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News & Research

Posted By Matthew P. Martin, Tuesday, August 8, 2017

News

See what’s happening with integration in your neck of the woods:

New Jersey: Making Integration Happen

Integrated behavioral health is receiving quite a bit of attention in New Jersey. A recent opinion piece states the following: “Creating a more efficient and coordinated system that treats the whole person is the right move for New Jersey and especially for patients who will benefit from having their behavioral and physical needs met in the same hospital clinic or community health center.”

Gov. Chris Christie wants to transfer responsibility for New Jersey’s four state psychiatric hospitals, community-based mental health and addiction services, and other behavioral health programs from the Department of Human Services to the Department of Health later this summer. The governor’s plan is designed to improve government efficiency and coordination, and enable patients to receive more complete and effective care by better integrating behavioral and physical health services.

Moreover, the Nicholson Foundation is interested in funding integrated care in New Jersey.

 

Michigan: Integration Plan Considered Controversial

“What is going on at the Michigan health department about designing four pilot programs to test a controversial plan to combine physical and behavioral Medicaid services among mental health agencies, providers and HMOs?” says Jay Greene of Crain’s Detroit Business newspaper.

Read more using the links above.

 

California Looks to Support Behavioral Health Data Exchange

“The California Health & Human Services Agency’s Office of Health Information Integrity includes a litany of use cases in the recently published State Health Information Guidance to illustrate numerous instance where sharing protect health information is feasible legally and in the patient’s best interest…

Because patients with behavioral health conditions most likely receive treatment from a multitude of providers across disciplines, their mental health or substance abuse data must be part of an integrated care plan that gives members of the care team access to important information.”

 

Hawaii: Call for More Integrated Care

Washington State: Integration Saves Lives

Arizona: What is Integrated Care and Why Does it Matter

 

Research

Here are some of the latest findings on integrated care:

Embrace, integrated primary care for older adults: Embrace slightly improved the perceived quality of care, particularly for elderly people with complex care needs for whom case management was organized. Caregivers judged implementation of integrated care to be greatly improved, though there was still room for further improvement. Further research should be carried out into the effectiveness of integrated primary care for the elderly on health, service-use and healthcare costs.

 

Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes: The Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health. The purpose of this study is to simulate the effects of the PCMH and I-PaCS models over a 3-year period to account for program initiation to maturity. The PCMH is expected to realize a 1.7% annual savings by year three while the I-PaCS program is expected to a 7.1% savings in the third year. The two models are complementary, the I-PaCS program enhancing the cost reduction capability of the PCMH.

 

Validating the Rainbow Model of Integrated Care Measurement Tool: This study aimed to validate The Rainbow Model of Integrated Care Measurement Tool (RMIC-MT) which assesses, using a self-administered questionnaire, micro level (clinical), meso level (professional and organisational), macro level (system) and enabling (functional and normative) aspects of integrated care. Preliminary results suggest that the RMIC-MT is both a reliable and valid tool for assessing integrated care in different integrated care settings. The results of the construct and reliability analysis across countries will be presented, interpreted and discussed.

 

Primary Care Physicians’ Ability to Detect PTSD: This investigation sought to determine whether the complex nature of PTSD, particularly the frequent presence of comorbid physical symptoms that may overshadow PTSD, makes the disorder difficult to detect in primary care settings. These results suggest that primary care physicians are fully capable of accurately identifying PTSD when it presents, regardless of whether the presentation is straightforward or complex. However, limitations must be taken into consideration when interpreting the results, including lack of variance in detection rates.

 

Ethical and legal issues in integrated care settings: Case examples from pediatric primary care: The purpose of this article is to examine salient ethical and legal dilemmas that may emerge in pediatric IPC practice. These issues are examined through the use of 4 case illustrations that collectively address issues related to consent for services among pediatric populations, confidentiality, scope of practice for the pediatric IPC psychologist, and multiple relationships. We apply an adapted ethical decision-making framework to highlight practice points drawn from each of these cases.

 

Family therapy as an integrated care model for pediatricians: Family therapy is an important therapeutic modality for children and adolescents with behavioral health problems and disorders. Research studies have consistently demonstrated the efficacy of family therapy for select pediatric patients and their families. Principles of family therapy are presented in this discussion. Examples based on actual cases illustrate what family therapists do and how they might integrate their expertise into cases, while working side-by-side with pediatricians.

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Hello CFHA. It's Me, Shared Care.

Posted By Jennifer Funderburk, Jodi Polaha, Nadiya Sunderji, Sunday, July 30, 2017

Greetings from Ottawa Canada, where we saw Parliament Hill, ate poutine, and made new friends! We’re writing to tell you about our experience with the Canadian Collaborative Mental Health Care Conference known as “Shared Care” where we (Jodi and Jen) attended as invited guests this June. 

 

Unlike CFHA, the Canadian event is an annual conference, not an organization, though it has some affiliation with the Canadian Psychiatric Association and the College of Family Physicians of Canada.  Another striking difference was the value placed on patient experience. Each year, a patient is invited to present his or her perspective as a keynote speaker. This year, a talented musician explained her preference for the term “patient” to describe her role within her healthcare, and helped the audience recognize the strengths and weaknesses within the current system in Canada using her own personal experiences. Her stories were deeply moving and we appreciated that Collaborative Care in Canada has incorporated this important perspective into their conference.

