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PCMH: A Promise Unfulfilled?

Posted By Matthew P. Martin, Thursday, March 27, 2014

PCMH (Patient-centered medical home) initiatives are familiar to many of us. In fact, some have probably considered getting those four letters tattooed in large gothic style on some part of their bodies. Why is there so much support? Because medical homes promise so much.  In theory, the PCMH is a team-based model of primary care designed to improve quality, efficiency, and patients’ experiences. Considering the lack of quality and efficiency in our current health care system, such a model should be a godsend. Indeed, some of the most recent PCMH studies are promising.

For those of you unfamiliar with PCMH, read the
Joint Principles for a nice introduction. For a quick rundown see this video.

Now the question is: can the PCMH model deliver on its promises? According to a recent study published in the Journal of the American Medical Association, PCMH failed to lower service use (i.e., ambulatory, emergency, and hospital) or total costs and produced little quality improvement over three years. The results of the study have been summarized here, here, and here. This isn’t the first time researchers have raised a warning flag for PCMH. Another study by JAMA suggests that medical homes have higher per patient operating costs while another author of the American Journal of Managed Care warns that consumers, especially the rising generations, will not want medical home-style care.

What do we learn from this most recent study then? According to Thomas Schwenk, PCMH may be “best deployed in a more concentrated approach for patients with costly conditions and high use” like the chronically ill. And according to the Patient-Centered Primary Care Collaborative, the NCQA-recognized pilot practices did not go far enough in transforming care practice. For example, weekend and evening hours were rarely offered to patients and there were no financial incentives to control costs. Marci Nielsen, the PCPCC CEO, even wonders if these pilot practices had yet transformed to be true medical homes.

Here are some other lessons:

  1. Clinic managers need to know what patients need and want from their primary care service (e.g., expanded clinic hours, walk-in slots). Few if any of the pilot practices in the JAMA study received feedback on their patients' care utilization.
  2. All key features of the medical home should be measured (e.g., patient engagement, behavioral health integration, team-based care). Several of these features were not measured by the authors.
  3. We need longer, larger PCMH studies with better practice comparisons. This recent study was from 2008 to 2011, only three years. Also, the response rate for the “control” group was only 24% compared to 91% for the “intervention” group. 
  4. The PCMH model needs integrated behavioral health care. Recently, one working group developed principles for integrating behavioral health care into the PCMH. Whether PCMH evolves into a model for the chronically ill or stays more general and comprehensive, patients should have access to behavioral health services.

Is this recent study a nail in the coffin for medical homes everywhere? I don’t think so. Undoubtedly, it is true that proponents of PCMH have a tough row to hoe. They must convert all the enthusiasm and activity for medical homes into a sustainable, evidence-based model. They must also decide if this model is a “one-size fits all” or a disease- or population-specific model or something else entirely. This study seems more like a clarion call for a more refined PCMH model that is supported by bigger, better research.

Personally, I am optimistic. I believe in the progression of science, that research will help us identify those key PCMH features and processes that lead to the greatest outcomes. Such research will require more time, energy, and money to determine which patients benefit the most from a team-based, care management model.

But I am still left with a few nagging questions. How we will know if this entire “medical home” approach is the wrong direction? Is this style of medical care what patients want these days? There are a lot of urgent care clinics in my town and they seem awfully busy. Moreover, will we have the primary care workforce that we need to run medical homes? Even if research shows that medical homes are awesome, will there be anyone to run them? Although these questions are interesting and somewhat important, maybe the most important question right now is: does PCMH deliver on its promises?

 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 research 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: matt.p.martin@gmail.com

 

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My Journey into the Integrated Workforce

Posted By Natasha Gouge, Thursday, February 27, 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!
 

I grew up in a rural community where the only exposure I had to “psychology” was through local churches where it was described as being equivalent to “witch craft”.  (I’m not joking.) In college I was exposed to the psychological “witch craft”, and I learned very quickly that I liked it and that I seemed to excel with the material (gasp!).  This didn’t exactly gain me any prestige among the local pastors, but my professional atlas had finally begun to narrow in direction.

I was naïve going into the field of psychology as a first generation college student.  First, I thought psychologists got training in everything from palm reading to forensic profiling (both of which sounded like fun!).  And second, I assumed you were a “psychologist” when you graduated college with your four-year degree and you left graduation on Saturday to enter the workforce on Monday.  Needless to say, my professional atlas was missing a few pages.  

 

A few months before completing my undergraduate degree a professor began encouraging me to apply to graduate school and my eyes were opened to another world of possibilities (and to the fact I had spent four years working on a degree that didn’t make me a “psychologist”!)  In exploring graduate school options, I had my first exposure to primary care psychology—I believed I had finally found my professional direction.  What took place over the next half decade was a combination of quality course work and training, excellent mentorship (shout out to Jodi Polaha!), innovation, and probably some serendipity that resulted in the creation of my dream job in the integrated workforce. 

Appreciate it’s not just busy work

I truly believe the graduate training program at East Tennessee State University (ETSU) set many of my successes in motion because of its mission, focus, and commitment to training and preparing students for the integrated workforce.  Among the mass of reaction papers, article reviews, and assigned research projects (at times seeming like “busy work”), I was exposed to viewpoints and curriculum through nursing, pharmacy, medicine, social work, anthropology, and public health.  I had classes that were incredibly innovative and pragmatic that allowed me to see standardized patients in real time with evaluations based on patient contact, case formulation, chart documentation, and debriefing the referring primary care provider.  I had courses that required multiple business pitches about integrated care to a variety of audiences: physicians, office managers, insurance companies, etc.  Through this I became energized around the idea of creating a position in an integrated setting close to home, but I found with each business model pitch I completed I was met with the same general response:  “integrated care sounds wonderful—now how do we pay for it?” 

