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Collaborative Triumph Part 1

Posted By Julie Kaprelian, Linda Rio, Friday, December 5, 2014
 

 

This is the first of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week

INTRO 

Approximately 2 ½ years ago, leaders in our field wrote brief anecdotes of their own collaborative care ‘follies’ in the main CFHA blog. These ‘aha’, ‘uh, oh’, ‘doh!’ or ‘SMH’ moments covered good learning points and insight. They normalized the experience of an accidental misstep or foot in the mouth in their efforts to provide solid collaborative healthcare. Veteran and novice collaborators alike took comfort (and perhaps a little chuckle) in knowing they weren’t alone, and took note of possible minefields to avoid!

In this series, we complement the problem based narrative with a strength based one and offer similar learning opportunities through collaborative triumphs! We focus on stories that emphasize ways to address family concerns in a collaborative setting and the importance of including family on the care team. Patient concerns do not occur in a vacuum; we are inherently social and relational creatures. Regardless of how well patients’ families are connected, involved, and aware of patient concerns, they impact patient well-being and vice versa. So, sit back, relax, and enjoy (and learn) as new and established professionals take you through stories of collaborative success. 

For a refresher on the Collaborative Follies blogs, click here, here, here, and here.

STORY FIRST

What else can I do for them?” is a common question that I hear again and again from pediatric residents in their weekly pediatric continuity (primary care) clinic.  It is inherent that they want to practice best medicine while meeting all of their patients’ need.  I have been providing integrated primary care services to the pediatric residents’ continuity clinic for several months and while implementing the service has been challenging, there have been important triumphs along the way – both for patient care and the department’s providers.

A week into summer vacation, 10 year-old Sara presented with her mom to see her pediatrician, a third year pediatric resident.  Mom had called the department for an appointment a few days earlier stating that there had been concerns raised by teachers about Sara’s back and the way she walked; Mom wondered if she injured it while playing softball but had not noticed anything unusual herself.  The resident obtained an account of the presenting complaint and completed a review of systems and physical exam – everything was within normal limits.  The resident thought it was peculiar that Mom reported that Sara ran around and played typically at home but that teachers went as far as asking Mom, “Does she have scoliosis?”  When the resident asked Sara about her “crouched walking” at school, Sara stated that she didn’t know why and immediately became tearful.

The resident briefed me on the situation and asked, “What else can I do for them?”  She knew a referral to Orthopedics was not indicated based on physical exam but also did not want to simply say, “Come back if the problem continues.” Integrated primary care allowed us the opportunity to discuss the patient’s presentation, consider additional relevant questions, complete a successful warm hand-off, and speak to the family together about the likelihood of anxiety playing a role as there was no organic cause.

The last time I saw Sara it was a shared visit with her pediatrician 

Sara came to see me in pediatric primary care for four brief visits over a period of 3 months.  She identified that her first trigger was presenting a project to her class; from there her anxiety escalated at school.  I encouraged her to practice getting into that stance in the privacy of her own bedroom and then practice regaining a straight posture.  She practiced this regularly and at her next visit was able to show me this in the exam room; she established mastery and control.  She then was able to identify a few other academic stressors that triggered her anxiety; psychoeducation and establishing coping strategies helped to decrease these.  Parents remained closely involved and encouraged her to practice her new skills at home; this was critical as parents helped her maintain an awareness of any physical responses.  The last time I saw Sara it was a shared visit with her pediatrician. She excitedly shared that she had gone to 5th grade orientation the day before; she met her new teachers, saw her classroom, and talked with peers.  She approached the next school year with enthusiasm and the knowledge that she had the resources to manage her anxiety effectively.  Parents were grateful and pleased that they were able to return to Pediatrics for any additional questions or concerns. 

 

In the pediatric residents’ continuity clinic we reviewed this case and continue to regularly review the patient cases that warranted an integrated care visit to understand how this model and family involvement provides better patient care and provider satisfaction.  We use this time to ensure that residents and attendings recognize that the reasons to complete a warm hand-off to the behavioral health provider are endless.  There is no neat, comprehensive list titled “Patient presentations that warrant bringing a behavioral health provider into the exam room” – rather it becomes educating the pediatric residents early on in their training that it is alright when they do not have all of the answers and how to then effectively use the available resources in an integrated model.  The opportunity, as a team, to collaboratively work with the family on answering the question, “What else can WE do for them?” improves the outcomes for all involved.

  
 

Julie Kaprelian, PsyD is a licensed psychologist and currently completing a two year post-doctoral fellowship in Pediatric Psychology at Marshfield Clinic in Marshfield, Wisconsin. She provides consultative-liaison services and brief therapies to children, adolescents and families within the inpatient services at St. Joseph’s Children’s Hospital in the pediatric, pediatric intensive care, and neonatal intensive care units.  She has especially focused on program development while at Marshfield Clinic, specifically designing, implementing and assessing integrative pediatric primary care services within Marshfield Clinic Pediatric Residents’ Continuity Clinic and Department of Pediatrics.  She has presented preliminary findings of patient experience and satisfaction data at the Rural Behavioral Health Practice: Integrated Care in Rural Practice conference this past October, with plans to present final program data to Marshfield Clinic and involved organizations later this spring.  Her clinical and research interests include pediatric psychology, integrated primary care in rural settings, coping with chronic medical conditions, and program development. 

 

STORY SECOND 

In my fourth private practice psychotherapy session with a 25 year old woman I knew that serious collaboration would not only be desirable but required. As this very thin, frail and ‘anorexic-appearing’ woman began to sob violently, she then became enraged as she talked about an altercation with a fellow-employee. Then she suddenly lost consciousness and collapsed into my arms as I caught her to prevent her from falling onto the floor of my office. I had many prior personal experiences with fainting/syncope episodes so I noticed the subtle signs just seconds before. I did not panic and assessed her basic vitals. I considered a 911 call but she regained consciousness and begged that sirens not be called. A friend was called and took her to urgent care, with a follow-up the following day with her PCP.

Over the course of her 24 month treatment I consulted (gaining appropriate consents) with her primary physician and due to my odd speciality with the hormonal-mental health connection I recommended an endocrine consult which he  agreed after her initial blood work showed my suspicions might be correct. Her endo and I spoke several times, especially since several trials were necessary to find the correct hormonal intervention. No signs of pituitary or adrenal disorders were found. This woman had severe menstrual irregularities and reported virtually no libido which was affecting her relationship with her long-term boyfriend. A host of additional issues were reported in her medical history. An eating disorder was ruled-out but only after I referred her to a nutritionist who specialized in working with eating disorders.

I met several times conjointly with this young woman and her boyfriend to assist in helping him understand that her lack of libido was medically/physiologically-based and not due to any deficit on his behalf. This was a difficult and sensitive issue for him to understand as well as for her to try to communicate to him. Other members of her family were also intermittently involved in family therapy sessions to help all better communicate and deal with the host of her perplexing behaviors that included depression, anxiety, low-energy, anger, and this woman’s general frustrations about her ill health. She was also sent home from work due to anger outbursts as well as tearful episodes that left her unable to function in spite of being well-educated and previously very competent. Her employer’s EAP case manager and I also spoke on several occasions due to fears about potential workplace violence (there was none).

I knew that serious collaboration would not only be desirable but required 

 

After 18 months of endocrine treatment menstrual balance was achieved and eventually also a return of sexual interest. Other health concerns were also finally resolved. She and her boyfriend got married. She maintained her job and eventually received a promotion. I don’t see her anymore but look forward to her occasional email updates.                                    

Mental and/or physical health issues do not just affect an individual. This young woman’s overall health concerns were intimately connected to her intimate/sexual relationship and her erratic and fluctuating moods certainly were a concern to her boyfriend as well as work relationships. Collaborating with all her physicians was essential to getting to core issues and helping promote an overall improved quality of life. 

 

Linda M. Rio, MA, MFT, is a Marriage and Family Therapist (MFT) in private practice in Southern California for over twenty-five years.  Her recent book, The Hormone Factor in Mental Health: Bridging the Mind-body Gap (2014) brings together contributors from around the world in the fields of endocrinology, medical research, psychiatry, nutrition, medical family therapy, and patient advocacy in addition to case studies and actual accounts from patients themselves. She has been an invited speaker at national, state, and local conferences, graduate and post-graduate educational institutions and others including: The American Association for Marriage and Family Therapy (AAMFT), The Collaborative Family Healthcare Association (CFHA), and The California Association of Marriage and Family Therapists (CAMFT). Linda is also one of the editors for, Pituitary Disorders: Diagnosis and Management ,(2013), which focuses on education for primary care physicians, nurses and others.

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Not All Models Are Created Equal: Which Tracks Are You On?

Posted By Matthew P. Martin, Thursday, November 6, 2014
Integrated primary care is growing in attention and presence. Recently, the Institute for Healthcare Improvement predicted that “in the not-too-distant future, “non-integrated” primary care practices … will become rare or even extinct”. Even more recently, the American Psychological Association devoted an entire special issue to integrating psychology into primary care. Working in the field of collaborative care is like riding a train: it has taken time to build momentum but once it reaches a top speed the train can become a juggernaut. Although the view ahead of us is exhilarating and breathtaking, it is helpful to notice what kind of tracks we are using for this train.
 

 

During my undergraduate training in psychology I enrolled in a class that required me to purchase a book entitled “What’s Behind the Research?” From this book I learned about the underlying (and sometimes hidden) philosophical assumptions of the behavioral sciences. For this blog post, I will borrow a page or two from that book to take a brief critical look at two models of integrated care. Understanding what railroad tracks we are using to move forward in this exciting field is important. This work involves helping human beings who are suffering. The way we view human suffering influences what kind of assessment and treatment we select and how we do collaborative care.

