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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.


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.



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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Meet Gwenivere: An Integrated Care Model for Newly Resettled Refugee Families

Posted By Eboni Winford, Thursday, January 5, 2017



"Please don’t tell my parents.” These were the words spoken by 20-year-old "Gwenivere” upon learning that her routine pregnancy test to determine which post-resettlement vaccinations she could receive was positive. Gwenivere had just resettled to Knoxville, TN, after fleeing the war and violence of Burundi, an East African country that borders Rwanda, Tanzania, and the Democratic Republic of Congo. She and her family, including her parents and younger sister, lived in a Tanzanian refugee camp for 12 years after fleeing Burundi; eight of these years were spent undergoing the UN Refugee Agency’s formal resettlement process.


Two weeks after arriving to Knoxville, and after being oriented to their new home by the local resettlement agency, Gwenivere and her family made their first visit to Cherokee Health Systems (CHS) where they received routine vitals and had labs that were specific to their country of origin or country of refuge performed.


At their second visit, which occurs 10 days after these initial labs are drawn, Gwenivere and her family met with a medical provider who performed a medical screen designed by the CDC and Office of Refugee Resettlement. She and her family also met with a behavioral health consultant (BHC) who assessed Gwenivere and her family’s adjustment to resettlement and screened for psychological symptoms including posttraumatic stress disorder and depression. The results of Gwenivere’s labs 10 days prior revealed a positive pregnancy test.


"Please don’t tell my parents,” Gwenivere said via an in-person Kirundi interpreter. "If they find out that I’m pregnant and I’m not married, they will kick me out of their home.” Because CHS has a well-established model of integrated care and because continuity of care is key as refugees settle into their new lives in the US, the care team collaborated with Gwenivere to quickly implement a plan to accommodate her new healthcare needs.


The BHC provided an overview of the available services at CHS including but not limited to blended primary care and BH services; obstetrical and gynecological care; care coordination from community health coordinators; and specialty services including psychiatry, cardiology, and nephrology, and worked to develop a culturally appropriate and sensitive treatment plan that best suited Gwenivere’s needs. The care team honored Gwenivere’s wishes to not disclose her health status to her parents and utilized that opportunity to teach an important lesson regarding protected health information and privacy, something with which Gwenivere was not familiar.

The care team coordinated an initial prenatal care visit on a day when Gwenivere was already scheduled to return to the clinic to receive another vaccination. As such, this additional medical visit did not appear unusual to her parents. She met with the OB/GYN provider and a BHC who worked with Gwenivere to explore pros and cons of informing her parents of her pregnancy. The BHC coordinated with a community health coordinator who met with Gwenivere to discuss alternate housing arrangements in the event that her parents did ask her to leave their home after learning of her pregnancy.


The CHC also provided resources for obtaining necessary supplies for the baby upon its birth. With coaching and support from the care team, Gwenivere made a plan to tell her parents of her pregnancy, which went surprisingly well. Her parents expressed disappointment but did not ask her to leave the home. Gwenivere continues to receive behaviorally-enhanced prenatal care at CHS, which emphasizes wellness promotion during pregnancy as well as ongoing monitoring for the development of trauma-related symptoms secondary to her exposure to war in Burundi.

When CHS began the integrated refugee resettlement program in October 2015, members of the care team quickly learned that offering care via our health care home helped eliminate barriers such as access to care, language difficulties, and a sense of displacement that may linger after being uprooted from one’s home of origin. We also learned that routine BH monitoring was essential for prevention, early detection, and intervention of trauma-related symptoms, which may not appear until several months after refugees have resettled in their new home countries.


Not only are BH providers able to implement interventions at the point of care but they are also able to reduce stigma associated with receiving BH care by being present at every clinical encounter refugees have during their initial year following resettlement. Sharing an EHR allows for enhanced communication of previous traumatic experiences to various care team members, which improves the overall delivery of trauma-informed and culturally sensitive care. Accordingly, whether Gwenivere would have had a positive pregnancy test or not, she and her family would have been invited to make CHS their health care home where they would then gain access to the range of services presented to Gwenivere.


