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We sit down with Claire Ellerbrock, a nurse practitioner with a background in psychiatric and behavioral health care. Claire shares her powerful and transformative experience with a patient named John, whose tragic passing highlighted the systemic failures in the treatment of individuals with severe mental illness (SMI). Claire discusses the significant barriers to providing adequate health care for this vulnerable population and the crucial role of integrated care measures. She emphasizes the importance of preventative screening and the need for systemic and policy changes to improve health outcomes for patients with SMI.

Claire Ellerbrock is a nurse practitioner.

She discusses the KevinMD article, “How one patient’s death transformed my approach to mental health care.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Claire Ellerbrock. She’s a nurse practitioner. Today’s KevinMD article is “How one patient’s death transformed my approach to mental health care.” Claire, welcome to the show.

Claire Ellerbrock: Thank you so much for having me. Really excited to be here.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Claire Ellerbrock: Sure. So I began my academic journey with a bachelor’s degree in psychology from Washington University in St. Louis. I’ve always had a strong interest in human behavior and the mind. Initially I thought research was my calling, and I spent several years as a research assistant during my summers in college. However, over time I realized I wanted more direct contact with others and to help people in a more tangible way. And this realization led me to pivot my career trajectory and pursue a nursing degree as a second career.

And so my desire to specialize led me to Case Western Reserve University, where I became a psychiatric nurse practitioner. My first role was in a community mental health setting, where I spent two challenging but very rewarding years working with complex and underserved patient populations. I then pivoted to addiction treatment, inspired by my collaborating psychiatrist at the time. This role, especially in a dual diagnosis PHP program, taught me the critical nature of addressing both mental health and addiction.

And then my journey took a little bit of an entrepreneurial turn as I opened my own private practice and provided more personalized care. And concurrently I was pursuing my DNP at Kent State University.

And over the years my curiosity about mental health treatment and how it varies across the U.S. led me to locum tenens work, and this allowed me to explore diverse patient populations. And one of the most rewarding experiences was working in Wisconsin as an Indian tribal health clinic provider, doing medication-assisted treatment for opioid use disorder. So many different experiences, and I’ve been fortunate over the years to have such diversity of experiences.

Kevin Pho: So you work at a tribal health clinic. Tell us what the situation is like.

Claire Ellerbrock: Sure. So this was a short-term contract job working at a clinic that does dual diagnosis treatment of mental health and addiction. I have very little prior experience working with Native American populations, and so I learned quite a bit about cultural aspects and how care is a little bit different. And each tribe is certainly very diverse, and so you can’t, you know, cast a broad stroke across all populations.

But in this tribal clinic I learned a lot about eye contact, and how actually direct eye contact is perceived as aggressive. And so when patients don’t maintain that eye contact, it doesn’t have to do with, you know, anything other than respect, actually. And so I learned a lot about how to prescribe in a certain way in this setting.

But there is just a lot of health disparities that I encountered working with this population. And it was just very rewarding to be able to learn about a new culture and also provide a little bit of an impact along the way too.

Kevin Pho: All right. So we’re going to talk about one of your experiences in your KevinMD article titled “How one patient’s death transformed my approach to mental health care.” For those who didn’t get a chance to read your article, tell us what it’s about.

Claire Ellerbrock: Sure. So I actually wrote a version of my article right after this particular event happened, as a sort of therapeutic way to process my emotions during that time. I was a relatively new nurse when I experienced my first patient pass away. So for me this was a very significant event, especially the way he passed away. I remember at the time just feeling that his death was very much preventable.

So just to summarize a little bit, in my previous role as a psychiatric registered nurse, I encountered a patient with severe mental illness and significant comorbid medical issues, including various heart conditions. He was admitted to our psychiatric facility after experiencing psychotic symptoms. And at one point he complained of chest pains, and despite being sent out for medical evaluation, he was discharged with the diagnosis of pneumonia. Upon return to our behavioral health facility, he was found unresponsive the next morning and later pronounced deceased.

And I think this incident absolutely underscores systemic shortcomings in recognizing and addressing the complex medical needs of individuals with severe mental illness, as well as systemic failures in integrating mental health and physical health care.

And I believe that much of this patient’s cardiac history could have been more proactively addressed in the years prior, with regular follow-ups with a primary care provider while concurrently seeing a psychiatric provider, likely through the assistance and advocacy of a dedicated case worker.

So this experience has driven me to advocate for better screening and integrated care measures in community mental health settings. And there are many ways to go about doing this. I think specific for this patient, integrated care measures might look like addressing metabolic health early, fostering collaboration between mental health and primary care.

Also, the two disciplines have historically existed in very distinct silos of, you know, mental health, physical health, and then also addiction as another distinct silo. And so I think the ongoing efforts to integrate care can improve outcomes and close the longevity gap for individuals with mental health illnesses.

Kevin Pho: So with this particular patient, tell us about the background of his primary care, if he had any. Tell us about what his care was like before coming to the psychiatric unit.