Care Management Model

One of the more prolific examples of this approach to integrated care is the IMPACT model, developed by psychiatrists from the University of Washington. IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) is an evidence-based collaborative care model that has an incredible amount of supporting literature. IMPACT is a stepped-care approach that includes a care manager (usually a nurse) and a supervising psychiatrist who collaborate with a primary care doctor to treat one or two conditions (usually depression).  Treatment typically includes psychoeducation (brochure, video), antidepressants, brief counseling and/or coaching, treatment monitoring, relapse prevention, and referral to specialty mental health as needed. This is class care management for chronic conditions. To learn more, click here.

Are depression measures and treatments adequate enough to address the suffering of primary care patients? The track record of the IMPACT model is extensive. According to the data, this model leads to a 50% reduction in depression symptoms at 12 months, works in various settings (e.g., inner-city, Veteran’s Affairs, HMO, fee-for-service) and with a variety of populations (e.g., older adults, adolescents, minority populations, co-morbid patients). Moreover, the average cost of the program per patient is usually less than $600! The strengths of this care management approach are obvious: amazing cost-effectiveness, effective symptom reduction, potential for implementing the model on large scales, and a perfect fit for experimental research. Despite the impressive résumé, there are several limitations to this approach that are a direct result of the philosophical underpinnings of the model. 

 

Care management approaches like IMPACT are a product of the disease model which assumes that disease is an abnormal, organic condition with symptoms that require medicine. Successful treatment includes symptom reduction or elimination. Providers using IMPACT track depression symptoms using a screening tool (usually the PHQ-9) and use treatment protocol to reduce those symptoms. If PHQ-9 scores go down, then treatment was a success. From this vantage point, depression is a discrete disease state that is qualitatively different from other mental illnesses like anxiety. Unfortunately, the biological etiology and pathway of most mental health disorders is largely unclear and rates of co-morbid mental illnesses (e.g., depression and anxiety together) are very high. This raises the question: are depression measures and treatments adequate enough to address the suffering of primary care patients?

On the upside, the disease model and experimental research approach is a match made in heaven. Clinical trials that use an intervention carefully designed to result in symptom reduction will probably produce outcomes of symptom reduction. That’s what they are supposed to do! But does symptom reduction equate to patient happiness or improved quality of life? Can a patient have a low PHQ-9 score and still be dissatisfied with her life? Treatment success then is evaluated using measures chosen by the researchers and not the patient. Isn’t this a little presumptuous?

Another drawback to the disease model and chronic care model overall is the narrow scope of treatment. Care management models are very good at targeting specific mental health conditions like depression. In fact, many care managers are referred to as depression care specialists. But what does a physician do when a patient experiences anxiety? Does the care team create another treatment algorithm for that new condition? Do you hire an “anxiety care specialist”? What if the problem is relationship-based or a result of community and environmental factors? In sum, the care management model is an approach rooted in the disease model that is great for experimental research and large-scale implementation but maybe not so great for comprehensive patient care.

Consultant Model                            

Another approach to integrated primary care is the consultant model which includes generalists (behavioral health consultants or BHCs who are licensed mental health providers) who provide treatment for a wide variety of concerns. BHC appointments are usually 15-30 minutes long and utilize brief interventions to reduce functional impairment. Like care managers, BHCs share an office with primary care physicians and work within the same clinic system. BHCs may see 10-15 patients a day with follow up appointments limited to 4 visits. The evidence base for the consultant model is not nearly as rigorous as the care management model. The major strength of this approach includes the wide scope of treating various conditions (e.g., depression, anxiety, insomnia, chronic pain, substance abuse, smoking cessation, anger).

Limitations include experimental research challenges, costs, and training. Since BHCs treat a wide array of problems and focus more on functional improvement than symptom reduction, it is very difficult to design randomized clinical trials for this model. The consultant model will never reach the same number of successful clinical trials as the care management model. It’s impossible because experimental research (which is reductionistic and mechanistic like the disease model) does not adequately capture what BHCs do.

I personally like the simplistic beauty of the care management model. You can train a large number of providers to treat a large number of patients using limited resources. This alone is a great improvement over the current system. I also like the breadth of the consultant model. You can treat mental illness as well as behavioral health problems (e.g., insomnia, substance use, poor concentration). Each integrated care approach has strengths and limitations but which one is the best for patients? I recommend using the pragmatic truth criterion to answer this question. According to this criterion, the “right” or “true” way is the one that facilitates a desired consequence. In other words, if a primary care clinic needs an integrated care model that can measure precise outcomes and treat a specific population of patients without increasing costs, then that clinic should use the care management model. If a clinic needs a model that can address a wide array of problems, then use the consultant model. 

What if you could combine both models? 

 

But what if there was a way to combine both to create a hybrid model that makes research and training a breeze and also meets the needs of a wide variety of patients? Let me know when you find it! In the meantime, let’s be mindful of the tracks carrying this train we call “collaborative care”. As the Cheshire cat told Alice, if you don’t care where you’re headed then it doesn’t matter which way you go. 

Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at matt.p.martin@gmail.com

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Conference Wrap Up: What Happens in DC Doesn’t Have to Stay in DC

Posted By Matthew P. Martin, Friday, October 24, 2014

Sitting at my desk, surrounded by familiar objects in my office, I cannot believe that I was in DC last week for the 2014 CFHA Conference. It feels like I woke up from a dream Tuesday morning and found myself back in Kansas. But the conference materials and the poorly written notes in front of me attest to two things: yes, I was in DC and, yes, it was a great conference.

 

 

I drove to the conference on a Wednesday through heavy rain and wind and then left on a Monday with sunshine and a calm breeze. The symbolism is not lost on me. I came to the conference with wishes and concerns and left with a sense that we are headed in the right direction as an organization. How do we keep that optimism and energy going? How do we start to implement all those ideas that distilled upon us in DC like dew? 


 

 

Well, let us first reflect. Here are some cool things that happened last week:

- CFHA leaders and advocates met with important people on Capitol Hill for a historic summit meeting to discuss the CFHA policy agenda

- CFHA celebrated its 20th anniversary by holding conference in the very same hotel as the first conference

- Parinda Khatri stepped down as CFHA president after a very successful year and passed the torch onto Rusty Kallenberg

- Four terrific plenary speeches were given:

Richard Frank, PhD spoke on the robust evidence behind integrated behavioral health care and the incredible need for delivery reform

William Beardslee, MD argued that family-centered care is key for mental health promotion and prevention but that we need more proper training and measurement

Marci Nielsen, PhD, MPH told us that we have too many people defending the status quo and that we must convince them with data and stories to make healthcare more patient-centered

Russell Glasgow, PhD and Deborah Cohen, PhD argued that program evaluation is vital for determining the reach, effectiveness, and implementation of an intervention


Our social media team interviewed a few die-hard CFHA conference attendees and asked them why they come to this conference. Here is the video:

 

Now that we are back in the swing of things, you may be wondering how to effectively implement all the great ideas you picked up in DC. Here are five ideas for doing just that:

1.      Dear Diary

Reflection is a great skill for developing self-awareness and for activating your parasympathetic nervous system. Make time to write down and organize your thoughts and impressions from the conference. Write a list of short- and long-term goals. Decide what changes are possible and meaningful for your organization.

2.      Thank You and Good Night

You probably met some great people at the conference. If you have contact information, reach out to that person to thank them for a conversation or presentation given. Talk about the ideas you got from the conference and what you plan to do. Networking is great for creating collaboration and energy.

3.      Blogs and Videos

Blog posts were written for each plenary speech and video recordings of the speeches should soon be made available. Make good use of these to remind yourself what you learned.

4.      Portland, Here I Come

Did you think of a great presentation idea for next year’s conference? Start now by fleshing out your idea and bouncing it off of other people. The submission deadline will be here before you know it.

5.      Through the Haze

Forgot what sessions you attended? Download the “Guidebook” app to review all the conference presentations including the names and affiliations of the presenters. Did you miss out on a particular presentation? Contact the presenters and ask them if they would be willing to send slides and handouts to you. 

 

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Live Blogging: Dr. Russel Glasgow and Dr. Deborah Cohen Plenary Speech

Posted By Administration, Sunday, October 19, 2014

This is the final in a series of live blogs posts for the 2014 CFHA Conference in Washington DC. Big thanks to all the writers!

Implementation, Evaluation, and Getting to the Triple Aim by Russel Glasgow, PhD, Deborah Cohen, PhD

October 18th 8-10 AM

 Colleen Fogarty and Stephanie Hern: Saturday blogging is more fun than cartoons any day 

 

8:38

Parinda announces those CFHA board members rotating off the board and encourages all members to participate in the election. She then passes the CFHA president baton off to Rusty Kallenberg, the new president. Rusty begins his presidential remarks noting the parallels between his career development and the organizational development of CFHA. When he was at George Washington, he often walked across the clinic to ask his behavioral health colleagues to help with patients. When he relocated to UCSD, he first met Todd Edwards and JoEllen Patterson, with whom he began to do collaborative care within the Family Medicine Department.

Rusty quotes Frank DeGruy, “Primary care fails without collaborative care.” CFHA is now at the developmental place of beginning “adult” activities. Rusty calls on us to grow the science and sustainability of collaborative care. “It’s a never ending job improving collaborative care.” “As a primary care physician who has taken 20 years to figure this out, we need to no have new physicians wait 20 years to figure this out. We need to teach them how to do this TODAY.”

Jennifer Hodgson introduces our plenary speakers, Drs. Russel Glasgow and Deborah Cohen.

9:00 

Colleen Fogarty (CF): Drs. Glasgow and Cohen take separate podiums; noting that given the nature of CFHA, they wanted to integrate their presentations together.

How is implementation science relevant to primary care? Dr. Glasgow explains: Implementation science is designed to address the pragmatic challenges; much research isn’t really relevant to real world practice. Conducted under such controlled circumstances, it’s hard to generalize the findings to real world situations.

Russell quotes a valued collaborator, the ‘public health Larry Green’--“If we want more evidence based practice, we need more practice based evidence” (Larry W. Green, UCSF) He shows a schematic model of a contextual systems approach to implementation science, and cites several different models for implementation science. Notwithstanding critics’ concerns that implementation science contains “More frameworks and models than well-done empiric studies!” Dr. Glasgow notes that frameworks can be helpful in identifying what steps are required for success and can inform both planning and results.