 

But Shared Care is more similar to CFHA than different. Importantly, its attendees have the same passion for integration and collaborative practice models. The conference instilled in us the same renewed enthusiasm for the value of integration. Like CFHA, it provided many creative ideas on how to improve our clinical research/practices.

 

Like CFHA, the Canadian conference is trying to grow capacity for research and evaluation, especially for clinician innovators in the “real world.” We (Jodi and Jen) were excited to hear what they were doing in this area, since we have led that effort within CFHA. Dr. Nadiya Sunderji, the Chair of the Scientific Committee for this year’s conference developed a “Works in Progress” or WIP format that has many similarities to our own Research and Evaluation Training Track.  I (Nadiya) was thrilled to have Jodi and Jen as coaches providing feedback to Canada clinicians wishing to evaluate their integrated care programs, and advising me regarding this type of capacity building within the conference. Thank you for playing in the WIPs sandbox with us! Like at CFHA, we (Jodi and Jen) loved hearing about the hard work of various clinician innovators who are striving to evaluate what they do in an effort to drive the literature and practice in integrated care.

 

We also co-presented a workshop together to introduce participants to evaluation based on Nadiya and colleagues’ new Quality Framework to Guide Measurement, Improvement, and Research. This work continues to challenge us to think about choices in evaluation in the service of local quality improvement versus generalizable knowledge, and we plan to explore that dilemma further next year.

 

Our experience in Ottawa left us hoping for more cross-pollination between CFHA and Shared Care.  We have much to learn from one another! Next year’s Canadian conference will be in Toronto in May or June 2018.  Apart from the conference, Toronto has much to offer visitors as Canada’s largest city, and the most ethnically diverse city in the world – food, nightlife, parks, museums and other attractions… and did we mention food? We hope you will consider attending! But, if not, stay tuned, we’ll have a Canadian presence at CFHA in 2018 as well. 

 

Jennifer Funderburk

Jodi Polaha

Nadiya Sunderji

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National Register Integrated Care Videos: Q&A with Morgan Sammons

Posted By Matthew P. Martin, Tuesday, July 11, 2017

Q & A with Morgan T. Sammons, PhD, ABPP, Executive Officer of the National Register of Health Service Psychologists

Earlier this year, the National Register of Health Service Psychologists released the Integrated Healthcare Training Series. This series features 41 videos averaging about 16 minutes each. The videos cover theory and models of integrated care, practice and implementation issues, and the medical, pharmacological and psychosocial management of specific conditions. I emailed Dr. Sammons to discuss the series. CFHA members can receive a 50% discount on the entire video series. Click here for more information.

 

1. Tell us about the National Register Integrated Care Video Series. How did these get started?

The National Register has long recognized integrated care as an important and forward-looking practice area. We’ve published articles on integrated care going back to the mid-2000s but a few years ago the Board of Directors started discussing a more comprehensive training program. When I took over as Executive Officer in 2014, developing this series was one of my top priorities. In some ways, it was fortunate that this sort of visual, self-paced training in integrated care didn’t really exist at the time, and we generated a lot of enthusiasm in the community. Happily, we were able to line up fantastic presenters including Parinda Khatri, Kent Corso, Jeff Goodie, Jeff Reiter, Bob McGrath, Marlin Hoover, Neftali Serrano, and more.

 

2. The videos cover a lot of ground, from models and concepts to pharmacological management. What do you hope members will gain from these videos?

First, I hope our psychologists (and other professionals accessing the series) will get a basic understanding of practicing in an integrated care environment. Some of our newest members may have been exposed to these concepts during their graduate education and training, but many of our 10,000 psychologists have had no training or exposure in integrated care fundamentals. At the same time, our survey data show a sharp increase in the percentage of our psychologists working in organized healthcare delivery systems. With some uncertainty surrounding healthcare reform and the challenges of starting a private practice these days, we expect that percentage to continue to rise. Beyond the conceptual aspects of training, we also knew there was a need to expose psychologists to management of various conditions in integrated care — such as pain management, arthritis, insomnia, anxiety, depression, and substance abuse to name a few — and to present the care concepts from a psychosocial, medical, and pharmacological lens.  

 

3. Workforce development is a challenge for many clinics wanting to offer integrated care. What role do you think videos play in preparing individuals for integrated care?

We’ve been very pleased with the utilization by our members, and been successful in licensing the series to a number of healthcare organizations. So the first step — getting these videos in front of our target audience — is moving along nicely. We can always do better, but we are pleased so far. As noted above, these videos were designed to be easily digestible, self-paced learning. Think Ted Talks. We view this training as a first or second step for providers, not the final step. But the videos do provide a fundamental level of knowledge and should be a springboard to more comprehensive training and, of course, experience. 

 

4. Finally, who should consider accessing these videos?

The series was primarily developed for psychologists (and the presenters are primarily psychologists as well). However, we’ve had a great reaction from other professionals, specifically social workers and counselors. I think it fair to say the videos are universally applicable to mental healthcare professionals.

