Posted By Colleen Fogarty,
Thursday, August 21, 2014
Today I sit at my desk, having blocked out time to write and cleared several piles of paper off my desk, (okay, honestly, pushed them behind the computer where I could no longer see them), facing an nth revision of a paper that has been rejected by two journals. Discouraged by the work in front of me, I again face the question “Why do I write?”
“A perfect time,” I think, “to write that blog for CFHA, plugging our preconference session on writing!”
Does writing this essay represent procrastination from the real task at hand, revising the manuscript before me? Or does this post represent an honest self-appraisal of the inevitable roadblocks, or “writer’s blocks” that all writers face?
Why do I write?
Sometimes when I’m asked this question, or ask myself, I wax philosophical about the importance of sharing experience with a wider audience, the role writing can play in helping me know what I think, and the academic currency writing can generate in larger circles.
Why do I write?
Aren’t there plenty of other things I could or should do?--Teaching residents, seeing my own patients, documenting evaluations for learners, writing clinical notes for patients. Administrative tasks galore in my roles in residency and fellowship education. I sandwich in the writing; one more thing to do! Sometimes I DO write because I AM stubborn. No way I’m going to let this lug of text that I’ve invested time in, go into the metal file or circular bin.
Why do I write?
That’s another question altogether. Why me, indeed? The person who suffered the indignities of the red pen from college writing instructors after having been awarded the Veterans of Foreign Wars “Voice of Democracy” essay contest prize during high school? Who sits today amidst a stack of marked up manuscripts, desperately trying to revise a paper in ways small and large. Who, like others in academic medicine, can feel no small dose of “imposter syndrome” when it comes to writing.
Why do I write?
Writing? Really? Why bother? It’s only patient volume in the form of my own patients and my residents’ patients that brings in the revenue to keep the lights on, after all. But the nagging voice of experience keeps saying, “Do it! Show them you have something to say!”
I slog back to the paper, pull new articles to review and reference, incorporate changes, discard ideas that I thought were truly revolutionary and reviewers found unhelpful, and allow myself to know, finally, that this revision won’t be finished today. But I have to coach myself to keep at it. Block the time, do the work, the slow, sometimes agonizing work of putting idea to word, word to sentence, sentence to paragraph, and slowly, slowly, build my thoughts.
For me, writing is a journey and a destination. Arriving at the destination requires embarking on, and continuing the journey. The rest stops, roadblocks, breakdowns, and route changes characterize the journey. Sharing these with others helps keep perspective that the journey is important, and allows us to collectively rejoice when we have reached the destination.
We will share the joys of writing, and offer strategies to address the inevitable barriers and frustrations that exist in the life of any writer, no matter how experienced. I look forward to sharing your writing journey!
Colleen Fogarty, MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine. She earned her medical degree at the University of Connecticut School of Medicine and completed residency at the University of Rochester. Dr Fogarty has additional training in Family Systems from the University of Rochester and a Master of Science in Epidemiology and Biostatistics from the Boston University School of Public Health. A community health center “lifer” she has worked at CHC’s in rural Michigan, rural and urban western New York, and South Boston. She now provides care for patients and families at Brown Square Community Health Center (CHC), the site of her residency practice. Dr. Fogarty’s publication record includes both empirical and creative work. Her scholarship includes work in primary care identification and management of mental health conditions, intimate partner violence, and cultural humility training. Her empiric publications have appeared in Family Medicine, Preventive Medicine, The Clinical Teacher, and other journals.
As someone who recently helped start a medical-legal partnership (MLP) in Philadelphia, I have found that there are important lessons to be learned about integrating services, not just from other MLPs, but from our healthcare partners themselves who already embrace other models of interprofessional, collaborative care. After working my way through Phase I of the 2014 MLP Toolkit, I wanted to offer two additional pieces of advice to anyone starting an MLP:
Mine a potential health care partner’s internal landscape and history for examples of service integration, whether successful or not. Indeed, advice and technical assistance from the National Center for Medical-Legal Partnership (NCMLP) and from other MLPs will be essential to your planning and implementation processes. However, it’s critical to dedicate equal attention to unpacking the history and experiences of the place where you plan to integrate legal advocates and learn all you can from their past attempts at service integration. As Phase I of the MLP Toolkit mentions on page 6, “Addressing psychosocial and care coordination needs have been increasingly accepted as critical to improving health, and both social workers and patient navigators have been integrated into the healthcare team at most healthcare institutions.” Leveraging these types of experiences, lessons learned, and best practices will likely streamline your integration process, making it more efficient and effective. They have lessons to teach MLPs, and an individual healthcare institution’s personal history with these types of projects may inform their willingness to partner with legal services.
