Posted By Randall Reitz,
Friday, May 3, 2013
| Comments (4)
Why do some clinicians excel at integrated care while others flounder?
Why do some of us embrace innovation while others yearn for traditional
The development and orientation of one’s professional identity plays a central role in predicting success in
integrated care. This 5-week blog series
will present professional identity development from numerous perspectives. Following this initial post, each week we
will host posts that react to and build upon the previous blog from the
perspective of a different discipline:
May 16th— Graduate student
May 23rd—Family Medicine
What is Professional Identity?
My interest in this topic was first piqued by the McDaniels et al
(2002) curricular article for training primary care psychologists. The authors observe that
"Psychologists-in-training need to develop the skills that solidify their
identity as psychologists. Psychologists
who have a positive professional identity are most likely to be able to work in
collaborative primary care settings.”
Intrigued by this comment, I set out to investigate professional
identity development. I found precious
little in the health education literature, and nothing specific to integrated care.
About the closest thing I could find was an article that applies the Chickering
Theory of Identity Development to medical residency education. The Chickering
Model describes 7 "vectors” through which trainees and students pass during
professional development. They are:
Developing mature interpersonal relationships
Most theorists apply Chickering’s 4th stage, "Establishing
Identity,” to under-graduate education and look at the global self-concept
(e.g. cultural identity, appearance, self-worth, social role). However, I would assert that professionals
pass through each of Chickering’s vectors at each level of training. The level of stress and the pace of
development become more manageable with each new training or employment
experience, but the vectors are clearly experienced.
For example, nearly all of us can identify our own experience with the
vectors upon entering grad school or medical school. We are finally entering the realm of our
chosen vocation and we don’t want to screw it up. Looking back at my experience at Indiana
State University, here are the cognitions I recall with each of the Chickering
Developing competency—"I need to learn
Excel, SPSS, Powerpoint, email (yes, I’m that old) at the same time I figure
out Minuchin, Bowen, White, and de Shazer.
I was able to fake my way through undergrad, but this is a whole new
level of expectation”.
Managing emotions—"I’ve got my
supervisor behind the 2-way mirror witnessing a completely out-of-control
couple in the middle of a screaming melted down. Chest tightening, palms sweating, thoughts
racing, tongue stuttering, just keep it together for the sake of the couple.”
Developing autonomy—"OK, the first day
of my off-campus internship site. I’ll have weekly meetings with my on-site
supervisor and the program faculty, and I can consult with them by phone if I
need. I can be successful here.”
Establishing identity—"I’m a narrative
therapist who has been able to help many couples and families. People with a similar skill level as me have
gone on to careers in academia, why not me? I love what I’ve read about
collaborative care, and working with physicians. People scream less in medical
Developing mature interpersonal
relationships—"I’m the only person in my program who fancies collaborative
care. How can I bring them along? Which
potential mentors could bring me along?
Developing purpose—"For the last 6
months of my masters degree, I haven’t read a single assigned reading,
preferring instead to read texts and articles on collaborative care and medical
family therapy. I’ve also sought out any
case I could find with a connection to physical illness.”
Developing integrity—"I’m confident in
my core family therapy skills and in my ethical practice. While my opportunities to collaborate have
been limited, I’ve demonstrated professionalism in my accessibility and
Each additional career stop has offered a fresh experience with the
vectors, but with the benefit of the competency and connections made with
program → Internship → Clinic management → Residency
Each of these experiences has broadened my perspective regarding
collaboration and has deepened my commitment to our field.
In my supervision and employment of medical and behavioral health
providers in integrated settings, I‘ve come to appreciate that these settings
are like the Briar Patch from the Uncle Remus stories: either noxious or
nonpareil. While some clinicians have a
preternatural, innate collaborative ability, others can’t get out of their own
way. I believe the key differences come from a professional identity that grew
out of personality. Perhaps
controversially, I will assert that the collaborative identity is a triad of
characteristics: extroversion, self-direction, and multi-tasking ability. And,
while I will make an exception for extroversion among physicians, I won’t do so
for behavioral clinicians.
In support of my triad, I believe that just about everyone who is drawn
to primary care and behavioral health settings comes with some desire to
improve the human condition. However,
this desire manifests itself differently based on one’s professional
identity. Some clinicians are
tailor-made for a traditional community mental health setting that provides
clearly defined roles, schedules, and patient panels. They provide amazing service to some of the
most marginalized and afflicted people in our communities. Others have the entrepreneurial chops to
build their own private practice through competition in the free market.
|I’ve seen several of these types of clinicians fail or flounder in
collaborative settings. I find that the
private practice entrepreneurs never accept that they are a small, but
important piece of a large and sophisticated system. They also struggle to accept that the
physician is the sine qua non of primary care, whereas the behavioral clinician
is the added value. Among clinicians trained for community mental health, the
lack of structure and the need for constant networking can seem tedious. They find the daily onslaught of new
referrals and "other duties as assigned” maddening and would much rather
provide continuity services to a known patient panel.||Perhaps
I will assert that the
collaborative identity is a
and Multi-tasking ability.
In contrast, the great collaborator draws energy from the non-stop,
unpredictable heterogeneity of integrated practice. We couldn’t tolerate the drudgery of eight
50-minute hours. We would also feel
terribly hampered by not having "our team” to help out. And by "our team”, I don’t mean the other
behaviorists, I mean the nurses, front desk, case managers, and physicians of
my pod. Rather than feeling competition by sharing care with clinicians with
different skills and scopes of practice, we are drawn to being a round peg in a
square hole. And, based on the
developmental newness of integrated care, rather than being intimidated by
cutting new trail in our professional settings, successful collaborators share
a pioneering spirit.
Those are my beliefs about the collaborative professional
identity. I’m hopeful that the next
posts in our series will:
Contradict many of my assertions;
Explain how this identity can be trained;
Expand the discussion to be more relevant to
Randall Reitz, PhD, LMFT is the
founding editor of CFHA Blog and Families and Health blog. He is the Director
of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand
Junction, CO where he directs a collaborative training program for family
physicians, medical family therapists, and psychologists. He is co-chair of the
2013 CFHA conference in Denver, CO.
This post has not been tagged.
Posted By By Laura Sudano (ft. Reitz),
Saturday, April 27, 2013
Updated: Thursday, May 30, 2013
| Comments (3)
Laura and Randall's
post is the last
in a 5-part series on
If you have been in your chosen career
for more than five years, please disregard this blog.
Stop reading now.
It is not intended for you.
Your persistence is starting to creep
There, much better. Now we can speak candidly.
Early career professionals are in a
tough spot. Not only are we asked to carry more than our weight in proving
ourselves, we do it with the limited networks and without the influence of
people who are already established in their careers. Facing this double whammy, what can we do to
exert leadership? How can we utilize
those who are willing to help us in moving the field in the direction we
believe is most fruitful?
