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
Growing up professionally in the field of integrated care has certainly been one heck of a ride over the last eight years. As a student and now as a professional, I have had the privilege of helping to design, implement, and refine collaborative/integrated care programs in a wide variety of primary and specialty settings. However, being a student for most of that experience, my focus was oriented primarily on outcomes (clinical hours for licensure, fulfilling the expectations of my supervisors, completing my thesis/dissertation, etc.), which left very little time and energy to think about the process of how those outcomes were achieved.
After graduating with my PhD and landing my first “grown up” job as the director of behavioral science for a family medicine residency program, however, that very myopic focus was forced to expand. Not only was I tasked with teaching behavioral science but also with building an integrated care curriculum and complementary clinical model for our organization’s family medicine center. So, somewhere between my immense excitement with such a wonderful opportunity and the mind numbing fear of…well, blowing such a wonderful opportunity, I resolved to put some intelligible structure to my process. I spoke with colleagues and faculty alike asking them for their insights, and yet I was still lost. However, it was only after a chance conversation I had with my father (the car salesman) that I finally realized what I had been doing for so long without knowing it, and what any behavioral health provider should not only know, but more importantly, embody when building an integrated model.
My father has been in the car business for over 30 years, and for the last 15 years his “forte” has been the restoration of failing dealerships. To think of it in terms of reality shows, he’s been a “Chef Ramsey” of sorts for dealerships struggling financially. By all accounts he excels at what he does, and not only do these dealerships recover but often end up stronger than when they were performing at their best. So, I made the remark that he must be a “master salesman.” After all, he has devoted half of his professional life to selling entire groups of people on the idea of change. I figured he would take this as a compliment, but his reply was more along the lines of “Son, you really have no idea what I do, do you?” That was when my father told me what his job really entails.
There are two types of salesmen in the world
He said that there are two types of salesmen in the world: the first, and I am sure we have all had the unpleasant experience of meeting this type, converge on customers when they walk into a dealership like a second year grad student on a Starbucks venti Caramel Macchiato. They seem to already think they know what the customer wants and knows more about those wants than the customer themselves…“Oh, you don’t want that one, you want this over here…No, no, no, that might seem like an added expense, but you really SHOULD get the extended warranty…” No matter what the customer thinks, no matter what their reasoning, if it deviates from that of the salesman, the goal becomes “selling” the customer on the salesman’s idea of what REALLY is best.
Sound familiar and, more importantly, sound annoying?
The second type of salesman, he said, sits back and watches customers when they come into the dealership. They pay attention to everything the customer looks at, they look for patterns in what models they go to first, what aspects of the cars they look at longer than others, and only after they have watched them for an extended period of time do they approach. “I noticed you spent quite a bit of time looking at that model, is there anything in particular about it you are interested in?”
Notice the difference?
These types of sales people spend the vast majority of their time asking questions, being interested, and letting the wants/needs/desires of the customer guide what they eventually show them. This, my father said, is the key to what he does and why he hates the idea of selling anyone on anything.
In the end, my dad said that great salesmen don’t actually sell anything; they GIVE the customer what they ask for. Instead of walking into a dealership and telling employees what they NEED or SHOULD do differently, he watches, waits, and then asks what they WANT to be different. Only after he feels like he has understood those wants does he help formulate a plan of change, a plan that incorporates those same wants as the main outcomes. So, what my father has devoted the last 15 years of his professional existence to hasn’t been selling outcomes but giving organizations a process for changing their inter-organizational relationships.
Great salesmen don’t actually sell anything; they GIVE the customer what they ask for
Now, what does any of this have to do with integrated/collaborative care? The short answer….everything….
More than once, I have seen well-intentioned behavioral health providers try and “sell” a healthcare system on their brand of collaboration, integration, or the like. We all have done it at some point, and we might even do our sales-dance very well most of the time. We proselytize about research on the effectiveness of collaboration and integration in treating behavioral health and medical issues. We point to increased patient and provider satisfaction, and we even throw out cost effectiveness as another benefit. Ultimately, we tout integration as a panacea for “everything that ails ya,” but how often do we ever stop to ask what that “ailment” really is before offering our brand of cure?