Integrated care
sounds wonderful—
now how do
we pay for it?
 
Develop a professional mantra

That question would haunt me in my sleep.  I mean, I am passionate about what I do, but I’m also passionate about making enough money to eat, play, do fun things with my husband and our kids, and dare I mention the S-L words?  (student loans!)  So working as a behavioral health provider (BHP) for free just wasn’t going to cut it, but how do we pay for it?!  This question became the driving force for my dissertation research. 

Put on your business hat

I believe it is important to explore the indirect ways in which having a BHP onsite can impact clinic revenue.  Through studying a pediatric primary care practice that offered a one-day-a-week integrated model, I found that even in the absence of direct billing from the BHP the clinic was able to generate over $1,000 average in extra income on days that a BHP was providing services on site.  How was this possible?  Mostly through time savings benefits.  As the providers handed off behavioral health concerns to the BHP, they were able to see (and bill) for additional acute visits which came in the form of extra walk in appointments and additional double-booking strategies on integrated care days. 

This data, along with many other nuanced findings, tied together nicely for the development of a business pitch—a business pitch in which I could finally offer some current, real-life suggestions to answer that reimbursement question that always comes at the end.  And even more exciting, a way to answer that question without relying on direct BHP billing and the barriers therein.

Throw it out there

Because of my training experiences through ETSU, I was well connected with some pediatricians who I met at my practicum placement.  I sent a text message out inquiring about where they were working and whether their current offices were interested in hearing my business pitch.  Guess what?  They all were interested!  And the first clinic I pitched to offered me a full time position! 
 

I’ve been at my current job now close to 6 months and we continue to rely on time-savings rather than direct billing to offset my salary and benefits.  Although my ongoing data collection and program evaluation is still underway, (stay tuned friends!) I can report that recently a provider told our finance manager that my service allowed her to see at least 6 additional acute patents a day.  Those visits add up folks!  If you haven’t compared the reimbursement rates for what a physician might bill for 6 acute patients versus what a BHP might bill for 6 sessions, I encourage you to do so!

To make a short story long, my blog post is an early career professional’s story about ways to get in the integrated workforce.  Surely there is no one right way.  After all, my journey began with “witch craft”.  

  

Natasha Gouge, PhD currently works as the full time BHP with Mountain States Medical Group Pediatrics in Kingsport, TN.  Dr. Gouge graduated from East Tennessee State University, Department of Psychology, within the Clinical PhD Program and completed her internship through the East Tennessee South West Virginia Psychology Internship Consortium.  Dr. Gouge is passionate about integrating behavioral health among primary care settings, prevention of and early intervention for behavioral health problems, and research and consultation regarding the development and sustainability of integrated health care programs. She appreciates a good dose of competition and sarcasm, as well as being outdoors, traveling, participating in sports, and spending time with her husband, son, and step-son.

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Put Creamer in the Coffee First

Posted By Alan Lorenz, Friday, February 14, 2014
On the way to work the other day, I was listening to an interview of an efficiency expert on NPR. He spoke about his work consulting with companies on how to be more efficient. Some recommendations were fairly obvious, some were more obscure, but one was stunningly brilliant and forever changed my life -- put creamer in the coffee first.

I drink coffee every day. I had always poured my coffee first, then added creamer, then stirred with a spoon. Granted, I’m not as alert before the coffee, but it had never occurred to me to put the creamer in first. Look around – most everyone does it this way. If you put the creamer in the cup first, the magic concoction is blended as you add the coffee. There is no need for the spoon!

Think how much greener this is. How much less energy will I use in my lifetime by not washing a dirty spoon?  How much less polluting detergent will be used? How much less landfill will be created? Not to mention what’s involved with wiping up that bit of mess on the counter, or the time it takes to find a spoon, and wash it.

I know it’s a simple analogy, but here’s my point – How many simple changes are there right in front of us that can make our lives easier, more efficient, and greener?  In particular, how many health care practices are done the traditional way – like using a spoon -- but could be done more efficiently and greener much of the time? Even more specifically, and to really push the analogy, what is the right mix, and what is the right way to mix, the Behavioral Health Consultant (BHC) and the Medical Provider? Who should see the patient first? Should a triage person see the patient first and then direct them to the professional that makes the most sense? Should they come in the room together? Should a BHC always see them last to ensure understanding and agreement about how to move forward?

By this time, most all of us have seen the advantages of shared location. Nothing beats great access of the "other” health care professional. Sometimes it’s a quick question; sometimes it’s a curbside consult; sometimes it’s an important update; and, sometimes it’s an urgent need to see someone now. There is some debate, and of course practical considerations, to decide between shared building, shared floor, shared hallway, or even shared office. Joint appointments are the best, if you can swing it (both financially and operationally), if even only for a few minutes of shared time.