Well, for starters, we can learn from
Nelson Mandela, Barack Obama, and Beyoncé Knowles.
In Nelson Mandela’s autobiography, "Long Walk to Freedom,”
he described his leadership style as follows:
"A leader is like a shepherd. He stays behind the flock,
letting the most nimble go out ahead, whereupon the others follow, not
realizing that all along they are being directed from behind.”
across the Atlantic, US historians parse political narratives to identify a
"doctrine” that encapsulates a president’s leadership style. The emerging "Obama Doctrine” is a
Mandela-esque "Leadership from Behind”. This doctrine is described in both
glowing (here, here, and here) and
derisive (here, here, here, and here)
supporters, leadership from behind describes a president who has assembled a
team of brilliant rivals that follows a rigorous process to hash out a
consensus. They describe Obama as a
president who is willing to allow all branches of government a role and in
international affairs they see him as diplomatic and insistent that America not
go it alone.|
Mandela and Obama are obviously world leaders elected to high offices, we wonder
if "leadership from behind” might be the optimal approach for early career
professionals who are positioning themselves for future collaborative care
figure from which we ECPs can learn is American singer, songwriter, dancer, and
actress, Beyoncé Knowles. Like Obama and
Mandela, Beyoncé has been a role model for leaders and young
professionals alike. Her unparalleled
entrepreneurial business savvy has been on display since an early age. She is
always re-defining herself and developing as an artist.
collaborative perspective, she promotes women musicians by having an all-female
band (as seen on Super Bowl XLVII Halftime Show here) and collaborating with artists outside her
genre including Sean Paul, Shakira, Justin Timberlake, and Lady Gaga. Through collaborating with other early career
musical leaders she asserts her own identity (influencing) and remains open to
others (being influenced).
may feel that they are still in a learner’s position, consider the following
question, "How can I be influential to those around me when I’m still in
training?” Asking the question of how you could be influential allows you to
examine where you have been in your professional career and where you would
like to go. And most importantly, who is
coming with you. More specifically, reflecting
on the unique aspects that you bring (or brought you) to the field of integrated
care and how you can access and expand your network
to influence the field accordingly is something that ECPs can do right now.
allegiance and support among current leaders can help you, the ECP, to lead
from behind. One can achieve this by
presenting ideas to those you look up to as current leaders in the field and
join collaboratively, whether it be for a paper, a presentation, or
interviewing the individual(s) for a class project.
approach to early career leadership is lifting others in your cohort. To riff off
the many versions of Advice, Like Youth,
Probably Just Wasted on the Young by Mary Schmich (see here), your
colleagues, like siblings, are "the best link to your past and the people most
likely to stick with you in the future.” Lifting others in your cohort and staying
connected to others who you’ve met through networking is an invaluable
relationship. Similar to you approaching
current leaders in your field, presenting your ideas to colleagues is invariably
impacting others. As a result, you build
your network and display your ideas to others so that you can continue to lead
from behind for ECPs may appear as a pro-active approach to an unfortunate
reality. However, as ECPs, we have an obligation
to influence and be influenced. As systemic thinkers, we know the value of
moving away from a linear approach (e.g., people are depressed because of an imbalance
of chemicals in the brain) to a systems approach (e.g., psychosocial factors play
a part in depression). As such, we
should move away from the top-down approach (e.g., implementing what our
leaders have shown us) to a cyclical approach (e.g., presenting our ideas to colleagues/leaders
and in turn, have them be influenced by us).
We hope this post will spark conversation about how ECPs "lead from behind” and (if any
mid- to late-career people stuck it out) how mentors have witnessed ECPs
"leading from behind.”
Here are questions to consider:
1. What are limitations faced by ECPs seeking leadership opportunities?
2. What can be done to overcome these obstacles?
3. Who are your role models in early career leadership?
4. What are other leadership styles you have seen to be effective
5. Does a feminist perspective support or
discourage "leading from behind”?,
|Laura Sudano is a Marriage and Family Therapy doctoral candidate at
Virginia Tech and works as a Medical Family Therapy fellow within the
Family Medicine residency at St. Mary’s Hospital in Grand Junction, CO.
She currently serves on the Denver 2013 CFHA conference planning
committee and is the co-chair for CFHA's Social & Networking
|Randall Reitz should not have contributed to or read this blog. The possibility that he still considers himself an early career professional is delusional, laughable, and probably creepy.|
This post has not been tagged.
Posted By Jeri Hepworth,
Friday, April 26, 2013
| Comments (0)
Jeri's post is the fourth
in a 5-part series on
Twenty-four hours in a day, thirty days in a month, twelve months in a year, thirty-five or forty years in a career – how do we want to spend those hours? What do we want to accomplish, what do we care about? These concerns of time management consultants are also salient for those of us fortunate enough to be collaborative consultants whether in clinical practice, administration, policy or academia. The better we work with others, the more frequently we will be invited to take on new roles.
Yet the success of new invitations and opportunities can easily slide into stress and distress. We all know colleagues who, when asked about their life, say, "Way too busy”. And though it can be tempting to consider them important in their many roles, I also find myself wanting to distance. I prefer to socialize, work, and learn from others who do not always appear overwhelmed. We want colleagues and leaders who manage their anxiety and their time, not those who act frenetically like Kramer from the Seinfeld episodes. So how can we do it? How can we take advantage of the multiple opportunities around us without letting them take advantage of us?
I do not pretend to always do it well myself, but I enjoy helping individuals and systems consider their passions and priorities. This has included clinical work with families, team and organizational development, and mentoring of other professionals. As Director of Faculty Development programs for our medical school, it is a privilege to support leaders, or faculty who are considering promotion, and help them think about what they do well and how they can be more successful.
Just like clinical work, it is easier to do it than write about it. My response is to simplify, and to organize my thinking as "Pearls”. It is also fun to use alliteration, so I suggest a list of pearls that includes: Passion, Plan, Prioritization, Pro-action, Prioritization, Promotion of Others, and Play.
What’s yourpassion? A powerful group exercise is to have people share why they decided to enter their career. Generally, it reflects deep meaning about wanting to make a change or an impact. Reminding ourselves of our ongoing larger commitments is core to professional success. We may not know how we are going to make the difference or what exactly we will do, but stating our core values and purpose helps us form a personal mission statement – a statement that can be used to measure the relevance of new opportunities.
What’s your plan?Create your plan to reflect your personal mission statement as well as a realistic appraisal of your interests and energy for new opportunities. Assessing interests seems relatively intuitive. Does this new opportunity excite me? Does it add to my evolving personal mission, or will it distract me and move me further away from the things I most care about? Opportunities for administrative roles are prime examples that require careful consideration. If I take on this Director position, for example, will I really be able to help set the direction of the clinic, or will I spend most of my time involved with budgets?
