Integrated Health Care – Starfish’s Integrated Pediatric Approach

By Kelly Mainville, MS, LLPC and Jung Nichols, LMSW

Jung Nichols, LLPC, Integrated Health Supervisor

A great need for mental health services is recognized

Many years ago, Starfish Family Services’ late CEO, Ouida Cash, and Oakwood Health Care (now Beaumont Health) submitted an application to the Health Resources & Services Administration (HRSA) to start a local Federally Qualified Health Center (FQHC) in Inkster, Michigan, which became Western Wayne Family Health Center.  Years after the clinic was established, the clinic staff realized there also was a great need for mental health resources, and the FQHC partnered with Starfish.  Initially, it began with a part-time therapist who worked in an office in the building.  They quickly learned that the outcomes they had hoped for were not being achieved. Transformation to a more integrated approach (as opposed to co-located model) began when Michelle Duprey from Starfish Family Services came on board around 2010 and worked closely with staff and with the support of the management.  They learned the valuable lesson that you can’t place a mental health professional into a medical clinic and think that integration will just happen because true integration requires change and transformation of culture, workflow, relationships and attitude.

A unique and creative approach to meeting mental health needs

About two years later, the Ethel and James Flinn Foundation granted funding, which was subcontracted to the Detroit Wayne Mental Health Authority, for Starfish to begin the Screening Kids in Primary Care Plus program.  This program was specifically designed to partner with pediatricians to embed a Pediatric Behavioral Health Consultant into their practice to provide screening, brief intervention, action plans, resources, referrals and consultation on children’s mental health issues. Although the grant ended years ago, the Detroit Wayne Mental Health Authority continues to support this important Wayne County initiative. During this time, the Authority also initiated the Pediatric Integrated Health Care Workgroup to ensure that work being done for the adult population was also being addressed for the pediatric population.  One result was the Wayne County Pediatric Integrated Health Care Concept Paper with Duprey as the lead author.  Starfish was awarded additional grants to continue integrated health care work and expanded to Integrated Infant Mental Health (I-IMH) with the help of a Flinn Foundation grant around 2013.

A Comprehensive Team Approach

Currently, the Starfish Integrated Health Care team has one director — Michelle Duprey, and two supervisors — Chy Johnson and Jung Nichols.  There are nine IMH therapists who provide specialized home-based Infant Mental Health therapy and are also embedded in OB/GYN settings (outpatient clinics and hospitals). This allows them to combine their specialized training with the OB/GYN team for optimal women’s health care.  The four full-time Behavioral Health Consultants and one Medical Care Coordinator, who are embedded in various medical settings including pediatrics, family medicine, and oncology, work alongside medical staff to provide behavioral health and community resource expertise.  Our staff are physically located right inside the medical setting.  This is the One Location, One Visit philosophy.

This philosophy is described in the Pediatric Integrated Health Care Manual developed by Duprey, who is a national subject-matter expert on PIHC

One Location, One Visit

One Location, One Visit ensures that the medical team has behavioral health expertise available on-site when patients come to see their doctor.  The goal is to treat the whole person, which means mind and body.  As behavioral health professionals, we know that social/emotional well-being impacts physical health and that physical well-being in return  impacts social emotional health.  Having a behavioral health professional on the medical care team allows the team to address the many concerns that may arise in various ways, including care coordination, referrals to specialty mental health treatment, and information about how to access community resources.  Families can also receive education and support about anything normative that comes up in primary care visits, such as child development, parenting/discipline, and educational needs.  This normalizes discussion about and awareness of behavioral health needs of their children, as well as knowing where to go for questions/concerns if they arise in the future.  We know that addressing emotional needs of families as early as possible can help with early detection and allows us to provide intervention before things develop into more serious conditions.  An added benefit is that the medical staff also receive education that allows them to become more aware of behavioral health and the impact on health behaviors and outcomes.

Example #1: Intervention on behalf of a 5-year-old

Cash, a 5-year-old boy, came to the primary care clinic for a Child Protective Services (CPS) physical following a referral from the school after Cash came to class with a gash on his head. When prompted, Cash told his teacher, “My mom gave me a whoopin’ with a belt.” The forehead mark was found to be from his 3-year-old brother, who threw a hammer at his head after Cash hit him with a broom. When Cash’s mom, Cheyanne, was interviewed by CPS, she admitted hitting him with a belt and leaving physical marks.

Cash is in the Detroit Public Schools Head Start program. He has been suspended five times. He can no longer ride the bus because he jumped on a boy on the bus and started hitting him with his fist. He also tried to kick a female classmate down a flight of stairs. He is disruptive in class and frequently throws temper tantrums.

Cheyanne is fed up, easily aggravated and worried. Cash’s little brother is reported to be “absolutely terrified of him.” His 7-year-old brother teases Cash and Cash reportedly gets easily angry and punches and spits on him. His biological father is only intermittently available to the family and Cheyanne worries because he has been diagnosed with bipolar disorder. Cash has an involved stepfather but he is not comfortable with discipline.

An internal referral was made to Starfish and the family successfully enrolled in services.  For the past five months, they have been getting home-based services, which emphasize parenting/discipline and family relationships.  Cash is making progress and is no longer violently aggressive toward his brothers.