Glasgow: Much of research isn't relevant to real world practice The RE-AIM model consists of 5 domains by which to consider an intervention:
- Reach
- Effectiveness
- Adoption
- Implementation
 - Maintenance

 

9:08 

Stephanie Hern (SH): The goal is to try to convince implementation and evaluation science as key to getting to the triple aim. Implementation science is one of the future directions. Deborah will talk about evaluation and how to word evaluations and both of them will share about population health. We will see video of patient experience of the triple aim being attained within primary care settings.

The pragmatic challenge is that the key issue is that the majority of research is not really relevant to real world practice, it is concocted in ideal conditions, with selective populations, and hard to translate the results to real world care.  

Implementation science is a multi level research practice with a contextual systems approach. Critical elements of the intervention are present, but when we deliver a program it is embedded in many other things. Other important elements include the program delivery staff, the research evaluation team, the fit of the program, and the partnership among all players.

Models are theories and frameworks. They can be helpful to what we need to key on in order to be successful, for planning and understanding the results.  The RE-AIM model helps plan, evaluate and report studies. 

9:15

CF: Deborah Cohen reports on a demonstration project funded by the Colorado Health Foundation, Advancing Care Together (ACT). This study enrolled 11 practices, 9 primary care and 2 community health centers, who were experimenting with changing models of behavioral health in practice. As a demonstration project, these were not massively funded, but rather, received “a paltry amount of money to do something that can be sustained.” She asserts that “Little steps are monumental in a program’s ongoing development.”

SH: They knew costs would be lowered based on evidence from other programs. So these things were already proven for co-morbid conditions. With ACT, they wanted to know how to do it. How does published research inform how you work on the ground? They wanted to focus on implementation; but once its implemented, how are they doing?

CF: The team used the RE-AIM framework, recognizing that implementation of a new innovation occurs through rapid, short cycles of improvement. The team collected lots of data over 3 years, including using online diaries, telephone calls, and clinic visits where the team of 2-4 researchers looked at all aspects of a practice, including actual visits. 

SHSite visits were extensive and included all facets of operations of patients in and patients out.  They evaluated the reach, percent of target screened, target positive, and received services. Clinically relevant measure for the teams not only just an outcome. They would be able to take a look deeper at their numbers. What do we do with the data collected? Showed important steps in the change process. They reviewed every quarter with the data from each clinic. Utilized the data for learning moments and teachable moments.

9:25

CFDeb hands the microphone over to Russell with a “research fist bump.” Russell talks about the differences between individual level changes and system level changes, noting that the “Reach” of an intervention encompasses the participation rate among eligible individuals and the representativeness of those participants. The “adoption” of the intervention reflects the system level involvement including the participation rates among invited settings and staff and the representativeness of them. 

Russell points out that denominators are crucial—reach and adoption are often confused; they ARE similar principles, but operate at different levels. If you don’t know the EXACT denominator, it’s okay to estimate!

SH: Deborah talks more about the ACT program. It included brief counseling in PC, referral to traditional long term therapy, warm hand offs, and joint PC and CH counseling joint visits. They looked at whether screening was done. Some clinics had 80-90% screening while others did discretionary screening. Why does this happen? It depends on how much you want to know about the patient population and what capacity you have to meet those needs. Not screening makes it impossible to fully know the needs of your pt population. Knowing the needs of your pop is a stimulator for practice. Not screening is a little like sticking you head in the sand. 

9:40

CFRussell takes the microphone and switches to talking about the patient experience. Effectiveness (individual level) represents the effect on primary outcome and the impact on quality of life. Maintainance represents the long term effects of the intervention at the level of the setting, e.g. the clinic or health system. Evaluators look at the sustained delivery and modification of the intervention.

SH:  Rusell talks about the lessons learned on those two dimensions (sustained delivery and intervention modification). Back to the systems perspective: there are always consequences, some positive and some negative unintended consequences. Some programs with greatest effect have the lowest reach. And vise versa. Second level maintenance is seldom sustained but almost never is a program continued the same way. 

CF: They show a powerful video of a patient health story, given by Patrick, who gave permission to share the video. Patrick talks about the impact of sustaining an injury that left him partially paralyzed and the family disruption, isolation, and ensuing alcohol abuse. He credits his physician with helping him find the motivation and resources for change, and the success of a behavioral health intervention when he reached a plateau in his change process.

SH: Patrick - Where do I find the courage to go further? My doctor could have said your great. But he said, okay if you want the courage I believe it is in your behavior. Coaching from his doctor opened the issues of where Patrick had plateaued and felt that could go up.

CFIn closing, Dr. Glasgow quotes a colleague saying, “All models are wrong” and noting the value of the RE-AIM model to inform our evaluation of integration innovations.

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Live Blogging: Dr. Marci Nielsen Plenary Session

Posted By Administration, Saturday, October 18, 2014

This is the fourth in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for one more!

Transforming Primary Care Practices in Pursuit of the Triple Aim: How Great Leadership Can Make or Break the Deal by Marci Nielsen, PhD, MPH

October 17th 12-1:30 PM

Jennifer Hodgson and Barry Jacobs: This isn't their first rodeo 

#CFHA14

 

 

12:36

Barry Jacobs (BJ): Sprightly, buoyant Dr. Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, opened her talk by stating that the American public doesn’t know the term “Patient Centered Medical Home” nor “Triple Aim”. It is our responsibility, she said, to help people understand these ideas and to bring their voices into the national discussion. It all comes down to influencing people who are voters and who are concerned that healthcare costs too much. We have to make the case that healthcare transformation is good for them.

Jennifer Hodgson (JH): Dr. Nielsen opening up her plenary to talk about the importance of leadership in enacting the Triple Aim. She advocates for Health System Transformation using the Triple Aim as the roadmap. She said our job is to translate what we do to the public so they can be brought in as real stakeholders. Healthcare Transformation is about “people.” She stated that the Affordable Care Act has been a great platform for payment and delivery reform but we have consumers that have no idea what their role is in all of this. Our job is to make sure that we are doing this as a part of our work.

12:40

BJ: She commended New Yorker writer Atul Gawande, MD for his skill conveying these complex healthcare concepts and through stories. She cited a Gawande speech that stated we train doctors to be “cowboys” and that we ought instead to be training healthcare professionals to be “pit crews,” valuing humility, discipline and teamwork.

JH: Dr. Nielsen pointed out that Atul Gawanda, MD, delivers this to the public via his incredible stories. She stated that we train our physicians to be “cowboys” and independent. She said Dr. Gawanda thinks we should train physicians to be members of pit crews instead. However, this requires changes in our values where we become more humble and allow the leaders to be those that can address the patient’s need at that time.

12:48

BJ: She said there are yet gaps in evidence about whether PCMHs work. She also said we need primary care in addition to super-utilizer care, as well as partnering with everyone else in the healthcare system and community. The US is one of the few countries that seems to believe that health and healthcare are the same thing. A lot of this comes down to politics. Many politicians think that the free market can fix all of our problems; many people in government believe that it is all up to government programs. She says that it needs to be all stakeholders pulling together. We have too many people defending the status quo. We have to convince them with data, stories and changing our values to make healthcare more patient-centered.

JHBelieves that we need both super utilizer and Patient Centered Medical Home data. She reminded us that primary care is only 5% of our expenditures. PCMHs need to be partners though with everyone in the healthcare system (e.g., community centers, schools, employers, faith-based organizations, and public health).

12:50

BJDr. Nielsen pointed out that employers are frustrated not just with personal health costs but also the impacts of behavioral health and other problems on worker productivity. But a recent Health Affairs article stated that only 14% of ACOs currently have perfectly integrated behavioral health. 43% have some behavioral health integration. She says that that’s our opportunity—to help those ACOs integrate more fully and benefit in terms of return on investment.

JHDr. Nielsen shared that there are more healthcare expenditures per person requires industry and government solutions. If half of all healthcare expenditure dollars in the US are linked to private and the other half gov’t, we need alignment of both camps to develop solutions. Noted we have to change the way we fund healthcare….we are fragmented and siloed….overused and misused. It is very frightening for the “haves” to have the “have nots” be a part of the solution. We need to convince them (the “haves”) that there is room for everyone at the table. The key is to focus on “the patient.”

Employers are focusing on productivity (absenteeism and presenteeism) …we need to focus on patients’ quality of life.  The top 5 conditions employers spend their money on are related to behavior health issues. Stated 14% of ACOs have integrated behavioral health but 43% total have started. 

1:00

BJShe argued that primary care is still incredibly undervalued. And that primary care must include behavioral health. Reported outcomes for policy-makers have to include costs. Presentations to patients and families have to focus on improved quality.

We are moving, she said, from a volume-based reimbursement to a value-based reimbursement system. We need to push this with policy-makers with data and stories. PCMHs and ACOS have to join forces. We have to partner with people we’ve never partnered with before. Public health and behavioral health have seats at the table now that they never had before. 

JHBarbara Starfield’s research tells us primary care is effective but Dr. Nielsen believes primary care is still undervalued as evidenced by only 4-5% of healthcare expenses being in primary care services. Job of Patient-Centered Primary Care Collaborative (PCPCC; www.pcpcc.org) is to share evidence in a way that is useful. They have a website that maps the programs and evidence in each state.  This is helpful when talking to policy makers. 

The number of PCMHs has quadrupled. To sustain this model we need to change from a fee for service to a value-based reimbursement system. Need to partner with healthcare specialists, pull in care coordinators, and public health specialists. We have to know when to “raise hell” and “hold our fire” to be able to work together effectively and align our interests vs being diametrically opposed. 

1:10 

BHLowering per capita costs requires hot-spotting. But we can’t stop there. We need prevent people from falling in the river in the first place. We have to be convenient and compassionate. We also have to work on the population health level through data sharing and improved care coordination. 

JHWe have data on how to lower healthcare costs…with first initial savings done with hot spotting but DON’T STOP THERE! We also need to be preventing people from getting to the point of high utilization. This is all relational! We have to also be convenient – group visits for example! 