To be honest, I have no idea how an integrated model should or needs to look at a site, but I do know the process that needs to happen in order for integration to be useful- and it is a process exclusively about building, supporting, and maintaining relationships. Now I know that is not very sexy (yes, I just used that term), I know that it does not carry the same weight as some of the other buzz words we have come to know and love when selling integrated care- a rather overlooked aspect of our IC “lexicon.” However, the quality of relationships between members is at the very foundation and heart of any successful team. We know this implicitly- even our seminal works about integration are littered with terms like understanding and appreciation1, which are inherently systemic and more appropriately, relational in nature.
Yet even with this relational knowledge we continue to “sell” integration as a model- a shiny new car that will make you thinner, have a fuller and richer head of hair, and will make you down-right more likable as a person. Up to this point our sales technique has been one of telling about features; telling about research, telling about effectiveness, telling about cost savings. In all of my time involved in this field I have yet to hear us asking- WHAT would YOU like this model to look like, HOW do YOU think this way of doing things might be useful to you, WHAT do YOU want to achieve by practicing this way. You see, at the end of the day we have been working so hard to create models that we have forgotten that it is not about building something successful- it is about building something useful; and utility is never about selling people on what we think they need, it is about giving them what they ask for.
So, at the end of the day what kind of salesperson for integrated care are you?
1Doherty, W. J., McDaniel, S. H., Baird, M. A. (1996). Five levels of primary care/behavioral health collaboration. Behavioral Healthcare Tomorrow, 5(5), 25-28.
Dan Marlowe, PhD, LMFT, is the Director of Behavioral Health at Campbell University School of Medicine. He holds a doctoral degree in Medical Family Therapy and master's degree in Marriage and Family Therapy from East Carolina University in Greenville, NC. Dr. Marlowe has primarily been embedded in medical settings over the course of his professional career, working alongside physicians to help manage the mental and behavioral health needs of their patients. Dr. Marlowe has published both nationally and internationally on interprofessional collaborative care, as well as presented at regional, state and national levels on collaborative care program development, teaching integration in graduate medical and behavioral health education, and the use of family therapy as a practice change model in healthcare settings.
Posted By Theodora Ooms, Jana Staton,
Tuesday, April 29, 2014
This blog post was originally posted on the Families & Health blog. Because of it's importance, we are posting it on the CFHA blog as well.
It is seldom that family-centered health care professionals get an opportunity to directly influence national health care policy. Alerted by Theodora Ooms and Jana Staton, several members of CFHA recently saw an opening when Senators Ron Wyden (D-OR) and Johnny Isakson (R-GA) introduced the Better Care, Lower Cost Act on Jan 15, 2014. (A companion bill, HR 3890 was introduced in the House.) This bi-partisan, bi-cameral legislation is aimed at providing better, more coordinated and integrated care at lower cost to the millions of Medicare beneficiaries with multiple chronic conditions. (In 2010, 68% of Medicare enrollees suffered from two or more chronic conditions and accounted for 93% of Medicare spending annually.) The Act amends the Medicare Program to set up a new model of financing and delivering services dubbed the Better Care Program, to create more effective networks of integrated, multidisciplinary health teams. These teams are aimed at keeping chronically ill patients as healthy as possible in their own homes and communities. However, the Act as introduced does not mention spouse or family caregivers, or consider them as an integral part of the health care team, serving as the “backbone or glue” of the long term/chronic illness care system.
Seeing this opportunity to educate national health policy leaders about this critical component of health care, Frank de Gruy, Susan McDaniels, Barry Jacobs, John Rolland and Bill Doherty enthusiastically joined Ooms, Staton and Mary Myrick, of the National Healthy Marriage Resource Center (NHMRC) to sign a three-page letter of comments to the Senators, pointing out the bill’s failure to acknowledge the critical role of spousal and family caregivers in the prevention, care and treatment of the chronically ill. The letter included a separate list of recommended changes in the legislative text to promote collaboration with spousal and family caregivers, identify caregivers in medical records, and conduct caregiver assessments along with the patient's in the Welcome to Medicare and annual Wellness visit. These suggestions also include setting up a national working group to develop curricula for training health care professionals in how to collaborate with family members.