Explore websites and publications authored by thought leaders from organizations in parallel movements like Collaborative Family Healthcare Association (CFHA), which was established around the same time as the first medical-legal partnership at Boston Medical Center. Just as NCMLP espouses the importance of fostering relationships across disciplines to “build a better healthcare team,” CFHA “envisions seamless collaboration between psychosocial, biomedical, nursing, and other healthcare providers, and views patient, family, community, and provider systems as equal participants in the healthcare process.” To get started, I recommend reading a recent blog post on interprofessional integration processes by Dan Marlowe, PhD, LMFT on CFHA’s website.
Medical-legal partnership and all other “strains” of integrated care delivery should not be considered as ends in themselves; rather, they are iterative processes, deeply dependent on thoughtful cultivation of trusting, equitable relationships. These critical relationships should be made horizontally and vertically, within and across organizations and movements, as we strive together to achieve the healthcare Triple Aim. And making use of existing infrastructure and familiar operational procedures is a strategic way for MLP practitioners to anticipate and answer institutional resistance to integrating legal advocates.
Maggie Eisen is the Director of Medical-Legal-Community Partnership at Philadelphia Legal Assistance. Their medical-legal partnership works with the Philadelphia Department of Public Health, Ambulatory Health Services Division. She writes for the blog "Bridging the Divide: Trends, Topics, and Tips in Medical-Legal Partnership".
(This blog post is based on the recent press release by the Families, Systems, and Health journal)
Constructive criticism and I have a, well, complicated relationship. I welcome criticism and then sometimes run away from it with my arms wide open. The first manuscript I ever submitted for publication was ripped to shreds by the reviewers. The little writer inside of me slipped into a coma after that doozy. But I survived and my writing vastly improved.
It’s not always easy to swallow criticism but how else do we improve? Here are some well-worn analogies that might illustrate this point. Criticism is the asphalt that lines the royal road of progression. How about this one? Criticism is the currency of the science kingdom. It allows us to operate the marketplace of innovation.
OK. You get the point: when someone shines a stadium light on your overseen deficits, just know that it’s for the best.
So why was I glad to see the recent call for integrating behavioral health care into the Patient-Centered Medical Home (PCMH)? Is it because I love behavioral health? Well, yes, that is true. But more importantly I value progression. This new report calls for making behavioral health care a central component of the PCMH. Isn’t science great?!
Here is what the new report calls for:
• Have a whole person orientation • Help patients adopt healthy behaviors and treat common mental disorders • Be coordinated and integrated within teams rather than fractioned between providers who do not collaborate • Emphasize safe, high quality care • Make access to behavioral health service as available as access to medical care • Use payment models that promote shared care and shared responsibility by primary care teams
It has taken this long to make a formal call for recognizing the importance of behavioral health in the PCMH
The original Joint Principles were published in February 2007 at a time when J. K. Rowling had announced the release date of her final Harry Potter book, the Indianapolis Colts had beaten the Chicago Bears in Super Bowl XLI, and George W. Bush was still POTUS. That was seven years ago. It has taken this long to make a formal call for recognizing the importance of behavioral health in the PCMH. But I’m OK with that because scientific progress marches onward. In fact, the authors of the Joint Principles 2.0 (my title) stated “PCMH is an innovative, improved, and evolving approach” (my emphasis). We are headed in the right direction.
Despite the numerous endorsements by major professional organizations for Joint Principles 2.0 (I count at least seventeen), there are still significant concerns about the current state of the PCMH model. The June 2014 edition of Families, Systems, and Health features commentaries from eight health care organizations that offer support and criticism for the Joint Principles. Here are some of the actual comments:
• “The treatment of patients is best done in collaboration with intimate networks and larger community and cultural connections” (full article)
• “Medical homes integrating behavioral health [should] follow principles that extend leadership and participation to all fully qualified providers, including nurse practitioners” (full article)
• “[t]he Joint Principles could underscore further the vital role of the family in a PCMH. … the supposition of a physician-led health care team proposes an overly narrow model.” (abstract)
• “Separate and unique confidentiality requirements for behavioral health conditions are deeply associated with the still-too-present discrimination and stigma connected to mental disorders” (abstract)
So, is there a Joint Principles 3.0 on the horizon? Will the next vision for PCMH include close collaboration with families, a more flexible leadership position, and unified behavioral and medical documentation systems? I certainly hope so. But even the most sound and well-worded criticism can fall on flat ears. If the real medical home is going to emerge, it’s not going to be with bullhorns and proclamations. It’s going to be through tough-as-nails research and constant critical analysis. It took seven years to even start talking about new PCMH principles. Will it take another seven years to start practicing them? Progression can be slow at times, but hopefully not that slow.
