, describing the connection between a patient’s medical, social-emotional and spiritual experiences, and their health. With my permission, Carly excuses Dr. Haffner and I find myself, again, sitting across from Carly feeling the weight of my eyes. This time, she is not on a poster.

Carly’s approach is a harmony of kindness, professionalism, and compassion. We have a frank conversation about my experiences being a single parent, my recent financial and workplace stress, and how my life goals that historically excited me, now felt deflated.

“It simply feels like everything I was working toward just passed me by,” I explain. “Now, here I am looking at it as if it is a distant mirage.”

Carly provides a sense of understanding and normalizes my stress. She talks about the importance of self-care, building motivation, and breaking down goals into small steps.

For the first time in a long time, I begin to see myself again…even if it’s at a distance. I used to think that I was so strong and independent, that I had to be for my boy. I thought my needs should come last. But Carly’s intervention really helps me understand the importance of taking care of myself.

I quickly realize that Carly — once just a stranger on a poster in the waiting room — is now a part of my healthcare team. She has provided me with a source of comfort and motivation. She has normalized much of my experience and encouraged me to revitalize old coping skills, such as painting, nature walks, and meditation. She has provided resources so I can explore some new strategies, as well.

After setting my follow-up appointment for two weeks, and walking out of the office, I truly feel cared for.

Thinking about past medical appointments, and how stress has impacted my day-to-day life, I think I was always looking for help from my doctor, but speaking in a code at times. It was a code that I did not know how to break. But Carly opened up a conversation that I did not necessarily think about going into the appointment, and I am so glad she did. I was beginning to crack the code. My happiness and health are intertwined and partially dependent on my self-care.

Welcome to the team, Carly.

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