 

In terms of utilization, psychologists who are credentialed by the National Register have access to the entire series, free of charge. We also make the series available for free to the students participating in our Trainee Register. The videos are available at a cost to psychologists and other healthcare providers who are not credentialed by the National Register ($200 for access to the entire series which includes continuing education credits). Given our close relationship with CFHA, we’ve offered CFHA members a 50% discount on the series (go to CE.NationalRegister.org and use coupon code CFHA50).

 

As noted above, we’ve also signed licensing agreements with healthcare organizations. Anyone interested in discussing licensing should contact Andrew Boucher (andrew@nationalregister.org).

 

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Integrated Care in India: Part 2

Posted By Matthew P. Martin, Friday, July 7, 2017

 

A year ago we highlighted the work of Dr. Manjunatha from the National Institute of Mental Health and Neurosciences in Bangalore, India, who had written a report for the Lancet describing an ambitious program to integrate mental health services into primary care systems. The program, called the Manochaitanya Programme, provides mental health services every Tuesday in taluk hospitals, community health centres, and primary health centres in Karnataka. The services are also available during the rest of the week at all primary health clinics.

 

This week Dr. Manjunatha reached out again to share his recently published critical analysis of the Manochaitanya Programme.  Click here for the publication

 

Here is an excerpt from the article:

 

"This is the first-of-its kind dedicated public mental health programme in India, launched by the State government with exclusive aim to integrate mental health at the level of primary care. It includes the treatment of psychiatric disorders by primary care physicians, and refer only the difficult-to-treat cases to specialized centres. Another highlight is making available psychiatric specialist care at every taluk hospital (TH) at least once a month for these referred cases. These benefits are available at about 2310 primary health centres (PHCs) and 180 community health centres (CHCs) and 146 THs covering more than 60 million population of Karnataka.

 

Training programmes and a manual for primary care doctors: The World Health Organization recommends effective training programmes to develop mental health skills of primary health care staff [3]. Traditional training programmes for primary care physicians in India are criticized as 'never properly trained'[25]. Providing continuing education for primary care physicians is more likely to improve the quality of mental health care than the recruitment of more psychiatrists.

 

The previous psychiatric training manuals were complex and could not be adapted properly for primary health care and caused difficulty for primary care physicians who had no or little previous exposure to psychiatry...  Hence, there is a need for a practical, concise manual which is adapted for primary care psychiatry."

 

The authors conclude that this is a major project and that next steps include workforce development, dedicated budget allocation, and clearer project outcomes. Read more to learn about integrated care on a large scale in another part of the world. 

 

Dr. N. Manjunatha, MD, DPM, MBBS

Assistant Professor of Psychiatry, Department of Psychiatry

National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

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Steps Toward the Routine Implementation of Brief Tobacco and Alcohol Interventions in Primary Care

Posted By Jennifer Wray, Thursday, June 22, 2017

This post was written by the 2015 winner of the CFHA Research and Fellowship Award. 

For me, one of the most challenging aspects of transitioning from traditional training in specialty mental health to working in a Primary Care Behavioral Health (PCBH) setting was learning ways to deliver interventions in that can be effective in a short period of time. Coming from a tobacco research background, I knew there were evidence-based interventions for tobacco use that could be delivered in just three minutes or less.

 

Not long into my postdoctoral fellowship I also learned about the evidence base for brief interventions as few as five minutes in length for at-risk alcohol use. I felt encouraged by the evidence that brief interventions for these presenting concerns could be effective, especially at the population level. I regularly started implementing brief alcohol and tobacco interventions into my work with patients in primary care, but research data at the time told us that behavioral health providers in integrated primary care settings were not routinely incorporating brief interventions for tobacco and alcohol use into their clinical work with patients. I wanted to learn more about why these brief interventions aren’t regularly occurring in PCBH appointments. 

 

I was excited to receive the Research Fellowship from the CFHA Research and Evaluation Committee in 2015, which allowed me to begin research to help answer this question. For the fellowship, our study team conducted a national online survey of PCBH providers to better understand the barriers to implementing brief tobacco and alcohol interventions when working with patients using tobacco or drinking above low-risk drinking.  We also collected data on the facilitators that could promote the use of these interventions.  

 

We were excited that 265 behavioral health providers across the country volunteered to participate (we know these providers are busy!).  The majority of providers were psychologists (48%) and social workers (33%), but we also had representation from other professions including licensed mental health counselors, psychiatrists, nurse practitioners, RNs, and marriage and family therapists. Primary theoretical orientation varied, but the most common (51%) was cognitive-behavioral.

 

It was encouraging to learn that almost all providers (95%) reported previous training in brief alcohol interventions (when assessed broadly; we included class course, independent reading, online training, supervision, and training workshop). Fewer (but still most respondents; 77%) reported some type of past training in tobacco use interventions. As such, we felt it was unlikely that lack of training is preventing providers from implementing brief tobacco and alcohol interventions.

 

Participants reported that they are conducting at least a brief tobacco intervention with their patients who use tobacco products approximately a third (32%) of the time. This was somewhat encouraging, but left us feeling like there is a lot of room for growth! We presented participants with a list of potential barriers to conducting brief tobacco interventions and asked them to rate each of these factors on a scale from 0=Not a barrier to 4= A significant barrier. The highest rated factors (i.e., biggest barriers) were: 1) the perception that patients have more immediate needs to address than tobacco use, 2) the patient not being interested in quitting or cutting down, and 3) the patient not identifying tobacco cessation as a treatment goal.  