Claire Ellerbrock: Similar to, I think, many patients who were presenting to us with severe mental illness, he wasn’t following up with a provider in a consistent way, and so wasn’t following up with his medical provider or psychiatric provider, so wasn’t necessarily compliant with his medications. And I think that was tough on its own.

And so he didn’t have a primary care provider who he was following up with, and so I think that’s where having a case worker who could help assess, you know, take him to appointments, keep him on track a little bit better, could have been more helpful. But he unfortunately didn’t have kind of an established team of providers that he’d been following up with over the years. He kind of resurfaced with a psychotic episode, which led him into our facility.

Kevin Pho: And you mentioned that this story happened early in your nursing career, and now that you’ve had years since, and you’re of course a nurse practitioner now, how common is it for patients to have that integrated care that you’re talking about? Having two offices, being arranged by care managers, being compliant with medications and primary care follow-ups. How common is that from your experience?

Claire Ellerbrock: Not incredibly common. I mean, I think over the years it’s becoming more common where there are centers that have integrated primary care and mental health care and pharmacies kind of all in one setting, so that patients don’t have to have various barriers to accessing treatment or the availability to see a provider.

In settings I’ve worked in, often they’re very distinct, and so I work in the mental health facility, we then kind of refer to primary care, patients then either decide to or not follow up with them. And so that’s where a case worker comes in and really steps up as an advocate to help encourage patients to keep their appointments and attend those appointments. And so I think having kind of a hub where all of those services are in one place is a very helpful way to kind of limit the fragmentation of services and drop-off that occurs.

Kevin Pho: Now you mentioned the silo between behavioral health care and primary care. Do you feel that individuals with severe mental illness, is there a difference in terms of the primary care and cancer screenings that they should receive, in contrast to those without severe mental illness?

Claire Ellerbrock: I think some of the psychotropic medications we prescribe can cause metabolic health effects, and so I think it’s really important that there’s a baseline screening occurring. But because the medications we prescribe can cause more metabolic abnormalities, it’s important that just those general baseline screenings are occurring.

I also think that people with severe mental difficulties have high rates of cigarette smoking and substance use at times, and so there are other conditions that need to be addressed as well. But across the board, I think it’s in line with most people, to be checking up on a regular basis with primary care.

Kevin Pho: So you mentioned that there could be some systemic or perhaps policy improvements that could improve that integrated care, especially those with severe mental illness. So talk about some of the changes that you would like to see happen.

Claire Ellerbrock: I think it would be incredible if mental health was on par with physical health, and I think insurance reimbursements can kind of help facilitate that.

In an ideal world, all patients would receive mental health coverage for services. Specifically, those with severe mental illness would have a case worker, a social worker, maybe a therapist, a medical provider, mental health provider, sort of a team that follows patients in a preventative and proactive sort of way, so that we’re not just on the reactive end of treating patients when crises occur, but instead proactively addressing these things, to make sure that metabolic abnormalities are being monitored, that psychiatric health is stable, that additional resources are obtained, whether that’s housing or employment assistance, all of those happening proactively.

It’s cost-saving, and it also helps prolong life expectancy. Those with severe mental illness die on average 15 to 20 years earlier than the general population, and that’s just something that should not be the case.

Kevin Pho: You mentioned earlier that sometimes mental health care isn’t on par with physical health care. Is that really true? Is that something that you see regularly when you go to these various behavioral health settings?

Claire Ellerbrock: I think that’s just more in terms of our culture. I think there’s a lot of stigma surrounding mental health. I think when someone presents to us with some sort of chest pain or something and they don’t have a psychiatric history, I think we’re a lot more maybe urgent with addressing that issue than someone who comes in, you know, floridly psychotic or struggling with substance use, addressing that as well. I think there’s just a nationwide and also just worldwide sort of stigma surrounding mental health. And so I think because of that there’s sort of a discrepancy between mental health and physical health.

Kevin Pho: So tell us a success story. Do you have a story, or it could be a hypothetical example, of a patient that has that great integrated care background that led to a positive outcome for a particular patient? Is there a story you could tell us of what your ideal would look like?

Claire Ellerbrock: Sure. So in that first job as a psychiatric nurse practitioner, I worked outpatient, but one day a week I worked on a crisis stabilization unit. And in that facility patients kind of stepped down from the hospital, they’re not quite ready to go home, but kind of discharge from the hospital to home is too big of a jump.

And I encountered a patient with bipolar disorder with psychotic features, who was still experiencing psychosis, not ready to transition home. And it was a team of her getting established with a case worker in the crisis unit, having a therapist, establishing with me, who would then later follow on with her in the outpatient setting, that led to her slowly getting better. Thoughts became more clear, and psychosis resolved.

She was in college at the time, she graduated and began working with a small corporate organization, and then started racing triathlons in years later. And so that I think is a great example of the power of having sort of a team that follows you from that crisis point to stability and then beyond. And she’s doing phenomenally. And I think I wish that were the case for all patients.

Kevin Pho: So you shared that story earlier in this podcast and on KevinMD, early on in your nursing career. How did the lessons from that story affect how you practice today? How did it influence how you practice today as a nurse practitioner?