Over 25 years ago, Michael Glenn, MD1 experimented with a medical provider and behavioral health consultant seeing all patients together, at least initially. I think we still don’t have that initial bit right. There are some out there who have tried "on the fly” triage. How is that working? There are some out there who have had a BHC stop in to visit with each patient for a "medical” visit either before or after the face-to-face with the medical provider. There are some who have experimented with universal availability of behavioral health consultants. Perhaps some have experimented with the scheduling person asking about the need for co-consultation during the visit when the appointment is made. Chime in.
Think outside the cup

My purpose here is to stir things up for those who are more separated, traditional, and in their own silos. I would like to encourage those who have thought "outside the cup” to speak up. I am particularly interested in the mix, from point of first contact to checking out. It’s probably even more than that -- what is the wording in the brochures, signs in the waiting room. Maybe there is something simple, right in front of us, that we can change that would simplify our lives, lead to better care, and conserve resources. Let’s mix it up and see what happens. Like the creamer in the coffee, it’s not just what the right proportions are, but what is the best way to mix together.

Now that the everyday coffee drinking behavior of some readers has changed, let’s think about why it took us so long to figure out how to put wheels on suitcases …


(1)  Glenn, M.L. (1987). Collaborative heath care: A family-oriented model. New York: Praeger.


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.

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Innovation as a Necessary Skill for the Integrated Primary Behavioral Health Provider

Posted By Joshua Bradley, Thursday, January 30, 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!


Innovation as Critical

Dr. Polaha recently highlighted the importance of innovation in primary care psychology and especially in newly integrated settings, which has been the case with my employer. Stone Mountain Health Services is a federally qualified health center with clinics in Southwest Virginia that has recently expanded the behavioral health program and currently has 6 licensed psychologists, 2 licensed social workers and a post-Master’s social worker, 2 pre-doctoral psychology interns, a psychiatric nurse practitioner, and a social work intern. Many of the primary care clinics have only recently become integrated, which has led to both exciting opportunities and challenges. As a further exciting, yet challenging development, at the site where I work, the medical providers, pharmacist, and myself are all early career professionals. One of the first hurdles that required innovation was finding ways to demonstrate that behavioral health providers can help patients with chronic health conditions. A second challenge has been addressing appointment and treatment adherence.

Increasing Chronic Health Condition Utilization

 

Although there is nothing innovative about interdisciplinary collaboration in integrated care settings, it soon became clear that there were tremendous opportunities to increase ways for different types of providers to work together in our clinic in new and creative ways. We knew that we had a large number of patients with diabetes so we developed a plan to increase behavioral health and pharmacy involvement in diabetes treatment. In fact, even the idea of "Diabetes Day” was a collaborative effort between myself, Olivia Bhutia, M.D., Natasha Gouge, Ph.D., and Crystal Kilgore, Pharm.D. During the winter of 2012, Dr. Kilgore mentioned the idea of collaborative treatment days, which led me to think about how this could decrease patient time with medical providers while simultaneously increasing quality of treatment. I began to think about how this might look in practice and talked to Dr. Bhutia about the idea.

 

I handed the project development to Dr. Gouge, who was then a predoctoral psychology intern at our site, and she ran with the idea and developed a comprehensive proposal for what would be called Diabetes Day. In short, Diabetes Day would occur once every two weeks on Wednesdays and would include one total hour of care, where patients would rotate among the medical provider, pharmacist, and behavioral health provider, depending upon provider availability. Each patient would spend 20 minutes with each provider addressing the various aspects of diabetes-related care. This plan would increase the number of patients medical providers could see because of the shared responsibility of patient care and could increase the amount of care each patient received because of the teamwork.

The Reality

We quickly learned that systematic change is difficult and requires significant flexibility
Well you know what they say about best laid plans. Getting the plan approved by administration was relatively easy. The administration was supportive and encouraged us to move forward. In fact, the Medical Director decided to implement a variation of the idea in her clinic. We discussed the plan with support staff and everything seemed to be in place for a successful and smooth transition. Unfortunately, we quickly learned that systematic change is difficult and requires significant flexibility. Everything from making changes to our scheduling templates to patient communication about how Diabetes Day appointments were different from standard medical appointments became challenges that had to be managed on an ongoing basis. The professional staff could clearly see the benefits of the service and many patients were extremely happy and often surprised that they were receiving such comprehensive care. Still, there were a few patients who complained about only having their diabetes-related care managed because they were used to having multiple medical conditions and prescriptions written at the same medical appointment. In addition, the change seemed most difficult for support staff and their struggles affected the treatment team members.

One largely overlooked problem was that we had underestimated the importance of having an office manager. Our site manager had left just before the implementation of Diabetes Day and the clinic was left without someone to troubleshoot the challenges we faced on an ongoing basis and who had the authority to handle the issues. Another unanticipated development was the fact that once patients had been to a Diabetes Day, they would not necessarily need to return for another Diabetes Day because patients often thought they received the additional information and care they needed to manage their condition in one Diabetes Day visit. Therefore, we began running out of patients and found that biweekly Diabetes Days would not be necessary to meet the needs of our patient population. As a result, we have decided to expand Diabetes Day to include other health conditions that would benefit from the collaborative care approach (e.g., hyperlipidemia, obesity, COPD) and change the frequency to once a month and call them "Wellness Days.”