 

Things that participants said would help them conduct more brief tobacco interventions included 1) the patient identifying tobacco cessation or reduction as treatment goal, 2) having a good relationship with the patient, and 3) getting referrals directly from primary care providers (or other PC staff) specifically for tobacco cessation.   

 

Switching to at risk-drinking, participants reported that they are conducting at least a brief alcohol intervention with their patients who endorse at risk drinking 40% of the time. The same lists of barriers and facilitators were presented as in the tobacco section. Like with tobacco, participants said that the top barriers to incorporating brief alcohol interventions into their regular work were 1) the patient not being interested in quitting or cutting down and 2) the patient not identifying alcohol reduction or abstinence as a treatment goal. 

 

However, with alcohol, the providers said that patients not being motivated to cut down or quit was among the top three barriers.  Participants identified the same top three facilitators as they did with tobacco; they reported that the patient identifying alcohol reduction or cessation as a goal, having a good relationship with the patient, and getting referrals directly from primary care providers would increase the rate at which they delivered brief alcohol interventions. 

 

So where do we go from here?   We were encouraged to learn that lack of time to deliver brief tobacco and alcohol interventions and lack of training to do so were not among the top barriers identified (as these are often cited as a reason that primary care providers are unable to deliver these types of interventions). In addition, all barriers identified are able to be addressed (e.g., encouraging behavioral health providers to use motivational interview techniques to address concerns such as a lack of motivation or not being interested in modifying these behaviors), and the providers have given us great suggestions for things that would help them deliver more of these interventions.  

 

If you are reading this and working in an integrated primary care setting, hopefully this gave you some food for thought regarding how you might begin incorporating more brief interventions for tobacco use and at-risk drinking into your regular clinical practice! Feel free to check out the provider education tab located at this website for some resources related to conducting brief tobacco and alcohol interventions.

 

 

Jennifer Wray, PhD, is a clinical psychologist in the Primary Care-Mental Health Integration Clinic at the Ralph H. Johnson VA Medical Center, located in Charleston, SC.  She completed a postdoctoral fellowship at the VA Center for Integrated Healthcare in 2017.  Dr. Wray is interested in the process of integrating behavioral health and primary care services, and has specific interests in brief behavioral interventions able to be delivered in the unique setting of integrated primary care.

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It’s Not Enough to be LGBT “Friendly”

Posted By Ryan Cox, Wednesday, May 31, 2017

 

 As health providers, we like to help anyone that walks through our door, regardless of background or identity.  Sometimes, though, it’s not enough to simply be open-minded, or accepting.  With certain populations it is imperative to not only be “open,” but also competent.  All minority populations have their own unique needs, backgrounds, influences, and struggles.  LGBT individuals are no different.  This post is a brief overview, though it is important to keep in mind that each letter of that acronym is unique with its own needs, especially trans*gender individuals.

 

            LGBT individuals face a myriad of health disparities.  A recent study found that many gay men, for instance, exhibit psychological symptoms of severe PTSD, and display the concomitant health risks, even if they have never been in a life-threatening situation.  Over 70% of trans*gender individuals report at least one instance of overt discrimination in a healthcare setting, ranging from everything to deliberate misgendering to outright physical abuse.  Lesbian women have significantly higher rates of obesity, smoking, and are far less likely to receive preventative care, such as mammograms, than their heterosexual peers, but also tend to have better mental health outcomes and more stable relationships than gay men.  In order for any healthcare setting to be affirmative and competent, education, consultation, research, and ongoing awareness are necessary.  Following are a few steps to help facilitate more open discussion.

 

            Many individuals will not feel comfortable disclosing what may be one of the most important aspects of their identity to someone they don’t know and don’t yet trust, so providers should get in the habit of asking about identity and lifestyle characteristics of patients.  A great place to start is with new patient paperwork.  Having multiple options for relationship status and gender identity, and overtly asking about sexual orientation can go a long way to opening the door to conversations about identity and health risks and disparities.  What this conveys to your new client is that you are aware they exist (in a broad sense), it’s something you have thought about, and it is something that you are probably (hopefully) knowledgeable about.  For LGB individuals, even the assumption of heterosexuality by their provider can be alienating and invalidating.  For trans*gender individuals, a disclosure of trans*gender identity might be met with skepticism and invasive questions at best, or outright hostility or medical harm at worst.

 

            Next most important is simply asking.  It should not be incumbent upon the patient to disclose information to a new provider that could potentially be used against them.  We can help ease that anxiety by taking the first step and overtly offering a safe and supportive space for disclosure.  Because being LGB, and often T, is an invisible status, meaning it cannot be gleaned just by looking at someone, it is easy for the patient to stay quiet, let the clinician make assumptions, and move on.  But that isn’t good healthcare.  Understanding what is most relevant to our patients not only helps build rapport and trust, it provides us with a fuller picture of habits and behaviors, risks, disparities, and protective factors.