If the real medical home is going to emerge, it’s not going to be with bullhorns and proclamations
Matt Martin, PhD, LMFT is a licensed marriage and family therapist and current Director of Applied Psychosocial Medicine at the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He is current editor of both CFHA blogs. His interests include integration of behavioral health services in primary care settings, behavioral science curriculum development, family-centered primary care, and self-awareness development in family medicine residents. Email: email@example.com
Posted By Maribel Cifuentes, Larry A. Green,
Thursday, July 31, 2014
It seems that everywhere you go people are talking about collaborative, integrated healthcare with new found urgency and enthusiasm these days. The many reforms occurring in our healthcare system since the implementation of the Affordable Care Act have raised national awareness about the need for behavioral health and primary care integration in order to realize the Triple Aim, and propelled us to action – lest we miss out on this singular opportunity to make collaborative healthcare the standard of care for every person in our country.
But did you know that CFHA has been advocating for this model of care for the past 20 years? In 1994, the “Wingspread Conference” brought together the pioneers in collaborative family healthcare, which led to the creation of CFHA. The following year (1995), CFHA held its very first meeting in Washington DC at the Omni Shoreham Hotel. It’s a happy coincidence that this year’s CFHA conference will again take place in Washington, DC at the same historic hotel. In the past 20 years we’ve come far as an organization and as a community of members. While there are still many pressing issues that require our attention, it seems that the opportunity for the field to take the next quantum leap has arrived. At this year’s CFHA conference we have an incredible opportunity to “leap together” by bringing CFHA members and conference attendees together with policy makers, federal agencies, and national associations to join forces in advancing the adoption and sustainability of collaborative healthcare.
This year’s program has all the elements you’ve come to know and love from CFHA conferences
While some may find this prospect very exciting, some may also be thinking “I’m not a policy wonk. What can I really expect to gain from this year’s conference?” We want to assure you that this year’s program has all the elements you’ve come to know and love from CFHA conferences, plus more!
We have lined up four outstanding plenary sessions that will explore the role of health policy and economics, mental health promotion and prevention, leadership for practice transformation, and implementation and evaluation in the context of collaborative family healthcare. Meet this year’s distinguished plenary speakers – you’re sure to love them.
Economics, Delivery System Reform, and Behavioral Health Integration: Don’t Be Left Behind Richard G. Frank, PhD Deputy Assistant Secretary for Planning and Evaluation US Department of Health and Human Services
Mental Health Promotion and Prevention in Primary Care: An Idea Whose Time Has Come William R. Beardslee, MD Gardner-Monks Professor of Child Psychiatry Harvard Medical School
Transforming Primary Care Practices in Pursuit of the Triple Aim: How Great Leadership can Make or Break the Deal Marci Nielsen, PhD, MPH Chief Executive Officer Patient Centered Primary Care Collaborative
Implementation, Evaluation, and Getting to the Triple Aim Russell Glasgow, MS, PhD Visiting Professor, Department of Family Medicine Associate Director, Colorado Health Outcomes Program University of Colorado School of Medicine
Deborah Cohen, PhD Associate Professor, Department of Family Medicine Oregon Health & Science University
On the first day of the conference, you will be able to take part in three terrific Preconference Workshops aimed at developing your skills and sending you home with practical tools for your day-to-day work. And did you know that this year there is a FREE Writing Workshop for students and early career professionals? You will learn from CFHA’s most expert and prolific writers in an interactive, hands-on setting. Sign up early, as space is limited.
You can expect to have many excellent concurrent sessions to choose from, organized around 7 content areas - (1) Focus on individuals and families, (2) Redesign of primary care services and structures, (3) Prevention and health promotion, (4) Sustainability and cost control, (5) System integration, (6) Education and training, and (7) Research and evaluation. And this year you will be able to download a convenient application that will allow you to view program details online through your mobile device. How cool is that?
Opportunities for networking and fun at the conference will abound. You can look forward to speed mentoring, dine-arounds, morning exercise offerings, and tours of the city.
Join us at this year’s CFHA Annual Conference, and come share your own ideas and innovative work while you learn with leaders in the field about the latest advancements and the most pressing issues necessary to bring about greater adoption and sustainability of a collaborative model of care. You are what makes CFHA great, and more than ever we need your voice, knowledge and passion to make this conference a success. Register now and don’t miss out on early bird registration fees, still available through September 15.
You can expect to have many excellent concurrent sessions to choose from
Maribel Cifuentes, RN Larry A. Green, MD 2014 CFHA Conference Chairs
Posted By Lauren DeCaporale-Ryan, Laura Sudano,
Monday, July 28, 2014
We (LDR and LS) are pleased to announce that CFHA will hold a free writing workshop titled, “From Dissertation to Dissemination: An Interactive Writing Workshop,” at the 16th Annual Conference in Washington, DC on October 16th, 2014 from 1:15-4:00 pm for registered conference attendees. This workshop will offer input from some of CFHA’s top writers about their approaches to writing and speak to the importance of disseminating one’s work, be it related to clinical, research, or policy endeavors. All writers who are registered for the conference are welcomed to participate. Now, allow us to explain why this workshop is going to rock the world for Early Career Professionals (ECPs).