For many Medicare patients the spouse is the most likely day-to-day caregiver
As their letter points out, family caregivers are spouses, partners, adult children, siblings, friends and neighbors who provide many kinds of support, assistance and, increasingly, help with medical procedures so as to enable millions of persons to remain living in their homes and communities. The term "family caregiver" however obscures the unique legal, emotional and social characteristics of caregiving between spouses. Spousal presence and influence on chronic illness prevention, care and treatment is much more common than generally acknowledged. In fact as the 2010 Census shows, the majority of those 65 to 75 years are still living with a married partner in the home. And if cohabiting partners (heterosexual and same sex) were included the numbers would be larger. (Even among those older than 75, 38% of women and 73% of men still live with a spouse, as Ooms and Staton point out in a 2012 CFHA blog post). For many Medicare patients, therefore, the spouse is the most likely day-to-day caregiver; some competent and willing, others unable or uncooperative, but in either case, a direct influence on patient health.
As Frank deGruy pointed out at the 2008 Wingspread Conference on Making Connections Between Relationship Quality, Marriage and Health, sponsored by the NHMRC, "Illness is individual; health is always social." If we're going to improve health outcomes and lower costs for the Medicare population by preventing or reducing serious chronic illness, better care needs to include collaboration with the patient's most intimate partner or close family member, both for the sake of the patient and for the sake of the well-documented health consequences for family caregivers.
Senator Wyden is the new Chairman of the powerful Senate Finance Committee and he is known for his passionate interest in improving care for the chronically ill and his ability to work across partisan lines. No one expects this bill to be enacted soon and it will go through a lot of changes, but it could be an initial step to significant Medicare reform. In our communications with several leading health policy experts, they agreed that the absence of any mention of family caregivers in the Act is a major drawback, and something that will certainly get attention eventually. And if Medicare opens the door to substantial collaboration with spouses and family as part of health care for chronic illness in seniors, the potential for even greater progress in illness prevention and care with younger patients is enormous. Fortunately, CFHA's 2014 Conference in Washington DC "From Fragmentation to Integration" is coming at a perfect time for members to make their voices heard about the crucial role that intimate partners and families can play in a truly integrated health care system.
The letter to the Hill was initially drafted by Ooms and Staton, co-coordinators of the Wingspread Conference on Marriage, Couple Relationships and Health sponsored by the NHMRC. (De Gruy, McDaniels and Doherty were key presenters at this conference). It is available on line here.
Theodora Ooms, a social worker and family therapist, has worked for thirty years in Washington DC to integrate a family systems perspective into federal and state policy and programs. She was a participant in the founding CFHA Wingspread conference in 1993 and is very happy to be reconnected.
Jana Staton, has her doctorate in counseling psychology, and currently works as a marriage and family therapist and couples educator in Montana. She is the co-author of A Few Months to Live: Different Paths to Life’s End.
Posted By Eboni C. Winford,
Thursday, April 24, 2014
This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!
Over the past 7 months, I have transitioned from being a student trainee to becoming an early career professional at my first “real job.” I work as a Behavioral Health Consultant at Cherokee Health Systems, a comprehensive community health organization that is both a Federally Qualified Health Center and a Community Mental Health Center. In these 7 months, I have encountered challenges related to the development of my professional identity. I figured I couldn’t be the only person to ever have these struggles, so I wanted to address these in this month’s edition of our early career professional blog and specifically focus on four tips that I’ve found helpful as I’ve come to embrace my role as a professional.