Kelly Mainville, MS, LLPC

Building relationships promotes health and wellness from the start

A major component of Infant Mental Health Therapy (IMH) is to promote the health and wellness of a child through close, secure relationships and attachments with their caregivers. As an Integrated Infant Mental Health Therapist/Behavioral Health Consultant working in an OB/GYN clinic, I strive to promote and model close, secure relationships and attachments with patients so they can go on to promote that same relationship with their loved ones. I help the patient understand the importance of forming a secure relationship with their doctor to further promote health and wellness throughout their pregnancy and early post-partum period and get them in the good practice of relationship building. And while my role is most certainly to promote healthy mental well-being in patients, more than anything it is to help them feel supported and held during their visits to the clinic. My IMH training and expertise is the foundation of my work; I apply it to my interactions with the patients I see — pregnant or not. My focus is to build relationships, to promote health and wellness at any stage of reproductive health, and to support patients. I also do a lot of advocating for baby — before baby is even here — and educating the patient on the importance of forming a close, secure relationship with their unborn child.

My work is slow but deliberate

Like much of the work we do in Infant Mental Health Therapy, my work with patients is often slow, but deliberate, difficult at times, but so rewarding. To see a patient’s face light up because this is the first time someone has really asked “How are you doing?” and is willing to listen to her concerns and to support her, validates that this work is important. To have patients say “hello” or “I was hoping you would come see me today” means that the relationships I am building means something to them. A few weeks ago, I encountered a patient for the first time and when I described my role in the clinic, she started crying. Of course, I asked her if something was wrong and her response was “I’m just really happy that someone cares about us.” She stated that her hormones caused her to be overly emotional but she kept repeating how happy she was that someone was going to check in at each appointment and support her. Other patients have shared similar sentiments, shaking my hand or giving me a hug and telling me how grateful they are to feel supported during a mostly happy, incredibly transformational time in their lives.

Example #2: Infant Mental Health Intervention with a Depressed Mom

Recently, Rosa, a woman in her late 20s, came into the clinic for her 6-week post-partum checkup. It was apparent that she was exhausted — mentally, physically, and emotionally. She had made a few concerning comments to the medical assistant (MA) during her vitals check and the resident doctor about not being able to cope with the baby’s crying, feeling very sad, and feeling very isolated. Both the MA and the resident doctor conferred with me and together we decided that it would be beneficial if I could speak with her. I entered the room and immediately saw a woman who was struggling. She had showered, gotten dressed, and looked physically presentable, but I could see worry, fear, and trepidation in her eyes. Instead of my more formal introduction of what my role is in the clinic, I simply said “I’m Kelly and I’m here to see how you are doing.” The minute I said that I could see a shift; mom became tearful, but I saw relief wash over her, too. She began to tell me her story. She and her husband had decided that because of some health issues, they would have children soon after they married. Mom said,  “I’ve nannied before, but never for kids under 2. I didn’t realize how much babies cry and I can’t take the crying.” She also reported feeling alone and like a bad mom because she couldn’t figure out what was making her baby cry and because she couldn’t handle the crying. I spent about 20 minutes with her, reassuring her that what she was feeling was a feeling shared by many new moms, that she was doing her very best to meet her baby’s needs and keep him comfortable, and that while this seemed overwhelming right now, it would not last forever.  It was at this time that I realized what an amazing candidate this mom would be for Infant Mental Health Therapy. I explained the program to her and I could see even more relief wash over her. Unfortunately, I was unable to add her to my caseload, but I was able to place her with a teammate who is also a mom and someone I felt would be a great fit. I will now follow up with Rosa in the clinic at her next post-partum appointment (the resident and attending doctors both agreed she should come to at least one more to monitor her mental health) and check in with how IMH is working out for her. I have a lot of hope that this program will benefit her greatly and I am so happy that I could play such an integral role in getting her the support she needed. This family makes me further believe in the importance of having a trained infant mental health clinician working as a Behavioral Health Clinician in OB/GYN offices. I was able to provide immediate support, which facilitated her acceptance of a long-term intervention to ensure optimal mental well-being and a positive outcome for her and baby.

Expanding the Model: Partnering with the University of Michigan

Of course, I value and believe in my work within the OB/GYN clinic, as do many of the patients and clinic staff, but it’s about more than just one clinic believing in the Integrated Infant Mental Healthcare model. It’s about the importance of integrated health becoming a regular practice in all OB/GYN clinics state and nationwide. This is why we have partnered with the University of Michigan to conduct an Integrated Infant Mental Health study that will evaluate the effectiveness of the Integrated Infant Mental Health Model (I-IMH) on maternal and child outcomes, as well as estimating the cost for implementing and delivering the I-IMH intervention in OB/GYN clinics. The hope is to show that the Integrated Infant Mental Health Model is a worthwhile investment in OB/GYN clinics and that through its emphasis on relationship building and support, it can promote healthier maternal and child outcomes in the process. We are in the beginning stages of this study; recruiting patients and getting other clinics we are embedded in on board with participating is proving to be a challenge, but we are working hard to show that the Integrated Infant Mental Health Model works.