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We are very good at taking care of others… but how well do we prioritize care of ourselves and our colleagues?

Posted By Natalie Levkovich, Sunday, March 10, 2013

As the name of our association proudly declares, Collaborative Family Healthcare Association has always seen the patient & family as integral to collaborative care. Long before the language of Patient-Centered Medical Home seeped into our lexicon, CFHA endorsed the centrality of the patient, the family and the community as determinants in the health of the population. Through research, policy and practice, CFHA has steadfastly advocated for the universal adoption of the values and practices that integrate a patient-centered perspective into the delivery of care. Effective adoption of this perspective requires providers to be proficient, efficient, present, compassionate and empathic in the practice of their profession.

So, as providers collaborate with patients, families and colleagues, what impact does their daily experience have on them as individuals, on their practice, on their families? As they offer support to their patients, absorb their stories, apply their professional judgment and implement empirically-supported interventions to help patients reflect on their goals and adopt more effective problem solving strategies, who helps the provider to reflect on the impact their work has on them? CFHA blogs and presentations have been devoted to the needs of family caregivers. What about the needs of professionals? Regrettably, in many if not most settings, little attention is paid or time set aside for clinical or reflective supervision.

Reflective supervision (RS) is particularly well suited to address the impact that repeated exposure to vulnerable patients and stressed environments has on the practitioner. RS seeks to embed reflective practice in the supervisory experience as a way to model parallel process and the inter-relatedness of all the relationships involved in collaborative care, including those of providers with supervisors as well as providers with patients/families and colleagues.
Reflective supervision
Reflective supervision is particularly well suited to address the impact that repeated exposure to vulnerable patients and stressed environments has on the practitioner.

In fact, the supervisory relationship should mirror the desired relationship between provider and patient. RS specifically attends to the emotional content of the work and how providers’ emotional responses directly affect the care they deliver. RS practices involve establishing an expectation of regularity, emotional safety, validation and collaboration that includes a supervisor guiding the supervisee, in the context of case review, to examine his/her own feeling and values and how to use that self-awareness to serve the best interests of the client.

While the mode and nomenclature of RS grew out of early childhood services, the importance of reflective practice as a critical component of effective practice is also noted in literature about education and supervision of healthcare practitioners (see Patricia McClure’s article "Reflection on PRACTICE) Growing evidence of the importance and efficacy of RS for identifying and reducing burnout, vicarious trauma and secondary traumatic stress is resulting in its gradual spread to other fields of human service. To learn more, read a brief but excellent white paper that outlines the practices and values of RS as a trauma-informed practice and provides additional references. Further, The National Child Traumatic Stress Network endorses RS as a critical component of preventing and addressing secondary traumatic stress among workers who are affected by repeated exposure to their clients’ traumatic histories, see here.

CFHA has begun to include sessions on trauma and trauma-informed practice in recent conferences. The Adverse Childhood Experiences Study was discussed at several sessions during the 2012 Annual Conference in Austin, TX. Now, as we continue to expand our audience and partnerships, the time has come for CFHA to integrate the needs of providers, beyond self-care, into our education and advocacy for strengthening systems of collaborative care. I hope that CFHA will take up the cause of making supportive supervision both a provider right and a necessity when striving for the gold standard in health care. Our 2013 Annual Conference in Denver presents an opportunity to advance this conversation. As the conference committee considers workshop proposals to accept and plenary speakers to invite, they should include clinical supervision as a priority. I challenge the conference planners and prospective presenters to consider this question with the same thoughtful approach that CFHA devotes to all of its work.

              See here, for an example of Reflective Supervision relevant to an integrated care setting.

 

Natalie Levkovich

Natalie Levkovich is a CFHA Board Member and was a co-chair of the 2011 CFHA conference in Philadelphia.  She has served as the executive of the Health Federation of Philadelphia (HFP) for nearly three decades. HFP is the SE Pennsylvania network for community health centers that provides comprehensive primary care to nearly 300,000 low income and underserved individuals per year. Under her leadership, HFP has experienced remarkable growth through the development of many innovative, collaborative initiatives such as the integration of behavioral health in primary care, including widespread implementation of a sustainable clinical, payment and professional development model.


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Healing Relationships, Conference Relationships

Posted By Amy Davis, Thursday, March 7, 2013

 2013 conference logo

Hi CFHA community,

I had the honor and privilege last week of interviewing young family therapists to come join the ranks of new learners and lifetime learners at St. Mary’s Family Medicine Residency in Grand Junction, Colorado. We, a team of physicians, behaviorists, nurses, and educators chatted it up around a table smiling and proudly described our environment to the interviewee. He asked us to each explain what we enjoyed most about our clinic. Each of us responded without pause…relationship...relationship with each other and with our patients.

What does this have to do with CHFA 2013?

I think this has everything to do with this conference. Ideally, the plenaries, discussions, workshops, networking hopefully all ultimately lead to a most positive, healthy environment for those we serve and for ourselves too. When Randall Reitz asked me to help plan this conference, I was a bit intimidated (and actually remain so!). However, I am passionate about the work of collaboration and of dynamic change to a "healthier” healthcare system, so with a deep breath, I have joined with Laurie Ivey on the program committee for CHFA 2013. In order to forge ahead with promise and creativity, we need the collective power of all of your hard work in your various disciplines.

The conference dates are October 10-12, 2013. The theme for the conference is "Disrupting Status Quo” which we think parallels changes in the health care political, economic, and clinical environments. We as providers and consumers are readying to embrace what will hopefully be a metamorphosis of healthcare. These changes are likely to be disruptive and uncomfortable but offer great hope and promise for those of us who advocate for collaboration in healthcare delivery.

In contrast to our "disrupting” theme, the conference will be set against the backdrop of the Flat Iron Mountains between Denver and Boulder, Colorado. Western poetry emanates from the open sky, crisp air and the rolling range leading to the foothills. I encourage you to consider submission, to come dialog, debate, and share…then relax under a clear Colorado sky. Make us think, make us squirm, challenge us to a better way.

The call for presentations began February 1st and will close March 15th. Please submit them at the CFHA website. We look forward to reading them!

Humbly,

Amy Davis

 

Amy Davis
Amy is Family Physician who has lived a varied professional life with public service in the IHS, residency education, work with under-served communities, and 13 years of collaborative care experience. She currently is the Medical Director of the SMFM Collaborative HIV clinic and works in primary care at the VA in Grand Junction, Colorado.
 


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Observations from a Living Laboratory of Collaborative Family Medicine

Posted By Tina Runyan and James B. Anderson, Thursday, February 28, 2013

"Collaborative care is done in many ways, by many people, in many settings—it is not ‘just one thing.’”

-C.J. Peek

Collaborative care promises not only opportunity to care for patients more holistically, it also provides a living laboratory for training practitioners across disciplines. Notwithstanding the vastly different training paradigms across disciplines, integrated settings offer rich opportunities to borrow and exchange ideas from the training traditions of other disciplines. Narrative medicine has been a time-honored component of family medicine residency training as a mechanism to enhance reflection, self-awareness, and process nuances of the physician-patient (or trainee) relationship. Analogous to "A Piece of My Mind” in JAMA, U Mass Family Medicine hosts a Thursday Morning Memo comprised of personal vignettes submitted by faculty, residents, and medical students; the popularity of the essays is demonstrated by a distribution list that has grown to over 450 readers. Included here are three reflective essays grounded in collaborative care practice and training.

