Rusty's post is the second
in a 5-part series on
Whenever one chooses to develop a vision that deviates from
"the norm” and build something that is new, different, ahead-of-the-curve, yea
– "disruptive” – strategic partnerships are necessary for both survival and
success. Looking back on the 10 year development
history of our "Collaborative Care” Team here at UCSD Division of Family
Medicine we have learned the following lessons about building strategic
1. Your own clinical team. Incorporating mental/behavioral health
(M/BH) services within one’s own clinical operation is, as we all know, a
substantial organizational challenge that involves policy, process and culture.
The details of the first two have been well addressed in many of the
presentations at CFHA over the past few years.
The cultural challenges are a
bit more subtle, a bit under the table, but no less important.
Here in San Diego, we began with an assessment
of clinician attitudes to gauge the perceived need, responsibility and skills
to detect and attend to M/BH patient problems.
Once we had concurrence among most of our clinicians we were able to
introduce M/BH clinicians to "help” our PCPs handle the frequent M/BH problems
they encountered. This interaction
spread person-to-person from the usual early adopters. Close communication (both written and verbal)
between the clinical sides over patient care work helped build the collegial
bridge needed for true collaboration.
The most difficult challenges were/are over clinical space utilization
where the dollars/hr. generation potential still favors medical care vs. M/BH
care. We have tried to solve this in
various ways but the strategic relationship that makes this happen peacefully
is between our CC Director (also a practitioner) and our office managers and
medical directors. If they are on the
same page then problems get worked out.
Assess/build consensus among clinical team that
M/BH patient problems are important and their responsibility
Ensure multiple convenient communication
pathways between PCPs and M/BH clinicians
Ensure close working partnerships between
clinical office-level leadership and CC leadership
2. Partnering M/BH teams. Seems like a no-brainer but this will play
out in many different forms depending on your setting. Here at UCSD it involved connecting with our
Dept. of Psychiatry as a first step due to their "all things psychological are
our business” view of the world. We
gradually weaned them off of this position and now handle all M/BH clinician hiring,
billing and clinical operations of our CC Team efforts as part of our Family
Medicine clinical shop. Having internal
licensed M/BH leadership has been key to our development of internal policies
and processes of collaborative care delivery and relating to the clinical
office leadership as noted above. Through
their efforts we have developed and assessed universal screening for
depression, increased coverage for warm-handoffs, and a plan for broadening the
definition of M/BH services to include health coaching.
A special strategic partnership we have built
is with the University of San Diego’s Marital and Family Therapy (MFT) Training
Program. This has allowed us to greatly
expand our service delivery reach while training more collaborative
care-oriented M/BH clinicians for the community. This works well in our academic training
environment and allows for inter-professional training involving our family
medicine residents to occur as well.
This is a very fast growing international movement in health professions
training. Trainees allow the "multiplier
effect” through converting licensed M/BH clinicians into clinical supervisors,
thereby being able to serve many more clients than those licensed folks could
Establish clear shared/mutual/joint "ownership”
of M/BH services within your clinical operation with your M/BH provider group
Identify and empower local M/BH leadership
Consider establishing precepting relationship
with local M/BH training programs
3. Operational Support Teams. These come in many varieties but are always
crucial to ongoing management success for Collaborative Care teams. They cover a broad span include provider
licensing and privileging, billing and insurance coverage, chart documentation
and electronic health records, and practiced data analysis. We have spent much time to establish and
nurture close working relationships with the many departments and supervisors
in charge of these services at UCSD.
This involved credentialling MFTs on our rosters of approved M/BH
clinicians and getting them approved by our local insurance providers, working
out billing codes for M/BH services within our clinical shops where they
represented new books of business, and working out specific rules with our
compliance office re: including and integrating M/BH chart notes within the primary
care medical record – which greatly facilitates PCP-M/BH communication. This latter task required specific
negotiation about wording of M/BH clinical notes in ways that reassured the
compliance folks but did not hamper clinical communication.
Electronic medical records applications
represent a topic deserving of special mention.
Our system is fully computerized so the success of any new clinical
operation is in part due to how well it is integrated into the EMR our
clinicians use all the time. So we have
worked to accomplish total integration of our CC Team’s work from
appointing/scheduling to documentation of clinical notes to inter-provider
communication and ultimately, data analysis.
This required lots of communications with the various EMR build teams
and an understanding with our EMR leadership that we considered our CC Team
services as integral to our clinical operation.
Finally, with regard to data analysis on the
back end of care – we feel that this is absolutely critical to knowing what’s
working and what needs further refinement.
We have long funded an internal data analyst who we direct, and whose
job is to analyze our clinical shop data for whatever purposes we
designate. The success of this person is
dependent on the strategic relationships we have built with all the owners of
clinical and financial data in our Medical Center. As a consequence our data analyst has the
"keys to the castle” for all the data systems in our institution. We are able then to generate reports on productivity,
costs and increasingly on clinical outcomes of interest to both clinicians and
researchers. Some of these services have
required us to fiscally support them and we have determined that at times this
is ultimately in our best interests.
Map all processes needed to carry out the CC
mission and determine who owns these processes in your clinical setting and
establish working relationships with all of them
Make clear your operational needs in order to deliver the best patient care possible –
as this is a goal all such support folks should be committed to serving
If you have an EMR – use it to support and
integrate your CC services.
Be willing to potentially compensate for support
services rendered if they are new or "above and beyond the call”
One really cannot do anything truly "collaborative” if one
isn’t successfully partnered with strategic allies. Because integrating M/BH services into
medical care sites is still often "revolutionary” and "disruptive” – it does
take collective effort across the board.
Building strategic partnerships
both internally and externally requires prospective partners to understand the
vision you are trying to achieve. That
vision – of better and more complete, whole person care – should be a shared goal
of all who are in the health care delivery business.
Dr. Gene "Rusty" Kallenberg has beenChief of the
Division of Family Medicine and Vice Chair of the Dept. of Family and
Preventive Medicine at University of California, San Diego since 2001. Previously
he was the Chief of Family Medicine and Asst. Dean for Curricular Projects at George
Washington University where he was from 1982-2001. He has been a member of CFHA
for the past 16 years (with some gaps!).
Dr. Kallenberg currently serves as one of the four Clinical Foundations Directors of the new UCSD Medical School
Integrated Scientific Curriculum and runs the Ambulatory Care Apprenticeship
component as well. He also is the
Director of the new UCSD Center for Integrative Medicine which started
operations in 2010.