 

            Third most important is self-learning and continuing education.  Research in trans*gender health especially is moving at a rapid pace, and it is important to stay informed and updated.  Consulting with other professionals who have experience with these populations, attending continuing education workshops, and going to conferences are all excellent ways to keep abreast of the latest developments in the field, but also to network.  See if you can bring in specialists to your organization to conduct trainings and seminars.  Even seeking out clinical supervision while you begin working with this population might be helpful and a good idea.

 

            The key to all successful relationships is adequate communication, and it is no different with our patients.  The better we can learn to communicate, and the better we can learn to listen, the more likely clients and patients are to open up to us, confide in us, and let us give them the most competent and comprehensive care we can.  And we can only speak as experts if we have expert knowledge, which includes not only education, but experience.

 

 

Dr. Ryan Cox earned his Bachelor's in Psychology at St. Edward's University in Austin, Texas, his Master's in Counseling at Pacific University in Forest Grove, Oregon, and his PhD in Counseling Psychology at the University of Memphis in Tennessee.  His primary clinical interests are LGBT health, integrated healthcare, holistic health and wellness, HIV/AIDS, and masculinity and gender issues.  He currently works as an integrated psychologist in Oncology, Sleep Health, and Pain Management at Truman Medical Center in Kansas City, Missouri.  Dr. Cox also teaches graduate courses at Avila University, and sits on the board of the Good Samaritan Project, a non-profit dedicated to ending the impact of HIV in Kansas City. 

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The Highs and Lows of an Early Career Professional

Posted By Ruth Nutting, Thursday, May 11, 2017

I remember it like it was yesterday.  It was an afternoon in early April—like every good post-doctoral fellow I was sitting in my office working hard and pondering my future.  Or, maybe you could say I was catastrophizing my future. 

 

I had been blessed with a wonderful pre-doctoral internship and post-doctoral fellowship within a leading medical university—I was happy and I was comfortable.  To think about the familiar ending in just two and a half short months was overwhelming.  Don’t get me wrong, I was preparing for the transition from fellow to early career professional feverishly.  I spent hours scanning available positions, throughout the country, and was consistently sending letters of interest and my curriculum vitae. 

 

However, there were times, like this particular afternoon, when vivid visions of my fellowship ending, and a one-way ticket to New Hampshire being purchased to return to my parent’s home in order to reside in their unfinished basement plagued my mind.  Granted, my parents would have been thrilled to give me back my childhood bedroom, but the thought of the basement seemed much bleaker; it matched my mood.

 

You see, I knew I was qualified.  I knew I had an impeccably comprehensive training in integrated healthcare and I knew my supervisors had spent endless hours investing in me and my future, but what I hadn’t found was that dream job.  I wanted to be a director of behavioral health, and the idea of any other position lacked satisfaction.  Perhaps this is why many letters of interest went unanswered and why some employers responded by saying my ambitions were beyond the scope of the posted position—readers could sense a strong desire for directorship regardless of the position being applied to. 

 

Then, they came, first one, then two, then three dream positions.  My letter of interest spoke to the current directors of these programs and I had interviews, fully funded interviews!  I have to admit that after being a graduate student for what seemed ages and spending a plethora of money to fly from interview to interview for different doctoral programs, pre-doctoral internships, and post-doctoral fellowships, I felt like a bit of a celebrity having all my interview trips arranged and paid for, as custom.  There was also a feeling of exuberance, as I met an array of dynamic professionals and could conceptualize my role in their programs and ways in which I could aid in enhancing these programs.  The idea of not knowing what part of the country I would end up in also energized me, testament to my adventurous personality!

 

As I was offered positions, and I chose the best position based on overall fit, negotiation came in to play.  Also a new feeling, as I had only experienced the thrill of acceptance prior.  Negotiation was an empowering experience as it continued to affirm my knowledge, skill base, and work related value.  In just days, negotiation was completed and contracts were signed. It was happening!

 

Like with every move and new position, there was a whirlwind of activities.  From apartment shopping and packing, to shot records and eye exams, it was all happening quickly.  Wrapping up my post-doctoral fellowship and training my successor proved challenging while I simultaneously planned for my position to come.  

 

Then the time came for me to embark in my professional career as director of behavioral health.  The first week was filled with orientations, meets and greets, and organization of my office, the second week work began.  I remember sitting in my office, staring at my computer screen, like every good director does, and it all of a sudden hit me…I was responsible for the maintenance and the development of this behavioral health program!  I could no longer walk across the hall to my supervisor’s office for her expert opinion anytime I needed, the responsibility was on me.  My immediate thought, “what were they thinking hiring me?”  Imposture syndrome had set in.  I somehow regrouped within the following minutes and began feverishly working on my first-hand initiatives.  I wanted to prove myself and prove myself quickly.

 

Over the next weeks, my feelings of imposture syndrome continued to dissipate.  My knowledge and hard work was allowing for my initiatives to align as I had hoped.  I was recruiting for four pre-master’s level medical family therapy interns from a local university’s marriage and family therapy program. Within just months of becoming director, we would have a fully integrated behavioral health program within our two clinics.  I was also in the process of piloting pre-clinic huddles, and anticipating another implementation victory.   However, implementation didn’t go quite as perfectly as my visions had.  On match day, I was incredibly fortunate to receive two marriage and family therapy interns, but this was not the sum of four I needed for full behavioral health coverage at each clinic.  I had failed, I had aimed for full coverage of an integrated behavioral health program and now I was not able to fulfill that.  To add to my dismay, not all faculty and residents were as excited about pre-clinic huddles as I was. Defeat! 

