Dr. Kallenberg's post is the second in a 5-week collaborative series hosted by the blogs of CFHA and STFM.
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I want to tell you a story that is both personal and also
parallels the evolution of primary care and collaborative care over the past
decade and predicts its future.
I arrived in San Diego to take over the Division of Family
Medicine at UCSD in the fall of 2001. I
came from "the East” where I had been at George Washington University Medical
Center and School of Medicine for the preceding 20 years.
My clinical primary care practice
fortuitously shared a waiting area with the outpatient mental health team. It was a short walk to the therapists’
offices and in the course of wandering over to seek help on various patients I
met a clinical psychologist with whom I developed a close working and collegial
relationship. When I needed help with a
patient I would seek his counsel and/or refer the patient over to the group
with an "Attention to Pat” comment on the referral. I ended up hiring him to be the psychologist
in our new family medicine residency program; we did an international
consultation together for an Eastern European country’s developing academic
family medicine program; and he introduced me to the concept of motivational
interviewing among other things.
to realize that without this kind of key help the practice of primary
care/family medicine would be a lot harder.
I began to talk with a psychiatrist who headed the 3rd year
clerkship about deeper collaboration, but then circumstances changed more
significantly at GW and I decided to move.
Long story made short I ended up taking up the leadership of the UCSD
Division of Family Medicine.||This began our decade-long effort to "do good” rather than
just talking about studying how to do good.|
One of the most pleasant and propitious surprises on arrival
was that there was an outstanding group of academic teaching PhD marriage and
family therapists from the University of San Diego (USD) who were in
discussions with our UCSD Psychiatry Department about transferring their
activities to UCSD from the Sharp Family Medicine Residency which,
unfortunately, was winding down to closure.
Todd Edwards and JoEllen Patterson were the dynamic duo I was privileged
to meet. Unfortunately these discussions
were mired down with our Psych folks in what seemed like a circular and
non-progressing research oriented discussion.
Being the new kid on the block I was able to ingratiate myself with the
Chair of Psychiatry and got him to "let our people go” and actually set up a
clinical operation where we could deliver co-located care along with directly
observed behavioral science teaching sessions (fondly referred to as "BS
Sessions”) within our family medicine offices.
This began our decade-long effort to "do good” rather than
just talking about studying how to do good.
And the journey has reflected every aspect of the maturation of
collaborative care that I have witnessed during my 15-year tenure with
CFHA. I had the privilege of being at
the founding meeting of CFHA in DC in 1996.
One of my colleagues at GW, Karen Weihs, was a skilled
researcher-clinician, an FP-Psychiatrist who was one of the first-generation
conceivers of CFHA. I was
intermittently active for the next 5 yrs. before coming to San Diego, and once
we began to deliver collaborative care I became more involved and have been a
regular CFHA attender since Seattle, where we presented on our initial UCSD
efforts. During this period STFM extended a key
organizational avuncular helping hand as CFHA adopted the mantel of the
sun-setting Family in Family Medicine conference and its faithful attendees.
Our system has been somewhat unique all along in that we use
trainees from USD’s Marriage and Family Therapy Program
along with both a supervising PhD MFT and psychologist who are both on our DFM
faculty. This solves some of the
financial challenges and is a disseminatable component of what we’ve
built. In short, we bill patients
co-pays only for student and intern
visits, which respectively either contributes to supervision costs or for
paying the interns their nominal hourly pay.
If patients wish to see a licensed person we have them see the
supervisors and bill insurance accordingly.
Medicaid patients are seen by students/interns on a reduced-fee sliding
scale. Additional supervision costs are
borne by our clinical budget as a justifiable expense for having this clinical
service – which clinicians recognize the benefits of and are willing to pay just
like they do for general nursing support.
The system of collaboration we built initially relied on
physician education and orientation, physician referral of patients they
identified needing help with common mental health and family issues and a paper
referral system, which actually introduced our faculty to "genograms” as a
baseline referral data requirement (pretty sneaky, eh?). Therapists shared space in our offices and
saw patients in exam rooms mostly and offices sometimes if needed and
available. Each of these elements has
seen substantial evolution over the ensuing years as our national discussion,
experience and knowledge about collaborative care has grown and been shared
largely through CFHA efforts. I will
detail these a bit.
Culture – We started with surveying faculty and
residents about their views on the importance of mental health and behavioral
health issues; their ability to engage and assist patients with these problems;
their need for help in such efforts; and their belief that these problems in
fact could be helped. We went from "Who are these behavioral people?”
to a now universal awareness of how ubiquitous such mental/behavioral problems
are in primary care and what such team mates and colleagues bring to the table
in successfully caring for the whole patient.
We now tout our collaborative care team as a selling feature of our
practice to potential faculty and to candidates for our FM residency.
