Treating the Whole Patient

By Autumn Heisler


Concord Hospital integrates behavioral health model into care

WITH THE UNDERSTANDING THAT  mental, behavioral, physical and social factors affect a patient’s health, Concord Hospital Medical Group’s Concord Family Medicine in New Hampshire treats the whole patient. Through a partnership with Riverbend Community Mental Health, the nursing team and the providers at Concord have been able to bring integrated care to patients.

“It’s not clear if mental health has an effect on physical health or vice versa, so it’s better to look at both,” said Brenda Lovely, BSN, RN, a nurse navigator for the integrated behavioral health model at Concord. The model provides patients with a team of healthcare professionals, including nurses, doctors, psychologists and social workers, who work together to determine the best care.

Utilizing Teamwork

Thanks to a grant from Concord Hospital Trust, Riverbend placed two part-time behavioral health clinicians at Concord. These clinicians quickly answer to the needs of the providers and patients through the integrated health support team.

“This integrated model helps get past the stigma that mental health is in its own world,” said Diane Davis, DNP, RN, director of the medical home navigation and the palliative care programs at Concord.

The team collaborates to provide care to patients who are therapy referrals or who face homelessness, depression, domestic violence or child welfare. The care, Davis noted, is embedded in crisis issues.

“We started asking [patients], ‘Do you have a place to stay?’ ‘Do you have food?’ ‘Can you afford food?’” Davis explained. “We’re looking at the whole patient.”

When a patient enters Concord in the midst of a social or psychological crisis, a provider assesses the situation. If the provider sees that having the patient wait for a referral is detrimental to his or her overall well-being, the provider will get the nurse navigator and the integrated behavioral health team involved in order to find the best care for the patient immediately.

If the patient visits his or her mental health professional and reports not filling an insulin prescription that month because he or she didn’t have the funds, or missing an appointment because he or she didn’t have a ride, the mental health professional will get the nurse navigator or social worker involved to start finding solutions to economic and social barriers.

The Whole Patient

The program’s goal is to support crises on the spot. People with chronic illness often have additional social, economic or psychological challenges. Once a patient becomes part of Concord’s program, Lovely explained, the team stays with them throughout their journey.

Lovely spoke of a patient she has been working with since the start of the program. The patient entered the facility homeless, depressed and ill. With the help of her support team, the patient has been able to take control of her health. Lovely said this patient still has a ways to go, but that she is making progress each day.

Both Lovely and Davis agreed that the system in place enables Concord’s patients and their families to feel comfortable, knowing that when they call in, they will have providers who know about their complex health issues.

“Being able to tell somebody, ‘Look how far you’ve come,’ and seeing the pride on their face is the most rewarding thing,” Lovely said.

Autumn Heisler is on staff. Contact her at