Behavioral Health and Treatment Adherence

The next opportunity for innovation was addressing the problem of patients who repeatedly no-show. Because we are a federally qualified health center who serves people who are poor, our administration did not think that charging patients for missed appointments was the right thing to do. The administration also did not want to dismiss patients because of excessive no-shows out of fear that patients would have no other source for medical services. As a result, in collaboration with other treatment team members, I developed a "Treatment Investment Plan.” Basically, after a patient missed 3 appointments he or she would only be allowed to attend same day appointments until meeting with a behavioral health provider to talk about treatment adherence and the importance of attending appointments. Based on an examination of data in our electronic record system, it was clear that same day appointments were attended at a much higher rate than previously scheduled ones. From a financial perspective, decreasing no-show appointments by just 2 a day could increase revenue by approximately $80,000 a year.

The Reality

While a comprehensive proposal has been developed, there are technology related problems that appear to have slowed the approval of the Treatment Investment Plan. However, there are an increasing number of medical and behavioral health providers within the organization asking about ways to address the no-show problem and we hope to get our plan approved in the near future.

Learning and Growth

Below are a few of the important learning points for me during the period of transition to an integrated program:

  • The significant changes associated with integrating behavioral health services and the addition of diabetes day likely added to existing clinic stressors and co-workers may seek out the behavioral health provider. I found it important to set boundaries early on as co-workers may not understand our ethical limitations related to multiple relationships. While I cannot provide treatment services to co-workers I can be a friend and a supportive co-worker.
  • When making systemic changes in the way the clinic practiced it was important to include the whole clinic staff in feedback related to integration of behavioral health services. I found it useful to utilize a 360 degree evaluation that sought feedback and input from providers, nurses, front desk staff, and medical records personnel.
  • Ultimately, the greatest lesson for me was that models and plans don’t always hold true and that there is a vast space between what the textbooks say integrated primary care is supposed to look like and what actually works. In that space is the struggle and the learning necessary to become an integrated primary behavioral health provider.


Joshua Bradley earned his Psy.D. from Radford University in the summer of 2012 and was licensed as a psychologist in November of 2012. Joshua works for Stone Mountain Health Services and his home office is located in St. Paul, Virginia. The St. Paul clinic was recently recognized as a Level 3 Patient Centered Medical Home. He provides integrated primary care services and is the only psychologist in Russell County, Virginia. In August of 2013 he took on coordination duties for the East Tennessee/Southwest Virginia Predoctoral Psychology Internship Consortium. Joshua oversees the weekly didactic trainings and is the clinical supervisor for group supervision. His current clinical interests include sustainability in rural integrated primary care clinics where the context of clinical practice may necessitate a hybrid system of providing behavioral health services.

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CFHA Blog Survey Results: You Spoke, We Listened

Posted By Matthew P. Martin, Thursday, January 23, 2014
During the recent annual CFHA conference in Colorado, we collected responses to a survey to help improve the CFHA blogs. Thirty individuals participated (23 identified as female while 7 identified as male). When asked what word described their professional identity, 33 used clinician (e.g., psychologist, social worker, physician, therapist), 7 used educator, 3 used researcher, 3 used administrator, 1 used student, and 1 used insurance company contractor. The average age was 43.7 years while the median age was 40.


Below are the six survey questions and results.







We asked survey participants to list topics they would like to see covered in the future and ideas for improving the blog overall. We got some good suggestions!

Please list any topics you would like to see covered in future blog posts:

"Inspirational blogs” "Things for educators to share with trainees”

"Useful measures, assessments, & tools for practice” "Outcomes, cost savings”

"Integrated care, health care policies at international level” "Best practices for addressing MH”

"Hospital reform - purchase of PCP practices, upcharging for outpatient office visits”

"Assessment tools” "Ethics of integrated care, informed consent, confidentiality” "Outcome measurement for integration” "Policy piece with data/evidence paired with a clinical story”

Please list any ideas you think would help to improve the blog:

"Fewer more poignant rather than many of marginal quality”

"More info in email announcing blog posts”

"Time constraints for reading - shorten messages into brief sentences.”

"Collection of articles, blogs that are user-friendly categorized by topic - easy access to resources” "Get some back-&-forth blogs going, pitching different perspectives on similar issues/themes”

Overall, it seems that most people are mostly interested in and satisfied with the blogs. However, it also seems that most of the blogs are not useful to readers. Our goal is to incorporate this feedback to improve the overall quality and utility of the blog posts. The specific ideas for topics generated by survey participants will especially help future blog posts. Thank you to all of the survey participants! If you have any additional ideas, please share those ideas with us in the comment section below. 

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CFHA 2014: Looking Back to Move Forward

Posted By Parinda Khatri, Thursday, January 9, 2014

(This is the first blog in an ongoing series that highlights what CFHA leaders are thinking and planning for the future. Check back in the future for more. The first post is by Dr. Parinda Khatri, current CFHA president.)

As I start 2014 as President of CFHA, I can’t help but remember my first CFHA conference: Newport, Rhode Island, November 2006. I remember it was November because it was really, really cold (at least for someone born in India and raised in Southeast. Those of you from cold climates feel free to smirk).  I was a few years into my job as Director of Integrated Care at Cherokee Health Systems (CHS), a comprehensive community healthcare organization that is a Federally Qualified Health Center and Community Mental Health Center in east Tennessee. While we at CHS were marching forward with integrating behavioral health into primary care, at the time there were few avenues for learning, sharing, and talking about integration and collaborative care in the usual circles.  At that CFHA conference, I was able to learn, share, and talk about integration and collaboration with brilliant people doing amazing things for two whole days.  It was exhilarating, validating, and comforting.  I had found my professional home.