   _ _ _ 

 The Three Questions

I made it to my car before I broke down in tears. I had just come from the hospital having seen a young woman in the hospital with acute fatty liver disease who nearly died in childbirth a few weeks earlier. I felt as tightly pulled in so many directions as the skin atop a snare drum. I was supposed to be home an hour ago and my daughter had already called twice. I had a grant report due by five o’clock, and too many e-mails in my in-box asking about something due or overdue. I felt as if I was letting everyone down and I couldn’t wait for the day to come to a close so I could just lie in bed and read stories to my children. And then it came to me … the three questions. One of the favorite stories in my home is a children’s adaptation of Leo Tolstoy’s short story about a little boy who poses three questions to the wise old turtle because he often finds himself unsure if he is doing the right thing.

The three questions are:

1. When is the best time to do things?

2. Who is the most important one?

3. What is the right thing to do?

All I knew about the woman I went to see in the hospital was a little bit of history about her disease, the medical events to date, and that she was refusing to see her baby which was concerning to all involved in her care and upsetting her family. There was worry about severe post-partum depression or psychosis. I entered the room to find a listless and soft-spoken woman with dull yellow eyes, too weak to reach for her water glass. Her husband and soul mate of 20 years, steadfast by her bedside for weeks, left us alone to talk.
Reflective writing and the use of narrative medicine can offer nascent practitioners a glimpse into the humanities of their
mentors and peers, help break down barriers across disciplines, and cultivate mutual respect.


She didn’t start with "the story.” Instead, she told me all about the life she and her husband had built together. She told me about her family. She described her longstanding uncertainty and the numerous conversations she and her husband had about whether to even have children. She told me about her birthing classes and her labor plan with a doula and her hopes for the baby’s first hours after delivery. She cried. She detailed the weeks leading up to the diagnosis and C-section and her emotions towards her obstetrical doctors. She explained how defeated she felt and how she does not have the stamina to even sit upright in a chair for any length of time. I tried not to cry. She kept telling me how dismissed she has felt and how no one was listening to her -- everyone was saying how good she looked and she still felt as rotten today as a few weeks ago when she nearly died.

An hour and a half later as I stood to leave, she looked me tearfully in the eye and asked "Will you come see me tomorrow?” Even though I was feeling time slip through my hands like dry sand, I looked right back and said "Of course I will.” So as I sat in my car it was exquisitely clear that the best time to do things was now, in this only moment we know to be certain, the most important one is the one you are with, and the right thing to do is to do good for the person you are with. I took a deep breath and took comfort in knowing I was exactly where I needed to be this afternoon. My drive home was serene. And the bedtime story that night goes without saying.

   _ _ _ 

Rejuvenation

On a cold winter morning with the plows finally moving for the first time this winter, I set off for the long drive to the Barre Family Health Center. Despite a long weekend, I felt a bit sluggish starting the day, perhaps because of the random text message that woke me early in the morning threatening to turn me into the police because of repeated harassing messages (I didn’t do it, I swear!).

I went through my morning, seeing a typical panel of behavioral health patients at the health center: A woman struggling to control her weight and mood following bariatric surgery, recurrent major depression, a middle-aged couple struggling to save their marriage, and a newly referred patient adjusting to her newly prescribed suboxone while also trying to find a way to re-narrate her life while free of drugs. While I felt some sense of competence and satisfaction after seeing this variety of patients, I also felt tired. After this clinical session, I entered into our monthly panel of meetings. As they do at times, the meetings bled into each other in my head. Finally, we got to the last meeting of the day—the providers meeting.

The meeting was led by our chief resident, who is pregnant. Earlier this month, she found out she had been accepted to join a prestigious fellowship program. In the middle of the meeting, she was pulled out by our lead nurse to tend to a patient who had been unexpectedly added to her schedule. Her colleague and fellow resident seamlessly took over the lead of the meeting. Towards the end of the gathering, I had the chance to present a project that my mentor and I are trying to initiate at the health center.

One of the attending docs, who has been at the health center since about the time I started pre-school, literally leaned forward in his chair to listen to the project description and offer incredibly insightful and concise advice about how to make it work. This man had been seeing patients all day since 8:30 and still was full of energy. Another doctor, this one a young woman just years out of residency, also provided helpful advice, while making a warm-hearted joke to keep the mood light even after a day full of meetings. Following discussion of the project I am trying to develop, two other docs piped in with their own ideas of how to improve our community, with ideas of a health center-based patient library and ways to help low-SES patients get transportation to and from the health center when they don’t have a car. One of these doctors is a Harvard product who selflessly and tirelessly devotes himself to medicine, the health center, and under-served populations. The other is a very young doctor who manages a full patient panel while running our resident in-patient service and raising a beautiful young daughter on her own.

As I drove home after the long day, I felt happy and inspired, feelings of fatigue from earlier in the day gone. I feel lucky to work with providers who are as energetic as they are competent. Not only do they have strong knowledge of a wide-range of medicine, but they also truly believe in the importance of behavioral and community health for overall patient wellness. As a psychology fellow at the beginning of a career that could have taken many different directions, these doctors and their actions reminded me of the importance of this work, and the privilege it is to work with such outstanding doctors and people.

    _ _ _

This final essay was written jointly written by Tina Runyan, PhD (italics) and High Silk, MD (plain text) about a notorious and divisive patient in our health center, the day after the presidential election this past Fall.

Caring Together

Waking to the news of Obama’s re-election this morning brings rekindled hope for the future of healthcare in the US. Still, the health and well being of many Americans hangs in the balance of a transformed primary care system. This new system of care promotes comprehensive, coordinated, whole-person, and patient-centered care. But let’s not forget quality. Quality as defined by metrics and thresholds chosen by insurance companies and linked to remuneration. As we sit and talk with our patient, looking back and forth from her to each other, we both know that we have accomplished something. Something that would never be detected from the types of quality measures the insurance companies value.

The young woman before us had not identified any with any health care provider in her first 30 years. In fact she had deep disdain for them all! And now, she had bonded with the two of us and was actually making progress on health goals.She had been handed a lot in life - diabetes at a young age, sexual trauma, an anger management issue, being overweight, and a predilection for alcohol. This constellation of health issues had been making life worse for her for years: a miscarriage, relationship issues, uncontrolled sugars and generally dissatisfaction with life. Many tears had been shed in this office; many rants about how unfair life is; many moments of despair and giving up. Now here was a woman sitting up taller than before. She was talking about "getting control of her life". Her tears contained near joy now. Her sugars had come down a little but more importantly, she was feeling good about lifestyle changes. Minimal alcohol,walking frequently, not drinking soda, and eating healthier - she was setting goals to get pregnant understanding fullwell what this would entail.

After the visit, Tina said that I should be proud to have moved her in the right direction over the last 5 years. Sure, I had not given up. Sure, I maintained full respect for her even at her meanest moments. But who was I fooling. This was a team effort. We had seen her back and forth like a ping pong tournament, caring for her week in and week out - listening, empathizing, prodding, tinkering with medications, accepting and congratulating small accomplishments. Together we had helped this woman make progress. We have both always been strong supporters of co-management between primary care providers and behavioral health, but this was the pinnacle. We had worked together, stopped each other in the hallway frequently for consultation and updates, supported one another's ideas and nurtured each other along. The success was not in her HbA1c, in fact we had failed miserably on that front alone. The success was in the transformation of the person, in the teamwork, and in progress and process. There is no quality measure on the scorecard for these outcomes … but there it was. And we sat in that room for a while longer, the three of us - it felt very good. It felt rewarding. It felt like quality care. Our patient felt it too.

PS – I saw our patient today. She is, for the first time since I met her, consistently taking all of her medications and checking her blood sugars. She has not had any alcohol in a couple months. She explained that she chooses not to have any around because she knows she cannot stop at just one drink. And she knows alcohol is not good for the baby she is now carrying. She wanted me to tell Dr. Silk the good news.

