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Developing a Professional Identity

Posted By Randall Reitz, Friday, May 3, 2013
Developing a Professional Identity

Why do some clinicians excel at integrated care while others flounder?

Why do some of us embrace innovation while others yearn for traditional models?

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 9th—Psychology

May 16th— Graduate student

May 23rd—Family Medicine

May 30th—Pediatrics

 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:

1. Developing competency

2. Managing emotions

3. Developing autonomy

4. Establishing identity

5. Developing mature interpersonal relationships

6. Developing purpose

7. Developing integrity

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 vectors:

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 settings.”

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 proactivity.”

Each additional career stop has offered a fresh experience with the vectors, but with the benefit of the competency and connections made with previous steps:

Doctoral program → Internship → Clinic management → Residency faculty

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 controversially,
I will assert that the
collaborative identity is a
triad of characteristics:
Extroversion, Self-direction,
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:

1. Contradict many of my assertions;

2. Explain how this identity can be trained;

3. Expand the discussion to be more relevant to medical clinicians.


Randall Reitz

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.

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Early Career Leadership (ft. Mandela, Obama, and Beyoncé)

Posted By By Laura Sudano (ft. Reitz), Saturday, April 27, 2013
Updated: Thursday, May 30, 2013

Laura and Randall's
post is the last
in a 5-part series on
leadership in
collaborative care.


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 us out.

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.”

Meanwhile, 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) terms.

For Obama 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.

While 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 leadership.
Mandela Obama Beyonce

Another 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.

From a 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).

Although ECPs 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.

Building 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.

Another 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.

Leadership 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 for ECPs?

5. Does a feminist perspective support or discourage "leading from behind”?,

Laura Sudano

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 Committee.
Randall Reitz
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.

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Professional Pearls: Perspectives on Passion and Priorities

Posted By Jeri Hepworth, Friday, April 26, 2013

Jeri's post is the fourth
in a 5-part series on
leadership in
collaborative care.

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

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.


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Integrated Primary Care: the (Somewhat Extended) Elevator Speech

Posted By Alexander Blount, Thursday, April 18, 2013

Sandy's post is the third
in a 5-part series on
leadership in
collaborative care.

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 an elevator.

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 pains.

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!


Sandy Blount

Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA.  At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’.  He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.

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Leading though Building Strategic Partnerships

Posted By Rusty Kallenberg, Thursday, April 11, 2013

Rusty's post is the second
in a 5-part series on
leadership in
collaborative care.


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 partnerships.

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.

Broad Lessons:

- 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 serve alone.

Broad Lessons:

- 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.

Broad Lessons:

- 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.


Rusty Kallenberg

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. 


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What I Wish I'd Known When I Started

Posted By Susan McDaniel, Thursday, April 4, 2013

Susan's post is the first
in a 5-part series on
leadership in
collaborative care.


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.

Family 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 understatement.

From the 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 is!

There were 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.


Susan McDaniel

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 edition appeared.

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Hawaii, Homelessness & Collaborative Care

Posted By Larry Lantinga, Thursday, March 28, 2013
Military and Veterans

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!"

Why would I say that? Let me explain.

Homelessness 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 coordinated healthcare.

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.

The 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 achieved.

VA 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 many cities.

H-PACT 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.


Larry Lantinga

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 University.

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VA Myths and Stereotypes: Myth Busting Continues

Posted By Katherine Dollar, Thursday, March 28, 2013
Military and Veterans

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.

Through 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.

Firstly, 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 expectations.

An 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.

During the 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.

Same 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.

Within 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.

As 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 technology.

The 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.

In 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 Dollar

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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Myth Busting at the VA

Posted By Andrew Pomerantz, Thursday, March 21, 2013
Military and Veterans

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.


Andrew Pomerantz

Andrew 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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Primary Care Behavioral Health Services for Active Duty and Retired Military Service Members and Their Families

Posted By Chris Hunter, Friday, March 15, 2013
Military and Veterans

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.

Brief Background:

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)

Under Development:

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.

Take Home:

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.


Chris Hunter

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 Interventions.


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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

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.