Since then, integration and collaborative care have experienced exponential growth as progressive approaches to transforming healthcare delivery, health education, and scholarly inquiry.   The concepts that were considered "novel” by all but a handful of vanguard healthcare professionals have morphed into commonly used terms and ideas highlighted in countless conferences, presentations, publications, and initiatives at the local, national, and international level.  Integrated and collaborative care, an area which developed organically at the grass roots level by people in the trenches, now attracts a cadre of clinicians, researchers, educators, and administrative professionals from a wide range of settings. 

Like an adolescent transitioning from childhood to adulthood, the field of integrated care is exploring and testing limits as it grapples with its identity and role in the world.   Like the field, CFHA is also in transition.  Initially an entity founded and led by visionaries who gave their time, energy, money, and probably some tears just to get it off the ground, CFHA is now a formal association with 500 members, an annual conference, affiliated journal, and a host of initiatives in support of its mission.   It has a basic governance structure, with staff leadership (including a stellar executive director, Polly Kurtz) and board of directors. Now, CFHA is on the cusp of its next developmental challenge – to transition from a budding society to a mature organization with a refined governance structure, sound financial footing, and well-designed programs while it maintains its foundational mission. To remain viable, relevant, and grow, CFHA must, in the words of Jim Collins, "preserve the core while it stimulates progress.” 


No sweat, right?

Well, maybe some sweat (okay, a lot of sweat) but hopefully also some movement forward.  To this end, we will be rolling out several initiatives to meet the evolving needs of CFHA’s membership and expand the organization’s impact on clinical service delivery, research, policy, and education. Here are a few upcoming ventures: 

1) In January, CFHA will launch two special interest groups (SIGs), a Families and Health SIG co-chaired by Randall Reitz and Kaitlin Leckie, and a Primary Care Behavioral Health (PCBH) SIG co-chaired by Chris Hunter and Jeff Reiter.  These SIGS will provide a forum for active dialogue, knowledge dissemination, and networking for CFHA members. If one of your favorite parts of the CFHA conference are the "post-session” hallway huddles with colleagues, these SIGs are a great way to keep the conversation going throughout the year. Be on the lookout for information on regular conference calls and other initiatives from these SIGs in the coming month. 

2) CFHA is also actively working on a policy agenda that will identify the priority issues for advocacy at the local and national level. If we, as educators, clinicians, researchers, and administrators in the field, truly believe that integrated behavioral and primary care is critical to an effective and efficient health care delivery system, we will have to be vigorously involved in policy change in this arena. This policy agenda is intended to be a stimulus and guide for the organization as well as individual members to help transform the rules, regulations, and procedures that affect the work we do every day.

There is more to come. CFHA’s 2014 annual conference (Oct. 16-18 – save the date!) is shaping up to be a pivotal event, strategically planned to be in the nation’s capital, Washington, D.C., during this year of ACA implementation and this era of healthcare reform. CFHA will continue to promote dialogue and knowledge dissemination through its blogs and journal, Family, Systems, and Health, through the course of the year.  
You will play a key role in CFHA’s strength and evolution 

Because CFHA is a member organization and is essentially a product of its membership, we ask that each of you become more engaged with CFHA.  Whether you write a blog, submit an article to the journal, become involved in the SIGs, participate in the conference, or contribute to CFHA’s mission through other activities, you will play a key role in CFHA’s strength and evolution as an organization. In turn, you will be part of a group of professionals who share your mission and passion to improve the health and quality of life of your community. If you, like me, think of CFHA as your professional home, the reward you will receive, professionally and personally, will far outweigh your investment. And that is a pretty good way to start off 2014. 

Happy New Year!!


Parinda Khatri, Ph.D., is Director of Integrated Care at Cherokee Health Systems, a comprehensive community healthcare organization with 56 clinical sites in 13 counties in Tennessee.  She earned her doctorate in Clinical Psychology at the University of North Carolina at Chapel Hill and completed a Post-Doctoral Fellowship in Behavioral Medicine at Duke University Medical Center.  As Director of Integrated Care at Cherokee Health Systems, she provides oversight and guidance on clinical quality, program development and management, workforce development, clinical research, and clinical operations for blended primary care and behavioral health services within the organization. Dr. Khatri also trains, consults, and presents extensively on integrated care. She also leads Cherokee's APA Accredited Psychology Internship Program and APPIC member Health Psychology Post-Doctoral Fellowship.  Dr. Khatri is currently President of the Collaborative Family Healthcare Association.  She also serves on the National Integration Academy Council for the Academy for Integrated Mental Health and Primary Care, is Co-Chair of the Behavioral Health Special Interest Group for the Patient Centered Primary Care Collaborative, a member of the Behavioral Health Steering committee for the National Quality Forum, and a member of the Research Advisory Committee for the Transdisciplinary Collaborative Centers for Health Disparities at Morehouse School of Medicine. 

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Integrated Care Thought Leader Series: Benjamin Miller, PsyD

Posted By Cheryl Holt, Friday, January 3, 2014

(This blog post is a reprint of a piece by Cheryl Holt on November 5th, 2013. Click here for the original post. Reprinted with permission)

"If we really think about how to change healthcare to make it more accommodating for integration, we must have comprehensive payment reform that pays for the whole, and not the part. We must recognize that administrative structures in health policy entities often perpetuate fragmentation inadvertently. And we must have a way to collect data that can inform not only the clinical case for why integration is good, but the business case for why integration is inevitable."