 

This time I stared at my computer screen thinking I had failed in my role as director, my thoughts simultaneously turned to my previous supervisor…I needed to e-mail her immediately to ask what she would do in this situation. I needed her immediate affirmation, or did I?  I took a minute, and then I took a couple more to breathe and reflect.  My thoughts shifted from what I hadn’t yet accomplished to everything I had accomplished.  In just a few short months, I had single handedly created a pre-master’s level behavioral health internship, was in the process of implementing pre-clinic huddles, and had increased my teaching responsibilities by nearly double; not to mention I had kept abreast of research efforts and fulfilled my clinical responsibilities. 

 

Why was I being so hard on myself?  Yes, my ideal plan and efforts had not been one-hundred percent fulfilled, but I had accomplished a lot.  This was not the time to succumb to defeat. This was the time to recognize my efforts and then strategize how to make this first internship year a success and to move forward developing a relationship with a nearby psychology program to expand recruitment for the following year, better ensuring a behavioral health intern cohort of four.  It was also the time to focus on providing further education to faculty as to why pre-clinic huddles would be invaluable.

 

I share these personally professional anecdotes to normalize and humanize the experience of being an early career professional.  Although different in nature, early career, mid-career, and maybe even late-career professionals alike face the highs and lows of leadership, sometimes winning and sometimes seemingly failing.  What I have learned and will continue to learn is that when challenges arise, as they will, we must allow ourselves to feel disheartened when things do not first go as plan, reflect on what still needs to be accomplished, and then re-strategize.  If you’re anything like me, cranking Sia’s “The Greatest” will cure any self-deprecation you may have and get you ready to conquer the world, or the workplace, all over again. 

 

Ruth Nutting, PhD, LCFMT, is the Director of Behavioral Health at the Via Christi Family Medicine Residency, and Clinical Instructor  at the University of Kansas School of Medicine.  She teaches a behavioral medicine curriculum to 54 family medicine residents, facilitates resident wellness initiatives, oversees the functioning and supervision of a pre-master's level medical family therapy internship, provides integrated and traditional therapeutic care to the underserved population, and continues her research on Chronic Illness and its Effects on Young Adult Populations. 

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Extroverts shine in team-based healthcare

Posted By Juliette Cutts, Tuesday, April 25, 2017

 

This is a reprint of a post originally published in May 2015. 

I have been asked by my esteemed colleagues at CFHA to submit a blog post explaining why I feel that being an extrovert is beneficial when working in integrated care. They have asked me to go first because they are still trying to convince my introverted counterpart to participate. I will do my best to represent my fellow extroverts, but if I get something wrong please let me know. I would love to talk about it! 


(Side Note: How do you know if you are an extrovert? You have to ration how many exclamation marks you use in written communication!!)

As a behavioral health consultant, I am well aware of the need to initiate interactions in order to work as a team in primary care. It’s not that primary care providers don’t want to work together; they just don’t always have time to stop long enough to bring me in. Occasionally they forget I’m available unless I remind them. These dynamics of primary care have helped me to develop some of my potentially dysfunctional character traits in order to further the cause of integrated care.

In my opinion, the best personality type for integrated care is an extrovert who is mildly hypomanic, somewhat inattentive, and has a touch of OCD. My hope is to convince you to develop some of these traits in yourself in order to better work together as a team. In preparation for this blog entry I talked to everyone I know… not about what to write, but because I’m an extrovert and like to talk to people. Now it is getting late so I should probably start writing something.


Anyway, back to my formula. In order to establish a new integrated care function you have to be willing and able to talk to anyone and by that I mean, anyone! No shrinking violet when it comes to talking to the grumpy provider, the resistant patient, or the reluctant administrator. Sometimes you have to just keep talking to them until they agree with you, right? It also helps if you do not mind looking ridiculous from time to time. Communication can get a bit muddled sometimes and you may end up going into the wrong exam room – turn that into an introduction to the service and move on!

Because of the pace at which we work it’s helpful to keep your energy up. You can do that by developing a nasty caffeine habit or regularly raiding the candy drawer (admit it; we all have one – or 5 - somewhere in the clinic). I have found it is easier to just nurture my hypomanic tendencies. It keeps things light and really helps to burn off the extra calories from the coffee and candy. Just make sure you are not experiencing distress or impairment and you are free and clear. It’s not just the artists that can benefit from hypomania anymore!

The next component, inattentiveness, is a bit blurry in that it is a fine line between hypomania and hyperactivity but just humor me on this; a formula with only two components is not as interesting. Integrated care, especially in the early days of forming a new service requires a person to wear many hats. Because of this, you have to be able to switch sets at the drop of a hat. You think you are going to lunch but then you are doing a crisis intervention because a patient might be suicidal. Of course, the down side is that you can sometimes find yourself getting ready to go to lunch and trying to remember what you were going to do a couple hours ago…then you remember that you were headed to the bathroom.