When I (LDR) sat down to transition my dissertation to something publishable, I kept thinking “all of this must be important or I wouldn’t have included it in the first place”. The notion of cutting it down was daunting. And the idea of creating multiple manuscripts (a work still in progress!) induced the same fears that the dissertation did: it’ll never get done. But here are some truths I’ve discovered as an early writer: it (whatever “it” means to you) WILL get done, starting sentences with “but” is okay depending on your audience, and there are a lot of ways to share your work. I have benefited greatly from the wisdom of others who have had successful writing careers and who have generously offered their support.
Free Writing Workshop!!
As a doctoral candidate and “launching” ECP (LS), I can say that the thought of picking apart the 100+ page dissertation into publishable journal articles gets me twitching a bit. The thought of having to re-visit this small novel which has consumed my life is overwhelming to say the least. So, the question for me became how to think about dissemination before the dissertation. It is a bit like family planning – conception being the day of your dissertation defense and the birth being a completed journal article(s); however, with family planning, you start planning before conception begins. Sorry if I lost you on the family planning metaphor. But the point is not asking the question of if you can plan, but how you can plan for dissemination during the dissertation process ... without losing your chutzpah (or mind).
The writing workshop will provide some tips on managing not only the content itself, but your emotional process of dissertation to dissemination. Our aim is to offer you the supports that we have received in our own writing, giving you greater confidence in your ability to share your experiences and enhance the field of collaborative care. Be sure to be on the lookout for more information in the weeks ahead, with another blog regarding this workshop from Randall Reitz and details from CFHA. We, along with our esteemed panel of colleagues, look forward to seeing you at the free workshop in October!
Posted By Amy C. Gallagher,
Thursday, July 17, 2014
Yes, this title is borrowed from Jerry Seinfeld’s web-series, Comedians in Cars Drinking Coffee. However, Mr. Seinfeld has it correct- there is a strong opportunity to connect with someone while driving in the car.
In western Colorado, collaboration occurs in order to create strong communication lines and transparency between organizations. The following visionary organizations drive the program:
• Rocky Mountain Health Plans (RMHP) • Foresight Family Physicians (medical practice) • Peach Valley Medical Practice (medical practice) • Primary Care Partners (medical practice) • Mountain Family Medical Center (medical practice) • Miller & Peterson (medical practice) • Stangebye (medical practice) • Mind Springs Health (mental health center) • The Center for Mental Health (mental health center) • Emergency Departments (EDs) • Independent Physician’s Associations (IPA) in Mesa & Montrose counties
Based upon transformative work in other states, a team of Community Health Workers (CHWs) was recently created. The main goal focuses on a small group of patients identified as “high ER utilizers”. With the steering committee comprised of membership from all of these organizations, cooperation drives the creation of work flows, brainstorming, and celebration of successes.
Due to the fact that healthy behavior change is a focus of this pilot program, it made sense to house the program within the mental health centers- the experts in behavioral change. However, stipulations regarding confidentiality and sharing of information can be a challenge to strong communication. To solve this problem, Whole Health, LLC was born! This subsidiary of Mind Springs Healtheases and enhances communication with the primary care physicians. Housed within the LLC, the CHWs do not fall under the mental health centers’ strict interpretations of HIPAA and42-CFR(privacy law for individuals receiving substance abuse treatment).
Preliminary data suggest that the CHWs have influenced patients’ decisions to visit the ED
How do patients get from being identified as “high ER utilizers” to the passenger seats of the CHWs’ vehicles? RMHP identifies potential participants through claims data. The medical practices review the potential patient list to ensure a strong fit to the program. Next, the medical practices invite the CHWs to “warm-hand-off” appointments with the patients. The CHWs explain the program and offer a longer appointment to meet with the patients in a different setting (e.g. home, coffee shop, etc.).
Through positive communication and rapport building, the CHWs identify patient health needs and goals. Work with the patients may include transportation, attending appointments, addressing psychosocial needs, and finding resources. These resources range from helping patients complete and submit applications for free cell phones, to obtaining free or low-cost medical supplies, to securing transportation to, and housing in, Denver (a four-hour trip away) for crucial medical appointments. Information is shared between the medical practices and the CHWs as per coordination-of-care. This includes progress on goals, resources obtained, medical and/or screening information, and updates regarding ER utilization.