Assessment of energy is a second factor. Do I care about this opportunity enough to work more? Or if I take on this role, what will I give up? This is the place to consider the developmental trajectory of a career. Early in my career, I made a choice to work three-quarter time, but not when my children were infants and enrolled in excellent child care near their father. Instead, I created more flexibility after I had gained my first academic promotion (part of my personal mission). At that time, my children were in public school, and I was able to participate more with them in sports and after school programs (also part of my personal mission).
A caveat holds for executions of plans. Interviews of later stage satisfied professionals rarely identify a rigid plan about how they achieved success. Instead, most report that they generally knew what they were interested in, but they were also open to new opportunities. The challenge is to take the time to measure those new opportunities against the most important ruler – that of personal passion and commitment.
How can you prioritize according to your plan? There are at least two factors that can help us make choices that move us toward our personal definitions of success. One is to select those opportunities that reflect alignment between our personal mission and the goals of our larger systems. The second is to prioritize activities and opportunities that we can and will actually do.
A clinician in a consulting practice may agree to give a series of parenting talks to a community group because the presenter cares about affirming families in the community (part of their personal mission). Giving those talks also helps market the collaborative practice (alignment with larger system mission). Colleagues skilled in collaboration know how to create win-wins.
The second factor about prioritization is to promise carefully, something I have not always done well. Sometimes opportunities seem so exciting that we jump for them without determining whether we have the skills or whether we can prioritize the time to complete them. Opportunities do not help us meet our goals if we have to apologize for not getting a promised task completed. Just as in personal interactions in which negative comments count far more heavily than positive comments, work that is late, incomplete, or poorly done is remembered far more than work which was appropriately done.
How can you be pro-active without being pushy? Sharing a plan with others helps provide personal commitment. It also makes it clear what help one can use from others. Pro-active professionals ask for formal and informal mentoring, and let others know what they are interested in achieving. "Graceful self-promotion” includes volunteering for an activity, letting a colleague know of an achievement, or informing another why you will not consider an offered opportunity. "Thank you so much for asking me to write the book review. I want to do a good job, and I feel this is not in my area of expertise. But I’d be very interested in reviewing a book about health system redesign. Could you keep me in mind for something like that?”
How can we best promote others? Great leaders celebrate others. Collaborative care professionals know why recognition is important and how to do it well. Appreciation – whether done privately through conversation, emails or notes, or publicly through other forums, builds relationships. Recognition of others creates a culture that facilitates success for many. In the example above, in which the opportunity to write a book review was turned down, a further statement can be helpful. "My colleague would do a great job with this book review. Can I give you her name?” Or, "Would it be helpful for me to think about who might be do a good job with this review and get back to you?” (And then, since it is a promise, make sure you do get back.)
What is the relevance of play? Successful people find ways to create play in their personal life as "balance”, but also find joy and play in their work. A sense of play leads to renewal, re-vision, and frequently gratitude. We are fortunate people to be able to engage in work that we have chosen, that is meaningful, and that we enjoy. We are doubly fortunate to be able to continue to determine how we change and grow in our work.
Play is not an add-on, but a responsibility. Play allows us to remember our passion, refine our plans, and prioritize our efforts. Our work is too important to be left to those who just put in their time.
Jeri Hepworth, PhD LMFT is professor and vice chair of the Department of Family Medicine at the University of Connecticut. She is the immediate past president of STFM. Her professional work has focused on families and health, psychosocial issues in medicine, and managing personal and professional stress. Among her publications, she is co-author of 3 books: Medical Family Therapy, The Shared Experience of Illness, and Family Oriented Primary Care.
This post has not been tagged.
Posted By Alexander Blount,
Thursday, April 18, 2013
| Comments (0)
Sandy's post is the third
in a 5-part series on
One of the roles of leadership in a field is being comfortable speaking
on behalf of the field. To do that, it helps to have a clear summary
that is understandable to someone outside the field. One name for that
summary is an "elevator speech. It
is called that because it designates what a person could say to
another person while making conversation riding together a few floors in
I had an opportunity to try out my skills at the elevator
speech for integrated primary care not long ago on an airplane. I was
seated next to a gentleman for a couple of hours but we didn’t start to
speak until the last 10 minutes of the flight. He was
a guy who has to fly a fair amount because he has several small
businesses. The businesses were quite varied. He was clearly a self-made
guy who was doing OK but was not extremely successful, an entrepreneur
on a comparatively small scale. He knew about doing
everything his own way and he made his own decisions. It was not in an
elevator, but we were changing elevation and the length was only
slightly longer that a 15 floor ride in a high rise.
This is not verbatim, but close, and the last line is a quote.
The conversation went something like this:
Bob: So, do you come to San Diego on business or pleasure?
Sandy: Business, I’m here for a conference on integrating mental health into primary care.
Bob: What’s the advantage of doing that?
Sandy: It’s the best way to improve the health of the people who come
to Primary Care. Primary care is where people bring all the problems
that theydon’t know what to do about. A lot of times those problems,
even the problems that are clearly physical, are
related to the fact that they don’t take care of themselves. They are
depressed or they are anxious, or they drink too much, or they don’t eat
right, or don’t take their medicine, so they feel bad, so they hurt.
When people are hurting it tends to make them
more anxious or more depressed, or they drink more, or exercise less.
If the doctor says he/she can take care of the part that hurts but they
are going to send them to a mental health service or a substance abuse
service for their anxiety, or depression, or
drinking, a majority of the people don’t go. For them it doesn’t feel
like two separate things. It feels like one thing. It’s only when you
bring a person who can deal with anxiety and depression and alcohol use
problems into the primary care and put them
on a team with a doctor that the patient feels like he/she can get
their whole situation cared for.
It even costs less because if the person doesn’t get the
whole situation dealt with effectively, they tend to go other places
like emergency rooms to try and get enough care to relieve their various
Bob: I’m trying to imagine what that would be like in the doctor’s office. How would it work?
Sandy: Well, if you came because you had a pain or because it was
time for your physical, the doctor might talk to you about how your life
was going or give you a screening test that would take about 5 minutes.
The test would help pick up if you were having troubles with
depression or anxiety or drinking. And if any of thoseseemed to be a
part of the situation that you’re bringing, the doctor might call in a
psychologist or a clinical social worker or some
other person that they would probably call a behavioral specialist. The
doc might introduce you to the behavioral specialist and go see another
patient or two while the both of you talked. Just like primary care
doctors take care of everyday kinds of problems
after they make sure it’s nothing that’s going to kill you, behavioral
specialist would probably do the same. He/she would ask you a couple of
questions to be sure that you weren’t in a very serious or dangerous
situation but then they would focus on getting
you better as quickly as possible. They might work with you to find
something that you like to do everyday, which actually has been shown to
start improvement for people with depression, orthey might teach you
some breathing exercises that actually make a
difference with people with anxiety. When the doctor came back in the
behavioral specialist might make a recommendation to the doctor about
whether the doctor might consider prescribing you some medicine. You
might come back to see the behavioral specialist
a time or two to be sure that things are heading in the right
direction. But in the long run you just go back to working with your
doctor and the behavioral specialist would be somebody who would be
available if you ever needed them again.