 

I have found it is easier to just nurture my hypomanic tendencies


Lastly, it helps to have a little OCD. When you are going from patient to patient you need to be able to keep track of all those little details like what you saw them for the last time and what interventions you have already tried. Being able to find handouts on the fly is important (you need to move on to talk to more people!) so a good filing system comes in handy. Of course, at the end of the day when you are trying to remember what happened after you set your coffee down that morning, being a bit anal retentive about paperwork is really helpful. For those who need some help developing these tendencies I recommend putting tape outlines for everything on your desk…then just for fun put the objects outside of the lines and see who squirms! Another fun strategy is to start making super complex spreadsheets for everything. Once you have created a spreadsheet to manage your spreadsheets, you have made it!

Now I think it is time to stop as I may be drifting into more introverted pastimes. I certainly do not want my readers of the introverted variety to be uncomfortable…though I suppose it is too late for that at this point. You know the saying: "We’re here, we’re uncomfortable, we want to go home” but alas one of you must speak out. Do not panic! We are here to support you and if you will only speak up to the rest of the group…wait, that can’t be right. For all of my teasing, I will concede that an introvert can function in integrated care but I suspect it would require a lot of naps. We will all have to tune in to hear what the next post will be about…

 


Juliette Cutts is a licensed clinical psychologist and Behavioral Health Consultant at Salud Medical Center in Woodburn, Oregon.  She is a native Californian and got her PsyD from John F. Kennedy University in Pleasant Hill, California in 2010.  After graduation she completed a post-doctoral fellowship in Health Psychology at the University of Wisconsin in Madison.  After post-doc, she stayed on at Access Community Health Centers as a Behavioral Health Consultant to provide services to underserved patients in the Madison area.  In 2012 she moved back to the West Coast to join Yakima Valley Farm Workers Clinic as the Behavioral Health Consultant at Salud Medical Center.  At Salud she works with predominantly migrant workers who are not well served by traditional mental health.  

 

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News & Research Column

Posted By Matthew P. Martin, Tuesday, March 14, 2017

 

Welcome to the fifth edition of the CFHA News and Research Column, a new series of posts that highlight recent developments in the field of collaborative and integrated care. Check back for additional reports.


NEWS

SAMHSA Webinar – Making the Most of your EHR

The SAMHSA-HRSA Center for Integrated Health Solutions is offering a webinar on March 28th, 2017 to help you make the most of the electronic health record (EHR) to support improved patient outcomes. Health technology experts and a behavioral health manager will show how to improve electronic health record workflows, data entry and reports for depression screening and follow-up interventions. They will also discuss practical strategies for sharing data with the team to improve benchmarking and quality.

 

Utah Legislatures to Require Physicians to Complete SBIRT Training

On February 17, 2017 the Utah House passed a bill designed to deal with opioid misuse by requiring medical professionals to complete several hours of training in SBIRT which stands for Screening, Brief Intervention, and Referral to Treatment. SBIRT is designed to identify patients with problematic use of alcohol and drugs. Utah physicians would complete the training when renewing their medical license and would then receive reimbursement afterward. Before the current legislative session, Republican Representative Steve Eliason met with former directors of the National Institute on Drug Abuse and the National Institutes of Health. "I said, if there’s one thing we could do to address our opioid overdose problem, what would it be? And it’s this bill," Eliason said.

 

National Coalition on Health Care Forum: Panelists Discuss Integrated Behavioral Health

New payment models and dedicated efforts to coordinate care are changing the delivery of health care, but more progress needs to be made, panelists said March 6, 2017 at the National Coalition on Health Care Forum on health policy. "Primary care has been overlooked for too long in discussions about health care reform," said National Coalition on Health Care President and CEO John Rother, J.D. Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center at the University of Colorado in Aurora, spoke about the need for greater integration between primary care and mental health, noting that treatment of physical and mental needs is too often artificially segregated. The forum was the first in a three-part series co-hosted by the AAFP, National Coalition on Health Care, National Association of Community Health Centers, American College of Physicians and American Osteopathic Association. The next event is a March 28 forum on primary care's role in underserved communities.

 

Humana and Quartet Team Up to Deliver Integrated Mental Health Care to New Orleans Residents

Humana and Quartet, a technology company, are teaming up to improve access to care for New Orleans Medicare Advantage members living with anxiety, depression and addiction. Quartet technology allows primary care physicians to initiate their patients into a proven collaborative behavioral program. Resources include a highly curated group of local behavioral health providers, live psychiatry consults for providers, data driven insights through adaptive learning algorithms, and concierge support for patients. An estimated $48.3 billion could be cut from the total cost of health care in the United States each year by effectively integrating physical and mental health services, according to a 2014 study by leading actuarial firm, Milliman Inc. Quartet provides a scalable, evidence-based solution to integrate physical and mental health care that reduces costs and improves health outcomes.

 

RESEARCH

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care: The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy.

Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review: Integration of behavioral health into primary care settings has the potential to address barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.

Experiencing integration: a qualitative pilot study of consumer and provider experiences: Existing frameworks for integration have been heavily influenced by the provider and organizational perspectives. They are useful for conceptualizing integration from a professional perspective, but are less relevant for consumers’ experiences. Consumers of integrated primary health care may be more focused on relational aspects of care and outcomes of care.

