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Leading though Building Strategic Partnerships

Posted By Rusty Kallenberg, Thursday, April 11, 2013
Leadership

Rusty's post is the second
in a 5-part series on
leadership in
collaborative care.



 

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 partnerships.

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.

Broad Lessons:

- 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 serve alone.

Broad Lessons:

- 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.

Broad Lessons:

- 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.

 

Rusty Kallenberg

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. 

 

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