This is the third in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the second and first posts.
Christine: Most evenings, I have the opportunity to cook dinner for my family. To break up the monotony of this daily task, I try to find new recipes to add to the rotation. Every once in a while, I inevitably mess these new recipes up; I forget a step, I don’t mix things in the order I should have (I mean really, who has time to read all the way through a recipe?), or my two year old enthusiastically offers to help...in her own way.
After some reflection, I have decided that cooking and baking are a lot like implementing Integrated Care. You can have all of the "ingredients” (provider, support staff, behavioral health clinician, patients, families, etc), but without the proper knowledge of how and when to put everything together, you may fall short of achieving that pretty meal pictured in the cookbook (a fluid, functional, evidence-based integrated practice).
So, without further ado, allow us to share with you a little of what we have cooking down in North Carolina.
The Center of Excellence for Integrated Care (COE), a program of the North Carolina Foundation for Advanced Health Programs, is comprised of a team of Integrated Care (IC) experts who are committed to helping develop and advance sustainable IC systems across the state. We have built a multi-faceted, systematic training, assistance, and capacity-building program that provides practice transformation and education to contracted entities as well as IC projects funded by the Kate B. Reynolds Charitable Trust.
All of the sites engaged in COE technical assistance are varied in their model, including primary care, bidirectional, and school-based health centers. Most sites receiving COE services have significant financial barriers to making necessary changes to their care delivery systems. The majority of the participants are safety net providers that have a mission or legal obligation to provide health care and other related services to uninsured and underserved populations. The sites we help provide physical and behavioral health care, including substance abuse services, to low-income, uninsured, and diverse populations. Additionally, the COE also assists universities, private practices, and specialty care groups.
In addition to the TA services, the COE also works with a variety of organizations through its Community Capacity Building services, including community organizations and stakeholder groups, universities, government agencies, AHECs, and other state and national organizations. In this role, we help educate and address the policy and systems barriers that prevent successful IC development and delivery.
Cathy: During my short time in North Carolina, I have had the unique opportunity to work with and learn from the extraordinary experts that comprise my team and the COE and in the community of providers across the state. My current list of lessons learned boggles my mind – just reflecting on what we know now and what we began this journey with is overwhelming and embarrassing, to say the least. I realize that we are all working on helping practices, organizations, and providers transform their services by helping them change their minds about how that can be done. We often apply the Stages of Change, systems theory, and other clinical/theoretical concepts to our work with these practices (it helps us keep down our anxiety and blood pressure while maintaining a healthy empathy bubble). Ultimately, it is not our practice, and we can’t take responsibility for their system change.
Just a few federally funded programs that promote Integrated Care concepts and models in NC:
· Project LAUNCH,
· HRSA Grant awarded to UNC-Chapel Hill to increase the number of Psychiatric Nurse Practitioners,
· 2014 HRSA PCMH grant awarded to 18 community health centers,
· SAMHSA/HRSA 2014 Workforce Training grant awarded to 4 universities
· Other non-federal groups include the Kate B. Reynolds Charitable Trust, Duke Endowment
We present to a wide variety of groups, including the sites in which we are providing technical assistance. Recently, I have noticed how the focus of the questions and conversations has turned from "why” Integrated Care to "how.” The "why” has been so widely established across the state and many other parts of the country that we rarely have to pitch it prior to being asked to assist in practice transformation. We still encounter some hold-outs, but overall, if a provider or practice is ready to evolve to meet the changing definition of health, it usually is a soft-sell. To help illustrate more of the work we do, we put together our Top 10 Lessons Learned as Practice Transformationists (sort of sounds like we belong in a circus):
Top Ten Practice Transformation Lessons Learned
10. We do not take credit for the successes of our sites. If they fail at some aspect of IC, we look at our part of the issue, take responsibility for what was ours, and then we hand it back to them.
9. People can hear about Integrated Care all day long, but many do not understand the complexities until they try to do it.
8. Transforming a practice does not happen in a linear fashion -- it is often a one step forward, two steps back proposition.
7. Accepting where the practice and providers are when they begin to implement Integrated Care is key in helping them move toward a more successful, team-based approach -- even if they are still across town and just beginning to talk to each other!
6. Always include the patient and their families into the team-based approach.
5. Practices and systems will follow the physics of relationships -- they will try to suck us into their conflicts and systems’ roles, but we resist, resist, resist. We are very often thankful to both have backgrounds as licensed clinicians - it’s pretty amazing how helpful our multisystemic therapy training has been! We do not do drama!
4. Practices naturally want to jump right ahead to money, payment, and the bottom line. While these things are very important, it’s also important to learn how to integrate. HOWEVER: Even though the best approach to building effective, successful Integrated Care services should be based on the needs of the practice’s patients, we can’t ignore the currently billing and payment issues that are influencing reimbursement.
3. Integrated care is not the same as integrative care...and yes, it’s usually worth taking the time to educate the practices on the difference.
2. Providing assistance to sites attempting to integrate follows a parallel process -- so much so that we sometimes slip and call the practice our patient!
And, the #1 Lesson Learned (drum roll, please) is:
1. Integrated Care is not for everyone!
Dr. Christine Borst is the associate director for the North Carolina Center of Excellence for Integrated Care, under the North Carolina Foundation for Advanced Health Programs. She has a master’s degree in Marriage and Family Therapy from Purdue University and a PhD in Medical Family Therapy from East Carolina University. Prior to joining the Center of Excellence team, Dr. Borst spent several years working in a rural community health center to set up and implement an integrated care model. Her research interests include brief behavioral interventions for use in medical settings, and identification of the needs of children and their families in rural integrated care.
||Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs. Dr. Hudgins has experience in Integrated Care management and development, crisis assessment and intervention, community-based and college-based outpatient counseling, in-patient assessment and intervention, and community mental health consulting. She has practiced in community mental health agencies, hospital and healthcare settings, as well as in private practice. She has also held a variety of posts in higher education administration and student affairs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care.