1. Introduce yourself the way you want to be addressed—own your role
Throughout my training as a student, I grew accustomed to introducing myself as “Eboni Winford; I’m a practicum student/intern;” however, upon completing school and starting my first “real job,” I had a harder time than I imagined learning to introduce myself as Dr. Winford. You’d think that after working for so many years to earn the title, I’d be screaming it at any and everyone who would listen, but I ultimately found that old habits die slowly. I frequently found myself saying to a patient, “Hi, I’m Eb…I mean, I’m Dr. Winford” only to be confronted with a host of confused faces. I’m sure it had to be interesting to be a patient hearing the so-called doctor coming in and not even knowing her own name.
After several awkward patient interactions, I spoke with a mentor (see below) about how she handled this transition. One piece of information she gave me was, “You have to own your title and who you are now. Whenever you get a chance to introduce yourself, make yourself say Dr.” Another piece of advice she suggested was that I request others to call me by my title. I’ll admit, I felt uncomfortable with this at first. I didn’t want to be “that person” who came across as narcissistic but at the same time, I knew that having others refer to me according to my title would be an important step in solidifying my professional identity. Needless to say, those two pieces of advice have proven effective in helping me to more seamlessly introduce myself without coming across as confused about who I am.
You have to own your title and who you are now
2. Identify a mentor (or two)
I’m not sure I would have had such a smooth transition had I not been linked up with mentors. I’d recommend looking for at least one mentor who is not too far removed from your experience in terms of years (ideally, someone who is 1-2 years ahead of you in his or her own professional development) as well as a more seasoned mentor, someone who has worked in your field greater than 10 years.
I personally have more than two mentors who collectively fall within each of these two categories. Meeting with these individuals has not only helped me to overcome immediate challenges including state licensure procedures but also in helping me see examples of successful professionals and learning from their past successes and failures. There have been countless times when I have gone to one or all of my mentors and asked something along the lines of, “Is it normal to feel x?” or “How long did you have to wait before you received all of your paperwork for x?” On each occasion, I walked away feeling “normal” and/or with specific information regarding next steps to take to address a specific dilemma.
3. Become a mentor
In the same way that having a mentor has been instrumental to my transition, I’ve found that becoming a mentor has been equally effective in my development as a new professional. As professionals, we spend so many years studying and practicing the skills that we’re learning but we often doubt how much we really know. I’ve fallen victim to this “imposter syndrome” where I questioned whether I really knew what I was doing or wondered how long it would take before someone “found me out.”
We often doubt how much we really know
Serving as a mentor to a group of students 1-2 years behind
me in their professional development has helped to cure this imposter syndrome,
if you will. My confidence in my knowledge and my abilities has grown rapidly
as I’ve filled the role for them that my mentors have filled for me. These
students have inquired about a wide variety of topics including specific
recommendations for patient care to the transition from practicum student to
intern. Speaking with them has served two functions: it addresses the student
inquiries, and it also reinforces the quality of the training I’ve received,
which, in turn, reassures me of my right to work in the role in which I work.
4. Find others like you
Network, network, network! I never really believed in the value of networking until I tried it. Since transitioning from student to professional, I’ve been fortunate to connect with fellow early career professionals through CFHA. It has been so reassuring to discuss with them some of these challenges. In the same way that I try to normalize feelings and thoughts with patients and my mentors have normalized feelings for me, speaking with peers further normalizes my own reactions to transitioning and has shown me that I’m not weird. And sometimes knowing you’re not weird is all you need!
I hope these four points are helpful for others who are either in my position or approaching it. If you’ve ever felt this way, you’re not weird. Your identity as a professional, like every other aspect of your identity, takes time to develop. In addition to having patience and experiencing what may, at times, feel like awkward situations, it is important to know that the process of developing your professional identity works best within an environment of support and encouragement. This supportive environment may not always offer itself to you; instead, you may have to be proactive and persistent. If mentors are not readily available, consider utilizing colleagues in CFHA. I’ve learned that CFHA serves as a great resource for soliciting help, support, and guidance via our listservs and through formal and informal networking at conferences. Additionally, if mentorship does not exist at work, perhaps you can reach out to students from your graduate program and assist them in some way toward their transition from student to intern to professional. In sum, developing one’s professional identity is a big first step toward solidifying one’s place within the professional world. It is my hope that these 4 tips provide a framework to help you navigate this new area and to develop a comfort with the new, professional you.
