Warm Hand-Off Referrals By the Primary Care Provider To the Behavioralist
Kirk Strosahl, an expert in integrated care, is a leading proponent of the “warm hand-off” by which the primary care provider directly introduces the client to the behavioral health provider at the time of the client’s medical visit. The reason behind the “warm hand-off” is both to establish an initial face-to-face contact between the client and the behavioral counselor and to confer the trust and rapport the client has developed with the provider to the behavioral counselor. Many clinicians report that this face-to-face introduction helps ensure that the next appointment will be kept.
Ideally, behavioral counselors would like to offer a complete counseling session at the time of the hand-off, but the client’s and/or the behavioral counselor’s schedule may preclude immediate treatment in nonemergencies. Moreover, some states do not allow government-provided reimbursement for two services provided on the same day.
To minimize the possibility of stigma attached to behavioral health services, the primary care provider is advised to use neutral terms that everyone can relate to rather than couch the introduction in strictly mental health terminology.
The following two examples of possible ‘warm hand off’ (primary care provider to behavioral health consultant) scripts and procedures are provided courtesy of Elizabeth Morrison, LCSW, Golden Valley Health Centers as detailed in her behavioral care operations manual. They are included here not as an endorsement by IBHP, but simply as an example of how one clinic handles referrals between primary and behavioral providers.
PCP’s have their own style of communicating, and will have different relationships with different patients; these and other factors (especially cultural considerations) will make each ‘warm hand off’ to best help the patient overcome any barriers to seeing a BHC. However, some general principles can be articulated:
- The referral to a BHC should be as directive as a PCP would normally make a referral to any other service. There should not be a discernable difference in content or tone between a referral to a BHC and a referral to a cardiologist. Patients will pick up the importance a provider implies regarding a referral, and respond accordingly.
- Unless a patient has used a diagnostic term themselves (“I feel depressed”; “I had a panic attack”; “I’m addicted”) it is more effective to use general terms like ‘stress’ to refer to behavioral health problems. BHC have the time and the skill to assess patients readiness to identify themselves as having particular problems, and can work with patients on de-stigmatizing these terms when necessary
- Similarly, it is more effective to use general terms such as ‘colleague’ or ‘someone who specializes’ instead of ‘counselor’ or ‘therapist’ or ‘social worker’. For many patients these terms evoke stigma, fear, and misunderstanding, and may keep a patient from seeing the BHC. Skilled BHC’S can identify themselves and intervene to address any of these apparent issues. Along the same lines, a PCP asking or offering a patient ‘counseling’ is less effective than offering them ‘education’ or ‘ideas’ or even ‘support’.
Example 1: It sounds like you might be having a lot of stress right now. I work with someone who specializes in helping with these issues, and I would like you to speak with them today to better help me help you. Is it alright with you if I introduce you to her/him?
Example 2: From some of your answers on this questionnaire, it looks as if you may be feeling down lately. I have a colleague who I work with who can give you some ideas of ways to help with this. Her/His office is just down the hall, is it okay with you if my MA walks you there after we are done so you can talk for a minute?
The following are two sample scripts for referring to a psychiatrist. Both address the major barriers in psychiatric consultation, which are stigma and fear regarding the implications of seeing a psychiatrist, and misunderstanding about the role of a psychiatrist. Because of their history, and an almost archetypical stereotype, patients commonly assume a psychiatrist is a super competent, specialized analyst, who will engage them in intensive therapy. Many patients feel disgruntled, ignored, and even angry by very competent and kind psychiatrists, because they ‘only’ received an assessment and a prescription.
Example 1 (high levels of stigma): We have already tried 3 medications that have not worked for you, and I know that has been frustrating for you. We have a specialist here who is a doctor for anxiety/depression/voices, who may be able to change your medicine and find something that works for you. He/She is right here, and could see you next week. Is that okay?
Example 2 (previous history with mental health services): You have a long history of struggles with this problem, and since you are a new patient to me, I am wondering if you would be willing to see our specialist to make some recommendations about medicine. She/He is just a doctor, so they don’t do counseling; however we do have a counselor that I think could be helpful to you. Is it okay with you for me to make you two appointments, one for medications, and one for counseling? I will follow up with you in two weeks…... “
The following script has been suggested in “Providing Behavioral Health Services in a Community Health Center Setting” developed by the Washington Association of Migrant and Community Health Centers:
Primary Care Provider: [to client] “As part of your overall health care, I’m concerned about (health concern). I have a member of our team who helps me assess these types of problems so that I can provide you with the best care. Together we can develop a plan to deal with this. May I introduce you?”
[The Behavioral Health Counselor is brought in.]
Primary Care Provider: [to client]: “[Client’s name], I’d like you to meet [Behavioral Counselor’s name].”
[to Counselor] “I have a concern about [client’s name] and [problem] and thought you could help.” Note: As discussed in the stigma section, mental health concerns can be described in more neutral terms like stress, sleeplessness, anxiety, etc.]
Behavioral Health Counselor [to client]: “That sounds like the type of thing that may be important to your overall health. I’d be glad to talk with you and see if we can come up with a plan for managing this.”