   _ _ _

Reflective writing and the use of narrative medicine to process rich and emotionally intense experiences in training and practice are not novel for any of the helping professions. However, sharing those musings, particularly with those in training, can offer nascent practitioners a glimpse into the humanities of their mentors and peers, help break down barriers across disciplines, and cultivate mutual respect. Over time, this cannot help but to shape a culture of interdisciplinary collaborators who find various creative outlets for the emotional experiences intrinsic to the practice of (integrated) medicine. In our Thursday Morning Memos, we have discovered gratifying solace and empathy among one another.

Christine Runyan

Tina Runyan is an associate clinical professor in the Department of Family and Community Medicine at the University of Massachusetts Medical School. She is the Director of an APA accredited, two year Post-doctoral fellowship in Clinical Health Psychology in Primary Care and the behavioral science director for the Worcester family medicine residency. . She recently joined the Board of CFHA and when not writing, practicing, training or talking about integrated care she enjoys being a mom, trail running, and practicing yoga.
James Anderson
James B. Anderson is an assistant professor and licensed psychologist in the Division of General Internal Medicine in the Department of Medicine at the University of Massachusetts Medical School. He is a recent graduate of the APA-accredited, two-year post-doctoral fellowship in Clinical Health Psychology in Primary Care in the Department of Family Medicine and Community Health at UMass (directed by none other than the co-author of this blog, Dr. Christine Runyan). James received his PhD in clinical psychology from Western Michigan University in 2010. When not working on integrated care, he enjoys playing hockey, SCUBA diving, and travel.

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Point / Counter-Point 2.2

Posted By Sandy Rose and Peter Fifield, Thursday, February 21, 2013


Being patient-centered means respecting patient confidentiality


Sandy Rose


 

 The DSM-V hasn’t shown-up in bookstores yet, so hopefully I can still convince the APA to add one more diagnosis to the tome: CFR 42.2 GAD (Code of Federal Regulations Section 42, Part 2 Generalized Anxiety Disorder). This diagnosis is narrowly defined, but is apparently spreading virally among mental health professionals. It originates from the effort to adhere to state licensing laws and professional ethical standards while practicing in integrated settings. It is, of course, primarily triggered by those stringent regulations imposed by 42CFR Part 2 ("Part 2”)’[1] which regulate the confidentiality of alcohol and drug information. Unlike HIPAA, Part 2 provisions require stringent confidentiality protections even for information used only for healthcare or payment purposes.

Symptoms include:

  • Loss of sleep for operations managers attempting to write policy (i.e. locking down access in EMR’s, obtaining appropriate informed consent);
  • Anger among exasperated medical records staff ;
  • Deflated self-esteem among clinicians;
  • Misery loving company with equally obsessive colleagues[2];
  • Recreational or therapeutic usage of wine among all involved;
  • Frequent co-morbidity with Part 2 Avoidance Disorder.

In this spirit, I offer the perspective of one non-legal, neurotic worrier and BHI provider/administrator in an FQHC. My case will be that, while Part 2 is arduous to implement as written, it is doable. And further, at its heart, it is a worthy regulation that protects patients and holds healthcare systems accountable to a reasonable standard for confidentiality.

There is indeed plenty of information to weigh in this debate. If you missed CFHA’s annual meeting this year, you can still find some great information on confidentiality issues from CFHA website posts and catch the March special edition of Family, Systems and Health featuring ethical issues in integration. SAMSHA-HRSA’s Center for Integrative Health Solutions site includes resources on understanding 42CFR. The Legal Action Center has a useful compilation of information including books, webinars, power points and free downloadable forms for compliance.

Why is adherence challenging but possible -- even with Part 2? For one, most generalist BHPs like myself are not considered Part 2 "programs”, even though we may diagnose and treat substance use disorder (SUD) conditions. As such, we are not required to do all that covered providers ("programs” in Part 2 language) must do to protect SUD information. The sticky part comes when receiving SUD information from a Part 2 provider, such as an LADC or methadone clinic that receives federal funds. A health center must still protect these records via Part 2 standards.

What does this mean? Well, a number of factoids leading to temporary 42GAD. My colleagues and I must still obtain a Part 2 release even to submit a SUD diagnosis for billing if received from a Part 2 (i.e., specialized) "program”. Most problematic for integration, a LADC or other Part 2 "program” operating as part of a team within a health center cannot freely exchange protected information with others outside of their specialized alcohol and drug unit at the center, except in limited circumstances, without Part 2 protections.[3]

As we do employ an LADC within our group, we present authorization forms for her patients at intake, using the unified HIPAA and Part 2 authorization template form available for download by the Legal Action Center at www.lac.org. Our protocol requires her patients’ consent for billing and for exchange of information with the team and agency. As for any records obtained by her or other "programs”, it is easy enough at least in my setting to secure her notes using our EMR’s locking capabilities. This allows our medical records staff to identify these and other protected "SUD” notes, which require the special authorization for re-release outside our agency.

Our new patient portal holds further promise for reducing the barriers to compliance, once workflows and mechanisms for communication with patients through this system are in place. With secure email for authorization requests and signatures, the process of consent could be quicker and more efficient. If you assume as I did that under-served patients are not likely to afford or use email or texts, consider that nearly 30% of the predominately Medicaid funded patient population in one sample primary care group used secure messaging for their health care needs. [4] Half of the author’s patients and even geriatric patients were on board.

Alternatively, a center may opt to establish a Qualified Service Authorization Agreement (QSOA) with outside parties that the center frequently uses, (or between the LADC and the health center) such as for referrals or billing. With these agreements in place, a patient’s authorization is not required for release of Part 2 information[5].

Our center also includes in its registration paperwork (which the patient is provided at the time of establishing care) signature lines for patients to indicate that they know that their BHP (if utilized) documents in one medical chart along with medical providers, and that their clinical information may be sent to referred providers for healthcare reasons, and that this includes, where applicable, alcohol and drug information. Our registration materials also include information about mandatory reporting. We feel this covers BHPs in the case of warm handoffs and unscheduled intakes. [6]

Practicing the serenity prayer so well known to Part 2 patients, I am well beyond wishing the law away. It is here to stay. In fact I see the need for the law’s strong protections, given the very real discrimination and stigma these patients must endure, such as in employment, custody battles and procurement of needed pain medications or procedures. I have seen providers omit diagnoses in the medical chart where protections don’t exist. This of course may lead to the same black hole that occurs when patients don’t disclose their SUD or seek treatment.

And, holes are costly. As we all know, lethal drug interactions occur, and inaccurate diagnoses or omitted information about SUDS lead to time and dollars wasted. Not surprisingly, hospital access to behavioral health records is associated with significantly lower readmission rates. [7]

Given compelling arguments for and against security protections, no wonder the angst. And if health care continues to evolve, we will have blessedly more information to safeguard. The prescription drug monitoring program just passed last summer in NH as in other states should no doubt increase SUD detection rates, as will the SBIRT program our center is rolling out next month. [8]

Contrary to popular opinion the law was not written to create 42GAD and thus drum up more business. Written into the code is its critical rationale--"so patients will not be made more vulnerable by reason of the availability of his or her patient record than an individual who has an alcohol or drug problem and who does not seek treatment”. [9] And, patient centered care is after all grounded in the belief that patients are fully informed and engaged in decision-making, after weighing information pertinent to care, including risks involved in treatment. [10] Why shouldn’t this include risks of having one’s information disseminated to third parties, when such release might impact on their care or reputation?

The solution is not to override patient choice for the sake of expediting treatment "for their own sake”. Nor should their choice be eradicated for the ease of providing care. Medical decisions are grounded on patient choice: Consent for disclosure of sensitive information is no different. Let’s work harder to make the choice more efficient and speedier, rather than the release. It is simply and only the patient who should decide where and how much their information gets disclosed. Given the chilling effect otherwise, it is well worth the technical fixes, extra paperwork and workflow headaches to enable this.