Bob: That sounds terrific, sign me up!
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
This post has not been tagged.
Posted By Rusty Kallenberg,
Thursday, April 11, 2013
| Comments (0)
Rusty's post is the second
in a 5-part series on
Whenever one chooses to develop a vision that deviates from
"the norm” and build something that is new, different, ahead-of-the-curve, yea
– "disruptive” – strategic partnerships are necessary for both survival and
success. Looking back on the 10 year development
history of our "Collaborative Care” Team here at UCSD Division of Family
Medicine we have learned the following lessons about building strategic
1. Your own clinical team. Incorporating mental/behavioral health
(M/BH) services within one’s own clinical operation is, as we all know, a
substantial organizational challenge that involves policy, process and culture.
The details of the first two have been well addressed in many of the
presentations at CFHA over the past few years.
The cultural challenges are a
bit more subtle, a bit under the table, but no less important.
Here in San Diego, we began with an assessment
of clinician attitudes to gauge the perceived need, responsibility and skills
to detect and attend to M/BH patient problems.
Once we had concurrence among most of our clinicians we were able to
introduce M/BH clinicians to "help” our PCPs handle the frequent M/BH problems
they encountered. This interaction
spread person-to-person from the usual early adopters. Close communication (both written and verbal)
between the clinical sides over patient care work helped build the collegial
bridge needed for true collaboration.
The most difficult challenges were/are over clinical space utilization
where the dollars/hr. generation potential still favors medical care vs. M/BH
care. We have tried to solve this in
various ways but the strategic relationship that makes this happen peacefully
is between our CC Director (also a practitioner) and our office managers and
medical directors. If they are on the
same page then problems get worked out.
Assess/build consensus among clinical team that
M/BH patient problems are important and their responsibility
Ensure multiple convenient communication
pathways between PCPs and M/BH clinicians
Ensure close working partnerships between
clinical office-level leadership and CC leadership
2. Partnering M/BH teams. Seems like a no-brainer but this will play
out in many different forms depending on your setting. Here at UCSD it involved connecting with our
Dept. of Psychiatry as a first step due to their "all things psychological are
our business” view of the world. We
gradually weaned them off of this position and now handle all M/BH clinician hiring,
billing and clinical operations of our CC Team efforts as part of our Family
Medicine clinical shop. Having internal
licensed M/BH leadership has been key to our development of internal policies
and processes of collaborative care delivery and relating to the clinical
office leadership as noted above. Through
their efforts we have developed and assessed universal screening for
depression, increased coverage for warm-handoffs, and a plan for broadening the
definition of M/BH services to include health coaching.
A special strategic partnership we have built
is with the University of San Diego’s Marital and Family Therapy (MFT) Training
Program. This has allowed us to greatly
expand our service delivery reach while training more collaborative
care-oriented M/BH clinicians for the community. This works well in our academic training
environment and allows for inter-professional training involving our family
medicine residents to occur as well.
This is a very fast growing international movement in health professions
training. Trainees allow the "multiplier
effect” through converting licensed M/BH clinicians into clinical supervisors,
thereby being able to serve many more clients than those licensed folks could
Establish clear shared/mutual/joint "ownership”
of M/BH services within your clinical operation with your M/BH provider group
Identify and empower local M/BH leadership
Consider establishing precepting relationship
with local M/BH training programs
3. Operational Support Teams. These come in many varieties but are always
crucial to ongoing management success for Collaborative Care teams. They cover a broad span include provider
licensing and privileging, billing and insurance coverage, chart documentation
and electronic health records, and practiced data analysis. We have spent much time to establish and
nurture close working relationships with the many departments and supervisors
in charge of these services at UCSD.
This involved credentialling MFTs on our rosters of approved M/BH
clinicians and getting them approved by our local insurance providers, working
out billing codes for M/BH services within our clinical shops where they
represented new books of business, and working out specific rules with our
compliance office re: including and integrating M/BH chart notes within the primary
care medical record – which greatly facilitates PCP-M/BH communication. This latter task required specific
negotiation about wording of M/BH clinical notes in ways that reassured the
compliance folks but did not hamper clinical communication.
Electronic medical records applications
represent a topic deserving of special mention.
Our system is fully computerized so the success of any new clinical
operation is in part due to how well it is integrated into the EMR our
clinicians use all the time. So we have
worked to accomplish total integration of our CC Team’s work from
appointing/scheduling to documentation of clinical notes to inter-provider
communication and ultimately, data analysis.
This required lots of communications with the various EMR build teams
and an understanding with our EMR leadership that we considered our CC Team
services as integral to our clinical operation.
Finally, with regard to data analysis on the
back end of care – we feel that this is absolutely critical to knowing what’s
working and what needs further refinement.
We have long funded an internal data analyst who we direct, and whose
job is to analyze our clinical shop data for whatever purposes we
designate. The success of this person is
dependent on the strategic relationships we have built with all the owners of
clinical and financial data in our Medical Center. As a consequence our data analyst has the
"keys to the castle” for all the data systems in our institution. We are able then to generate reports on productivity,
costs and increasingly on clinical outcomes of interest to both clinicians and
researchers. Some of these services have
required us to fiscally support them and we have determined that at times this
is ultimately in our best interests.
Map all processes needed to carry out the CC
mission and determine who owns these processes in your clinical setting and
establish working relationships with all of them
Make clear your operational needs in order to deliver the best patient care possible –
as this is a goal all such support folks should be committed to serving
If you have an EMR – use it to support and
integrate your CC services.
Be willing to potentially compensate for support
services rendered if they are new or "above and beyond the call”
One really cannot do anything truly "collaborative” if one
isn’t successfully partnered with strategic allies. Because integrating M/BH services into
medical care sites is still often "revolutionary” and "disruptive” – it does
take collective effort across the board.
Building strategic partnerships
both internally and externally requires prospective partners to understand the
vision you are trying to achieve. That
vision – of better and more complete, whole person care – should be a shared goal
of all who are in the health care delivery business.
Dr. Gene "Rusty" Kallenberg has beenChief of the
Division of Family Medicine and Vice Chair of the Dept. of Family and
Preventive Medicine at University of California, San Diego since 2001. Previously
he was the Chief of Family Medicine and Asst. Dean for Curricular Projects at George
Washington University where he was from 1982-2001. He has been a member of CFHA
for the past 16 years (with some gaps!).
Dr. Kallenberg currently serves as one of the four Clinical Foundations Directors of the new UCSD Medical School
Integrated Scientific Curriculum and runs the Ambulatory Care Apprenticeship
component as well. He also is the
Director of the new UCSD Center for Integrative Medicine which started
operations in 2010.