Personnel from local EDs are also involved. They maintain lists of the patients involved with the program and are able to contact the CHWs if an ED visit occurs. The CHWs respond in a timely manner (either that day or the next business day) in order to understand what brought the patient to the ED and brainstorm ways that an ED visit could be avoided in the future. While the program is barely six-months-old, preliminary data suggest that the CHWs have influenced patients’ decisions to visit the ED. Calling the primary care physician and visiting “urgent care” offices are now realistic and viable options.
Having access to agency fleet cars has proven to be effective, given that reliable transportation may be a road block to care. Additionally, driving together creates opportunities for conversation. For example, one patient lived within walking distance to an ED, making it easier for him to visit the ED instead of his primary care physician. While driving the patient to a medical appointment, the CHW brainstormed ways to decrease ED visits. Success occurred when the patient called the PCP prior to going to the ED. The CHWs build upon these small successes and encourage the patient to make other changes that may positively affect their life journeys.
CHWs build upon small successes and encourage positive changes
Further, many of the patients involved with the program have significant mental health and/or substance abuse challenges. Some have not accessed services. The CHWs help facilitate access due to their close relationships with the mental health centers. For example, one patient had an extensive amount of trauma. Her anxiety was so crippling that it prevented her from seeking treatment. After many days and several attempts, the CHW helped the patient enter the building and sit through the intake. While the road to recovery may be long, she is now receiving the treatment that she needs.
Driving and transporting patients are clearly important, however, goodness-of-fit is vital. Successful CHWs are energetic, extroverted, persistent, and creative. These qualities are fundamental for building relationships, finding local resources, and communicating with a variety of medical and non-medical providers.
Finding resources, attending appointments, and driving together all relate to the goals of the Triple Aim. By reducing ED use, health care costs are decreased. This patient-centered approach allows for all involved to be aware of the whole person. Money spent on these types of services will positively impact population health as individuals’ physical and psychosocial needs are addressed.
Yes, the CHW spend time, in cars, driving patients. However, the relationship building, the conversations, and the brainstorming provide the essence of their time. The road may be bumpy at times and the CHWs have their hands on the steering wheels.
Amy Gallagher, Psy.D. is a Licensed Psychologist with Whole Health, LLC, a subsidiary of Mind Springs Health, Inc. in Grand Junction, CO. As Director of Integrated Care, she provides support, consultation, and training to community agencies focusing on the integration of mental/behavioral health services. Along with managing a multi-county team of Community Health Workers, she provides supervision to Post Doctoral Fellows and Integrated Care Specialists. Her research interests include integrated care initiatives, affective supervision and consultation, and autistic spectrum disorders. Dr. Gallagher received her Psy.D. in Clinical Psychology from Argosy University in Seattle, WA, a MS in Clinical Psychology from Loyola College (now University) in Baltimore, MD, and a BA in Psychology from Le Moyne College in Syracuse, NY.
Being a trainee in mental health primary care integration is exciting, cutting-edge, and innovative, but not easy. Primary care mental health integration is a new frontier compared to other modes of clinical intervention. Because of this, there are few established models for how to prepare trainees for inter-professional interactions within primary care settings.
As trainees we’ve spent much time learning various theories, assessment measures, and therapeutic techniques. We have much to offer in clinical consultation and intervention, but when placed in a new role, new system, or new setting it can be difficult to feel like an expert in anything. We may come across challenges in figuring out how to carve out a role as well as understanding the roles that already exist in a particular clinic. In addition, each clinic and healthcare system that we navigate is likely to be different, thus requiring constant adjustment despite previous experiences or training.
When I began as the new child psychology fellow in primary care I was excited to have the freedom to carve out a position and draw from my previous experiences and training; however there was no blueprint for how to establish my role in an unfamiliar clinic with professionals from different disciplines. I felt awkward, uneasy, and questioned whether I was useful, or just in the way. I learned that establishing a welcome presence is an important step to building collaborations in a new setting and creating opportunities to articulate my potential role. It is an important first step that is rarely talked about explicitly and can feel very uncomfortable to stumble through.
I offer 10 practical steps from the perspective of a trainee and based on my experiences working in three different primary care clinics over the course of my training. I do not focus on the clinical skills, knowledge base or required training for primary care mental health integration, instead I offer some basic tips about introducing oneself to a new setting to establish a role that may be new to you and/or new to others. These are beginning steps to help establish familiarity with a new space, build allies, and feel comfortable in a new role.
1. Introduce yourself - Introduce yourself to anyone who you may encounter on a regular basis and anyone that will listen. This includes administrative staff, interpreters, physicians, nurses, medical assistants, other mental health professionals on site, cleaning crew, and mail deliverers. Include your name, title and role. This can be difficult if your role is not yet clearly defined. If that is the case, (as it was for me) introduce what you hope to learn and how you hope to be useful. Be friendly and greet everyone as you enter and leave in order to become a familiar face. Familiarity is an important precursor to warm-fuzzy feelings.