Affiliation/Space – Initially our interns were
employed by the Psychiatry Dept. and
when we hired our first supervising faculty MFT – Michele Smith – and our first
clinically active psychologist – Bill Sieber – we had to do so with approval
from Psychiatry. Over the course of the
first few years we wrested that control from Psychiatry and have directly hired
and overseen all our licensed folks and interns within Family Medicine. As we have grown we have dealt with space
wars about who should be seeing patients in increasingly limited exam room space
to now incorporating our collaborative care needs into our most recent building
plans for new office construction.
Medical Records/Communication – We computerized
our practice in 2005 with the EPIC EMR system and converted our referral system
into the computerized medical record. We
now do all referrals through the EMR which has increased both use and tracking
efficiency. However, as many have also
experienced, we lost our genogram abilities, but we hope this is temporary and
are working on ways to re-computerize this most useful social data recording function. We dealt with the HIPAA challenges and
achieved the ability of our therapists to write their notes in a reasonably unrestrictive
manner within the EMR so that they included enough useful data that would appraise
collaborating family docs of the issues, therapeutic approach and progress
being made on their referred patients.
Our docs are universally cc’d on ALL notes from collaborative care. In fact, this initially decreased oral and
interpersonal communication for a while, but this has since rebounded even more
strongly under our new T-Care system (see below).
Referral Process/T-Care – Under the new
leadership of Zephon Lister we have developed T-Care – a more directed effort
at identifying patients who may benefit from CC. Rather than just allowing the docs to
identify patients needing referral we now have collaborative sessions where MFT
students work with docs in their assigned exam rooms to review the roster of
patients together and determine who might need CC services. Sometimes the MFT student goes in ahead of
time and sometimes with the doc, and sometimes even staying after a while with
the patient. These initial shared collaborative
sessions intimately teach the doc and the MFT student about each others’
mental/behavioral health and communication abilities, help identify problems
and issues that were NOT known to the doc beforehand, and facilitate follow up
referrals to our CC Team. The time to
"collegial level peer relationship” between new MFT students and our physician
staff has been cut dramatically through these T-Care joint sessions. Initially each MFT student spends a couple
sessions with each doc "getting to know each other”. By rotating around between
docs everyone gets to know everyone in a few months rather than a year or more
previously. Once the MFT students get to
know everyone – they can provide T-Care services for 2-3 docs a session, identifying
patients on all their schedules who
might benefit from CC services.
Screening – Finally, with this structure of care
in place and with our ability to use data from our EMR we were able to respond
finally to the new US Preventive Services Task Force recommendation for
universal screening for depression if and
only if the care system has a way to respond to those patients identified by
screening. We had spent years
developing our service arm and it was time to complete the work by embarking on
the task of identifying ALL the patients in need of such services. We were able to initiate universal PHQ2-PHQ9
sequenced screening on all our patients over an amazingly short 3-4 week period
this past spring. We are now preparing
to add anxiety screening as well. Each
of these efforts involves teaching our MAs new skills, developing EMR data recording
capabilities and back-end data analysis reports to evaluate our efficiency and
measure outcomes (referrals to CC, diagnostic labeling of problem list,
medication prescribing and effects on medical co-morbidities). We are excited to further expand our efforts
to cover all common mental and behavioral health issues in our practices.
What this progression details is the inner workings of our
development of increasingly sophisticated Collaborative Care and how important
this has been to our practice. This has
been true with regard to specifically providing mental/behavioral and family
therapy services for our patient population.
But even more important going forward is how effective this effort has
been in generating a GENERAL TEMPLATE for incorporating additional team members’ efforts within the new practices we are
trying to build today. Now collectively referred
to as the "Patient Centered Medical Home” (PCMH) and supported by STFM and all
primary care specialties, this concept is solidly built on the concept of
team-delivered care – with many different health professionals working together
to provide the care that any patient population needs to care for their chronic
illnesses and to stay as well and
functional as possible.
We have used our
successful collaborative care template to replicate introduction of pharmacy
services, acupuncture/TCM services and RN care-management services. We are, in fact, now planning the
introduction of health coaching services,
to complete the full range of team skills for our PCMH practices. For these coaching services we will actually
employ our MFT students in true behavioral
health counseling roles in addition to more traditional mental health
roles. Thus our CC efforts have really
led and guided our efforts to develop a fully functional, one-stop-shopping Patient-Centered
We believe, from our own experience and from the influential
work CFHA leadership has done leading to the successful incorporation of the
requirement to attend to mental/behavioral conditions in order to qualify for
PCMH status - as certified by the National Center for Quality Assurance (NCQA),
that collaborative care will be central
to the new PCMHs primary care is developing all across the nation. This
is why we agree wholeheartedly with the words of the past CFHA President, Frank
Collaborative Care – the PCMH fails!”
Gene "Rusty” Kallenberg MD is a long-time member of both CFHA and STFM.
He is UCSD School of Medicine Division Chief of Family Medicine and Vice Chair
of the Department of Medicine and Preventive Medicine.He received
his medical degree from the University of Cincinnati College of Medicine in
Cincinnati, Ohio, and completed his internship and residency in Family Medicine
at Los Angeles County Harbor-UCLA Medical Center, Torrance, California.