We need EHRs/technology that unifies rather than divides care! Period!

1:20

BHThere are PCPCC slides on behavioral health in primary care that are available for download.

JHThree types of models: Consultative, co-located, and collaborative (embedded) ….this requires partners between all types of medical providers and behavioral health providers… with health coaches/care managers being the glue. 

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Live Blogging: Dr. William Beardslee Plenary Session

Posted By Administration, Saturday, October 18, 2014

This is the third in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for more!

Mental Health Promotion and Prevention in Primary Care: An Idea Whose Time Has Come by William Beardslee, MD

October 17th, 8-10 AM

 

Christine Borst and Laura Sudano: Tag team blogging in style 

#CFHA2014

 

8:57

Christine (CB): A new college student thinks, “Six months ago I didn’t even know what an English major was, and now I are one.”

For so many of us integrated care is just inherent – we have naturally gravitated to it because it made sense. And now we are working to figure out what on Earth we’re doing.

Laura (LS): Dr. Beardslee reflects on his career as in integrating family care for depression and acknowledges that there are many societal challenges, like war, that may get in the way of research; however, there are exciting things that are happening such as government support for research. Dr. Beardslee gives kudos to the speaker Dr. Richard Frank regarding the current healthcare policies implemented to make mental health integration happen.

9:00

CB: Dr. Beardslee discussed the good things going on for the world of integrated care – the ACA (with the emphasis on prevention and collaborative care); parity legislation; lots of innovative programs at many levels. “Healthcare is a basic civil right and a basic human right – this is not negotiable. Mental health care is a basic civil right and a basic human right as well”. “Families are the cornerstone of emotional development”. How do we meet the needs of families in healthcare? We need family-centered care.

Amen. We need change. Change!

LS: Mental health care is a basic human right and basic civil right. Participants clap in agreement with his strong statement. Dr. Beardslee notes that we need to disseminate our [members of CFHA] work with proper training and measurements. Family-centered care is key to tackling promotion and prevention of mental health. 

9:06

CBDr. Beardslee discussed the importance of the Triple Aim – improving the experience of care, improving health, reducing cost. Most of the mental adult disorders have early onset – we need a developmental perspective! Need to use this to move towards prevention FROM THE BEGINNING. 

I think we are doing our children a disservice if we’re not intervening (preventatively) when it’s most helpful (Honestly, how long will it take before we a) realize early intervention is remarkably important, and b) actually implement it across the board? Family, family, family. No one lives in a vacuum, especially not children.

LS: Dr. Beardslee presents statistics of mental health and calls for a developmental perspective on mental illness. One way to decrease these statistics is to help the parent be an effective parent. Dr. Beardslee presents implementation strategies that include family-based prevention strategies, effectiveness trials, getting the community involved, and to address cultural issues related to pt care.

9:10

CB: Dr. Beardslee brought up the importance of cultural sensitivity/humility. A great reminder that it’s so important to not make assumptions based on the dominant culture. “One factor lurks in the background of every discussion of the risks for mental, emotional, and behavioral disorders and antisocial behavior: poverty…We must address poverty.” Specific and general risks for depression. 20% of significant episodes of major depression can be prevented!

“We” ask for so much physical family history (heart disease, cancer, etc) – we really should screen for mental health concerns in the same way across the board and use prevention strategies in the same way. Depression is preventable! What a great opportunity for behavioral health clinicians in primary care.

LS: Dr. Beardslee notes that we need to offer a range of treatment to people as research suggests that people who are offered a range of treatment will tend to get better. Interventions needed to help the family and treatment of parental depression is critical in prevention and treatment.

9:17

CB: “Individuals should have informed choices in treatment ‘tools’ that are available to them.” Dr. Beardslee discussed the need for family interventions if we identify a parent who is depressed. Treat the parents, provide help with parenting, and using a two-generational approach.

Parenting is a remarkably intense job. What an incredible opportunity to intervene and be helpful on this subject as clinicians/providers…to help parents be more likely to actually enjoy the job they have.

9:20

CB: “A friend, not an apple a day, will keep the doctor away.” Social connectedness.

Eat an apple with a friend maybe…while taking a brisk walk? How’s that for collaborative care?!

LS: Up to this point, Dr. Beardslee discusses the IOM report and multiple studies/papers. He states that a friend once said, “A friend, not an apple, will keep the doctor away.” His point here is that social interaction and relationship is important, and of course, low cost. We need to think about this as clinicians. Dr. Beardslee talks about the difficulty getting reimbursed by insurance, as a psychiatrist, when using preventative interventions with families; however, it appears to be the bread and butter of healthcare. Perhaps this is one way policy should be shaped in the future.

9:23

CB: Developing systems that can give two-generational responses to parental depression. Tough for reimbursement because there’s not a diagnosis for the child. Responding to the needs of vulnerable populations, especially low income, culturally and ethnically diverse families. Depression can look different. We need to be educated and aware.

LS: Dr. Beardslee reviews his study of “Family Talk Component” launched in the late 1980s and notes that it is built on principles of risk and resiliency. He acknowledges that his work has been guided by resiliency perspective.

9:25

CB: “There is a lack of a payment structure [for preventive/family care].”

Ben Miller, can you fix this too!?

Screen. Treat. Prevent. Save gobs of money. Problem solved! 

9:30

CB: How can we cultivate openness in our children? This is often lost in households suffering from depression. Dr. Beardslee’s secret to prevention treatment = systemized common sense.

Can you bill for that?

Dr. Beardslee explained that the art of the process is helping the families make sense of depression, eventually seeing the emergence of the healer within. There is also a need for families to “understand depression anew across the development.”

LS: Dr. Beardslee walks through the treatment of depression and notes the first step is psychoeducation with the parent. He states, “Good preventions are systematized common sense.” Dr. Beardslee reviews the six principles for a successful family meeting and interventions with families and depression. He says that he is a “practical person” so the six principles are practical tips for working with families.

9:35

CB: Web-based training in Family Talk at ww.fampod.org for free. Parental depression is prevalent in family practice; when recognized and treated can have a multiplier positive affect on the family. Use the PHQ-2/PHQ-9 to screen parents annually. Dr. Beardslee advocated that it is essential to work with parents who are depressed as parents first.

LS: Dr. Beardslee notes that his work with Latino population suggested that the children were curious about the immigration journey of their parents, something that differed from the implementation of this program with the general U.S. population. As such, the use of immigration narrative is important in implementing Family Talk programs.

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Live Blogging: Dr. Richard Frank Plenary Session

Posted By Administration, Friday, October 17, 2014

This is the second in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for more!

Economics, Delivery System Reform and Behavioral Health Integration: Don’t Get Left Behind By Richard G. Frank PhD

October 16, 2014 6-8pm


Stephen Mitchell: blogging like a champion #CFHA14 

 

7:00     Dr. Frank opens his talk making the point that placing behavioral health on the same level as general medical care has been shown to be affordable.  The Affordable care act fosters parity by “marrying it to a mandate.”  Thus, behavioral health is provided on par with general medical care.   

7:04     What this means is 30 million people will have behavioral health services at parity.  Have you noticed more people getting better behavioral health services at general medical care standards?  Folks who are working in the trenches what have you seen? 

            What’s working?  What is not?  How does the Affordable Care Act influence these failures and successes? 

7:07     Dr. Frank points out healthcare has become incentivized.  This is an economic idea influencing medical care.  Incentives work theoretically in economics but they can’t factor in the human element.  Theoretically incentives bank on everyone “doing the right thing.”  Unfortunately not everyone “does the right thing.”  

7:11     Patient-centered care in an organization like CFHA means meeting patients where they are.  Parity allows patients not to be forced into certain care settings but provides parity across all systems.  Thus, no one falls through the cracks.  I like this idea but is there another way to motivate all these organizations outside of money?  I think we could learn a lesson from the banking industry, the more money available the more incentive to cheat, not do the right thing. 

7:17   I like the flipped view Dr. Frank addresses.  We have research exploring how behavioral health has been brought to medical care, but we have little evidence on how medical care is brought to behavioral health.  I like how this flipped view works against the power dynamics inherent in bringing behavioral health to the medical field (ie. Trying to convince the medical community behavioral health matters). 

7:21     Dr. Frank makes a compelling point: Cost-effectiveness does not mean huge savings but quality care and quality services are provided.  There are some things that are worth paying for because they enhance quality of life and care.  It’s like building a home with high-quality materials rather than cheep materials.  The cheap materials make the house more cost-effective in the short-term.  Quality materials make the house cost-effective in the long-term.  Which would you rather have?  Healthcare reforms need to be made for the long-term.  

7:25     Dr. Frank returns to his flipped perspective (medical care to specialty behavioral health) and gives some data on what helps this collaboration work. 

7:28     You can get a lot of the work of integration done without co-location.  Is this statement legit?  Can behavioral health needs and medical needs be met without co-location?  What needs can be met? 

Ben Miller: Making social media look cool #CFHA14

 

Dr. Richard Frank, Assistant Professor for Planning and Evaluation for HHS, our opening speaker today at CFHA. Dr. Frank has done a tremendous amount of work around mental health. For example, consider how Dr. Frank and colleagues were instrumental in bringing about mental health parity. Kicking off this year’s conference is totally appropriate as the majority of Dr. Frank’s work has been focused on evaluation and policy around mental health.

1)      Expand overage around behavioral health (e.g. mental health parity)

2)      Create new organizational arrangements to advance integration and the like  

Dr. Frank opened up his session describing the robust evidence behind integrated behavioral health and primary care. However, he didn’t stop there; in fact, he described how we need to continue to push for delivery reform where we move from volume to value. His brilliant expose on mental health parity, which should the holes (e.g. small employer market).

Dr. Frank then took a bit of a u-turn and got the audience to pay attention to the specialty mental health space. His logic? The recent focus on the patient-centered medical home in primary care has also sparked discussions in the behavioral health community about creating a similar model in specialty behavioral health settings to help meet the health care needs of patients with severe and persistent mental illnesses and substance abuse conditions. SAMHSA has recently published evaluation data on some of these projects.