Being Type A and returning home from a one week vacation without internet, you can imagine my reaction to yet another New Hampshire power outage as I type this, and the prospect of hours, if not days of no home internet. Yet I will begrudgingly accept the speed limits along the way to the nearest Starbucks outlet and wi-fi to plug in my computer. After all, even ambulances slow down at dangerous junctures.

 

I think Dr Rose may need therapy...

Peter Fifield



 

The new DSM-V may not include Dr. Rose’s proposed CFR 42.2 GAD diagnosis but as we continue to navigate the pathways of sharing patient information across the integrated spectrum of care, I’m continually reminded that there is potential for a diagnosable "CFR 42.2 Delusional Disorder”. Subtypes include but are not limited to the following:

  • Bizarre Delusions that involve common medical culture phenomena that are totally implausible such as a fully integrated health record
  • Delusional Jealousy regarding the perception that Behavioral Health personnel do not have the same free flow of information sharing that medical provider’s do.
  • Grandiose Delusions related to one member of the medical team having delusions of inflated worth, power, or higher status.
  • Of Being Controlled Delusions where data entry in the EHR, face-to-face communications and other interaction are being monitored and controlled by a higher force.

My colleague and co-presenter deserves respect for her comprehensive investigation of this topic and subsequent informed opinions regarding confidentiality and consent. She however, may have gone a bit over the deep end this time. The core issue here regards assuring that we do the best thing for patient at all points of contact right? Right! And, if accurate and relevant information does not flow freely between agencies how can we, the providers of integrated care, the disciples of medicine self-chosen to transcend all the boundaries of traditional patient care—be it biological, psychological or social—ensure the best care for the patient has been accomplished? How can we know that medications are not being duplicated, misused, abused or prescribed in an unsafe manner? How can we ensure that patients are checking their A1C’s, are eating healthy foods and exercising three times a week or not overusing emergency services?

I try to imagine what a physician would do with an incomplete EKG reading or an MRI that only showed the upper left quadrant when the issue was in the lower right? Providers need the right information to make the right decisions and with humans being so complex it is safe to say the more information we have, the easier it would be to make a safe, calculated decision. It would be wonderful to believe in the conceptual comforts of patient controlled information sharing but I can’t help but wonder if patients really control their information? More importantly, if they had the opportunity, would they really want that level of responsibility? How could they know what is best for them regarding the complexity of most chronic illnesses? I guarantee that there is not a provider out there that has not experienced the increased hypochondriasis happening just from patients overindulging in a simple WebMD! How do patients know what information is relevant to their overall health? Providers are trained to care for patients and to do this they need full access to the patient’s biopsychosocial history.

One of Dr. Rose’s concepts I think we can all get behind regards the futility of wishing away the laws. In this case, the Serenity Prayer may not be as effective as Mother Necessity. We need to get creative. One key element Dr. Rose mentioned pertained to 42 CFR Part 2 and the exchange of information between "program” specialists and providers. Why in anyone’s right mind would they hire a specialist such as a LADC if it is going to inhibit the flow of information? What we are talking about here in the first place is short-term solution focused interventions. We do not need a specialist license for that.

Furthermore, why would we not adhere to the KISS [keep it so simple] model and just hire non-specialist BHS providers that could communicate between providers without all of these complicated policy and licensing barriers? Reimbursement models for licensed specialists are not that robust to begin with, never mind being unsustainable. We could simply continue Behavioral Health tax write-offs and hire less skilled BHS providers. Why do we need a highly skilled, highly specialized Ph.D level Psychologist to deliver generalized short term brief therapy? We could simply have our highly integrate-able, non-licensed, non-specialized BHS providers send a note to the medical provider explaining the rationale behind giving the patient the substance use or even mental health diagnosis and the medical provider could enter in the chart. Workaround complete!

One concept worth mentioning is the idea of Regional Health Information Exchanges [RHIE] and how they are designed to access and distribute patient information. RHIEs could be designed so patients have to opt-out of the privilege, not opt-in. Giving them the opt-in option will only increase their skepticism of the beneficence of their shared information. Various countries in Europe designate organ donation as opt-out. The results are that some countries have donation rates as high as 99% while other countries have opt-in policies resulting in organ donation rates as low as 14%. If what we are looking for is getting the information out there to share, we need to reduce the number of hurdles in the way as well as proactively create opportunistic policies to maximize the number of people in the system.

I honor Dr. Rose’s reverence and optimism towards confidentiality. She mentioned that a solution is not to "override the patient choice for the sake of expediting treatment for their own sake and to focus on working harder to make the choice of release of information more efficient and speedier for the patient”. This may be falling on deaf ears. We have been trying this approach for years and no one seems to listen! All the guilds want their control. The Substance Abuse people won’t meet with the Mental Health folks; the Mental Health folks won’t meet with the Primary Care folks; this proverbial sandbox is a mess and no one is playing well together. It appears that the folks in the sandbox don’t want true equality across the spectrum of care as much as they want to be the one with the best sandcastle.

Although the biopsychosocial model was officially postulated in the late 70’s, common sense has supported the integrative nature of healthcare way before we started officially silo-ing providers. Our grassroots movement that has been growing and expanding over the past two decades has hit a ceiling. Above us now sits the three-siloed thrones of care--medicine, psychology and substance abuse--none willing to heed advantage to the other. None willing to collaborate from the top down to meet the grass root efforts growing upward like vines.

The ultimate question is this: Do we really want a patient centered medical home where the patient has "real” control of the information? In the end, consumer choice typically leads to over-consumption, confusion and waste of resources. So regardless of what end of the spectrum your beliefs lie, ultimately, we need to focus patient care the triple aim—improving health, reducing costs and improving the patient experience. All of the above could be attained by paying more attention to access to, not permission for, complete patient information.

 

Sandy Rose is a psychologist and Director of Behavioral Health for Goodwin Community Health, an FQHC in the Seacoast area of NH. She is past president of the New Hampshire Psychological Association and served two terms on the Council of Representatives of the American Psychological Association. She is currently a Psychology Advisory Member of the New Hampshire Board of Mental Health Practice.





Peter Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. He presented with Sandy Rose on this topic at the 2012 CFHA conference and they are co-authoring an article in the upcoming special iethics issue of Families, Systems, and Health. 
 


[1] The Federal Law for Confidentiality of Alcohol and Drug Abuse Records.

[2] Steve Arnault, Cathy Hudgins, and Peter Fifield—see our upcoming article on ethical issues in the Family, Systems and Health special addition on ethics due March, 2013.

[3] See Legal Action Center’s Confidentiality and Communication, A Guide to the Federal Drug and Alcohol Confidentiality Law and HIPAA (2012) for internal program communications, pp. 72-73.

[4] Franklin, R, (2013, Jan/Feb). Secure Messaging, Myths, Facts and Pitfalls. Family Practice Management Magazine.

[5] SAMSHA (2004) The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Use Programs. Retrieved on February 3 at http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf

[6] Apparently (and hopefully) peculiar to NH, we have prescribed language for informed consent under our licensing law and so we are bound to provide informed consent documents specific to MH at time of scheduled intakes.

[7] Bakalar, N. (2013, January 7). Sharing Psychiatric Records Helps Care. The New York Times.

Retrieved January 7 from http://well.blogs.nytimes.com/2013/01/07/sharing-psychiatric-records-helps-care/.

[8] SAMSHA’s interpretation of Part 2 excludes SBIRT information as requiring Part 2 protections if arising outside of a "program”—See FAQs-revised, Q10.

[9] 42CFR 2.3(b)2.

[10] Peikes, D,and Torda, P (2011). The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care Retrieved 2.2.12 from http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_HTMLConversion_11-0029_v2.

