The Importance of Integrated Behavioral Health in Orthopedics and Beyond

More than 20 years ago, Children’s Hospital Colorado brought psychologists into its main primary care clinic (known as the Child Health Clinic). The goal of this integrated model was and is to elevate the importance of behavioral health, improve access to high quality services for families, deliver the full continuum of mental health services and reduce stigma.

Now, that model is expanding into specialty surgical care, where psychologists like Jessica Kenny, PhD, help families navigate complex medical decisions and the complex emotional and social needs that come with them.

Specialty-focused behavioral health integrations are becoming increasingly common — and for good reason. According to Dr. Kenny, a psychologist who works within the Child Health Clinic as well as two orthopedic clinics (the Limb Differences Clinic and the Amputee Clinic), these touch points ensure behavioral health is always part of the equation to promote well-being and prevent more acute concerns.

“Integrated pediatric psychologists are different than your standard outpatient psychologist because we don't necessarily have a set therapy appointment once a week. We see the family when they come to Children’s Colorado for medical care. In doing so, we greatly increase access to care because we meet the family during their medical visit instead of asking them to return for a separate appointment, potentially with a different provider,” Dr. Kenny says.

This means that when a patient seeks care from an orthopedic surgeon or a primary care physician, they meet with two clinicians — one focused on physical well-being and one focused on emotional well-being. From the very beginning, behavioral health is part of the conversation and consideration, which normalizes discussions about mental health and well-being.

Integrating mental health in orthopedic care

Until 2021, behavioral health was not integrated into orthopedics. That work began after Dr. Kenny met orthopedic surgeon Julia Sanders, MD, who had recently received a grant to bring behavioral health care into the hospital’s Limb Differences Clinic. At first, Dr. Kenny wasn’t sure what to expect from bringing her expertise to the orthopedic setting.

“I quickly learned that the path that brings a child to need care for a limb difference is almost always complex or traumatic in some way for at least one person in the family. At the same time, these are some of the most resilient kids and families that I have ever met,” Dr. Kenny says. “Through my work, I can help address a kid’s anxiety regarding surgery or a change in their appearance, promote healthy coping, help a parent work through their grief, recommend needed school supports and accommodations, or help a family understand the importance of a long-term therapist.”

After two successful years in the Limb Differences Clinic, the team decided to expand Dr. Kenny’s services to another complex orthopedic arena: the Amputee Clinic.

In addition to assessing kids and families from a mental health perspective, Dr. Kenny has the unique role of being a bridge between surgeons and patients. When the medical language becomes too complex, she can ask surgeons important questions that help the family understand. When the family has tough decisions to make, she can serve as a thought partner, balancing psychosocial, cultural, socioeconomic and medical needs. And when the family isn’t ready for surgical intervention for any number of reasons, Dr. Kenny can work with the medical team to help find optimal solutions for both the family and the medical team.

“Because of my leadership role and the program that I have built with Dr. Sanders, I can help facilitate communication among the medical team and family, acknowledge risks and benefits of surgery, triage barriers and logistics related to recovery, and assess child and family well-being and capacity,” Dr. Kenny says.

The ethos of the integrated clinic model in orthopedics is that psychology is an integral member of the team. The priority, Dr. Kenny says, is to create relationships with families and providers with the goal of shifting the culture toward a prevention model and away from a reactive model, in which psychology is only brought in during a crisis.

“So much of what goes wrong in the pediatric surgery and medical subspecialty space could be avoided if a psychologist could meet with a family before things get really bad,” Dr. Kenny explains.

This involves psychosocial screening and gaining an understanding of resource and family well-being needs. 

“For example, if we learn that a child and family do not have reliable access to a car, it doesn't feel right to send them back from surgery with just a wheelchair and wish them luck attending all of their needed follow-up medical and physical therapy appointments,” Dr. Kenny says. “There are many families who, in theory, should have a surgery, but the correct supports and resources need to first be in place before it is appropriate to operate on them.”

For most kids, Dr. Kenny’s short-term intervention is enough to support them before connecting them to the resources they need for long-term health and well-being. For kids facing more acute behavioral health conditions or concerns, she can be a bridge to longer-term care that allows them immediate access to help, rather than waiting to be seen elsewhere.

Mental health in primary care

The integrated behavioral health model Dr. Kenny uses in orthopedics originated in the primary care setting. While Dr. Kenny is the only psychologist integrated in orthopedic care, she’s one of a few attending psychologists in primary care who oversee a large behavioral health team. This work is so well-established that it’s become routine for families and clinicians alike.

“Patients come into primary care, and they get height and weight. And they also answer questions about their health and well-being,” Dr. Kenny says. “Mental health is just like another vital that families are expecting to have as they come in.”

In addition to leading efforts to maintain routine implementation of mental health screenings and intervening when a concern arises, a large part of Dr. Kenny’s role is being a consultant to her physician partners. 

“So much of our role as consultants is supporting the care teams so that they can provide the right care,” she says.

Looking ahead

As Dr. Kenny and her team members continue making an impact across disciplines, specialties and families, the role of integrated behavioral health continues to grow. Currently, the Pediatric Mental Health Institute is exploring new ways to integrate into more specialties, as well as reach more families in the community.

Dr. Kenny is proud to be one of many leading the charge for integrated behavioral health in primary care and subspecialty surgical and medical settings. “One of my very favorite things about integrated care is that I am often the first behavioral health provider that a family encounters,” Dr. Kenny says. "That's a privilege and a responsibility. We have to make sure they have a good first experience so that whoever and whatever comes after me is more likely to successfully connect with and support them.”