Throughout his presentation, Dr. Frank reminded us that there is a robust evidence base and principles to follow for integrating care. “We can measure the things that promote this stuff; if we can hold that, we can embed within our accountable systems, those measures so we do not go off the rails.”

Bottom line (from my live blogging): We have the evidence; we have much of the know how; we should scale (for behavioral health in primary care); we still need more evidence for integration in other settings

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First CFHA Writing Workshop A Success

Posted By Colleen Fogarty, Friday, October 17, 2014

This is the first of several blog posts being written live at the 2014 CFHA Conference. Check back for more!

A group of early career professionals gathered at the session “From Dissertation to Dissemination: An interactive Writing Workshop” organized and led by Lauren DeCaporale-Ryan and Laura Sudano.

After introductions in small groups, and shared reflections on the questions, “why do I write?” and “What do I write?” a panel of speakers addressed key questions of importance to writers and aspiring writers.

Matt Martin reflects on his journey as a blogger, and gives advice from one of his early faculty mentors: “Find a story and tell it.” This advice applies to BOTH creative and scholarly works!


Randall Reitz takes the podium, and says he’ll talk about collaboration in writing using the names of three people who each need only one name: Mandela, Obama, and Beyonce. Nelson Mandela, leader of the African National Congress, and Barack Obama, current POTUS, both value leadership from behind. They both use strategies of collaboration in their leadership, focusing on consensus building to get a job done. So should writing, says Reitz. He proposes the following strategies for developing writing collaborations: Find a story and tell it! 

 

1. Symbiosis starts at home. Look locally for mentors and collaborators. Who inspires you?

2. Outreach intentionally—Answer the question, “who out there is doing what I want to do?” Develop personal connections and shared contact. Episodic email is a great way to go!

3. Show loyalty to your own peeps! (not the Easter candy….) Advance your careers together with people within your training cohort; you have with them a sense of timeline and shared experience.

4. Pursue non-traditional publications—Randall presents us with a screen shot of a current Google search of images associated with “medical family therapy” and finds luminaries: Susan McDaniel, Jennifer Hodgson and newer/younger folks including Laura Sudano. All of these people have a strong online presence, based on their work, and some of the work is online blogging.

Where does Beyonce fit in? Beyonce, in Randall’s estimation, is the ultimate musical collaborator, and she stays true to her roots and extends her growing beyond it.

Next up, Larry Mauksch and I, facilitating a discussion about barriers to writing. Participants throw out the following examples of barriers:

• Not enough time

• Competing demands on time

• Fear of rejection, or not being good enough.

• Fear of feeling stupid, or worse, actually being stupid!

• Pressure to produce, perfectionism.

• Personal barriers, including, but not limited to, a lack of focus and getting stuck.

"The reason I write is to find out what I think" The major factors break down into psychological factors and time factors. To overcome the psychological barriers, one idea is to use Anne Lamott’s idea of a “shitty first draft.” The only role here is that it get done, then we revise! Larry points out that learning to write well is much like the learning required in any other activity, and requires coaching. I point out that we all need to develop a new relationship with “red ink;” We need to cultivate an open stance towards feedback and not personalize it into something being “wrong” with us as people. 

 

Next up, Susan McDaniel on writing productivity. She says, “The reason I write is to find out what I think… It’s hard to figure out what one thinks about something. If the writing isn’t clear, the thinking isn’t clear.”

She notes the importance of early mentoring in developing oneself as writer. Lyman Wynne a psychiatrist/psychologist, an exceptionally clear writer, served as an early mentor for Susan. They collaborated on a book about Systems Consultation, shortly before word processing became available. They revised each chapter at LEAST thirty times, each revision requiring hand re-typing of every page.

Susan recommends identifying local mentors and asking for feedback about your writing. She counsels, “When engaging potential collaborators, be careful. It’s like moving in together!... Choose your writing partners carefully!” She especially suggests choosing co-authors who will do their share of the work. When you find good collaborators, notice the dynamics and look for honest feedback to make your work better!

When thinking about why to write, she counsels colleagues that the opportunity to influence people is far greater with writing than with direct teaching; your work can reach across geographic boundaries and develop distant collaborations. Your writing can cultivate a rich opportunity for intellectual exchange!

She notes that it’s crucial to commit the time to writing and to learn to prioritize and protect the important time for writing! Everyone has the demands of clinical work, trainee precepting, managing interruptions and writers need to learn how to manage this. Don’t schedule anything else during this writing time! Put a do not disturb sign on your door, turn off e-mail. Even if you commit 2 hours per week to your writing, after a year, you will have something! Learn to prioritize and protect the important time for writing! 

 

When you are sitting with a manuscript, thinking, “spare me, I can’t stand this anymore!” Keep at it; the rewards are there though certainly DELAYED! Pay attention to the important, not only the urgent!

Participants began the small group work of a mini-writing seminar. Each group had 2 or 3 participants who had sent in writing ahead for the group to review and critique. Hats off to these folks who showed the courage to share and the faith in the events’ organizers, to make good use of the time and receive feedback on their work.

During the large group debriefing at the end of the session, participants reflected about their experiences in the writing seminars, as both reviewers and authors.

I am looking forward to the red ink On reviewer commented that she could use the feedback that the authors received in her own work. An author noted that she felt the comments drove home Susan McDaniel’s ideas about clarity, saying, “where my reviewers were confused, those were the same spots that I was confused when I wrote it.” Another author reflected that she found that coming together in a group to review helped her get “unstuck” and helped to get her thinking back on track. A third author commented that “Looking forward to the red ink” is something she’s been developing, saying, “The more I do this the better it gets!” 

 

In closing, groups were tasked to write down a writing goal for the upcoming year and then share the goals within the small group. Goals in my small group included working on a memoir for an hour each week, submitting poetry to a journal, scheduling writing for two hours per week, removing patient appointments during pre-scheduled writing time, and committing to dusting off manuscripts that have languished and prepare them for submission or re-submission.

DeCaporale and Sudano knocked this one out of the park: They included expert tips, facilitated large group discussion, experiential writing/reviewing in a small group setting, and personal/professional reflection and goal-setting. I hope the participants of the session gained as much as I did from participating!

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An Interview with Donald A. Bloch, MD

Posted By Administration, Tuesday, October 14, 2014

Don Bloch, MD died on September 18, 2014 at 91 years of age. He founded the Collaborative Family Health Care Association and its affiliate journal, Families, Systems and Health (formerly Family Systems Medicine).  He was a funny, creative, authentic human being, one of the original family therapists who saw the importance of applying systemic approaches to healthcare.  Don was a generative visionary who found and nurtured new talent and created organizations, journals, even health care movements through recruiting and harvesting the energy of many colleagues. 


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In this CFHA blog, an interview of Don originally published in 1996 one year after the first CFHA conference, is republished with permission.  Don remained heavily involved in CFHA into his early 80s after founding CFHA at the young age of 72.  

 

With gratitude and deep respect for Don,

 

Larry Mauksch, M.Ed,

Susan McDaniel, PhD.,

and Jeri Hepworth, PhD

 

An Interview with Donald A. Bloch, M.D. by Eric Weiner, Ph.D., M.S.W.

Families, Systems, & Health 14:95-105, 1996

 

Prediction is difficult, especially about the future.

—Chinese saying

Let's begin by having you tell us what you believe is most noteworthy about your career.

I think what I value in myself is having a fairly good early sense of what will be important in the midterm. This meant abandoning psychoanalysis for family therapy in the mid-1950s and recognizing the unfolding importance of systems issues in healthcare in the early 1980s. In connection with the development of each of these fields, family therapy and collaborative family healthcare, I have been the Editor of the two key journals for important periods: I edited Family Process for the volume years 1970-82, thirteen years in all, when family therapy quite literally burgeoned. Similarly, I have edited Family Systems Medicine from its founding in 1983 up to the completion of 1995, again thirteen years, and again I think those were critical years for the early delineation of the field.

Tell us about your early family years.

In many ways, the family I grew up in was typical of the second-generation, Jewish immigrant families that arrived on these shores in the late 1880s. All four of my grandparents immigrated here as youngsters, met here, married and had their four children: two boys and two girls in each instance. Both grandfathers started out as itinerant workers, one a peddlar, the other a painter. They opened small stores, worked heroic hours to hoard up protection against the anxiety and dread that they brought with them from Eastern Europe. They raised their families in the often described atmosphere of gemiitlichkeit, guilt, and ambition that characterized immigrant Jewish families. My father, as oldest son, married a youngest daughter, as did I—twice. He became an attorney and ultimately, after many anxious years and before Alzheimer's struck, walked into the 20-year sunlight of his true vocation as a judge—a role that played to the best of his intrinsically sweet and thoughtful disposition. Truthful, quick sketches of my mother and sister are beyond me. My mother, like countless numbers of her sisters, certainly was an under-utilized woman, and angry and depressed about that—but still with a wonderful capacity for love and humor. My sister Barbara was and is my lifelong friend—at least after I recovered from the dark sense of gloom that attended her arrival when I was five, and the hot Oedipal love affair I was having with our mother was disrupted.

What about college and medical school?


My college years were very turbulent, continuing a pattern that had been established in high school. At the personal level, I was struggling with what I would later come to see as major difficulties in leaving my family of origin. I lived at home and went to college, riding the subway like so many New York City kids—just as I had done for high school. I had a hunger for knowledge and a total inability to conform to the official demands of education because that was what my parents were pushing—an evil combination. My adolescence was often chaotic and painful. Confusion and guilt abounded along with an idealistic yearning to be connected to the great causes of the world. Unfortunately, family therapy had not been invented yet.

 

It sounds as if politics would have been important to you under these circumstances.