This post has not been tagged.
Posted By Susan McDaniel,
Thursday, April 4, 2013
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Susan's post is the first
in a 5-part series on
WHAT I WISH I’D KNOWN
WHEN I STARTED:
Vision and the Evolution of a Collaborative Leadership Style
I could start this story with my Family of Origin-- my
energetic, Ob/Gyn father and my strong-willed, arts activist mother. I also have a competitive and very successful
journalist/businesswoman sister. But
I’ll spare you the details on all that, and start with 1982. I was 30, and got my first academic job in
Family Medicine. It was .35FTE and I was
the first female and first non-MD on the U of Rochester Family Medicine faculty. The Chair encouraged me not to "worry about
coming to faculty meetings.” Somehow (perhaps because of the structural
family therapy training I had complained about as a postdoc) I knew not to
listen, and told him I’d be there. First lesson: Try to hone your skills about when to listen
to others and when to have the courage of your own convictions. (I was also discouraged from several
people about taking a job in Family Medicine as "it’s the stepchild of
medicine.” And earlier, the
psychologists I worked for during my year as a research assistant after college
urged me to go into Law rather than Psychology.
I’m sure glad I didn’t listen to them.)
Really, I do seek a lot of advice and I
usually take it. But when I really
believe in what I’m doing, I take the risk; then at least it’s my fault, not
someone else’s, if it doesn’t work out.
I just went to a Tribute at the Fort Lauderdale Museum of Art for my
mother who died 12/24/12 In addition to
comparing her to Scarlett O’Hara, one of the speakers talked repeatedly about
her "courage” in advocating for the arts in Fort Lauderdale and across the
state. When they broke ground on the big
new Museum of Art 25 years ago, there was a photo of 6 men and my mother, all
with shovels. I hope I inherited some
amount of courage from her, as it’s critical when you’re going against the
tide. From a family systems view, I
think we’d say that individuation is critical for healthy collaboration.
Medicine was and is a wonderful laboratory for someone like me interested in
biopsychosocial medicine. I was so
fortunate to work with pioneering people like Lyman Wynne (a psychiatrist and
father of family therapy) and George Engel (and internist and the father of
biopsychosocial medicine) during the first 25 years of my career. They were wonderful mentors--educating,
coaching, supporting, and challenging me.
Second lesson: Seek out experienced people you respect and
ask to work with them, no matter their discipline. The mentoring will come naturally. I learned so much from these two men. Their work forms the foundation of mine. To say I stand on their shoulders would be an
beginning, it was clear to me and many of the faculty and residents in Family
Medicine that family therapy has so much to offer patient care and
education. The key was really learning
about primary care. That took connecting
with a key collaborator. For me, it was
family physician, Tom Campbell. We were
both young and new. (It helps to be
idealistic, energetic, and somewhat stupid early on. You see the world with fresh eyes. I just couldn’t understand how medical care
could be delivered without attention to psychosocial issues. Actually that’s still true….) In the early 80s, Tom taught me about family
medicine ("I don’t care about theory.
Just tell me what to do.”), and I taught him about family therapy ("Slow
down. I want to know the history and the
relationships. Give me a
genogram.”) Together we developed a
family-oriented curriculum for primary care that eventually became a book. Third
lesson: Choose your smartest, healthiest
collaborators. This is as important
as your marital or life partner. You
need many of the same attitudes and skills:
respect, communication, conflict management, problem-solving. It’s a very intimate relationship, in the
professional sense of the word. I did
and do learn a tremendous amount from Tom.
Then through professional meetings, I became close with family
therapists, Jeri Hepworth and Bill Doherty, who were (and are) working in Connecticut and Minnesota. The three of us were fortunate to be at a Family Process quadrennial in 1988 in Costa Rica, and we talked once again (a favorite topic of ours) about how we now
knew how to teach primary care physicians about psychosocial medicine and
family systems, but we were frustrated about how all our mental health
colleagues didn’t understand biopsychosocial medicine. It was a one-way street far too often. For some reason, maybe the palm trees or the
drink beside the pool, Jeri didn’t join in complaining this time. Rather, she challenged us: why don’t we write a book for mental health
professionals about this work? The 3 of
us flew together from Costa Rica to the Family Medicine Amelia Island meeting
via Nicaragua (where there were soldiers with machine guns outside the plane,
but we didn’t stop working). By the time
we landed in Jacksonville, we had an outline for
the first edition of Medical Family
Therapy. Like any good partner, once
you find good collaborators, don’t let them go!
It took some major arm-twisting at various points to get Bill and Jeri
to do the 2nd edition of this book, which will come out this
summer. But collaborators that they are,
once on board they were fully on
board. And what a beautiful product it
and are many, many challenges to this work.
I left out all those stories in order to tell you these. And that brings me to the Final lesson: Persistence! If you have a vision, challenges help
clarify what it truly is. Some projects
take weeks, others months, still other decades.
I’ve often thought persistence may be my strongest talent. For new professionals, having the long view
can really help when the inevitable difficulties and hard times arrive. Collaborative care is not yet the dominant
paradigm, so challenges are to be expected, endured, even occasionally
embraced. And they make the successes
that much sweeter.
Dr. McDaniel is the Dr Laurie Sands Distinguished Professor
of Families & Health, the Director of the Institute for the Family in the
Department of Psychiatry, Associate Chair of the Department of Family Medicine,
and the Director of the Patient- and Family-Centered Care Physician Coaching
Program at the University of Rochester Medical Center, where she has been since
beginning her career in 1980. Her career
is dedicated to integrating mental/behavioral health into healthcare. Dr McDaniel is the author of numerous journal
articles and 13 books, translated into 8 languages. She was co-editor of Families, Systems & Health for 12 years, and is now an Associate Editor of the American Psychologist. She is very excited about her latest book,
co-authored with Bill Doherty and Jeri Hepworth. Medical Family Therapy and Integrated Care, 2nd Edition, is
In Press and will be published late this July--21 years after the 1st
This post has not been tagged.
Posted By Larry Lantinga,
Thursday, March 28, 2013
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Larry's blog is the fourth
post in a series on
integrated care for
military and veterans.
Hawaii, Homelessness & Collaborative Care!
These three concepts can’t possible be included in a blog for CFHA, can
they? Well yes, I think they can and here goes.
While vacationing in
Hawaii with my lovely wife, children and grandkids I awakened early
Sunday morning, brewed a pot of Kona coffee, and grabbed the Honolulu
Star Advertiser to begin my Sunday morning ritual. The front page
headline in 44 point type read: $77 million Proposed for Homeless! The sub-headline read: Honolulu’s Sidewalk Blight!
