An Interdisciplinary Approach to Recovery
Care at DVCH – Girard Medical Center is characterized by an interdisciplinary team-based approach. Many of our patients are struggling with substance use disorder and have a complex web of needs that are most effectively addressed when seen by multiple members of the GMC team.
There is a medical-legal team that can assist with a wide range of concerns, including applying for government welfare programs, replacing lost or expired personal identification/documents, and personal legal matters as well. We also have a Behavioral Health Coordinator who can offer onsite counseling as well as referrals to community and mental health resources. Additionally, we have our MAT program coordinators who check-in with patients and engage in care coordination with local recovery programs and pharmacies. My role is to screen patients for social determinants of health and make community resource referrals as well as internal referrals to these GMC team members.
Due to this approach, sometimes new patients will meet with three people individually before seeing the provider. Sometimes this can be overwhelming or frustrating for patients who are simply expecting to get a prescription. However, the recovery process is often more complex than simply taking medication. A patient’s holistic needs should be understood to better help them achieve their recovery goals. We also try to streamline this process by seeing the patient together, when possible, rather than individually.
However, it is not possible for each of us to see all patients. Thus, an important aspect of an interdisciplinary approach is efficient and open communication between each of us. A key component is that our communication is two-way. For instance, we all report to the provider to keep them updated on how the patient is doing but the provider can also request for us to see the patient if they find they need our services.
Communication is especially important for me as I make many internal referrals. For instance, if a patient screens positive for interpersonal violence during my social determinants of health questionnaire, with their consent, I will give them the number to the domestic violence hotline and then I will direct the patient to the rest of the team. I can refer them to medical legal to pursue any legal action such as filing a Protection from Abuse order and to the Behavioral Health Coordinator for counseling and mental health resources. In this way, we address interpersonal violence and health as a multifaceted issue rather than a single concern.
Overall, the road to recovery can be difficult without receiving an interdisciplinary approach to care. This may translate to longer visits initially but we hope this also means decreased chances of relapsing and being lost to follow up.