The integrated refugee resettlement program is still in its infancy, but since its inception one year ago, we have provided services to individuals from Iraq, Burundi, Ukraine, Sudan, Colombia, Tanzania, Cuba, South Africa, and Burma. As we continue to evaluate and improve the care we provide, we seek to do so in a manner that is culturally sensitive and responsive to the needs of this unique population while also remaining true to the spirit of integrated care. We are honored to serve these families and to work as a bridge as they start their new lives here.

Eboni Winford, Ph.D. is a Behavioral Health Consultant and licensed psychologist at Cherokee Health Systems in Knoxville, TN. Dr. Winford is involved in workforce development and is a member of the training committee of CHS’s APA-accredited clinical psychology internship and the APPIC-approved postdoctoral fellowship program. She supervises trainees at multiple levels including postdoctoral fellows, clinical psychology interns, and graduate-level psychology practicum students. Additionally, she consults with other primary care organizations as they seek to integrate their practices. She is currently involved in multiple integrated care initiatives including the refugee medical screening process and the National Institute of Medicine’s All of Us: Precision Medicine Initiative. She is the incoming Co-Chair and previous co-secretary to the Primary Care Behavioral Health Special Interest Group, a member of the Early Career Professionals Task Force, and the recipient of CFHA’s 2016 Founders’ Early Career Professionals Award. Dr. Winford earned her degree in Clinical Health Psychology from the University of North Carolina at Charlotte.

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Organizational Change Management: Common Pitfalls in Leading Transformation Efforts

Posted By Rick Ybarra, Thursday, December 1, 2016



A version of this piece was originally posted on the Hog Foundation for Mental Health’s blog site "Rick on Reform.” Click here for the original posting.

Re-engineering. Reinventing. Rightsizing. Reorganizing. Restructuring. Turning around. You have heard them before. Just a few of the terms used to symbolize "transformation.”

We talk much of transformation. Actually, we talk about transformation all the time. But I submit to you that in both the private and public sectors, many transformation change management efforts to date have not been successful. We continue to hear countless stories of well-intentioned change efforts that have fallen short or completely come off the rails. "Our strategy? Well, it seemed like a good idea at the time…” Most of these efforts end up somewhere in between, likely skewed toward the lower end of the scale. Think of the bell curve: outliers at each end; most folks fall somewhere in the middle, with the majority tilting towards the lower end.

Certainly this was not the intention of those leading unsuccessful change efforts. So what can we learn from this?

John P. Kotter, renowned for his work on leading organizational change, shared the results of his observations in a 1995 article (reprinted 2007) for the Harvard Business Review titled "Leading Change: Why Transformation Efforts Fail.” He highlighted the biggest errors that can derail transformation efforts as well as basic lessons that can be gleaned from successful organizational transformations.

To the health care industry: listen up as Kotter's observations still hold true many, many years later!

To know where you are going, you have to know where you came from. In other words, institutional culture and history.

First, a basic lesson from the more successful case examples is that the change process goes through a series of phases. Check. It’s also important to note that these phases usually require a considerable period of time and often the right staging. Check again! Nothing comes easy or fast during the implementation of change management.

A second basic lesson is that critical mistakes during any of the phases can have devastating consequences, either slowing momentum or worse (such as your change process effort "coming off the rails”).

Kotter emphasized that the most unsuccessful transformation efforts almost always occur during at least one of the following phases:

  • Generating a greater sense of urgency.
  • Establishing a powerful enough guiding coalition.
  • Developing a clear vision.
  • Communicating (or under-communicating) the vision clearly and often.
  • Removing obstacles to towards the new vision.
  • Planning for and designing short-term wins.
  • Premature declarations of victory.
  • Embedding or anchoring changes in the corporate culture.


No real surprises here, right? That said, many transformation efforts continue to fail or fall short by not paying attention to and not nurturing the organization through these critical phases.

