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A Beautiful PCBH Clinic

Yesterday afternoon at CHCW’s CWFM clinic was one of those textbook PCBH days. We started the afternoon shift (1 – 5 PM) knowing we had great BHC coverage, as there were 14 medical providers on with 6 BHCs. Thus, all the BHCs heading into the afternoon were PUMPED for the expected busy clinic, filled with scheduled patients and many WHOs. Side note, my mind is so excited to share with the CFHA community the incredible year the team at CHCW has had. While we still have the whole month of December to go, already, the team has achieved the most visits and warm-handoffs in our program’s history. Truly, the team’s dedication to serving the community by providing compassionate, contextual, person-centered care in the moment when requested is, simply, inspiring. Be on the look for a “CHCW data dump” at the beginning of the new year!


Okay, back to yesterday’s afternoon clinic. Typically, the handoffs don’t start flowing until a little after 2 PM, as, one would imagine, PCPs are finishing up with their first few visits of the clinic, resulting in the potentiality of handoffs occurring. And, right at that time, and in the span of 20 or so minutes, four handoffs were sent from the medical teams. As we always discuss, the improbability of a single handoff occurring is something that continues to fascinate my mind. For a single handoff to occur, the PCP or MA has to be knowledgeable, embrace and be willing to include the BHC. Then, the PCP or MA have to introduce the idea to the patient, which, then the patient has to be open to seeing the BHC. If the process can survive the first few error-filled steps, there needs to be a process of getting the BHC quickly into the room to capitalize on the fragile moment that is occurring. Fully embracing and acknowledging the reality of how rare and improbable these handoffs moments can be, the team of BHCs were dedicated to making sure not a single handoff was missed. “Keep them here,” “Sweet! Be there in 5 minutes!” “OMW, ATS!” (on my way, add to schedule) were responses from the BHCs to the medical teams, conveying a sense of gratitude, excitement, and appreciation for the initiation of the handoff. While at times the TEAMS messages coming in were many and difficult to track, even while responding to them and still being present for the patients I was with, there was a realization and peace that came to my mind. Knowing that I had five other teammates that held the same dedication to our community, the will to make sure no one was going to leave without seeing a BHC, and the excitement of being a true part of the primary care team was motivating, it was inspiring, and made me want to do the work of PCBH.


During one of my scheduled follow-up visits, a patient that I had seen multiple times over the past year came to see me. Picking them and their partner up from the waiting room after I was already 20 minutes late, as I had taken a handoff just as they had checked in, they offered me grace for the tardiness, saying, “we know you are helping others.” As I write that, tears fill my eyes with gratitude and the awareness they had that other people in their community were struggling. As we approached the exam room, the patient asked, “can I check my weight real quick?” “For sure!” I responded and as we made our way to the scale, something the patient had been adamant to avoid in previous medical visits, they confidently stepped on the scale. Several pounds had been lost and the patient’s face brightened and proclaimed, “hell, yes!” As I was telling Bridget this morning as my mind reflected on the visit, my mind was in awe of the moment happening, as this was an individual close to a year ago that would have never smiled, never acknowledged their hard work, and definitely would not have celebrated a win. To make a long-story short and to protect PHI, I had met the patient via a phone warm-handoff and proceeding through the CI, there were numerous traumas, hardships, and ACEs present. As the patient began to disclose them over the initial phone call and following visits, it was clear, they were a fighter, they were a survivor, and a life of hardships had resulted in numerous behavioral responses that while functional when in a fire storm, were proving to lose the function when not. As we worked on building up awareness, noticing and normalizing their actions and internal processes, more willingness began to occur. Then, in what seemed like out of nowhere, the patient began saying things during visits like “I know that’s my mind.” “My mind doesn’t like it but I kinda am proud of myself.” “I think I want to start focusing on some of my health goals.” As we entered the exam room and completed the visit, the patient had a celebratory moment with their partner, filled with never before seen joy and laughter. All three of us paused in the moment and acknowledged how incredible of a moment it was, as well as how incredibly hard the patient had worked to get here. As we wrapped up the visit setting goals to build on their successes related to their health, along with continuing to grow a sense of gratitude, the patient pulled out a holiday bag and handed it to me. “What’s this?” I asked. They responded, “I have been working on crocheting at night, as it helps my mind to stay present.” The items were INCREDIBLE and so well done, as I commented on how impressive they were, the patient responded, “well, when you use them, make sure to hang them up this way?” Somewhat confused and then becoming more aware, I responded, “wait, these are for me?” The patient responded, “of course!”


As the clinic day was coming to a close, I found my way to one of our medical pods. The nursing team was lively, having a debate on who could cook the best meatloaf. As they chastised me for not being able to cook anything more than an egg McMuffin sandwich, I ran into Bridget and our residency program director. We laughed about some recent clinic meetings we recently attended and then we heard one of our BHC fellows and a BHC intern round the corner. They were chatting about the busy clinic that just occurred, feeling tired from the day, yet still fulfilled. All of us then began exchanging gratitude for each other being on the spot with responding to handoffs, joking about the internet going out mid-way through the afternoon, and sharing in another successful ending to a day of PCBH where all handoffs requested were completed!


As always, my mind worries about sharing stories at times as there is ego clinging (more of that to come in a future PCBH Corner) to a patient improving and a sense of being boastful, as well as owning too much of that outcome. Yet, the moment felt yesterday standing with the nurses, the medical providers, the MAs, the other BHCs was so powerful, so enriching, so healing, I just couldn’t NOT share with this community of likeminded, selfless individuals doing the hard, yet important and meaningful, work of primary care. My gratitude for you all and making it this far in this Story of PCBH, and hope the weekend is healing and restorative!

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