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Point / Counter-Point 2.1

Posted By Jerica Berge and Tai Mendenhall, Thursday, February 14, 2013


Including Significant Others in Health Care Visits: Here to Stay…

Or, like Valentines Day, a Short-lived Temporary Celebration?


Jerica Berge



 With an entire recent issue of Contemporary Family Therapy focused on Medical Family Therapy (MedFT), a second edition of Medical Family Therapy by McDaniel, Doherty, and Hepworth coming out, and several MedFT training programs (Ph.D.’s, post-docs, certificates, and fellowships) being established around the country, we have hit a high point in the field. It appears that Marriage and Family Therapy (MFT) and health care delivery entities (e.g., Primary Care, Pediatrics, Internal Medicine) may have finally tied the knot regarding the importance of systemic thinking and relational involvement at the center of care-provision.

For example, the value of including a significant other in the health care of a partner—while not standard medical practice yet—is no longer questioned. It is common for a primary care provider to request a patient with diabetes to bring in their significant other to be included in treatment planning. Furthermore, many of the Patient Protection and Affordable Care Act (PPACA) requirements lend themselves to supporting a relational view of health care. "Team” and "group visit” approaches used in federally-qualified Health Care Homes rely on a systemic and relational view of a patient’s health. Additionally, the new CPT (Current Procedural Terminology) codes 90832, 90834 and 90837 are defined as "psychotherapy with patient and/or family member” and the 90846 and 90847 are defined as "family psychotherapy with or without the patient”. Even reimbursement systems are embracing the move towards systemic and relational care. Thus, including significant others in care (i.e., mental and/or physical health) visits may become the "gold standard” in the near future.

There are many advantages of including a significant other in a partner’s health care visit, from getting their buy-in and support for (and involvement in) the patient’s treatment plan, to perturbing their worldview about why their partner has a certain condition. Including a significant other in a patient’s health care visit may ultimately allow the provider an opportunity to increase the likelihood of treatment compliance, understand more about the health care motivations of their patient, and establish trusting relationships which promote collaborative efforts between the patient/significant other/provider subsystem to be mutually invested in a patient’s health and well-being.

I see examples of this type of collaboration often in the residency clinic where I work. Residents are encouraged to bring in patients’ significant others to team visits to get a better perspective of the presenting problem(s). Faculty doctors have couples they have seen for years and model the importance of systemic and relational care to their residents. Patients either bring in their significant other themselves or suggest bringing them in. It seems that providers, patients and significant others all can see the vision of systemic and relational thinking in health care delivery!

 



I Beg to Differ

Tai Mendenhall

Jerica, my long-term collegial sibling, I must counter your enthusiasm with all of this. To be clear: I agree that it is good to see MedFT’s visibility increasing in academic literature and professional circles, and the fact that many health care sites are beginning to recognize the utility of including patients’ significant others in care is a long-awaited change. As a MedFT provider and educator, myself, I am happy to see our guiding tenets gaining some traction after so many years of spinning our wheels. But to be honest, I think that you are looking through lenses here that a bit too rose-colored.

I do not think that we are anywhere near the mainstream or "gold standard” yet. To begin, medicine as we know it is still rigidly-structured around a one-patient-at-a-time model. Our diagnostic and billing codes reflect this, insofar as those "belonging” to individual patients (e.g., 296.32 / Major Depressive Disorder, Recurrent, Moderate Severity or 250.02 / Diabetes Mellitus, Type 2, uncontrolled) are generally paid-for by 3rd-party payers and those having anything to do with patients’ relationships or psychosocial situations (e.g., V61.2 / Partner-Relational Problem or V62.2 / Occupational Problem) are not. Further, our new ICD-10 mental health billing codes require even more cumbersome documentation that identifies when significant others’ involvement is disruptive (e.g., 90785 for factors "complicating” care delivery), but not when it is helpful.

Alongside this, most biomedical and mental health care providers are still not required in their training to gain experience with or confirm competency in systemic interventions. To my knowledge, MFT (and within this, MedFT) is still the only camp that mandates a large percentage of logged patient care to include family members and/or significant others. And – health care home movement notwithstanding – these systemically trained providers (like you and me!) still tend to earn less than their Psychology counterparts, and their services are still not as broadly recognized as reimbursement-worthy by major payers (e.g., Medicare) in many states.

With our physicians, those who are more likely to work systemically (e.g., Pediatrics, Family Medicine) are paid significantly less than all other medicine specialties. I mean, let’s be real: Have you ever compared the cars or houses (plural) owned by cardiologists, dermatologists, and surgeons to those owned by a family-doc? And, coming full-circle, it gets even worse when you compare that to what we MedFTs live in or drive. Put simply, those who focus biomedically on one-patient-at-time are rewarded handsomely for it. Those who dive into patients’ complex interpersonal and psychosocial worlds are not.

And when we get right down to it, Jerica, you know that many providers find working with individual patients (sans significant others) to be more comfortable. Conversations are more simple, chaos and conflict are less likely, and visits/sessions are more "smooth.” Even our MFT and MedFT colleagues attest to this (I know that you’ve heard them!), recognizing that their individual patient at such-and-such time during the day represents a "break” of sorts from the comparative intensity of couple- or family- work.

I think that we all see the utility of including significant others in care, but the reality is that many (or even most) providers do not do it until they "have” to. When their 1:1 services do not seem to be working, when their patients are "noncompliant” with whatever they are telling them to do, or when they (providers) are overwhelmed and frustrated because the course of care is not going the way that they would like to see it go – only then do they begin asking questions like "What is your wife’s take on all of this?”, "Could you bring your mother in with you next time?”, or "My thinking is that it would be best to talk with both of you about how to eat well with this new ‘diabetes diet’.”

I think that all of us (providers and patients alike) tend to take the people who are most important in our lives for granted – at least until we’re "supposed” to appreciate them (like on Valentine’s Day or their birthday), until we really need them (because of the support that they can offer), or after it’s too late (because we have lost them). I see much of health care following this very path. Including significant others because we’re incentivized to do so, or because we don’t know what else to do, is good. But it’s not ideal. Maybe someday we will all do this naturally. But my sense is that this is still a very long way off.

 

Jerica and Tai

Jerica Berge, PhD, MPH, LMFT, CFLE
is an Assistant Professor at the University of Minnesota in the Department of Family Medicine and Community Health. She received her PhD in marriage and family therapy from the University of Minnesota. Dr. Berge is a Medial Family Therapist at the North Memorial Residency Program and Research Faculty at the University of Minnesota Medical School. Dr. Berge’s research interests include childhood obesity prevention and community-based participatory research around child and family health issues.

Tai Mendenhall, PhD, LMFT is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Social Science, Director of the UMN’s Medical Reserve Corps’ Mental Health Disaster-Response Teams, and Associate Director of the UMN’s Citizen Professional Center. He works actively in the conduct of collaborative family healthcare and community-based participatory research (CBPR) focused on a variety of public health issues, including more than a dozen community-based projects.



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Caring For Our Mothers: A Plea for Action

Posted By Cassidy Freitas, Thursday, February 7, 2013

"I just want to sleep…I just want to go rent a hotel room, and go to sleep.”

"I’m not strong enough for this....”

"I look at my twins and I don’t know them, shouldn’t I feel differently?”

"I’ve never felt so dark and low. Sometimes I wonder if they’d all be better off without me.”

"I can’t stop worrying, I can’t even bathe him. What if I drowned him…”

"I wouldn’t have said anything if my doctor hadn’t asked…”

Fluctuating hormones. Little or no sleep. A fledgling maternal identity filled with self-doubt. These are the experiences of almost all new mothers, not just the ones who experience a Postpartum Mood and Anxiety Disorder (PMAD). Typical statistics regarding the prevalence of PMADs vary anywhere from 10 to 20%, but I don’t believe they capture the full picture. What would happen if we accounted for those mothers that may not meet DSM criteria? What about those mothers that never come forward due to shame or fear? What about those mothers who experience Psychosis? Where do we account for them?