Healthcare policy plays a crucial role in integrated care. Our current healthcare system contains barriers that prevent successful implementation of behavioral health and primary care integration. We will not be able to effectively adopt whole-health approaches to healthcare until critical changes are made in existing health policy. Thankfully, we can be grateful for those who are out there, tirelessly advocating for changes daily.

Dr. Benjamin Miller has graciously agreed to offer his insights on this important topic for the Integrated Care Thought Leader Series. He has made significant contributions to the healthcare industry and health policy, and continues to collaborate with a number of organizations focused on driving the necessary change for creating a more effective healthcare system. Dr. Miller has been the source of considerable inspiration to many (including me). It seems very appropriate, somehow, that I first met him through Twitter. His many tweets on healthcare, policy, and integration, with excellent links to current resources, provide me and many others with an education like no other. I have learned the value of Live Tweeting and Tweet Chats through his example. Thank you, @miller7!


Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. Dr. Miller is a principal investigator on several federal grants, foundation grants, and state contracts related to comprehensive primary care and mental health, behavioral health, and substance use integration. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care projectas well as the highly touted Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon.

He received his doctorate degree in clinical psychology from Spalding University in Louisville, Kentucky. He completed his predoctoral internship at the University of Colorado Health Sciences Center, where he trained in primary care psychology. In addition, Miller worked as a postdoctoral fellow in primary care psychology at the University of Massachusetts Medical School in the Department of Family Medicine and Community Health.

He is the co-creator of the National Research Network’s Collaborative Care Research Network, and has written and published on enhancing the evidentiary support for integrated care models, increasing the training and education of mental health providers in primary care, and the need to address specific healthcare policy and payment barriers for successful integration. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Miller is the past President of the Collaborative Family Healthcare Association, a national not-for-profit organization pushing for patient-centered integrated healthcare.

Having long been a firm believer in the need to provide healthcare in a unified manner, Dr. Miller has determined that three barriers prevent integrated care from becoming more widespread: financing, policy, and data.

Financing

Dr. Miller: If you ask people why integration is or is not making a larger stand in healthcare, it usually comes out that they aren't able to sustain their clinical innovation. So practices try to figure out ways that they can sustain themselves through all kinds of workarounds. Here in Colorado about three years ago we did a survey of integrated practices and found that 77% of those we surveyed were solely funding their integrated efforts through grants. I don’t think that’s uncommon. Actually, I think it’s very common across the country. A lot of practices that are doing this got funding from foundations, federal government, etc., to make it work. They’re only able to keep their doors open for the program while they've got those dollars. I wanted to figure out, why is that such a big deal? Why can’t we just pay for health? We proposed a project to test out a global payer model for primary care that includes the cost of mental health, just to see if we were to pay primary care a lump-sum of money that includes the cost of that primary care provider, could they sustain themselves? That’s where the Sustaining Healthcare Across Integrated Primary Care Efforts or SHAPE came from. We wanted to see if paying for primary care differently with mental health, behavioral health, substance abuse providers, working in that integrated context could be sustained. We’re about a year into that and the answer is going to be unanimously, yes.

Large Scale Policy Issues and History

Dr. Miller: If you look at how healthcare is set up, it’s set up to continue to perpetuate fragmentation. It’s set up so that administratively, it’s easier to manage pieces rather than a whole. Our states, communities, and government have done something, in an attempt to manage multiple systems, which has really hurt our attempts to integrate. I’ll give you a very high-level example of that: If you just look at most states, they usually have a different department or division for mental health. We decided to take all the dollars that were going into institutions for folks that had mental health issues and put it back into the community in established community mental health centers. The dollars didn't really follow the patients in that experiment. Community mental health centers actually didn't get a whole lot of money to do the job that they were intended to do. And so you have entire systems at state levels that manage mental health. When you want to try and integrate, whether it be in primary care or in the community mental health center with primary care, there are multiple administrative structures that you have to figure out how to align. And often, from a policy perspective, it doesn't make sense fiscally as to how to align these and what to do with the administrative entities. There are a lot of policy issues. Mainly, how we've set up our systems to deliver care at the policy level.

Data, Research, and Infrastructure

Dr. Miller: The other reason I think integration hasn't been taken to scale nationally as much as we would like, is that practices are relatively immature in their ability to collect data, especially as it relates to collecting that informs the outcome around the whole person and not just a physical health outcome or mental health outcome. If you go into a primary care practice and want to determine how effective a behavioral health provider is, often the electronic medical record and how they are tracking the data are in forms that don’t allow you to extract those data. They’re in free-text notes, or they’re in something that just makes it difficult to get at the data to show what they did and how effective it was. In the same vein, if you look at community mental health centers, it’s even worse. With vast amounts of EHRs, if they even have an EHR, are built around this old-fashioned, almost antiquated, "I need to tell the whole story for the patient” model. That’s good on the clinical level. However, if you’re looking at making a case for something, you need to be able to extract data from those electronic medical records and then tell a story with your data. Many of the community mental health centers simply are not there. They have an opportunity here to advance themselves by collecting better data at the practice level.