Note that even if you get seven of the eight phases right, misjudging or not thoroughly planning for that one phase is enough to bring your entire change management effort to a slow down or screeching halt! A valuable insight, I’d say!

I realize this is an oversimplification as there are a multitude of complexities that all organizations face during their transformation journey.

So what can we learn from these important observations dating back to the mid-90s? The big take-away is that all transformation efforts (yes, even successful ones) are stressful, hectic and sometimes chaotic – and often combined with new and exciting discoveries! Just as a clear vision is needed to guide an organization through a major change process initiative, a vision of the actual change process and phases, clarity on the endpoint for each of these phases, anticipating some of the challenges to expect and ways to navigate these challenges can certainly minimize the bumps to be expected. And fewer bumps can be the difference between a successful transformation effort and failure.

So which end of the bell curve do you want to find yourself on as you move through your change management process?

Rick Ybarra serves as program officer for the Hogg Foundation for Mental Health and leads the foundation’s Integrated Health Care Initiative. With over 25 years of clinical and administrative experience in both private and public sector behavioral health, Ybarra’s policy and program experience extends to county, state and national efforts promoting reforms, public policies and clinical practice to improve effective service delivery and health equity for racial/ethnic populations. Ybarra joined the foundation in 2007.

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What Has CFHA Meant To Me And For My Career

Posted By Christine Runyan, Thursday, November 17, 2016

 Dr. Tina Runyan is the CFHA President-Elect. She spoke at the recent 2016 CFHA Annual Conference in Charlotte, NC.

I’ve worn a lot of hats in my career – Air Force psychologist, academic dean of a graduate school in psychology, behavioral health clinician, post-doctoral fellowship director, and a psychologist in academic medicine to name a few. Throughout this career tapestry, CFHA has been a unifying thread for me. It is the organizational and professional home I can count on for inspiration, information, collaboration, socialization, and opportunities to advance and challenge myself.


Most recently, this opportunity and challenge will be presenting itself as the Presidency baton is passed to me in October, 2016. I am standing on the shoulders of giants in the field of integrated care and honestly do not feel entirely worthy, but I do feel empowered and ready to chaperon the organization for the next two years. When I first joined CFHA and started going to conferences, I struggled a little bit with its softer science and more applied philosophy as compared to other professional conferences I attended and organizations where I sent my annual dues.


However, I quickly realized that the practical focus on CFHA and the collaborative – not competitive – spirit was exactly what kept me coming back and actually fit my needs better. Within CFHA, I have found both likely and unlikely collaborators, mentorship, mentees, and an organization I am proud to introduce new professionals to and encourage them to attend a conference or join the organization.


As I approach the academic promotion process yet again, I undoubtedly owe some of my professional success directly to CFHA. The organization is small enough to find a hook for leadership opportunities and once I ran for the CFHA Board, I was catapulted into what previously seemed like the "private back room” of the organization. However, I was pleasantly surprised and delighted to learn that the engine of the organization was hard at work trying to help CFHA survive and thrive, volunteering copious amounts of time spawned from dedication to the mission in general and the organization specifically.


The board strives for transparency in managing the organization but at times has needed to be cautious to avoid inducing fear or igniting panic when the organization was in financial jeopardy. Being willing to serve on the board (and it is a volunteer, time intensive service role) allowed me the chance to work alongside some of the brilliant leaders in the field, which always serves to elevate my own thinking and contributions. This willingness eventually manifested as an invitation for the presidency role (voted on by the nominations committee and then by the board), which I am both nervous and excited about in relatively equal measure. And I think these are the right emotions for the job actually.


Anytime I step to the edge of my comfort zone, I know I will be challenged and that I will grow in ways I cannot fully predict but trust that whatever is on the other side of this challenge, it will serve me well to face the next one. And I suspect CFHA will be right by my side for that one too … and the one after that … and the one after that. CFHA is the constant thread in the ever-changing tapestry of my career, and truthfully one of my favorites.