According to the American Pregnancy Association, approximately 6 million pregnancies occur in the U.S. each year (I report the number of pregnancies rather than the number of live births because every postpartum mother is at risk for PMADs despite the outcome of her pregnancy.) While postpartum mental health issues are far more common than gestational diabetes, every woman will get screened for diabetes during her pregnancy and not nearly as many new mothers will get screened for postpartum mental health issues.
Postpartum Health Alliance logo
Postpartum
Resources
for Integrated
Care Settings

The University of California San Diego’s (UCSD) Department of Family Medicine has come a long way in addressing these issues. With trailblazers like Dr. Katie Hirst (who teamed up with LMFT Amber Rukaj to found the Maternal Mental Health Clinic at UCSD in 2007), we have implemented screening, educational resources, and interventions that are helping postpartum mothers and their providers. As a Medical Family Therapist Intern at this site, I’ve had the special privilege of working with primary care physicians and psychiatrists who believe in what my presence can offer which affords me the opportunity to work with women and their families during pregnancy, postpartum, and beyond.

While changes in the treatment of maternal/pregnancy/postpartum, etc. are called for, it is also important to consider the financial ramifications of these pressing issues. The U.S. has not really tried to quantify the cost of postpartum mental health disorders, but Australia has. Their nationwide organization Post and Antenatal Depression Association found that perinatal depression alone will cost them an estimated $433 million dollars in 2012. This number includes health care costs, lost productivity and foregone tax. Let’s also note that Australia has a population of 22.6 million people, and we have 311.6 million. Do the math. Not caring for our mothers is costing us, big time.

Whether it’s due to stigma, limited skills and training, a fast paced schedule, or lack of resources, not enough providers are talking to mothers about postpartum mental health risks and disorders. In order to address these important issues, I suggest a collaborative approach between physicians and mental health clinicians to increase detection and treatment.

If you are looking to help this population, a way to begin coordination in this area is to get in contact with your local postpartum health organization. In San Diego we have the Postpartum Health Alliance, an organization whose entire mission is to connect mothers and providers to each other and to the vast array of resources that exist out there. I’ve been lucky enough to serve as one of their warmline volunteers, and through the process have run into some amazing resources that you can find at the bottom of this post.

We know that untreated postpartum mental health issues have long term costs for mothers, their children, and their families. Whether it’s the personal or financial costs that make you cringe, that doesn’t matter to me. What matters to me is that we do something. Let’s amplify the voices of our hurting mothers. Let’s tell them that they’re not alone, that we care, and that we are taking action.

 


Cassidy Freitas is a Marriage and Family Therapy doctoral student at Loma Linda University as well as an AAMFT Minority Fellow. Along with her PhD she is pursuing a certificate in Medical Family therapy offered by the doctoral program at Loma Linda. She is currently working at the UCSD Department of Family and Preventive Medicine as an MFT Intern.

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Come Disrupt the Status Quo at CFHA 2013

Posted By Laurie Ivey, Friday, February 1, 2013

Disrupting Status Quo

Hi CFHA community,

 

It’s that time of year again—time for you to help us create the best CFHA conference yet! The conference dates are October 10-12, 2013 in Broomfield, Colorado. Disrupting Status Quo is our theme and we are ready to shake things up. I am one of the co-chairs of the CFHA 2013 conference and with Amy Davis, am leading the program committee to develop an exciting curriculum for presentations next fall. I have attended many CFHA conferences and find them inspiring. I helped out with the planning process when CFHA came to Denver in 2008 and was excited to do so again when Randall Reitz approached me to be a part of the Denver planning team.

 

We have spent a lot of time as a group talking about how to energize the 2013 conference and how to breathe some fresh air into our days together next fall. We chose the theme "Disrupting Status Quo” because we wanted to highlight the fact that it is time to bring new energy to our conference, particularly for the long-time attendees. We are all facing many disruptions in the workplace, from the institution of electronic health records, the changing demands resulting from the patient centered medical home movement, and from changes imposed by health care reform. Continuing to weave integrated care into this disruption is both challenging and exciting as we find successes and improvements in our delivery systems. Disruption is the norm for many of us right now and we wanted to capitalize on the notion and use it to give momentum to CFHA 2013.

 

The good news about our conference location is that you’ll be breathing in some good old Colorado Mountain air, as we have chosen a beautiful location in the foothills of Boulder. We are out of the city bustle this year and in the relaxing open space and sky of Broomfield, Colorado, with spectacular views of the Flat Irons of Boulder. The resort-style hotel is situated between Boulder and Denver for those of you who would like to explore both places. We plan to provide transportation to Boulder by bus for our traditional dine-around night. Our hotel is spectacular with outdoor heated pools and hot tubs. There is a beautiful outdoor reception space in which we will showcase a fun, beer tasting fund-raiser to benefit the CFHA scholarship program—Colorado style.

 

We need your help with fresh, new presentations. Consider being creative this year and bring us new ideas and new presentation formats. Let’s get the audience engaged. We need a few basic presentation that educate new attendees about Integrated care 101, but otherwise, we have an audience of repeating attendees who needs to leave refreshed and ready to go home and shake up their routines and practices with new thoughts about moving integration forward and through the twists and turns of the changing climate of health care. We have also had requests for excellent presentations on clinical topics.

The call for presentations just opened and ends March 15, 2013. So, click here and start typing up your best ideas. We look forward to reading them!

 

Laurie Ivey
Laurie Ivey is the Director of Behavioral Health for Swedish Family Medicine Residency and The Colorado Health Foundation. She enjoys teaching both family medicine residents and post-doctoral fellows to work and thrive in the integrated primary care environment. She lives in Denver Colorado with her partner and twin sons.

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Home Grown Providers in Rural Integrated Care: The Web of Interconnectedness

Posted By Catherine Jones-Hazledine, Thursday, January 31, 2013
Updated: Monday, February 4, 2013
Rural blog series logo
Cate's blog is the
last post in a
month-long series
on integrated
care in rural settings.


Read the entire
series here.

 

Much has been written about the advantages of integrated or co-located behavioral health care in rural primary care settings. At this point, most in the field understand the practical benefits of this model, especially in our most rural and underserved areas. There is a growing understanding, as well, that there are many factors to consider in successfully implementing this model. Dr. Joe Evans and Dr. Rachel Valleley wrote very eloquently about some of these in a blog post earlier this month. And they would know. Over the years, they have worked to establish these services in many settings across our 99% rural, and 87% underserved state of Nebraska. I would like to think of myself as one of their success stories.

Almost 9 years ago now, after working with the Munroe-Meyer Institute Rural Outreach Program for two years as an intern, and obtaining my Ph.D. in Psychology, I made the decision to return to my own home area of the state. Dr. Joe Evans and Dr. Jodi Polaha were instrumental in helping make that happen. We originally established three integrated behavioral health clinics within primary care settings in small, isolated communities along Hwy 20 in the far northwestern corner of Nebraska. Our services were well received by the local family physicians and over the next few years the three clinics grew to five, and ultimately turned into a privately-owned network of clinics called Western Nebraska Behavioral Health.

Over these years, as well, we began to take on practicum students and interns from a small nearby college. These students were mostly Nebraska natives, many from the immediate area, who were training to receive a Master’s Degree in Community Counseling. Many of them ended up staying on with the clinic network after graduation, with the result that several of our clinicians, myself included, now find ourselves working in our home communities – a fact that has proven to add many layers to the collaborative care/integrative care model.