2. Be/appear confident and professional - You may not feel confident, but you do have something to offer. Temper confidence with professionalism and humility. You will at first be inviting yourself into someone else’s space. Be respectful of that, while being confident that you belong.
3. Name drop - Make connections through existing connections. Mention supervisors, colleagues, or other providers that you know in common.
4. Shadow - Shadowing is important to help you get a sense of specific clinic culture, flow, and style of providers.
5. Ask questions - Do not be afraid to ask questions. Ask about the clinic and existing roles there. Ask questions to providers, medical assistants, nurses, and front desk staff. Find out about workflow, screening tools, protocols and patient demographics.
6. Share ideas - Sharing ideas and getting feedback is helpful to sustaining relationships and developing buy-in for your role. State new ideas as tentative and include providers in the process as much as is appropriate and desired by the providers. Get feedback and ask how they see a particular idea playing out in their clinic. They may add to your idea, help implement it, and/or offer a different perspective.
7. Be a squatter - Space can be hard to come by. Hang out in space identified for you and in shared space. Become a usual and expected part of the environment. Many of my clinic questions were answered and my “curb-side” consults conducted while standing around in the shared work area.
8. Stay visible - Keep office doors open if you’re not working on confidential work, say hi and bye to providers and front desk staff as you enter and leave the building. Share your schedule and be visible on a regular basis.
9. Speak up - Expect the atmosphere to be busy. Physicians, nurses, and medical assistants will be coming and going, walking around, sitting at computers, moving from one space to another. You may always feel that you are interrupting something important when you have a question or offer an observation, but don’t be afraid to speak up.
10. Connect with other behavioral health professionals in primary care - It can be lonely, especially if you are the only mental health person on site. Connect with others at your clinic, within your healthcare system, or within other groups or organizations. Attend meetings and conferences to network and to learn about other’s experiences.
These are steps to help build allies and feel comfortable in a new role
Establishing a role for yourself in a new setting requires flexibility and perseverance. Humility, humor, confidence, and professionalism when entering a new space will also help form relationships in order meet goals to assess needs, offer new ideas, and offer new services.
I recognize that not all experiences are the same, and I offer what was surprising and useful to me in developing collaborations and becoming part of a healthcare team. After 6 months of stumbling and 3 months of settling, I currently offer consultation during well-child visits at a community hospital and feel like part of the clinic team. The providers and staff are welcoming, and I feel like I have something useful to offer.
Amber Landers is post-doctoral fellow in pediatric primary care and behavioral health at Cambridge Health Alliance/Harvard Medical School where she also completed her APA-approved clinical psychology internship. She received her PhD in Clinical Psychology at Purdue University and obtained her BA (summa cum laude) in Psychology and Sociology from the University of California-Riverside. Her doctoral dissertation examined the effects of stress and parent-teacher communication on the psychological adjustment of ethnic minority elementary school children. Currently she works in primary care behavioral health integration at CHA providing consultation and brief intervention during pediatric well-child visits. In addition, she conducts developmental assessments and outpatient psychotherapy, and offers mental health and developmental consultation to the Early Years Project in Cambridge, MA
On the topic of number of visits: The short number of visits with a behavioral health clinician in primary care is because of the population encountered and the work done. It is not because there is a rule about the number. In fact, number of visits can be one way of assessing whether a practice is using its behavioral health clinicians as part of the primary care team (in which case the modal number of visits will be 1 and the average will be 2-3) or it is using them for specialty mental health services, in which case the average will creep up toward 6 or more depending on the population.
Primary care behavioral health will be more focused on assessment, patient teaching, goal setting, healthcare behavior and family/social context. Most of us in primary care BH do not think of what we do as “psychotherapy.” That doesn’t mean we don’t see some folks several times or episodically for several years. For a lot of these folks it is as if from time to time they get a visit or two as a booster.
There are many more who will need several visits in the first episode of care and will be referred to specialty mental health either immediately or after some initial assessment visits. I often say to patients whom I am referring “You are working on very difficult issues, and you deserve someone who can see you every week to work with you. Let me find someone who will be a good fit to help you with your work.” Remember we don’t open or close behavioral health involvement in cases in primary care.
Some under value the difference between primary care behavioral health and specialty mental health
Specialty care is psychotherapy and medication management with the purpose of working together for longer periods of time. It can be done by a clinician in the same floor or building as primary care, or in a different organization. Most places have not had good luck having one clinician who does specialty MH for some days and primary care on others. The mind sets are too different. Programs with good primary care behavioral health make specialty mental health services working with them better targeted and more efficient. Programs who try to stick specialty mental health into primary care without a strong primary care behavioral health program tend to fail. The specialty folks get overwhelmed and don’t function as part of the team, thus failing to add the benefits of behavioral health expertise to the rest of the primary care services.