The story led with findings from a recent survey that Waikiki tourists’
number one complaint was the presence of the homeless near many of the
best hotels in town and how these poor travelers are often forced to
"….walk out of their way or into the street to avoid getting too close
to homeless campers who are blocking sidewalk access and loitering near
the convention center.”
Although I wasn’t among those doing the
complaining, I didn’t feel very good about being a tourist at that
moment. The story went on to report that a local city councilman was
proposing $77 million dollars be used to address this problem with the
most prominent proposal being the creation of a tent city, well removed
from the areas frequented by those poor tourists. I felt like
calling the Honolulu paper and telling them "don’t let your politicians waste
your money on a tent city, spend it instead on healthcare for your
homeless and specifically make that collaborative healthcare!"
I say that? Let me explain.
among Veterans is an important issue. Approximately 76,000 Veterans
are homeless on any given night in America. And over the course of a
year, approximately twice as many will experience some episode of
homelessness. Eliminating Veteran homelessness is one of VA’s top
priorities and is a challenge that Veterans, their families, and VA have
been working to overcome for a number of years. In 2009 the Secretary
of the Department of Veterans Affairs, Eric Shinseki announced VA’s goal
to end homelessness among Veterans within five years. We are not there
yet, but each year the number of homeless Veterans has been decreasing
as VA has increased homeless Veterans’ access to permanent supportive
housing, supportive employment and benefits, and well designed and
Homelessness is caused by some illnesses, e.g.,
mental illness, substance abuse, disabling medical conditions.
Homelessness causes other illnesses, e.g., exposure, infestation-related
disorders, and exposure to infectious diseases such as TB. And last
but certainly not least, homelessness exacerbates management of other
diseases such as diabetes and hypertension. Homeless individuals are
three to six time more likely to become ill than housed individuals.
And within the VA, the cost of providing healthcare to homeless Veterans is
three times the cost of care for non-homeless Veterans. Thus, the
provision of accessible, comprehensive, coordinated and collaborative
care is essential to the effective treatment of the homeless.
research literature pretty strongly suggests that traditional primary
care is not a particularly effective health care delivery system for
our homeless Veterans. However there is a growing number of studies
that show strong support for a model of care in which primary care
services are linked with care management, embedded mental health, and
housing support. Sounds like collaborative care to me! In a
Chicago-based study a program using this approach, a 29% reduction in
hospital days and a 24% reduction in emergency department use were
is betting that its new and improved primary care system known as PACT,
in combination with dedicated and embedded services for the homeless,
will provide a better alternative to address the healthcare needs of its
Veterans with multiple medical problems and chronic states of
homelessness. PACT is the acronym for Patient Aligned Care Team—VA’s term for patient centered, team based, collaborative primary care. PACT
is each Veteran working together with health care professionals to plan
for the whole-person care and life-long health and wellness, with a
focus on partnerships with Veterans, access to care using diverse methods, coordinated care among team members, and team-based care
with Veterans as the center of their PACT.
To make PACT even more
relevant to the care of homeless Veterans, VA created a new program
known as H-PACT --Homeless-PACT teams. H-PACTs are uniquely
formulated to meet the healthcare needs of homeless Veterans. There are
several different H-Pact Models being "field tested” in VA at the
present time. These models vary depending on geographic location and
estimated numbers of homeless Veterans. The most comprehensive H-Pact,
suited for larger VAs in urban areas with a large homeless Veterans
population, combines a full blown PACT and a comprehensive Homeless
Veteran Treatment Team that are co-located and fully integrated and have
their own panel of homeless primary care Veterans. And yet another
H-PACT model targets those Veterans who are chronically homeless,
treatment and service disengaged, or treatment resistant Veterans. This
latter model is usually located in the areas frequented by the
homeless, often near the non-VA community shelters that are operated in
is a very new program, that was initially started as a small pilot. VA
is considering expanding the number of H-PACT teams nationally, if it
can find the most effective type of H-PACT from among the several
variations that have already started. The Center for Integrated
Healthcare will be assisting VA’s Homeless Program Office in conducting
some of the initial evaluation work, so stay tuned. Perhaps in a future
blog I’ll have more information for you. For now, just remember that
collaborative care is at the heart of H-PACT.
Dr. Lantinga is a licensed psychologist who has worked for VA for over
40 years and is currently the Associate Director of the Center for Integrated
Healthcare. In this role
he is responsible for the day-to-day leadership of the Center, in
support of the Executive Director. He also closely collaborates with the
researchers and educators in the Center. Dr. Lantinga maintains
academic affiliations with faculty positions in the Psychology
Department at Syracuse University and in the Departments of Psychiatry
and Urology at the State University of New York Upstate Medical
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Posted By Katherine Dollar,
Thursday, March 28, 2013
| Comments (0)
Kathy's blog is the third
post in a series on
integrated care for
military and veterans.
When I began my training as a clinical
psychologist, I did not envision myself working for the Department of
Veterans Affairs. In fact, I would have predicted that I would end up
in almost any other setting. The myths or stereotypes described by Dr.
Pomerantz’s prior blog predominated my thinking. As I suspect happens
to many of us, my early career projections were wrong, as were my
stereotypes of the VA.
the lens of a clinician, I hope that I can further dispel some of the
common myths and present a clear picture of integrated care within the
VA. There is a great deal of variation across our large network of
facilities, and my thoughts may not be consistent with the experiences
of clinicians at every location. However, I do believe that there are
common themes experienced in most VA integrated care settings.
it has been my experience that providers within the VA care deeply
about Veterans and Veteran healthcare. I consistently see primary care
colleagues going to extraordinary lengths to ensure high quality,
patient-centered care. In a recent hallway conversation with two of my
primary care colleagues, we ended up discussing the overwhelming sense
of duty and responsibility to provide exceptional care for the Veterans
and how this translates not only into direct service delivery, but also
into interactions with patients in hallways, over the phone, and in
the community. The reality is that VA employees care tremendously about
Veterans and about providing high quality care.
We also have a high
degree of accountability built into the system through policy and
programmatic expectations. It is experienced as a system of checks and
balances with multiple requirements and high levels of accountability
and oversight. Integrated care, including both collocated collaborative
care and care management, are not options, but programmatic
integral part of functioning as a behavioral health provider in a VA
primary care clinic is communicating and working closely with all
primary care team members. Typically, this means that days begin with a
team huddle, including the primary care provider, the RN, LPN,
administrative support, and other primary care-based professionals
(e.g., dieticians, pharmacists, medical social workers). Fully
consistent with the tenants of the medical home, we are implementing
team-based care. Skills in collaborating with other medical professions
are necessary to be successful. Indeed, several of my colleagues who
were not used to team-based care have had to change their practice
management styles or risk becoming irrelevant to the clinic.
huddles we usually review patients who are scheduled to be seen by the
team that day and discuss the plan for care. As the integrated
clinician, and the behavioral change expert, I provide input for mental
health concerns as well as medical conditions that have a strong
behavioral component. I might discuss potential ways for the other team
members to approach these concerns, offer to join the provider or one
of the nurses in their appointment with the patient, or offer to see
the patient individually the same day.
day, or open/advanced access is another integral component of
integrated care within the VA. There are many ways this can be
achieved and this has been structured differently in various locations.