 

Left-wing politics, with which I became heavily involved as a college student, was God-sent. The Spanish Civil War began in 1936 when I was 14, and the heroic struggle between good and evil—the Loyalists and the Franco Falangists, as transmuted and romanticized through the writings of Hemingway—was the stuff of my adolescent dreams. Heroism and sexuality: an unbeatable combination. Later on in college, I could be so busy selling the Communist newspaper, The Daily Worker, that there was no time for school work—actually I had a goodly number of devices for avoiding school work. The whole enterprise terrified my parents, but they could not do much more than leave me alone and hope for the best. I was frightened myself, but also fascinated and really enjoyed the endless discussions and the political work.

 

My first serious girl friend was a Young Communist, she later persuaded me to straighten up and become a pre-medical student as a "contribution to the class struggle." She correctly assessed that I could parlay a middle-class background from a working-class school into a rare and much sought after admission to medical school. 

 


When I began to think about going to medical school, I turned into a model student. The possibility of being a doctor wove together a multitude of strands in my life. Physicians were revered in my family and, it seems to me, there was a strong delegation for me to be the physician in my generation of the extended family, which had already had several distinguished doctors in earlier years. More than that, I had been asthmatic as a child and often had severe ear infections—painful and debilitating in the days before antibiotics, when deafness and mastoiditis were not uncommon sequelae. My mother was certainly the best nurse/ mother any child could have, an expert at creating a cozy counterpane world that almost made the extremely painful eardrum lancing for my many middle-ear infections endurable. My mother and I made the tightest of bonds around my illnesses. And, since I was a voracious reader, the romance of medicine and the high adventure of science captured me in a heady swirl. 

My mother and I made the tightest of bonds around my illnesses 

 

During the war, students were enrolling in the military, either the Army Medical Corps or the Navy V-12 program, so as to avoid being shipped overseas. I was accepted for the more desirable Navy program, very strange and somewhat embarrassing even at this remove because there was so much privilege involved. The intentions were good: not to tie attendance at medical school to the student's financial situation. But, of course, the majority of those admitted had the advantage of education and class background.

 

You married first at about this time?

               

I was married just a couple of weeks before medical school started. Natalie and I were just 21 years old. Among other things, she introduced me to psychoanalysis in a form that was understandable, and palatable to me, mostly through the writings of Karen Horney, whose most influential book was The Neurotic Personality of Our Time. 

 

Remember that the 1930s was the decade of the Great Depression. It is almost impossible to convey the impact of this on the lives of ordinary people. To say that one out of four workers was unemployed does not begin to convey the dread people felt. A sense of personal identity and any feeling of self-worth dissolved. Later, when I came to know Nathan Ackerman and to reconstruct some of his history, I learned how much his thinking was molded by the experience of the Depression, not only in his own family but also in his work as a young psychiatrist. 

 

Psychiatry as a profession began to make sense to me 

The appearance on the scene of the social science oriented psychoanalysts permitted psychoanalysis and my political and social interests to come together, and psychiatry as a profession began to make sense to me. It was also very evident, at the personal level, that I needed some help since I was faced with the stress of leaving home, a new young marriage, and the assault of medical school. Deciding to become a psychiatrist and psychoanalyst legitimized my getting into personal analysis in medical school, and undoubtedly helped keep me somewhere close to sanity.

 

 My first analyst was both a political Marxist and a psychoanalytic radical, Bernard Robbins. As I reconstruct him now in my memory, Robbins had the early intuition of an idea that has dominated my own thinking over the years. At that time, most theory was devoted to considering how personality unfolded from within and was modified by traumatic events. Against this background, it was a major dislocation to think that social responses to individuals played a significant part in maintaining the continuity of personality, and that individuals were active in constructing and modulating these responses.

 

You trained at Chestnut Lodge, did you not?

 

Chestnut Lodge Sanitarium, where I went as a first-year resident, was a small, private psychiatric hospital just outside of Washington DC, in Rockville, Maryland. It was then the premier, psychoanalytic hospital for treatment of psychotics and severe behavior disorders. Frieda Fromm- Reichmann, the remarkable refugee psychiatrist who was the central figure in the novel / Never Promised You a Rose Garden, was on the staff and one of my teachers. The brilliant and eccentric American psychiatrist Harry Stack Sullivan, who defined "psychiatry" as the "study of interpersonal relations," was a consultant and taught at the Washington School of Psychiatry where we all were students. It probably seems weird to the reader of today, but this small hospital, in many ways precious and self-involved, was a significant crossover location for the evolving field of what was to become systemic psychiatry. 

 

The "Lodge" had started life in suburban Maryland, just outside of the District of Columbia, as a drying-out place for congressmen and others of their ilk. Somehow, Dexter Bullard, the owner, on inheriting the place from his psychiatrist father had the glorious notion to turn it into a psychoanalytic hospital—just at the time when American psychiatry was being pumped up to previously unimaginable heights by the influx of refugee analysts interacting with the returning young doctor war veterans who were trying to find a place for themselves in a rapidly changing medical world. The residency appealed to me because it provided the opportunity to work intensely with a small number of patients. The custom was to see patients four, five times a week for one-hour analytic sessions; the focus of the work was on examining the interpersonal field constructed in the transference relationship—an effort to bridge interpersonal and classic analysis. I believe a persistent trend was established there, and that it has provided structures supporting the collaborative family healthcare movement some 40 years later. 

 

Why do I give it such importance? This hospital and the Washington School of Psychiatry were committed to understanding and treating psychosis in interpersonal terms. A broader view of this enterprise, and particularly of the idea that the treatment system included the therapist as much as the patient, is so powerful that we are still only at the beginning of understanding its importance— although the idea of collaborative family healthcare captures that notion in action. It provided the logical foundation for the transition from exclusive concern with intrapsychic events to a broader interpersonal and eventually an ecosystemic view of "mental" life.

[They] were committed to understanding and treating psychosis in interpersonal terms 

 

The influence of these ideas can best be illustrated by research that went on there—ultimately published in the still interesting book The Mental Hospital by the sociologist Morrie Schwartz and the psychiatrist Alfred Stanton. In what is still a model of research strategy, they attacked the problem of psychotic excitements. These days, heavily medicated patients are not likely to show the fearsome combination of behaviors covered by the term "psychotic upset or excitement"— grueling and dangerous outbreaks for patients and staff. These were patients in extreme psychic pain, restless, disoriented, combative, self-damaging. We did not have any medications available except for chloral hydrate and phenobarbital; Thorazine had not yet come on the market. We used cold, wet-sheet packs to help people quiet down, and we provided a tremendous amount of nursing for patients. But it was still a major source of distress for patients and staff. 

 

In what remains a model of research, Stanton, the psychiatrist, charted the excitements, Schwartz, the sociologist, monitored and charted staff interactions with patients, all of whom were on the closed women's ward, about 20 patients. These records were kept separately and analyzed later. The intriguing finding was that there were disagreements and covert struggles going on between key staff involved with patients and that these preceded the excitement. Let's say that the charge nurse and the patient's analyst might have a major disagreement about how she (the patient) should be dealt with; the covert disagreement would go on for day after day, after which she would go into a psychotic excitement. By independently charting the relationship between the nurses and administrators or individual therapists, and by demonstrating that there would be these hidden wars, it was possible to predict before the patient was going into an excitement that this would happen. Not uncommonly, the episode would end when one of the staff members left the field, by resigning, requesting transfer, or by hospitalization of the staff member for "mental disorder." Family therapists can recognize the isomorphism with patterns that undoubtedly characterized the families from which these patients came. 

 

A number of the people of my generation who went on to become leading innovators were there as residents when I was: Don Jackson and Harold Searles probably being the best known names. The "Lodge" had the quality of a golden land: we were intensely involved in new ideas about the "self." This involvement took us into looking at our own lives, looking at how we fit into what was happening with our patients, what our part was in creating the transference. Transference could no longer be thought of as something that the patient dropped on you like a soggy blanket, but rather something you participated in constructing. The notion of a co-constructed reality—although that was not the language for it then—was alive and well at this hospital in the late 1940s. The years have passed, but I think the early patterns of interest for me were really established at that time.

 

What happened next? 

The intellectual excitement was almost overwhelming at times. We were exploring the territory of the new social sciences and bringing back treasures for our work: linguistics, semiotics, cultural anthropology, sociology, general systems theory, cybernetics: Parsons, Goffman, Wiener, Korzybski, von Bertalanffy, McCulloch, Margaret Mead, Harry Stack Sullivan and, later, Gregory Bateson. Only a few names from a long list whose work we studied and whose ideas we adapted to the clinical problems with which we struggled. Their ideas were exciting in and of themselves, and they were applicable to the human dilemmas with which we were dealing. 

 

The intellectual excitement was almost overwhelming at times 

I finally had to fulfill some obligated military service because of my deferment during the war. I joined the Public Health Service, was stationed at the National Training School (NTS) for Boys in Washington DC for 2 years, and later at the National Institutes of Health for the same period. NTS was the federal prison for youthful offenders. At NIH, because I was now an expert in delinquency, I was on the planning staff of Bob Felix, the Institute Director. The entire Mental Health Institute was housed in a Quonset hut on the NIH campus in Bethesda—hard to imagine in the light of the Institute's current size. When the Clinical Research Center opened, I was invited to join Fritz Redl in opening the first research unit—improbably studying delinquency by housing a half dozen 10 years olds on a ward in the gleaming glass and steel building. It was an embarrassingly zany effort: the difficult task of getting the government to permit our nurses to wear street clothes on duty was topped only by the problems of the twice-a-day convoy of our kids past the glass-doored laboratories in the hall outside the ward. What kid, delinquent or not, could resist putting an occasional hammer through one of those doors?  

 

I published my first paper in 1952 based on this experience. The paper, "The Delinquent Integration," defined delinquency as an interactive pattern rather than as a personality characteristic. It attempted to identify what there was in the growing-up experience of the to-be-delinquent child, and what adaptive defenses he had to develop to live and minimize anxiety in that experiential world, defenses that would later be known as his character or personality structure. The paper was about the social interactions in which circularity was established so that responses were evoked and made for the reality in which one lived and that had to be dealt with by recycling the same interpersonal patterns. Some years after that I coined the term "portable reality" to describe how the individual, moving through time, evokes from the social fields in which they are moving, a set of responses that in effect create the same reality—so the reality is portable. That has interested me all of my professional life and is a large part of how I look at family and other areas as well.