Typically administrators and clinicians who have worked in mental health their whole careers at first do not notice or under value the difference between primary care behavioral health and specialty mental health. We created our Certificate Program in Primary Care Behavioral Health specifically to help them make the transition from mental health specialist to primary care generalist.
And having said this, I hear from programs in rural areas or who are just starting up who are right in the middle between PCBH and specialty care, and are doing good work and very appreciated by the physicians they are helping. And that gets us back to the first point, when you try to make a rule, rather than an observation about numbers, you are likely to impede rather than facilitate things.
Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.
Posted By Alan Lorenz; Jennifer Funderburk,
Monday, June 9, 2014
Legend has it that the infamous bank robber Willie Sutton, in response to the question, “Why do you rob banks?” replied, “It’s where the money is.” This saying is often repeated for questions where the answer should be obvious – but often is not. Our question here is, “Where is an ideal place to develop collaborative care,” and our “obvious” answer is, “College Health.”
Our prediction is that all of you who are reading this went to college and likely obtained advanced degrees. Collaborative care practitioners can include doctors, nurses, psychologists, social workers, and a wide array of other health and mental health practitioners. There are also physical and occupational therapists, dieticians, and a variety of allied health professionals. We even have individuals with MBA’s and accounting degrees responsible for managing collaborative care. It is highly unlikely that you do not have a college degree.
Therefore, think back if you ever received health or mental health care at your college health center? If so, what was your experience? How much collaboration was occurring at your health center? We can argue all we want about how collaborative care is cost effective and a better approach to treating our patients, but nothing is more persuasive than direct, immediate, personal experience. It is our opinion that direct encounters with collaborative care will trump intellectual arguments every time. Having a positive collaborative care experience in college can have far reaching effects.
How different would people think about health care if everyone had been a direct recipient of collaborative care at their college health center? Not only are you all college educated, but our legislators and law makers are college educated. How different would the laws of our land be if every member of our government had been the direct recipient of collaborative care? And, not just those in government but extend this to all health care administrators? Our guess is that the world of healthcare would likely be a very different place.
College presents several uncommon opportunities for innovation
College Health not only presents an opportunity to provide this type of direct experience with collaborative healthcare early in an individual’s life path, but it also presents several uncommon opportunities for innovation. First, the barrier of reimbursement is reduced and/or eliminated altogether within College Health because there is often a capitated system where students pay a flat “health fee” and then receive care as needed for the year. This removes constraints of third party reimbursement and frees health care professionals to provide care in the way that makes the most sense. Generally in College Health there is no need to figure out how to bill for collaborative services or how to work around common restraints set by insurance policies against same-day visits. In part as a result of this overarching financial umbrella, medical health services and mental health services are often located in the same building. This co-location facilitates collaborative care. The bump in the hallway or curbside consultation, the brief introduction, the ease of access all facilitates collaborative care. Often, there is a shared record and this further facilitates collaboration.
There is a surprisingly dire need for mental health services in College Health. Across the nation, colleges are scrambling to identify ways to help increase access for mental health services for college students. According to a recent American College Health Association survey as many as 10% of all college students are on psychotropic medications (not including meds for ADD). Collaborative care provides an additional “piece to that puzzle” by opening the door to brief interventions/treatments that can be applied to help prevent or treat mental health symptoms in a population-based framework.
In addition, college students are often developmentally at a stage when mental health disorders tend to show their true colors in the absence of confounding camouflage in the home environment. College students go to the college health center for their escalating symptoms. Why? College students are often living in an unfamiliar city far away from their families and friends when they experience symptoms that trigger the idea that a doctor can help. Therefore, College Health is an ideal setting for collaborative care providers to be a part of the team providing initial care. It also presents the opportunity to do early intervention or prevention work before multiple medical and psychiatric co-morbidities develop.
Mental Health Professionals are often trained in, or in close proximity to, College Health centers. Trainees are a tremendous source of inexpensive, enthusiastic, idealistic creative energy that is available. It’s also an ideal time to teach them good collaborative habits, especially before the less helpful ones get entrenched.
For international students, the College Health Center is often the only place where they feel comfortable seeking help for various biopsychosocial complaints. Collaborative care provides the opportunity to help these individuals in a setting that does not carry the same stigma as specialty mental health care. Therefore, collaborative care can not only provide an avenue to treatment, but also serve as a bridge to more specialized care if necessary.