The clinics in which I have become most familiar, have structured
schedule grids such as scheduled 30 minute appointment slots on the
hour, with the back half of the hour usually unscheduled. This allows
access to appointments for Veterans the same day that they see their
primary care team.
Although there is much variation in implementation,
Veterans and the other primary care team members value this scheduling
feature. It provides direct access to a behavioral health specialist not
only allowing the Veteran to start an intervention the same day that
symptoms were identified by the primary care team, but also allows the
primary care team members to have direct communication and
consultation with a mental health provider. This process de-mystifies
mental health service delivery.
the VA primary care setting, we see a surprisingly diverse population
of Veterans, including women, reservists, individuals who served in the
National Guard, and younger individuals recently returning from active
duty who have young families. If you visit expecting to find the image
of the Veteran conjured up from the song, "Take Me to the Mountains”,
you will be surprised. Clinics are busy, vibrant locations with diverse
patient populations, that have dramatically moved beyond the
stereotypical view of Veteran healthcare settings.
part of meeting the needs of the diverse population we have
incorporated technology into our communication and interventions for
patients. We routinely use telephone, video teleconferencing, and
secure instant messaging to communicate with Veterans and provide
service delivery. As the Veteran population has shifted to include
younger individuals, who communicate primarily through advanced
technological platforms, the VA has embraced these technologies and has
remained relevant to this population by finding ways to incorporate
technology into care within and outside of the primary care setting.
Further, these innovative advancements allows us to increase access to
and communication with Veterans living in rural locations, who may not
be able to make routine visits to medical centers to obtain mental
health services. As a clinician, I like having to capacity to serve
Veterans who may not be engaged in treatment without the use of
types of services being provided in VA integrated care are
complementary. Through the provision of collocated, collaborative care,
and care management, we combine same day access to a therapist who may
provide a brief intervention, with the use of evidence-based screening,
assessment, decision support, and symptom monitoring . Thus, patients
receive a unique blend of evidence-based services that are tailored to
their individual needs, are tracked over time, and adjusted based on
symptom severity. This system, when optimally functioning, creates a
feedback loop between the patient and all team members.
closing, I hope through a combination of our posts, we have dispelled
many of the myths and outdated stereotypes about VA service delivery
while providing a picture of a modern, patient-centered, results-driven
healthcare system. I am honored to work for the Department of Veterans
Affairs, as are my colleagues and co-team members. I am thankful that
my career projections were just as erroneous as my stereotypical views
of the VA. Through continued implementation of the medical home model,
the VA continues to be a leader in patient-centered, team-based,
results-driven, innovative care.
Katherine M. Dollar, PhD is the Clinical Coordinator at the VA Center for Integrated Healthcare (CIH) and a Research Assistant Professor, in the Department of Community Health & Health Behavior at SUNY Buffalo. Dr. Dollar is also a Consultant to the VA Office of Mental Health Operations (OMHO). CIH is VA Center of Excellence
devoted to advancing research, education, and clinical consultation to
enhance the integration of mental health and primary care services for
America's Veterans. She provides consultation, education,
and technical assistance, for facilities, networks, and individuals
requesting program assistance to achieve full implementation of VA
integrated care components.
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Posted By Andrew Pomerantz,
Thursday, March 21, 2013
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Andy's blog is the second
post in a series on
integrated care for
military and veterans.
"Found him on VA ward, feelin’ kind of low.”
"A pardon from a VA ward, just ain’t so easy done…but a good old friend and doctor there said it could be done.”
Those lines, from the old song "Take Me to the Mountains,” invariably conjures images that were popular a generation or two ago when the Veterans Administration hospital system was the last vestige of hope for combat Veterans who had fallen off the rails of society. Whether the image was true even then is arguable and I don’t think worth discussion now. Suffice it to say, the Veterans Health Administration (one of three arms of the Department of Veterans Affairs, created 30 years ago) is now a highly developed single payer capitated healthcare system and the largest healthcare system in the United States, with over 8 million enrolled Veterans and nearly a thousand VA facilities and community based outpatient clinics in the US, Puerto Rico and the Philippine Islands. Now, more than half of VA care occurs in community based outpatient clinics and, by quality measures, is outperformed by no other systems.
Old perceptions die hard (and slowly), so, as we take a little time for a
few of us in VA to provide perspectives on this blog, a couple of myths
need to be tended to.
- "You can do that in the VA because you are part of the military and can do whatever you want”:False. VA is distinct from the military healthcare system and is held accountable to the same standards as any other healthcare entity.(It should note that the military health system is also an integrated care leader).
- "Only combat Veterans can get care in VA”: False again.Just about anyone who has been honorably discharged from the military can enroll for care, as can many others, like active duty national guard members returning from combat. Some Veterans have a co-pay for some of their care, just as they do in the private sector.
- "VA facilities get as much money as they want. When they need more, Congress gives it to them.”Wrong again. We do have to live within our budgeted appropriation from congress and each facility’s budget is based on workload. At times, seed money (similar to grants in the private sector) is earmarked for new program development but after a few years, the special funding ends and the programs stand or fall on their results (yes just like grants).
These myths are only the tip of the iceberg but are the three most common statements I hear when I talk with people outside of the federal sector about the development of integrated care in this system. VHA provided special funding 5 years ago to help facilities develop integrated care programs, which are now mandated to be present in every VA medical center and the larger community based clinics. Many facilities are working now to develop innovative ways to integrate mental health and primary care in the smaller and more rural clinics.
There are two core components to integrated care in the VA, both resulting from local innovations and research whose results were so positive that went viral and became requirements.
1.Collocated collaborative care: This refers to the mental health clinicians (nurses, psychiatrists, social workers, psychologists) who are members of the primary care (medical home) team. They provide consultative advice and education, as well as direct assessment and treatment as part of the primary care treatment plan. CCC clinicians have a patient-centered, problem/function focused approach that streamlines care for patients identified (clinically or by routine, required screening) in primary care, Open or advanced (same-day) access is an important feature of the program. Despite broad variation in program development and function across the country, almost half of the primary care patients seen in integrated care last year never needed referral to specialized mental health care.
2.Care Management:This is the familiar telephone based care that provides disease registries, assessment, ongoing monitoring, medication management, problem solving and behavioral activation for patients treated for depression, anxiety and at-risk drinking. Similar protocols for chronic pain and other problems are currently being honed. The CM programs are based on the familiar RESPECT, IMPACT and other integrated approaches that have shown strikingly positive results over 20 years of research. The Behavioral Health Laboratory is a care management program developed within VA and has modules for all of the above disorders plus a referral management module. TIDES (Translating Initiatives for Depression into Effective Solutions) is the VA adaptation of the other programs in the research literature.