 

Then, and perhaps now as well, I was always pushing—out of some inner discontent or restlessness—to the edges of wherever I was at the moment while trying to stay connected to the center. In the early 1950s, having heard dimly of something later called family therapy, I began to record my therapy sessions with analytic patients; this was before the days of taperecorders, and video of course was unheard of. I bought a magnetic wirerecorder that, in those days before transistors, was the size of a large suitcase. You could barely carry it. It would make a magnetic recording on the magnetized wire spool and play it back through what looked like a large radio. The entire project was suspect: analytic colleagues sniffed at your unanalyzed voyeurism. After making recordings for a while, I did something even more outrageous: I began to invite the spouse in when I had patients in analysis. I was intrigued by the notion that I could take a firsthand look at the folks I had been hearing about from their mates and check my impressions directly against what I had heard in the sessions. It also helped ward off analytic boredom, which threatened to descend all too often. 

 

Let me tell a story that I don't tell a lot. I have had only one "successful" suicide of a patient in my entire career. The patient was a woman who came to me for analysis. She was a PhD married to an MD, had two kids, and was pregnant with the third. It was very clear in the first couple of sessions that she was dangerously suicidal. I told her I needed to talk with her husband. She refused, saying that, if I did, she would not work with me. "I have to know that this is confidential," she said. So I didn't contact her husband. She killed herself. She took an overdose, and her husband woke up in bed one morning next to his dead wife. I've regretted that all my life; I know I would do it differently now. At times, the severe limitations of one-on-one, confidentiality oriented psychotherapy were compelling and evident.

 

How did you happen to go to the Ackerman Institute?

 

Altogether, I spent 13 years in Washington. My wife and I had our three children there. In 1961 we left Washington DC to move to Northern Vermont for what was to be a one-year sabbatical on a farm, and we ended up staying there for 7 years. I had a research consulting job in New York at the Jewish Board of Guardians, to which I would commute 2 days a week. It seemed as reasonable to commute to New York from Vermont as from the District of Columbia, and we could live on the reduced income under those circumstances. Midway through that period on the farm, around 1965, I began to become actively involved with Nathan Ackerman and the then Family Institute, renamed after Ackerman's death. 


Ackerman and I had been lurching toward each other off and on for several years. He fascinated me; I knew I was interested in family work, and a mutual friend, Marjorie Behrens, who was an associate of mine on a research project and a longtime and loyal friend of Nathan's, would talk about him to me a lot. One day, Marge felt it was time for us to get together, and we all had a drink together, which turned into several drinks and finally a night of talk between Ackerman and me. He asked me to come work for him, which I did, first as Research Director, then later as Associate Director.

I knew I was interested in family work 

 

Originally called The Family Institute, it was a very part-time enterprise originally run out of Nathan's private office; the staff consisted of Nathan, his secretary, and the wonderfully capable Judy Lieb who was titled administrator but did just about everything. I imagine Nathan paid them out of his private practice income. To say that it was a shoestring operation is to exaggerate. When I joined them in the mid-60s, the Institute had just bought the lovely townhouse on East 78th Street in New York City, which it still occupies. The Board, in those days, was made up mostly of Ackerman's present and past patients. They were just beginning to give the Institute some meaningful financial support, and about 1965 bought the building and finished paying off the mortgage. For the next 25 years this building was the sole capital asset providing, literally, a roof over our heads and the place where teaching and clinical work could go on with some measure of safety. 

 

Nathan Ackerman died suddenly but not unexpectedly in June of 1971. He was only 62 when he died; he had rheumatic heart disease, smoked and drank more than he should. I believe he had made no real effort to prolong his life. There was a way in which he was deeply sad at how things had gone in the world. He had dreamed the dream of family in a way that was rapidly becoming anachronistic since it was deeply rooted in the idealized image of the patriarchal family—not a bad deal when it was going well, but rapidly played out as a goal. Yet family therapy would live on and be incorporated into the newer ecosystemic approaches to human misery. Sometimes students are surprised to hear that there was a man called Ackerman, not only just an institution. That would certainly not have surprised Nathan, but it would have amused him.

 

I was Associate Director and the logical choice as Director. By 1971 there was a solid core of clinical and teaching talent as well as a fully operating low-cost family clinic that provided our student externs with clinical material. It was worth continuing for the possibility that, with people like Kitty LaPerriere and Peggy Papp, we could carry the ideas and techniques of family therapy into new project areas.

 

Did some of the activities at the Institute relate to family systems medicine?

 

Early on, Ackerman and I were involved in two hospital programs. We regularly visited with the head of Orthopedics at New York Hospital—he was a most unusual orthopod who had collected family case histories on a large series of his patients, and who was impressed with the unexpected frequency with which disasters ranging from divorce to homicide had been part of the lives of the families of his patients with severe orthopedic deformities. We also regularly visited the Obstetrics Department at Lenox Hill Hospital to explore the possible benefits of a family intervention early in the lives of vulnerable families. With this in mind, we set up a series of meetings with young families that were observed by professional staff. 

 

I'd also like to mention a project called Family House that I set up in my very early days at the Family Institute—the mid-1960s is the time period involved— because it clearly delineated the ideas that have been enunciated in the collaborative family healthcare paradigm. The Family House project design called for moving a multidiscipline team, built around social and healthcare services, on-site into a housing project building. It would selectively choose for residence those families denied access to more conventional housing projects, denied access because they were alleged to exhibit social or personal pathology too severe to be accommodated in such housing. For all intents and purposes, these were families that 20 years later would be identified as homeless, although that term had no currency then. A central idea of Family House was to deal with the pattern whereby families, as they strengthened themselves and became less "pathological," would move out of the community in which they lived—the housing project, for example. We had the notion of reversing this process and having the professionals "move out," hopefully leaving a vital community behind them.

The Family House project called for moving a multidiscipline team into a housing project building 

 

Amazingly, the project was approved for joint funding by both NIH and by the Children's Bureau. But that was in a year when all the funding crashed. So, we got a small amount of money but never got the project really funded. It was approved but never really came to be. Looking back on it now, I think it was laudable but naive and unsophisticated. My guess is that it, like so many similar projects, would have been sustained for a time only by unreasonable inputs of energy and financing. It would have demonstrated one kind of truth, that families can be rehabilitated with those levels of support, and also demonstrated another kind of truth, that such levels are unsustainable. A much more advanced and valuable demonstration of these points was being made around the same time by Dick Auerswald and the Gouverneur Hospital program in a well-funded project where an ecosystemic and family point of view was being applied to a community mental health center, and with outstanding results.

 

What were your goals for yourself and the Institute when you became Director?

 

My goal as Director, during the 19 years I held that position, was to have the Ackerman Institute be a flexible and dynamic home for outstanding people and exciting projects. We tried to build these on a first-rate, clinically based, teaching program. I believe doing this well meant setting quality standards, but not pretending to know just where it all would go or what the ultimate model to be promulgated should be. The choice to nail one's flag to the mast of a specific model of therapy has clear tactical advantages if the model works, as almost all do somewhat. The alternative is for an institution to teach clinicians more eclectically, with the best current models available. That way builds institutions along more of an academic model. At the Ackerman Institute we did both, not always without some conflict. Under the star system, it is often hard to persuade others as to what an equitable division of the glory or income should be. 

 

Running the Institute was not always smooth sailing for another kind of reason. Things kept changing in the field, and it was particularly painful to realize that sometimes people had to leave the Institute because they did not fully keep up with these changes. It is not always true that a rising tide lifts all boats. Mercifully, this did not come up too often because the people who had to leave had been my colleagues and friends for years.

 

How did you start Family Systems Medicine?

 

My pathway to a closer relation with physical medicine was long and, as I have tried to indicate, goes back to my childhood and my family. More proximately, at the Ackerman Institute I began to feel more and more strongly that our view of our work as family therapists was too limited and partial. Many family therapists still act as if people were disembodied. The comment that the physicians' view of a person stopped at the skin was as true in the opposite direction: family therapists had little to say about things taking place inside the skin. And yet I knew from my clinical, and indeed my personal experience, that this was just not so. People came into therapy for a multitude of reasons related to their biology; endowment, development, disease, aging were all slighted. Later on we learned that they often came into family therapy because they were getting better from some physical disease. So I began to be intrigued by that. It seemed to me that we were not thinking enough about the biological and, as an extension of this, that we were not thinking enough about our relations with physical healthcare providers. Little did I know then how true this would turn out to be.


We wanted to know more about families in which there is chronic illness 

Somewhere in the early 1980s I had invited Henry Lennard, a medical sociologist, to consult with us on a regular basis, and we spent many long hours discussing healthcare, where it was going, and what might be done to improve things. That began to get the juices flowing. Later, we set up a chronic illness unit under the direction of Robert Simon, with whom Peggy Penn worked so productively. Over the years, many projects at Ackerman have started in just this way: a group of families showing some common pattern of interest—school problems, AIDS, family violence—would be invited to work with us. This involved assembling a small staff group that would systematically observe sessions with these families. In this instance we wanted to know more about families in which there is chronic illness, to look at them really closely, and try to unriddle what relationship there was between the illness and the family. The chronic illness project continued for many years. 