Tina Runyan is an associate clinical professor in the Department of Family and Community Medicine at the University of Massachusetts Medical School. She is the Director of an APA accredited, two year Post-doctoral fellowship in Clinical Health Psychology in Primary Care and the behavioral science director for the Worcester family medicine residency. . She recently joined the Board of CFHA and when not writing, practicing, training or talking about integrated care she enjoys being a mom, trail running, and practicing yoga.

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High Jinx in Charlotte: First-Time Faculty Views of the CFHA Annual Conference

Posted By Jodi Polaha, Tom Bishop, Reid Blackwelder, Beth Fox, Brian Cross, Diane Sloan, Leigh Johnson, and Di, Tuesday, November 8, 2016


At East Tennessee State University Department of Family Medicine, we are working hard on team care transformation. Our Department has a long history of embedded pharmacy, psychology, and social work services in each of its three primary care residency training programs. Recently, however, our HRSA-funded project "Collaborative Training in Team Based Care in Appalachian Primary Care Practices” is providing us with the opportunity to develop a more progressive team approach.


We are four medical doctors, two psychologists, a pharmacist, and our director of clinical services. We were excited to have the CFHA annual conference come so close to home for us during our project development. We returned from the meeting so energized we decided to share our notes in a blog.

We lead with big praise for CFHA. The trip proved to be funding well-spent. At least three affirmations resonated with all of us. First, kudos on bringing LBGTQ healthcare to the forefront across multiple presentations. This content was an impactful, albeit unexpected, aspect to our attendance. Drs. Heiman and Johnson have already initiated changes to clinic practice to improve care for transgender patients and building more training into our residency programming.


Second, we loved the innovative ideas for building team care. We all agreed we had not seen this caliber of progressiveness in any other professional meetings. We are already looking at next year’s budget to see if there are others on our staff who could have the advantage of learning about these ideas firsthand in Houston.


Finally, we definitely appreciated the spirit of collegiality in the atmosphere including an openness to professional networking and supportive engagement. We valued the validating audience response to our presentation on an implementation strategy for building innovation into primary care. We thoroughly enjoyed the engaging audience discussion with our panel on Interprofessional Education. To sum, even though we were first-timers, we felt like we fit right in.


Thinking critically about our experiences, we wondered if CFHA can stretch to accommodate a wider range of health professions such as pharmacists, nutritionists, and public health professionals. We saw starting places for broader "team care” in multiple presentations and, well, we wanted more! Behavioral health has certainly been one of the leaders of primary care integration and there is substantive content at CFHA that can be readily generalized to another professional member of the team. Our pharmacist (Dr. Cross) said several times how he was amazed at the parallels of so many issues related to integration of clinical pharmacy services into primary care compared to that of behavioral health, both victories and obstacles. We would love to see CFHAs vision expand!

More connections to more diverse professions would add significant value for us. While we recognize that academic medicine accounts for a minority of attendees, there is certainly a priority in university settings for broader interprofessional practice and education. At CFHA, the strong participation of a clinical audience from non-academic settings provides an excellent sounding board for the pedagogical content we develop for our student learners. In other words, we see CFHA as having the potential of providing non-academic health care "ears” to help us "keep it real” and in turn, we can develop training programs that graduate professionals who are better prepared for their needs.

Thank you again, CFHA, for a quality learning experience outside the office. We are looking forward to next year!

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How to Establish a Great Music Festival (and PCBH Group)

Posted By Corey Smith, Friday, October 28, 2016



PCBH groups and music festivals couldn’t be more different experiences, right? Well, sure, most groups don’t suggest earplugs, don’t have food trucks and usually don’t include intoxicated "20-somethings,” but there are a few lessons music festival promoters have learned that are pertinent to PCBH groups. Namely, setting the date, getting useful feedback and clear practical information for attendees.


The biggest limitation to setting a good lineup for a music festival: the date. Once the date is set, 95% of bands have been eliminated thanks to the world’s consistent refusal to revolve around me. ("But I really want to see Coldplay at Coachella!”) The task of coordinating the schedules of multiple groups of people is too much work, better to set your date and send out as many invites as possible. For behavioral providers in primary care, the challenge is similar, starting a group can be a long process and success is not guaranteed.