Claire Ellerbrock: I think I make sure that I’m not just addressing the mental health piece. I’m a psychiatric provider, and so it’s outside of my scope to address anything medical, but I’m very vigilant about making sure I’m referring patients to other services. And it’s not just the referral, it’s the assistance, the handoff, to make sure that that’s going through. And so if it’s establishing with a case worker, getting a counselor, making sure that they follow up with primary care, especially if I’m prescribing meds that are going to cause metabolic issues. Those are some of the things that I take as I provide patient care day-to-day.

Kevin Pho: And what are some of the common medicines that you prescribe that lead to potential metabolic abnormalities?

Claire Ellerbrock: Unfortunately, a lot of our atypical antipsychotics that we commonly use to treat mood disorders, psychotic disorders, are known to cause metabolic difficulties. And so whether that is olanzapine, aripiprazole is less so, haloperidol, risperidone, all of these medications are known to cause metabolic issues. Helpful with helping mental health conditions, absolutely, but do come with these side effects that need to be monitored.

Kevin Pho: So take us into your exam room. So if you’re talking to a patient and you’re treating them for a behavioral health issue, but they have some type of primary care screening that is not done, like if they had, you know, high cholesterol, or their cancer screening wasn’t done, or some primary care issue that you feel needs to be done. Tell us what exactly would you do next? Like, how would you address that in the behavioral health room?

Claire Ellerbrock: I am very collaborative as a provider, and so I want to make sure my goals are aligning with my clients, my patients, so I’m not just kind of dictating what we’re going to do. And so I first find out what their ultimate goals are. Is it to not have to be on medications long-term? I hear that from patients sometimes. Or be in a relationship, or have a stable job.

And so we kind of start working from what the ultimate goal is and kind of working backwards from there. And so if a patient doesn’t have a primary care provider but they’re often sick and aren’t able to hold on to a job, we kind of look at, well, what are the ways that we can get to that goal? And sometimes that might involve working with a primary care provider. Well, what are the barriers? It might be transportation. If that’s the case, getting a case worker is a great fit. If there are some sort of cognitive distortions that are getting in the way, that’s where I would recommend a therapist.

And so it depends on what the patient’s ultimate goal is and how I can work with them to facilitate their ultimate goal. And that often involves medications, but also therapy and other resources, housing, transportation, those sorts of things.

Kevin Pho: And in your area of practice, how difficult is it to collaborate with the different silos of medicine, whether it be case management or primary care?

Claire Ellerbrock: It’s a bit difficult. I think it depends on the particular setting. I mean, in more rural, smaller towns, there’s resources. Other providers in other specialties are often very busy themselves. And so it’s not incredibly common that I’m on the phone talking about a mutual patient they share with me, maybe a primary care provider.

But that’s where case workers I think can really play a part, of attending the mental health appointments, helping transport patients to their primary care visits or neurology visits, and kind of being that additional advocate for patients. And so I think that’s a great point of integration in places where those services can’t be in the same sort of little hub.

Kevin Pho: One of the things I said earlier when we talked about the disparity between physical and mental health was that there’s still a stigma associated with mental health even today in 2024. What are some ways that we can reduce that mental health stigma?

Claire Ellerbrock: I think sharing about how prevalent mental health difficulties are. I think there’s the most stigma surrounding severe mental illness, schizophrenia, bipolar disorder. But I think today more than ever, especially post-pandemic, there are a lot of other mental health difficulties people struggle with, whether it’s depression or anxiety, or adjustment disorders, or PTSD, trauma, complex PTSD as well.

And so I think acknowledging that it’s common, sharing experiences about it, and helping normalize and validate those experiences. I think the more we talk about it, the less stigmatizing it is, and allows for people to seek help and assistance.

Kevin Pho: We’re talking to Claire Ellerbrock. She is a nurse practitioner. Today’s KevinMD article is “How one patient’s death transformed my approach to mental health care.” Claire, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Claire Ellerbrock: I think my take-home message is sort of maybe an important lesson I’ve sort of learned along the way from being a nurse to a nurse practitioner. And I think that lesson is that patients’ progress is not always a reflection of how good of a provider you are.

I think this is something I’ve really struggled with, and sometimes still do. I carry a lot of personal responsibility for the wellness of my patients. If they’re not getting better or doing better, sometimes I think that’s because of me and I’m not effectively treating them. But in reality, there are so many factors that play into the mental well-being of people. And this is even tougher with complex patients with multiple psychosocial stressors.

So learning that my role is to be present, to meet patients where they are, obviously provide evidence-based treatment, and help them find wins along the way is key. So progress, no matter how small, is progress. So not every patient will come to optimal mental health when working with us. Sometimes you’re just getting to see some small steps in the right direction, such as a patient not having suicidal thoughts in seven days, or a patient maintaining sobriety for the first time in a month.

When I started releasing personal responsibility for patients’ global health, some stress was released for me, and this has become a valuable ongoing lesson that I hope others take with them as well.

Kevin Pho: Claire, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Claire Ellerbrock: Thank you so much for having me.