Though many in the healthcare industry see policy as something beyond their responsibility and concern, the reality is that it has an impact on each of us. Unless we collectively express our concerns, voice our professional opinions, demand the necessary changes, legislators will continue to make uninformed decisions that have significant impact on healthcare delivery.

While there remains a long way to go before the needed changes outlined by Dr. Miller are in place, the industry as a whole is making significant strides in the right direction. Policies are slowly beginning to change.

Perhaps the perfect storm is approaching for healthcare


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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The Social Work Hat of Behavioral Health Consultation

Posted By Preston Visser, Thursday, December 26, 2013

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!


Imagine with me for a moment that you are on a journey hiking through Yosemite National Park (the government stays open in this imaginary world). On day 2, a surprise snowstorm forces you to veer off your trail. On day 3, you have lost your map and are becoming increasingly convinced that each step you take gets your more lost. At the brink of desperation, to your great relief you spot someone wearing that iconic Park Ranger hat. The friendly Ranger gives you a map with directions to get back to your trail, and in a few minutes you are headed "True North” (the Ranger bore a striking resemblance to Kirk Strosahl). Technically, you are still far from your original trail. Also, the Ranger was too busy to accompany you, so you are alone again. Nonetheless, your brief encounter with someone that understands the park helped you make sense of things, which changed everything.

Each patient we encounter is on his or her own life course. While we do not choose this course, we can be of assistance in reducing unnecessary detours and pains. Unlike traditional therapists, behavioral health consultants (BHCs) are generally too busy to accompany patients for long on their journeys. Therefore, our best function is often to help patients get their bearings set. This process often occurs through brief interventions that help patients connect to values that guide their choices. Increasingly, however, I see that we also have a great opportunity to help patients understand, navigate, and even benefit from complicated social systems.

As an early career psychologist, the last few years of my clinical work have been dominated by efforts to rectify the great predicament affecting us all: how to address the tremendous need we encounter despite substantial limitations of time and resources. My struggles with this ubiquitous issue have helped me to broaden my own professional identity to include the belief that I need to maintain a good understanding of the systems and resources affecting patients in my community. I think of it as wearing a social work hat.

In an insightful CFHA blog series on the topic of "Professional Identity” earlier this year, Tom Bishop and Jeff Ellison reminded us that, perhaps more so than other professionals, we BHCs need to view ourselves broadly in the context of the diverse teams with which we work. My role in integrated care teams involves more than being a good therapist and diagnostician. As the BHC, I need to be able to help patients determine what factors, personal and systemic, can be altered to get them closer to the health they want.

Throughout graduate school, I had little experience interacting with social service agencies, insurance companies, residential treatment facilities, nonprofit organizations, and other entities that patients often engage during their treatment. I now fully recognize my ignorance in these matters, so I ask a lot of questions. I frequently call organizations to ask for guidance, and I am blessed with a spouse that is a social worker and with colleagues that work hard to obtain and share information about systems and organizations.
I need to maintain a good understanding of the systems and resources affecting patients in my community

Here are a few real-world examples of interventions that seem to involve a social work hat:

  • Patient is experiencing early to middle-stage Alzheimer’s symptoms, and family does not understand the diagnosis: Connect family to Spanish-speaking support groups and information
  • Family is dealing with alcoholic father: Provide information about Al-Anon group to attend
  • Patient with mental retardation (MR) describes major stressor is that the payee for his social security income is abusing him and stealing his money: File report of abuse with appropriate office, and contact Social Security Administration to learn about options for changing one’s payee
  • Elderly patient is suffering physically and psychologically due to difficulty caring for her niece that has severely uncontrolled schizophrenia: Assess available familial supports, help patient problem-solve about why her attempts to transfer niece to residential care have failed in past, and call hospital and legal authorities to help patient plan for transfer of care
  • Patient is considering applying for deferred action in order to attend college, but fears that she will be deported in future: understand White House executive order in order to help the patient explore pros and cons
  • Patient is distressed by unplanned pregnancy: connect to appropriate support services
  • Young adult obtains custody of 2 younger siblings after her mother and grandmother both pass away, and their house is in foreclosure: connect patient with appropriate social services
  • Patient’s primary concern is inability to find employment: help patient locate unemployment programs
  • Patient with schizoaffective disorder and alcohol dependence is fired from psychiatry for continued alcohol abuse: help patient locate a substance use program close enough to his home, and call patient periodically to encourage adherence to treatment plan
  • Patient feels stuck in relationship with violent partner due to fear of homelessness and deportation: Connect patient to "Mujeres Latinas en Acción,” an organization for such women
  • Mother is worried about academic performance of child that appears to have learning disability: Help mother to understand and follow protocol for requesting IEP evaluation
  • Mental Health Referrals: Unless you are fortunate enough to work somewhere with both integrated care and co-located therapy (ahem, Cherokee), then you will need to have a list of places to refer patients needing long-term therapy/psychiatry. In Chicago, maintaining such a list can be challenging, particularly since mental health resources seem to change frequently. Our department set aside admin time to create a large excel file with referral sources and relevant information, including insurances accepted, languages served, sliding scale fee, etc. We also took a field trip to the place that we refer most patients for psychiatry and therapy services. I wish we could take a similar trip to all of our referral locations.

By disposition and training, BHCs are generally good communicators and capable of helping patients connect to adaptive coping skills and guiding values. I believe we can maximize our impact by becoming comfortable wearing a social work hat. Better knowledge of systems and context will help us create better maps for getting patients back on trail.


