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Surviving Where The Grass Is Browner: A Story Of Integration In Tennessee

Posted By Parinda Khatri, PhD, Thursday, July 14, 2011
When most people hear that I live in Tennessee, they tell me they have traveled through Smoky Mountain National Park. It is, after all, the most visited national park in the country. Some tell me they have always wanted to visit Graceland, home of Elvis, or that they love Tennessee barbecue. A few ask if I’ve run into Keith Urban and Nicole Kidman (sorry, we don’t travel in the same circles). I also hear with alarming frequency, "We can’t integrate. We can’t be like Cherokee Health Systems. It is too difficult. It is not possible.” Here is the interesting thing: Tennessee is a state rich in culture, beauty, and warmth but not in wealth. Poverty is present hand in hand with low literacy and poor nutrition in many communities from the hills of the Appalachian Mountains in the eastern portion of the state to inner city Memphis on the western border and many points in between. Limited resources for health and education are stretched well beyond capacity. Healthcare coverage for underserved populations and reimbursement for healthcare services have been cut dramatically. Demand for health care services, particularly for the underserved, invariably outstrips supply. Sound familiar?

I work as Director of Integrated Care at Cherokee Health Systems (CHS), a comprehensive community healthcare organization based in east Tennessee that blends behavioral health and primary care as its model of care. At CHS, our CEO Dennis Freeman has always maintained that the organization goes "where the grass is browner.” Not surprisingly, the organization has expanded at a dramatic rate to meet the needs of our communities. CHS moved into counties where primary care and behavioral health resources were scarce and often nonexistent. People routinely asked us what grant and team of experts we used to plan our model of integrated care. They are surprised when we answer "No grants. No planning.” We simply responded to the needs of our patients who showed up on our doorsteps, asking for comprehensive care for a wide spectrum of needs.

People presented with a plethora of physical, behavioral, and relational issues so intertwined we could not tease them apart to fragment care even if we tried. So, we put behavioral health clinicians in the middle of primary care. We brought primary care to our "behavioral health” patients, many of whom had previously untreated diabetes and cardiovascular disease. We set up multidisciplinary treatment teams to collaborate and co-manage care with the patient and family. When we could not find enough providers to travel to remote clinics, we set up telehealth equipment so primary care and behavioral health providers could beam into clinics and schools to increase access to care. When people ask, how in the foothills of the Smokey Mountains, with few resources, did we develop a system of integration that is now is fairly well progressed, our answer is simple, "Our patients led the way.”

We are not alone. Safety net clinics in Tennessee have initiated collaborative efforts to improve the health status of their communities. Matthew Walker Comprehensive Health Center in Nashville holds a monthly "Diabetes Day” when patients see a primary care provider, behaviorist, ophthalmologist, dentist, and podiatrist, all of whom work together to improve the patient’s management of diabetes. Matthew Walker’s high- risk pregnancy clinic has a behaviorist who sees every pregnant woman as part of the OB visit (come hear Dr. MaryClare Champion talk about her work in this program at the CFHA conference in Philadelphia). Perry County Health Center in middle Tennessee brought a behaviorist into their rural primary care clinic who became, and still is, the only licensed mental health provider the county has ever had. East Tennessee University in Johnson City developed a PhD program in Rural Primary Behavioral Health care to help build a workforce for the rural safety net health care community.

The Tennessee Primary Care Association has been a stellar leader in integration efforts in Tennessee. They have teamed with health centers to advocate for changes in billing, coding, credentialing, and policy to foster and sustain integration efforts throughout the state. They have organized representatives from a variety of health centers to work together to advance integration on both clinical and administrative levels. Every TPCA clinical conference now has an "Integrated Care track” for both primary care and behavioral clinicians. Just this year, TPCA successfully lobbied the state government to pass a resolution supporting primary care and behavioral health integration.

It may be no fluke that innovation and collaboration emerged from such an impoverished landscape. Without significant extramural funding, little access to specialty resources in public nutrition, mental health, and health education, clinicians committed to the underserved communities realized that they should, well, work together….as a team…with the same mission. Because, in effect, we, as a team and community, were all we had. Several years ago, a team from a well known policy center in D.C. visited Tennessee as part of their research for a white paper on Integration. As they traveled with us to clinics in the mountains of rural east Tennessee and inner city Knoxville, one visitor observed that innovation often emerged in communities with few resources. To paraphrase the famous saying, they had to invent out of necessity.

As we move forward in these challenging times, with continued budget cuts in our state (as likely in yours), I am reminded of an article I read years ago written by a journalist who visited the lush wine regions of France. After touring beautiful vineyards ripe with plump grapes, the guide took the group to view vines in a remote area with rocky and dry terrain. Few grapes were produced from these scrawny vines that had to overcome the adversity of poor soil and climate. However, it was these grapes that yielded wines rich in clarity and complexity of flavor. It was these grapes, he explained, that had the potential for greatness.

Those of us committed to integrative and collaborative care continue to be faced with walls to climb and obstacles to overcome. But we can never say "This is impossible” or "We can’t do it” because if it possible in one place, then it is possible anywhere. In fact, we can and we are doing it. So, the next time you are driving through the Smoky Mountains, check out the local health center and learn about the cool stuff they are doing. Who knows? Maybe you’ll run into Taylor Swift on the way.


Parinda Khatri, Ph.D., is Director of Integrated Care at Cherokee Health Systems. She is a Clinical Psychologist with extensive experience in Behavioral Medicine. She earned her doctorate in Clinical Psychology at the University of North Carolina at Chapel Hill and completed a Post-Doctoral Fellowship in Behavioral Medicine at Duke University Medical Center. Dr. Khatri has led Cherokee's integrated care implementation at a number of primary care sites.  Dr. Khatri has presented extensively on integrated care and is involved in training and consultation in this area as well. She serves on the organization’s Clinical Leadership team, which provides oversight and guidance on clinical issues.  Dr. Khatri is involved in program development and supervision of several of the organization’s health and wellness initiatives and leads Cherokee's APA Accredited Psychology Internship Program.


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