College health is an ideal setting for collaborative care providers
So back to our original question: where is an ideal place to develop collaborative healthcare? Our answer is the College Health Center. Let’s not waste the opportunities that exist within this setting and begin to evaluate how we can take advantage of it not only improving the care for college students, but also providing those direct experiences necessary to help give different viewpoints to future legislators, leaders of insurance companies, and healthcare administrators.
Alan Lorenz, MD is a charter member of CFHA and now works at the University Health Service at the University of Rochester where he is an Associate Professor in both the Departments of Family Medicine and Psychiatry.
Jennifer Funderburk, PhD, is currently a clinical research psychologist at the Center for Integrated Healthcare at Syracuse VA Medical Center, an Adjunct Assistant Professor at Syracuse University, and an Adjunct Senior Instructor at the University of Rochester Department of Psychiatry.
When Bob Dylan wrote this iconic song, many felt that it captured
the spirit of social and political upheaval of the 1960s, much in the same way
that we view mental health as “a-changin'.” And these changes require
mental/behavioral health providers to change the manner in which they deliver
Reports over the past
decade have brought attention to the current mental health crisis:
In addition, over the
past few years far too many catastrophic events have brought attention to this
mental health crisis, resulting in a public outcry, demanding that changes are
made to prevent future tragedies.
But change isn't easy.
The relatively brief
history of community mental health services has been a challenging one. Just a
few months ago, as we celebrated the 50th anniversary of President John F. Kennedy's signing the
Community Mental Health Bill into law, the
conversations quickly progressed to the subject that is on the minds of
virtually all behavioral health providers—and an unusually large number of the
general public and policy makers, given the historical lackluster interest in
the topic—mental health is in dire need of change.
The economic downturn in
the US in 2008 resulted in massive budget cuts in all but a few states.
The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services
in the U.S. during that time was nearly $1.6 billion. Community mental health
services plummeted from being barely adequate to the critical point in many
states. Safety-net providers were forced to close programs due to the slashed
budgets. Many of those affected ended up on the streets or in jail.
The recent announcement
on the anniversary of the Sandy Hook tragedy, of
the planned infusion of dollars into help repair our broken mental health
system, is encouraging. However, the entire mental health system is in dire
need of an overhaul. One that looks at the broader healthcare picture and
strategically plans for mental health and substance use disorder treatment to
be included. A person-centered, whole health approach to treatment is necessary
for improving the patient experience of care; improving the health
of populations; and reducing the per capita cost of health
care: the Triple Aim.
Dr. Dale Klatzker knows that,
although it isn't easy, change is vital for community behavioral health
It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformeWe need to be proud of what we do, but also to expand it and extend itd the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island. Click here for Dr. Dale Klatzker's bio.
a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared
themselves to change a lot and have marginalized themselves and the people that
they serve by not being more a part of the mainstream. We have sets of skills
that are integral to wellness and to health across a wide spectrum. We need to
be proud of what we do, but also to expand it and extend it because this is the
perfect time for this. We have a lot of things to offer that others are trying
don’t stay static. You have to look though the windshield but also through the
rear-view mirror. You have to know where you are but you also have to know
where you’re going.
executive director/CEO of a behavioral health organization, you have the
obligation to push yourself, and that will push your organization, to do what
is necessary so that your mission is reinforced but also to serve the needs of
the community. It’s hard to do that if you’re doing the same thing you did 20
years ago. We do our consumers a disservice if we do that.
We need to be proud of what we do, but also to expand it and extend it
approach to care
Klatzker: What we’ve embraced here
– what’s part of the DNA of the organization at The Providence Center –
we believe in a person-centered approach to care. No two people are
exactly the same. The people that we work for deserve as much access to a wide
array of both health and social supports as anyone. That’s how you have to
guide yourself. When you’re thinking of those things, primary care integration,
working much more toward the mainstream of traditional healthcare is imperative
we’ve found is, if you can build those relationships and find the right
connections, then others will embrace you and value you for what you bring to
the table. In fact, we bring a lot. Partnership is always the first choice, the
We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.
Example of a successful integrated care partnership Dr.
Klatzker: The Providence Center is
closely connected to one the largest federally qualified health center in the
state of Rhode Island, the Providence Community Health Center. We have
become the largest community mental health center. Neither had a desire to
replicate the services that the other provided. Over the years we’ve built this
into a “no wrong door” integrated collaborative effort so that in the mental
health center, the FQHC runs a full-service practice with 1100-1200 patients.
In the FQHC, we are integrated in their physician practices building and we
also have a separate section of their building where we provide longer term
care and some other types of specialty care. We’ve integrated our records with
each other. We meet frequently to process and to try to figure out how to make
our care efficient and effective. We are working closely with them now on
adopting our health home model to integrate a modified health home into the
Yes, the times they are a-changin'. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.
Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth
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What We Do
CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.