 

In 1982, I had completed my term as Editor of Family Process and was feeling somewhat bereft. Michael Glenn, who earlier had been a student at Ackerman, and whom I valued highly for his intelligence, honesty, and clear views of corrupted systems, approached me for some help on his idea of starting a journal. At that point, Michael had left family therapy (to which he later returned), moved to Boston, and was practicing family medicine. Michael and Barry Dym had been discussing the idea of a new journal, but needed someone with enough credibility with publishers to persuade them to undertake this chancy venture. I seemed to fit the bill, and we set about putting it together. So, Family Systems Medicine was born 13 years ago, with Don Ransom, Michael, and Barry as the initial, core guiding group. Fortunately, we were supported by a generous private donation for the first 3 years of publication and, since then, have gradually built up a readership and group of authors and advisory editors. It is a source of great satisfaction to me to see the journal, renamed Families, Systems & Health, in the competent hands of its new Editors, Susan McDaniel and Tom Campbell, with the leadership of Bill Doherty as Board Chairman. It is the same sense of solid pleasure that I feel when I think of the Ackerman Institute being directed by Peter Steinglass. It is a great tribute to be succeeded by people whom I admire and to whom I can unhesitatingly pledge my own loyalty and support.

 

And, now you have started the Collaborative Family HealthCare Coalition.

 

Readers who will have followed the trail I've laid out about my life should not be the least bit puzzled as to my part in starting and building the Collaborative Family HealthCare Coalition (CFHcC). They could indeed say, "What else could the fellow have done given that long-term interest in doctoring, family, and ecosystemics?" In the winter of 1992/3, having left Ackerman almost 2 years earlier, I was occupied with editing the journal and doing a bit of teaching and private practice. I began to obsess over the directions being taken by the professions of psychiatry and family therapy, each of which seemed to be on a downward spiraling course. Psychiatry had long since chosen to define itself as a biological discipline—a decision that filled me with anguish when it first became evident, and then finally left me despairing about any possibility of change in the profession. It was particularly worrisome that family therapy, by defining itself exclusively as a mental health discipline, was condemning itself to eating crumbs from the psychiatric table. And it seemed to me that this was going to be leaner and leaner fare as things moved forward. 

 

There was a tangle of epistemological, clinical, and political issues here as well, which seemed to cry out for some new thinking. Paradigm change toward an ecosystemic model of healthcare (in my view, a somewhat more satisfactory term than George Engel's biopsychosocial model) might just be possible because of the economic and cultural changes that were taking place in the U.S. Certainly, if the holistic vision in healthcare was ever to come to pass, this was the time for it. Difficult as the situation was turning out to be nationally, the turmoil seemed to me to provide opportunities that had not existed before. The essential ingredients for paradigm change seemed to be in place: the prevailing linear epistemology was less and less able to handle the data being generated, and a systemic epistemology was available and more promising; the economic interests of large groups could benefit from a paradigm shift; a work force (mental health providers) and a technology (systemic interventions) were available to implement the operationalization of a new paradigm. It was hard to assess the meta-stability of the present system; the influence of the medical-industrial complex could not be overestimated; there were the enormous problems of redesign and retraining. Since all these issues would have to be dealt with at some point in time, this seemed as good a time as any. 


Moreover, it seemed that we were not fully connecting with the natural allies of family therapy—family medicine practitioners. In the course of my years as Editor of Family Systems Medicine, I had come to know many people from family medicine, especially through the Amelia Island meetings of the Task Force on the Family of the Society of Teachers of Family Medicine (STFM). We had been traveling parallel paths, often without fully knowing about each other's work. I had high regard for their ethical and technical excellence. It seemed that this was the appropriate core of a new movement if it were to take place. 

We were not fully connecting with the natural allies of family therapy—family medicine practitioners 

 

With that in mind, I initiated a planning meeting at the March 1993 Amelia Island meeting of STFM that, by happy accident, Lyman Wynne was able to attend. Lyman's early support for this development was critical; he brings impeccable credentials as a scholar and clinician/researcher, and his indisputable integrity gives a stamp of approval that is priceless. The group was wonderfully lively and wanted to continue the explorations. The Amelia meeting was followed the next January by a meeting at the Johnson Foundation Wingspread Conference Center. Wisconsin in the dead of winter is an unlikely place for buoyant new growth, but that meeting of 50 professionals from many different disciplines ended on a Spring-like note. The Collaborative Family HealthCare Coalition was born and named, and a possible conference was outlined. The ship was sailing even as it was being designed and built.

 

Do you have any final thoughts you would like to add?

 

 

I am particularly conscious of having said almost nothing about my present family: Abby Heyman and our son Lazar. Those who know us know how central they are to my life and how much they are in my heart. My three older children have lived a lifetime with me, and we still care deeply about each other—for which I am endlessly grateful. In addition to Lyman, Carlos Sluzki and Dick Auerswald and I have labored together in all kinds of contexts, and now, at the shank-end of life, are bound by deep ties of friendship, as I am with many other valued old friends. New, younger friends bring me much pleasure and stimulation, and I miss and mourn those who have passed on. I hope I can adequately repay them. 

 

I keep thinking of the line from the play Born Yesterday in which the girl says to the boy, "Tell me the story of your life." To which he replies, "Well, you know, it's a long story—and none of it true." It is a long story—but it is true.

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Medical Homebodies’ Social Phobia

Posted By Barry Jacobs, Thursday, October 9, 2014

Dr. Jacob's post is the third in a 3-part series leading up to the 2014 CFHA Debate at the Conference in Washington DC. The debate will present major issues that have yet to be clearly resolved in the professional literature.

What’s wrong with American healthcare can’t be fixed by office redesigns, personal physicians or other hallmarks of the much-hyped, slow-to-deliver Patient-Centered Medical Home (PCMH). Integrated team-based care is nice--especially if you’re a professional who likes chilling with other professionals--but it hasn’t yet bent the cost curve. New quality improvement systems have made scant difference. It’s because what ails American health is bigger and badder.

 

It’s the social environment, stupid. And it’s our current blinkered hubris to believe that primping the pods and priming the processes of where most of us work—namely, primary care offices—is going to produce revelatory societal change.

New quality improvement systems have made scant difference 

 

That conclusion seemed obvious to public health experts Elizabeth H. Bradley and Lauren A. Taylor in their noted 2013 book, The American Health Care Paradox—Why Spending More is Getting Us Less. They pointed out that the evidence that medical homes save healthcare systems money is nebulous and inconsistent. (To wit, see the May 2014 JAMA review by Friedberg of the three-year results of 32 medical homes that were part of the Southeastern Pennsylvania Chronic Care Initiative; no cost savings and only limited improvements in quality.)

 

Bradley and Taylor posited instead that it is social causes of human misery—e.g., substandard housing, food deserts, lack of transportation, underemployment, chaotic families, dangerous neighborhoods—that are responsible for our middling healthcare outcomes on nearly every measure because the United States earmarks far less money per capita for basic social supports than do other countries. Poor children who don’t eat well will have poor health regardless of how many EMR-templated flow sheets we use. Hobbled, isolated seniors who can’t easily climb stairs to the medicine cabinets where their medications are located won’t benefit much from office-based medication reconciliation.


Social causes are responsible for our middling healthcare outcomes

It is daunting to address our culture’s myriad and complicated social problems. It’s much more comfortable and gratifying for healthcare professionals to target what’s within our easy reach. I’ve worked in the same innovative family medicine office in a socioeconomically mixed Philadelphia suburb for 20 years. We became an NCQA-accredited PCMH in 2009—one of the first on the East Coast. (We were one of the 32 practices in the JAMA study.) I’ve been thrilled by the changes that the PCMH has wrought—more integration, more accountability, more thoughtfulness and passion about every aspect of how we provide care. And we have plenty of improvements in diabetic and other medical indices to point to. But we have no proof as yet that the health of our patients is discernibly changed or that their overall healthcare costs are declining.

 

We Medical Homebodies need to look out the window upon the greater social world with its much more convoluted ways and processes. Better yet, we need to get out of our insular, cherished offices.

 

Dr. Jeff Brenner, a 2011 CFHA conference plenary speaker and a bonafide healthcare genius (see his 2013 MacArthur Award), has bolted the office to grapple with the social determinants that are the main drivers of exorbitant healthcare costs. His super-utilizer model of interdisciplinary team-based, intensive care coordination does several things that the PCMH does not:

 

--It focuses precious clinical and case management resources on the highest utilizers of hospital and emergency room services because addressing the biopsychosocial problems of those individuals is the quickest way to lower their utilization and healthcare expenditures.


--It seeks to forge lasting partnerships between facility-based healthcare providers and community-based social service specialists who are in the best position to marshal community resources for our most complicated cases.


--It embraces trauma-informed care, addictions medicine and patient empowerment as foundational tenets of the care it provides.


--And it addresses patients’ needs in all settings where they find themselves—medical offices, hospitals, sub-acute rehabs, at home, and in homeless shelters—because that is the most effective way to establish reliable healing relationships for those tossed about from one healthcare provider and facility to another.


And where is the gold standard research that Brenner’s super-utilizer model really meets the Triple Aim? It’s on its way. Brenner invited researchers from JPLA, a research group from MIT’s economics department, to do an 18-month, randomized control study of his super-utilizer programs in Camden, New Jersey to prove or disprove that they really lower costs. That study will be completed within the coming year.


An earlier study in Camden looked at the top 35 emergency room super-utilizers who rang up $1.2 million per month in charges in that city’s 3 hospitals. After a year of Brenner’s super utilizer team interventions, the costs for those same patients decreased to $531,000 per month. 

Where is the gold standard research that really meets the Triple Aim? 

 

Brenner’s work has also inspired other health systems to try their hands at super-utilizer care. A group of five of these systems, including my own Crozer-Keystone Health System, formed the South Central Pennsylvania High Utilizer Learning Collaborative 2 years ago and recently pooled their data. According to a white paper which the group will release in October 2014, the group provided super-utilizer care to a combined 138 patients and decreased their inpatient utilization by 34%.


In truth, I believe that we need the home base of a well-oiled PCMH working in close tandem with nimbly mobile super-utilizer teams to cover the office world and the real world. That’s the only way we can provide the flexibility of care to meet the mundane and complex demands of average and outlying patients. That’s the only way the under-achieving PCMH can possibly live up to its fulsome hype.

 

Barry J. Jacobs, Psy.D., Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency in Springfield, PA, has been the lead faculty member for the past 2 years for the 2 super-utilizer programs that are run out of the residency’s primary family medicine office. 

 

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