Until next time, Dr. Winford ;-)
Eboni Winford, Ph.D. is a Behavioral Health Consultant and provisionally licensed psychologist at Cherokee Health Systems in Knoxville, TN. In addition to behavioral health consultation, she is involved in research assessing health outcomes associated with substance abuse during pregnancy, particularly neonatal abstinence syndrome. Dr. Winford currently serves as a co-secretary to CFHA’s Primary Care Behavioral Health Special Interest Group as well as a member of the Early Career Professionals Task Force. Her research interests include the relationship between religion, spirituality, and the process of meaning-making in the context of chronic illnesses. Her clinical interests center on primary care behavioral health, integrated care, refugee and minority health care issues, and psychopharmacology. She earned her degree in Clinical Health Psychology from the University of North Carolina at Charlotte.
Posted By Mara Laderman, Kedar Mate,
Thursday, April 10, 2014
Behavioral health integration is becoming the standard of care; in the not-too-distant future, “non-integrated” primary care practices we predict will become rare or even extinct. So, where is the frontier now? Where are innovators in the field focused at this point in time?
Where is the frontier now?
We believe there are currently four areas of primary innovation. The first is deployment of integration into high-risk specialty clinics which often serve as the health homes for patients living with chronic conditions such as heart failure or spinal injuries. In such settings, while the principles of integration are similar to those employed in primary care, care can be more episodic which can challenge consistent behavioral health service delivery. The second area is around scaling up integration to entire communities, regions, and even states. Solving structural challenges of measurement, interoperability of records, and behavioral health resource availability at scale is an important area where innovation is needed. Current efforts in Colorado, Washington, and New York are leading the way to tackling these state-level challenges. Third, significant innovation work will be needed to understand how much integration costs and what financial models and alternative payment methods will allow integration efforts to thrive.
Finally, as we describe in a recent article, while the majority of integration work has
focused on individual clinics, this may overemphasize the clinic environment
itself and not the functions of the primary care practice, which include an
emphasis on providing continuous supportive care beyond the clinic encounter,
navigating community support systems, and engaging family and relationship
support systems. More comprehensive
primary care systems are designed to support patients in the many thousands of
hours patients spend outside of the clinic, living with behavioral illness and
co-morbid medical disease. Much thinking is being done right now about the
so-called “5000+ waking hours”1 that patients live with their chronic conditions outside of their clinic visits
and face-to-face time with medical providers. We strongly believe that this is
where the frontier is in behavioral health integration in primary care.
To guide innovation in this area, we turned to some of the work that is beginning on chronic disease care outside of the clinic visit.2 3 This thinking led us to a conceptual model for full-spectrum integrated care that identified three key components: 1) frequency of the points of interaction, 2) where is the service provided, and 3) who it is provided by. We identify five layers of potential service using these three dimensions. All are needed for a complete care system for patients living with behavioral and physical chronic conditions. In this model, costs are reduced as the service moves closer to patient self-management.
The first layer, Acute Care, applies to patients during a hospitalization. Many hospitalized patients are not evaluated for behavioral health problems as their medical needs supersede other issues. However, the need for intervention remains. There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomes; for example, St. Charles Health System implemented an intervention in which a behavioral health consultant routinely rounds in the NICU to work with parents of premature infants to teach what to expect, how to stimulate neurodevelopment, and how to care for their children. The intervention reduced NICU utilization (measured by earlier discharge) with better outcomes and retention in post-natal care.
There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomes
The second, the Clinic Visit, is the focus of most integration models. Innovations here might include group visits—a concept that has been employed for substance abuse disorders, in ‘centering pregnancy’ models, and for multiple chronic conditions. Integration innovators in this arena might purposely build patient groupings of individuals living with both depression and diabetes, for example, who would meet together to discuss coping and living strategies. Another innovative model, the Ambulatory Intensive Care Unit, pioneered in California by Arnie Milstein and others, might utilize smaller panel sizes of patients with co-morbid mental illness and employ primary care “specialists” to help manage these patients more intensively in the ambulatory setting.