How many Master’s or
Ph.D. level clinicians
are dying to move to
Cody, Nebraska,
population 155?

One of the challenges of rural practice highlighted in another blog earlier this month (by Alysia Hoover-Thompson and Natasha Gouge) is the amount of turnover among those who decide to go into the area of rural integrated care. It is an unfortunate fact that many initial placements of clinicians into rural areas across the nation do not last much past the training phase or, as the authors indicated, the loan repayment phase. This obviously happens for many reasons: family obligations, spousal careers, health issues, financial concerns, lack of resources and support. One fact that contributes to the problem, I think, is that most of our training facilities for clinicians – especially doctoral level clinicians – exist in urban (or at least more urban) areas. As a result, individuals can be identified who express rural interest or commitment, but many of them are not actually from, or familiar with, truly rural settings. Even those who are from rural settings end up living for an extended period in the urban area to complete their training, and develop ties there that make it more difficult to jump out to a rural setting when the time comes.

Our real-life rural settings have many advantages: clean air, simplicity of life, wide-open spaces, good people. They also, however, have many peculiarities that make them challenging for those not accustomed to the lifestyle: lack of resources, lack of anonymity and privacy, distrust of outsiders, sometimes a slowness to open to new ideas, etc. Rural individuals exist in a web of interconnectedness that those from larger areas are often simply uncomfortable with. I once attended a meeting of psychologists at which a provider in a larger community was telling about the awkwardness of going to a home improvement store on a weekend, dressed casually and unshowered, only to run into a client. This was a rare event to hear about for many of the providers at the meeting, but our contingent was struck by surprise that it had only happened once to that provider. In our own rural area, it is the case that we rarely leave our homes without seeing a client or member of a client family

We see our clients outside of session more here because the population and communities are so small, and this issue would occur for us regardless of where we were from. Being originally from the area ourselves means that we are also more likely to know our clients or patients before they come to see us, or have some other level of connection to them. This web of connections is not limited to client connections, either.

Several years ago, I was contacted by a local woman who was in the process of getting her degree in community counseling (from the small local college I mentioned) and needed a practicum placement. I recalled that many years before that, when I was a middle school student and she was a precocious preschooler, our families had been next door neighbors. Further, her father (now retired) was my dentist, her older brother and my younger brother were very good friends in high school, her sister-in-law ran a local daycare that my children had attended as infants, and her nephews were in the same grade and school as my own children. None of these connections were close enough that it felt problematic to train the student, and few other options were available to her, and so she ultimately did a practicum placement, a pre-master’s internship, and an advanced training placement to accrue licensing hours within our clinic. Further, she continues on with us to this day - providing services in a clinic just blocks from where she used to run through my yard as a preschooler, pretending to be a horse. Having so many connections locally, she has no plans of living anywhere else. She is also well versed in the challenges of rural life, and very comfortable with that web of interconnectedness.

This clinician’s story is a common one in our clinic at this point, and it definitely raises issues to consider. It frequently occurs that our collaborating physicians refer a patient to us that one or more of our clinicians has some other connection (current or historical) to. This requires careful thought and supervision about the closeness of the connection, and any way in which it might be ethically problematic. A large number of our referrals end up being cases that, were we in an urban area, would be referred to another provider due to the additional connection. There is a fabulous model that we often refer to by Kitchener (1988) that helps us determine which connections are too close to be ethical for us to work with. This is an ongoing area of thoughtfulness in our work.

Some consider these multiple levels of connectedness to be a serious drawback in rural work. I remember hearing in graduate school the recommendation that if you were to work in a rural setting you should not live in the same community. Or, if you did live there, you should refrain from participating in local life (communities, organizations, etc). Being from a rural area myself, this struck me as silly. I remember thinking about most of my rural neighbors growing up, and realizing how they would perceive someone who kept themselves so distant from the community they meant to serve. Now, being in practice here for several years, I can tell you anecdotally that it is often the case that individuals come to see us BECAUSE we are known to them. There are many conservative rural residents who would be unlikely to seek "behavioral health” or "mental health” services (even at their physician’s recommendation) but who end up following through because the identified clinician is "Gene and Carol’s daughter” or was in their brother’s graduating class. We are a known, and therefore often a more trusted, quantity. Because they exist all the time within a closer web of connections, our rural clients are also just naturally more comfortable with the additional connections and casual interactions that occur outside of clinic.

Summarizing all of this thought, then, it seems that another key to the successful establishment of integrated behavioral health in rural settings involves greater recruitment of local individuals, as well as training of these individuals from the beginning within the rural settings they will eventually practice in. Not only does this seem likely to reduce turn-over and offer better preparation for real-life work scenarios, but it also provides additional job opportunities for rural individuals – thereby reducing the problems of de-population, unemployment and poverty in rural settings.

So positive have our experiences been of training locally raised clinicians, that we have recently taken things a step farther. Working with support from BHECN (the Behavioral Health Education Center of Nebraska) we have designed a program to help identify and mentor rural high school students in particularly isolated areas who have an interest in behavioral health careers. By catching them early in their education, we hope to help provide a pathway for them to access the training to eventually provide much-needed services in their home communities –spots that would have considerable difficulty drawing trained providers. How many Master’s or Ph.D. level clinicians, after all, are dying to move to Cody, Nebraska, population 155? It will be some time before we have available data to tell how successful this approach is, but we are excited to find out!

References:

Kitchener, K.S. (1988). Dual role relationships: What makes them so problematic? Journal of Counseling and Development, 67, 217 – 221.



Dr. Catherine Jones-Hazledine is a psychologist and the owner of Western Nebraska Behavioral Health, PC, a network of five integrated behavioral health clinics in rural western Nebraska which are affiliated sites with the University of Nebraska Medical Center’s Munroe-Meyer Institute Rural Outreach Program. She is also adjunct faculty with Chadron State College, in Chadron, Nebraska.

 


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Integrated Care in Rural Communities: A Psychologist’s Perspective

Posted By James L. Werth, Thursday, January 24, 2013
Rural blog series logo
James's blog is the
fourth post in a
month-long series
on integrated
care in rural settings.


Read the entire
series here.

As the Director of a doctoral program in Counseling Psychology since 2007, I have attempted to keep up with the literature, anecdotal reports, and personal opinions regarding the future of psychology as a profession so that I could help our students be ready when they graduate. I started hearing about "integrated care” almost immediately upon assuming my position but it was not until I served on the American Psychological Association's Committee on Rural Health that I fully appreciated the importance of integrated care for the field, especially for practitioners who would be working in rural areas. My colleagues helped me understand the value of integrated care for the patient, family, medical providers, and psychologists and other behavioral health professionals. As a result, I became convinced that we had to try to provide training opportunities in integrated care settings for our students.

   Fortunately, such an opportunity arose when the Executive Director of two of the local free medical clinics contacted me and asked if we had any students who would want to work alongside their providers who struggled with some of the psychological issues presented by patients. At about the same time I was contacted by the Development Director of a federally qualified health center who wanted to apply for a Rural Workforce Development Grant and hoped to use the grant to expand their provision of behavioral health services.  
These two collaborative efforts have led to a popular advanced practicum placement site at the free clinic and an internship site at the FQHC. Even more, these sites are helping to provide training and experience that our students will be able to take with them as they move into their first jobs while also filling some significant needs in these Health Professional Shortage Areas.


For those of us in rural
areas, the challenge may
be
especially important to
meet because of the
difficulty recruiting and
retaining professionals
in these communities.