Two related programs are also part of VA integrated care. These include health behavior coordinators and health promotion/disease prevention programs that help Veterans achieve and maintain healthy lifestyles. They provide a wide range of services including training for providers, direct clinical care (MOVE! is an effective intervention for obesity and is often provided via telemedicine), health coaching and other interventions.
As the National Mental Health Director for Integrated Services it has been my privilege not only to develop policy but also to work closely with dozens of programs across the country as they grow and mature. I have learned a great deal as I see many programs adapting the core components to fit a wide variety of local environments. Having once been a primary care physician who went into psychiatry wanting to be able to do more, it’s almost enough to make me go back to primary care. But not quite.
Some of my national colleagues are going to follow this tome with more details of integrated primary care in VA. I would also refer you to the summer, 2010 issue of Families, Systems and Health, which was dedicated to the VA programs.
S. Pomerantz, MD is the VA’s National Mental Health Director for
Integrated Services, Associate Professor of Psychiatry at the Geisel School of Medicine at Dartmouth and a current member of the CFHA board
of directors. He has been a primary care physician, Consultation and
Geriatric Psychiatrist and was Chief of Mental Health at the VA in
Vermont for nearly 20 years. He has received many local and national
awards for his work integrating mental health and primary care and other
programs and is a Distinguished Life Fellow of the American Psychiatric
Association. He telecommutes from his home base in Vermont..
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Posted By Chris Hunter,
Friday, March 15, 2013
| Comments (0)
Chris's blog is the first
post in a series on
integrated care for
military and veterans.
In a recent article, the president of the American Medical Association highlighted the importance of integrating mental and physical health care. He noted important policy, finance and paradigm service delivery changes that make today ripe for such change. He further argued the importance of providing integrated care for at risk individuals with a special emphasis on retooling health care service providers so they can deliver efficient and effective whole person care. He goes further to highlight the importance of ensuring these services are available for our military service members. I couldn’t agree more and am pleased to report that the integrated care for our active duty and retired military service members as well as their families has been available for the last 13 years, and has continued to grow and improve.
Integrating behavioral health services into primary care in the Military Health System (MHS) is not a new concept. In 2000, the Air Force launched its Behavioral Health Optimization Program (BHOP). This program embedded behavioral health providers (primarily psychologists) into primary care clinics to provide integrated behavioral health services using a Primary Care Behavioral Health (PCBH) model of service delivery. In 2003 the Navy launched a 2-year demonstration project building on the work of the Air Force BHOP. The Army launched the Re-Engineering Systems of Primary Care for PTSD and Depression in the Military (RESPECT-MIL) feasibility study in 2004. This was a systems-level, care management model approach to improve recognition, management, and follow-up of depression and post-traumatic stress disorder.
|Despite the early work done in the Air Force, Navy and Army, the Department of Defense (DoD) MHS had no shared vision or implementation strategy across Services for integrating behavioral health services into primary care. The need for an enterprise-level vision and strategy was amplified when the Report of the DoD Task Force on Mental Health in 2007 recommended the integration of mental health professionals into primary care settings to improve the access and outcomes of behavioral healthcare. |
"As AMA president, I will note the need to
better integrate mental health care into
other aspects of medical care – to provide
more resources to treat more people."
"Just like we'll need you to make a
concerted effort to help our returning
troops, veterans and their families."
Inaugural address of AMA President,
Jeremy A. Lazarus
It was clear that if the DoD was going to move forward with a shared vision and strategy there needed to be a DoD level lead. To that end a DoD Program Manager for Behavioral Health in Primary Care position was created. I was fortunate to be hired to fill this role.
Over the last 4.5 years a number of milestones have been reached.
1. Agreement on "minimum” staffing levels…a minimum of 1 behavioral health provider (BHP) in clinics with 1500-7499 enrollees using a PCBH model of service delivery and 1 BHP and 1 Care Manager using a blended model of care with enrollments of 7500 or greater.
2. Funding began in FY 2012 to hire and train 470 behavioral health personnel to meet those minimum staffing levels by the end of FY 2016.
3. Clinical, Administrative, and Operational Standards for delivery of behavioral health services in primary care to include a phased training process with over 21 hours of in person intensive didactic and role play training to meet minimum core competency standards prior to the BHP engaging in any service delivery in primary care. This is followed by in-clinic training and feedback to facilitate acquisition of additional core Clinical, Administrative, and Operational competencies.
4. Currently 61% (207 of 336) of MHS adult primary care clinics have full-time staffed integrated care programs:
Percent of Clinics with Specific Model:
Care Management Model Only: 32.8% (68 of 207)
PCBH Model Only: 46.3% (96 of 207)
Blended Model: 20.7% (43 of 207)
Electronic medical record (EMR) BHP screening, assessment and clinical documentation and service delivery templates for mental health, substance misuse and health behavior problems (e.g., tobacco, pain, obesity) are in the process of beta and pilot testing. Once pilot testing is complete, behavioral health personnel in 120 military treatment facilities (which can have more than one primary care clinic) will be trained to use the EMR templates and expected to use the templates on every patient encounter per Army, Navy and Air Force practice standards. These notes allow for centralized data pulls in common fields with the same medical terms and screening/assessment scores across the Army, Navy and Air Force.
Program evaluation plans are well under way and are expected to start within this fiscal year. Evaluation is centered around the Quadruple Aim….improved readiness to deploy, better outcomes, patient and provider satisfaction, and cost management. Both process and outcome metrics will be collected, through enterprise wide program assessment as well as discrete process improvement projects in selected clinics across the Army, Navy and Air Force.
Ensuring that our active duty and retired Service members and their families have outstanding healthcare is a top priority. Integrating full-time behavioral health services in our MTF Patient-Centered Medical Homes, is an important part of that outstanding care. A great deal of work has been and is still left to be done. However, I’m confident that the programmatic clinical, operational, administrative, financial and program evaluation components in place will facilitate meeting Quadruple Aim goals and provide easy access to evidence-based behavioral health services in primary care.
Additional information can be found in: Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the department of defense patient-centered medical home: History, finance, policy, work force development and evaluation. Journal of Translational Behavioral Medicine, 2, 355-363.
Dr. Hunter graduated from the University of Memphis specializing in behavioral
medicine. He is board certified in clinical health psychology and works for
TRICARE Management Activity (TMA) as the DoD Program Manager for Behavioral
Health in Primary Care. He is a previous Chair for the Society of Behavioral
Medicine’s integrated primary care special interest group and has been
Collaborative Family Health Care Association board member. In
2002 he received the Arthur W. Melton Early Career Achievement Award
from AP Division 19 (Military Psychology). He has published several research articles and book chapters and in is
the lead author on the book Integrated
Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and
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