In the third layer, Community Care, innovators might use Community Health Workers (CHWs), a category of interventions that have long been used in resource-poor environments for supervision of therapy for tuberculosis and HIV. These are being applied by novel programs like PACT and Commonwealth Care Alliance in Boston to target high-risk, high-cost patients to help with their management. Behavioral health issues are often the hardest to solve for these programs, but CHWs with training in behavioral health could assist with co-morbid disease. This layer may also include group visits in community based-settings. Finally, in this layer, alternative service providers such as “community paramedics” like those being deployed by MedStar Ambulance system in Fort Worth, Texas might be mobilized to care for patients living with comorbid physical and mental illness to assist in keeping them healthy at home.
The fourth layer, Family Engagement, has been used for some time to help with the management of infectious diseases and chronic conditions. Training family members to also help with the management of co-morbid behavioral illness would provide a near continuous asset to the integration process.
Finally, Self-Management would put the patient at the center of their care. New technologies to track movement (pedometers), sleep (sensors), mood (SMS technology), weight (scales), blood pressure (BP cuffs) in the home and wirelessly transmit them to providers are allowing patients to see their own data and manage their conditions themselves. These solutions may not be for everyone, but they can often passively collect substantial amounts of data and help patients and providers better characterize contexts that affect both their physical and behavioral ailments. Tools like the Big White Wall, a web-based platform to assist patients in finding community and consultative support in the home, can greatly assist patients with self-management.
We have not encountered, to date, anyone in the field looking at this full spectrum of “complete care integration” for behavioral health and primary care. While many organizations are still in the early stages of implementing integration we believe that those innovators on the frontier are and will be thinking seriously about how to address some of these key issues to achieve the Triple Aim of better health, care, and lower per capita costs for patients with comorbid medical and behavioral health needs.
Asch DA, Muller RW & Volpp KG. Automated Hovering in Health Care – Watching Over the 5000 Hours. New England Journal of Medicine. 2012;367:1-3.
Logan AG et al. Mobile Phone-Based Remote Patient Monitoring System for Management of Hypertension in Diabetic Patients. American Journal of Hypertension. 2007;20(9):942-948.
Koehler F et al. Impact of Remote Telemedical Management on Mortality and Hospitalizations in Ambulatory Patients with Chronic Heart Failure. Circulation. 2011;123:1873-1880.
Jaber R, Braksmajer A & Trilling J. Group visits for chronic illness care: Models, benefits, and challenges. Family Practice Management. 2006;13(1):37-40.
Mara Laderman, MSPH, is a Research Associate at the Institute for Healthcare Improvement (IHI). She leads IHI’s work in behavioral health, developing content and programming to improve behavioral health care in the U.S. and globally. In addition, as a member of IHI’s innovation team, she researches, tests, and disseminates innovative content to inform IHI programs and further IHI’s strategic priorities within the Triple Aim for Populations focus area. Prior to IHI she managed a nationally representative psychiatric epidemiologic study investigating the effect of social and environmental factors on the behavioral health outcomes of vulnerable populations. Ms. Laderman received a Master of Public Health from the Harvard School of Public Health and a Bachelor of Arts in Psychology from Smith College.
Kedar Mate, MD is an Internal Medicine physician and an Assistant Professor of Medicine at Weill Cornell Medical College and a Research Fellow at Harvard Medical School’s Division of Global Health Equity. In addition, he serves as the Vice President for Innovation at the Institute for Healthcare Improvement and the Regional Vice-President for the Middle-East and Asia-Pacific. In addition to his clinical expertise in hospital-based medicine, Dr. Mate has developed broad expertise in health systems improvement and implementation sciences. In his leadership role at IHI, Dr. Mate has overseen the developments of innovative new systems designs to implement high quality, low cost health care both in the US and in international settings. He graduated from Brown University with a degree in American History and from Harvard Medical School with his medical degree. He trained in internal medicine at the Brigham and Women's Hospital in Boston and currently resides in Virginia.
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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.