Integrated Psychological Services for Anxiety and Depression in a Safety Net Primary Care Clinic: Despite the recognized importance of integrated behavioral health, particularly in safety net primary care, its effectiveness in real world settings has not been extensively evaluated. This article presents 2 successive studies examining the effectiveness of integrated behavioral care in a safety net setting. These results support the short- and long-term treatment effects of brief primary care behavioral interventions, further strengthening the case for integrated behavioral healthcare in safety net settings.

Outcomes of Integrated Behavioral Health with Primary Care: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care. Results show that integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care.

 

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Reflections in TeleHealth

Posted By Elizabeth Banks, Wednesday, February 15, 2017

 

 

There is a lot to be said for physical presence. As licensed mental health care providers (LMFT in my case), we are taught to diagnose and treat in person. Connecting with people in a therapeutic, healing, and professionally intimate manner over a telemonitor is difficult at best. It is possible to read body language and tone through a monitor, but the amount of emotional energy it takes to convey compassion, empathic presence, and sound clinical interventions through a virtual space is harder than it sounds.

 

While tele-presence is better than no presence, and comparable to in person care [1-2], there are patients who distrust technology, who display emotions that can be hard to help regulate in a virtual space, who have hearing deficits, who speak a different language than the provider (more challenging over telehealth than in person), and any number of other barriers. A thorough assessment of functioning can be made more difficult without the benefit of having all senses available. For example, if a patient is not bathing regularly, this could be a sign of poor self care related to level of depression and impairment. Poor hygiene can be difficult to assess in a virtual environment.

 

Advantages include the elimination of provider safety issues. The two times that I can think of in the past 2 years that someone made sexually inappropriate comments and/or gestures on the telemonitor, I didn’t have to worry about a panic button or alerting someone to come help me. All I had to do was give a warning to the patient, and when that warning was not heeded, I let them know I was disconnecting due to their inappropriate behavior, hung up, called the nurse on site to follow-up with the patient, and voila! All bases covered.

 

Another great thing about Telehealth is that it is a therapeutic modality that is evolving in terms of technology available and as a billable service. When I first started in telehealth in the mid 2000s, telehealth really meant talking on the phone…a land line at that! Imagine doing therapy with a blind fold on and the client is the next town over! Now, we have sophisticated HIPAA compliant, encrypted teleconferencing hardware and software. At a teleconference conference in Maryland earlier this year, I saw an actual telehealth robot that moved around the room seemingly independently.

 

In my current position I work with patients who live in rural areas with no or limited access to specialty care. The teleconferencing equipment is in their primary care physician’s offices, so they still have to travel to receive care. As such, there are the typical no show rates and transportation issues. There are connectivity issues, but there are also huge pay offs and success stories.

 

I think about the woman with the 30 year old gunshot wound who presented to telehealth for rising A1C, gastrointestinal distress, a colostomy bag, and poor diet compliance. This woman had been seen for years in her primary care clinic and there was no evidence in her chart that any provider had ever asked her the origin of her gunshot wound or colostomy bag, or the reason that her diet was so incompatible with her diabetic and gastrointestinal status. A brief conversation about her social and emotional environment revealed that she was in a long term abusive relationship, that she was still living with the partner who shot her, and that the partner’s new form of control of her was to prepare and monitor the patient’s food intake, with violent consequences if she did not conform to his expectations.

 

By having access to a behavioral health provider with the time and the skill set to assess for psychosocial stressors that could be impacting her medical compliance, she was able to disclose the abuse, problem solve around her options, and make strategies with regard to maintaining her health as much as possible within an abusive environment. Knowing her home environment was directly related to her inability to manage her A1C and gastrointestinal issues, it took someone to ask her a direct question about her home environment for her to disclose.

 

With this information, I was able to work with her physician and a nutritionist to tailor her treatment goals to her particular situation. This is an uncommon example, but I continue to be amazed at what is revealed in telehealth sessions that are designed to be about health behavior, but so frequently are tied in to relational and systemic issues.


1. Bashshur, R. L., Shannon, G. W., Smith, B. R., & Woodward, M. A. (2015). The empirical evidence for the telemedicine intervention in diabetes management.Telemedicine and e-Health,21(5), 321-354.

2. Izquierdo, R. E., Knudson, P. E., Meyer, S., Kearns, J., Ploutz-Snyder, R., & Weinstock, R. S. (2003). A comparison of diabetes education administered through telemedicine versus in person.Diabetes care,26(4), 1002-1007.

 


Dr. Banks is a clinical assistant professor at East Carolina University at the Family Medicine Center. She has a PhD in Marriage and Family Therapy and is a AAMFT Approved Supervisor. In her current role, she provides telebehavioral health services to people with diabetes and co-morbid behavioral health challenges. In addition to her clinical work, she teaches at both the undergraduate and graduate level. She serves on the CFHA Research and Evaluation Committee and is Continuing Education Chair for the North Carolina Association for Marital and Family Therapy. She is also a member of the American Telemedicine Association, She currently has 6 journal publications and has presented 24 times at local, state, and national levels.  She is particularly passionate about keeping issues of social, human, and relational justice alive in our personal and professional roles.

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