Preston Visser is an early career psychologist working at a federally qualified health center located in an underserved neighborhood in Chicago, Illinois. He was part of the inaugural class of students in the integrated primary care psychology doctoral program at East Tennessee State University. Preston completed his predoctoral internship through the Chicago Area Christian Training Consortium, with his primary rotation at Lawndale Christian Health Center (LCHC). He later completed his postdoctoral fellowship at LCHC and is now a licensed behavioral health provider at the clinic. At LCHC, he works collaboratively with primary care providers to address behavioral health concerns of patients diverse in age, culture, and language (English and Spanish). Since graduating, he has been developing coping skills for managing withdrawal stemming from a lifelong dependence on school. He is 18 months sober, but with the RxP movement underway, relapse seems possible.

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Mentorship: A More Generous Approach to Those Needing Guidance on Their Professional Journeys

Posted By Deborah Taylor, Thursday, December 19, 2013
"A lot of people have gone further than they thought they could because someone else thought they could.” – author unknown


To me, this is the foundation of the best mentoring experiences for which I am grateful to have received. How many of you would agree?

Another favorite guiding quote says that:

"There will always be a reason why you meet people. Either you need to change your life or you’re the one who will change theirs.” - author unknown

Dr. Jeri Hepworth, Vice Chair at the U. of Connecticut Dept of Family Medicine, and I recently co-presented a workshop entitled "Intentional Mentoring: Paying It Forward as a Family Medicine Behavioral Science Educator” at The Forum on Behavioral Science in Family Medicine conference. Using a modified World Café technique, we captured great wisdom from engaged attendees worth sharing with a larger audience….that would be you!

One theme that strongly emerged was that Family Medicine educators are much more comfortable in the role of mentee vs mentor, especially those early in their academic career. The more senior faculty were helpful in convincing the more junior faculty of their value as mentors. Mentoring areas identified by senior faculty included use of technology, innovations in information delivery methods and social media as a communication and teaching tool.

Another embraced thread was that "forced mentoring” – being "required” to participate in a mentor-mentee relationship that is imposed upon you with little room for autonomy or choice - was not perceived as being particularly helpful from either side of the mentoring relationship. Even when someone in authority defines a need for "forced mentoring”, mentee being afforded some control over the choice of mentor yields a stronger and more helpful outcome according to both mentee and mentor.


The last wisdom from our audience that struck us was how many barriers seem to be in their way around devoting time and energy to a mentoring relationship. Time was obviously #1, but others barriers emerged including lack of allotted resources available for identified mentee needs, dyadic power issues that prevent the mentee from being authentic/honest, and a lack of structure affecting the clarity of roles, goals and expectations.

I am sure you will agree that our students inspire us. I would encourage you to consider ways to gather the wisdom of your learners (who are often identifying you as a mentor) and in turn transform the bidirectional influence of your professional connections.

The best mentors are those who show you where to look but do not tell you what to see.
- Alexandra Trentor

In closing, please take a moment to reflect on the following questions to help you be more intentional in your mentoring efforts:

  • How can you increase your mentoring activity in your professional home?
  • Who or what people/groups can you identify that would benefit from what you have to offer?
  • How will you make yourself available (addressing issues of time and resources)?
  • What is your intention (i.e., what do you think you have to offer/share)?
  • What are potential challenges that will need to be addressed in order to be successful as a mentor?

Happy intentional mentoring!


Dr. Deborah Taylor has been a Behavioral Science Educator and Associate Program Director at Central Maine Medical Center FMR (a community based program with a rural training emphasis) for the past 21 years. She received her PhD in Clinical Psychology from the U. of Kansas and has worked in medical education for the past 25 years. Deborah recently "retired" as a Co-Director of the STFM Behavioral Science/Family Systems Educator fellowship.

 

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A Poem

Posted By Natercia Rodrigues, Monday, December 2, 2013

This is the first in a new blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!

Smiling, he told me he didn’t know
That his heart had stopped in the ICU

I probably didn’t need to mention it
But here he is, with newly diagnosed end-stage everything
And he’s still smiling.

Wow, he breathed.
I know, I said. Crazy.

A year later, his teeth still shone
He wore three pairs of pants to keep his skinny legs warm in the Rochester winter

I saw him sporadically
He had his calendar filled with doctors for each organ

One evening, when I was on call for our practice a page came through with his name
Seven hours of vomiting with no fever.
He never gets a fever, I remembered.

He said he had a ride to the ED and that he’d go now.

The next day, with no ED visit recorded, our nurse called to check in on him. There was no answer.
The next day, the coroner’s office called.

I called all of his specialists. I told my close colleagues.
It was therapy, repeating the story and its abrupt ending

I sought no reassurance, just shared shock

On my last phone call, my eyes rested on the new green surrounding the trees outside the window.
A Scarlet Tanager, bright red and sparrow-shaped, jumped from branch to branch.
Fearless, open to predators, and not caring to blend into upstate gray
It stayed in my view for 30 seconds.
I relayed its movements, like a sportscaster to the gracious ear
It kept jumping, brilliant wings aflutter until it flew west
The branch bounced and I grew quiet 

Wow, I breathed.
I know, She said, Crazy


I'm a 3rd year resident at the University of Rochester Family Medicine program where my patients' stories become a part of my life.  I like writing, taking photographs in Iceland and buying produce at the public market.

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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.