My typical strategy includes posting information about the group to medical providers and compiling a list of as many patients as possible. Once the date is set, I send out letters with the expectation the date will whittle the list down considerably. If 20-25 patients express interest, I’m doing pretty well. The process of securing "commitments,” scheduling and reminder calls may further dwindle the list. Once we get to the date of the opening visit, we may arrive to find 4-5 people waiting to begin (one of whom needs to leave after 15 minutes).


Thing is, this is pretty successful. Coordinating the schedules of more than two adults can be extremely challenging, especially without any momentum off of which we can feed to inject energy into the process. It’s much easier to get someone to attend a meeting that has been taking place for months or years; the risk it will not be what they are looking for is lower with a known entity. Selling tickets to Bonnaroo is easy, try selling tickets to the Maha Music Festival….


Any music festival worth its’ salt has a twitter handle and at least one hashtag (@govballnyc, @ACLfestival, #youredoinggreat, #smile) to promote the experience via social media. Often, promoters project tweets and Instagram posts onto screens near the stages. The audience, those on the fence about paying for a last minute ticket, and promoters get real time feedback on what is going well ("Gogol Bordello is melting faces in That Tent #Bonnaroo2009”) or not so well, ("The Port-a-lets look like a war crime #ACL2012”) and respond accordingly. While PCBH groups may not rate high enough for a hashtag, feedback measuring outcomes is important and can inform our practice going forward. Determinations of effects will depend upon the type of group and the information the practice believes to be most important.


For example, outcomes for a group focused upon Acceptance and Commitment Therapy for chronic pain may include patients’ subjective reports of their pain levels, changes in narcotic medication dosages or number of visits to the Emergency Department for treatment of out of control pain. Providers working on a mood management group may simply choose the PHQ-9 and/or GAD-7 to determine efficacy; this is certainly acceptable and may yield significant and actionable results. The word actionable is used intentionally in this context.


Rather than simply serving as formative and summative evaluation of the intervention, measurement may be used to inform changes to the process, intervention or make up of the group. Outcome measures are easiest to track and disseminate within the electronic health record (If you find yourself in a setting where this is possible, practice gratitude and enjoy! #youredoinggreat). Without such tracking capability my strategy has been to record data via my own excel file and, although more time consuming, this works just fine.


Festival goers like to know what to expect, as most humans do, and a festival’s smartphone application can facilitate or limit the flow and organization of the event. People need to know where to eat, how to find the bathrooms and on which stage their bands are playing. PCBH groups, similar to warm hand offs and initial visits with a BHC, should be described effectively at the outset. For some clinics, group therapy can be an effective adjunct for patients that would normally be considered for referral to specialty mental health but lack the insurance coverage for a successful referral. However, the expectation of many patients, as we often see in the PCBH setting, may be reflective of their understanding of traditional mental health. This misunderstanding can be corrected with clear conversations regarding the nature and duration of treatment prior to starting.


Over-all, the business case for group visits is clear and the increased efficiency in primary care makes group visits a wonderful addition to your practice. Behavioral providers are well trained in running groups and can take the lead with the recruitment, planning and execution of a traditional group, shared medical appointment (SMA) or other innovative group process to meet the specific needs of the practice. You won’t always get Desert Trip but you can certainly have fun, make a difference and demonstrate again the value of behavioral health providers in primary care. #smile

Corey joined the faculty at the Maine Dartmouth FMR in 2015 after serving as the director of behavioral health at MidValley Family Practice in Basalt, CO and the Lincoln Family Medicine Residency in Lincoln, NE. He completed his doctoral training at Spalding University in Louisville, KY and internship at the Wyoming State Hospital. Corey is enthusiastic about integrated behavioral health care, primary care and education. In his spare time he practices martial arts and enjoys cycling, reading, hiking, and spending time with friends.  Corey and his wife Karen are anxiously awaiting the arrival of their first child in January of 2017.

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