Based on the facts that one of the American Psychological Association's three strategic goals is to expand psychology's role in healthcare, that the Affordable Care Act promotes interprofessional care, and that insurance payments for psychological services are falling in many locations, I am convinced that psychology graduate students must receive the training necessary to work in integrated care settings. I am fully aware of the challenges associated with setting up these types of training sites but I believe faculty will need to be proactive in finding or creating sites in order to ensure their graduates will be employable. This may mean that faculty members will have to go into the community and provide supervision for students at sites that do not have psychologists or other mental health professionals on site. We need to expand the types of sites that we have considered for practicum and internship to include physician offices, emergency rooms, and university health centers.

For those of us in rural areas, the challenge may be especially important to meet because of the difficulty recruiting and retaining professionals in these communities. Even with the National Health Service Corps loan repayment program available for psychologists and other providers, many outlying areas do not have access to sufficient numbers of mental health professionals. However, if we can get trainees into these areas and provide them with learning opportunities, especially on internship, we have a greater chance that they will stay. Setting up a private practice in a rural area may not be feasible but continuing to work at a FQHC or in a community mental health center that has begun to recruit medical personnel or at a VA's community-based outpatient clinic could provide employment options.

On a related note, I have noticed that in our FQHC training sites, where both psychology and social work interns have begun providing primary care-based services, we have uncovered other needs in the community. The most obvious ones are referrals for traditional mental health services and psychological assessment. Our behavioral health providers in these rural clinics have ended up having to move away from the typical brief behavioral approach to more of a blended model where they also provide longer-term sessions on a weekly basis because there are no referral options, or at least no options without a several month waitlist. The need for assessment, especially neuropsychological assessment, is even greater. Without university-based training clinics that operate on sliding scales and sometimes waive fees entirely, many people would not be able to get the testing needed for appropriate care. Thus, appropriately trained behavioral health professionals could collaborate with clinics to provide these additional services.

One final area that has been increasingly on my mind as I have thought about training psychology graduate students for the future and about the needs of rural communities is the contentious matter of prescription privileges for psychologists. The military and Public Health Service as well as the states of New Mexico and Louisiana allow properly trained psychologists to prescribe (or unprescribe) psychotropic medications. This is a hotly contested issue and until I started practicing in a rural area where there are virtually no psychiatrists or psychiatric nurse practitioners, I did not think I would ever be interested in this if it were to become a reality in my state.

However, I have changed my mind and now think that if I and my psychologist-colleagues had the appropriate training and our state law allowed it, we could provide significant help to patients as well as the medical providers who are reluctant to prescribe these medications. In fact, I think that hospitals, FQHCs, free clinics, and other primary care practices would be perfect places for pilot programs because of the collaborative relationships with medical personnel. Thus, I hope that psychology trainees will receive significant training in psychopharmacology and that psychologists and medical providers in rural areas can work together for policy change in order to expand the numbers of trained personnel who can meet the psychiatric needs of underserved individuals.

In conclusion, I hope that we will see more graduate programs in behavioral health preparing their students for practice in integrated care settings. Within some programs, such as psychology, this would also include ensuring sufficient training in psychopharmacology. If this happens, then perhaps at least some of the significant needs of people living in rural areas would be met through collaborative efforts between training programs and health care facilities.

 

James L. Werth, Jr., Ph.D., ABPP is currently Director of the Psy.D. Program in Counseling Psychology at Radford University (located in Southwest Virginia). For the past several years he has been collaborating with Stone Mountain Health Services, an FQHC in the Westernmost counties of Virginia and is leaving Radford this fall to become Stone Mountain's Psychology Director. He may be reached at jwerth@radford.edu

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Necessary components of Integrated BH in Rural Primary Care

Posted By Joe Evans and Rachel Valleley, Thursday, January 17, 2013
Rural blog series logo
Joseph and Rachel's
blog is the third post
in a month-long series
on integrated care in
rural settings.

Read the entire
series here.


Recently, while preparing yet another grant application, I resurrected one of my favorite quotations related to integrated behavioral health care. Dr. David Lambert, of the Rural Health Research Center at the University of Southern Maine, stated, back in 1999, that, "Integrated behavioral health care is a concept that is frequently discussed, but seldom implemented.” Over the years, this quotation has resonated with me and colleagues as we attempt to prepare students to work in integrated pediatric primary care practices. Just what is it that makes an integrated behavioral health clinic in primary care successful? What are the essentials that we need to pass on to our trainees as they enter the field, particularly those who opt to work in rural primary care?

The concept of integrated behavioral health in primary care is certainly far from a "new” idea. Dr. Nick Cummings and his associates have been espousing this notion for over three decades. As noted by Alexander Blount, the integration of physical and mental health care seems to be such an "obvious” and necessary part of the overall health care system that few can argue with its theoretical underpinnings and utility. Why, then, has the implementation of such a beneficial approach to healthcare taken so long in being recognized and implemented. Why have attempts to integrate behavioral and physical health care failed in the past? What makes some practices extremely successful in this venture while others have experienced major difficulties? Are we looking at the essential and necessary components for positively integrating behavioral healthcare and can we learn from successful implementations by others in the field?

Using the approach of "translational research”, Carol Trivette of the Puckett Institute in Morgantown, North Carolina, has emphasized identifying the "kernels, nuggets, and gems” from research findings that are applicable to applied practice. Identification of those characteristics of programs and practices that "stand out” as most important in successful practices is an approach that we, as a field, have not yet applied to integrated behavioral health care, particularly in rural settings. While we all have ideas of what should be involved in an integrated behavioral health practice in primary care, we have not conducted investigations into what factors truly differentiate what makes a practice successful versus unsuccessful in integrated care.


During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments.
 

By way of example, Wolfe and colleagues at the Achievement Place Project in Kansas conducted an analysis of the necessary components of a treatment group home program for delinquent adolescents following an initial "failure” of the program to be replicated. While, initially, it was felt that their well – researched token economy would be the most essential component of the treatment program, further investigation revealed that it was actually the "relationship” and "teaching style” of the group home Teaching Parent staff that was most important in the implementation of the program. Based on this finding, the training component of the program shifted emphasis to development of "teaching skills” with the token economy being a secondary "tool” in the social skills educational process. This program has now been successfully replicated in literally hundreds of agencies in the USA and in foreign countries.

Similarly, in the area of integrating behavioral health into primary care practice, we need to examine some of the parameters that have separated successful versus unsuccessful implementations of the integrated care approach. We may also need to assess whether there are "differences” in the necessary components for Pediatric versus Family Medicine versus Geriatric primary care practice. Our experiences would lead us to propose that there may be significant differences in successful implementation of an integrated behavioral health approach in a Pediatric or Geriatric setting where much of the intervention implementation is mediated by caregivers (parents and nursing staff) versus direct intervention with the patient as is typical in adult Family Medicine integrated MH care.

Some attempts have been made at identifying commonalities of integrated behavioral health care services by examining existing programs. A study funded by the Robert Wood Johnson Foundation, (2007) reviewed 16 programs that, in various ways, identified themselves as providing integrated behavioral health services. Findings suggested that "Integration implementers and goals varied,” and "Integration approaches vary.” Differences in definitions of integrated behavioral health care, a variety of funding mechanisms, and differing target service populations made the task of identifying commonalities difficult to impossible. Additionally, almost all of the programs reviewed operated in major urban areas and focused on "publicly funded” mental health care for severe mental illness.

Examination of components of successful integrated care practice in rural areas may have some distinct advantages due to commonalities found in rural practices. First, the majority of health care in rural areas is provided by Family Medicine or Pediatric primary care physicians. Secondly, there is generally a lack of local "MH specialists” to whom primary care physicians can refer within the immediate area, particularly psychiatrists. Thirdly, most primary care practices in rural areas have a small number of physicians (with an increasing number of Nurse Practitioners and Physician’s Assistants). Fourth, these primary care physicians are expected to address the full range of health problems, with very few having any type of "specialty” clinical practice. Finally, rural primary care physicians generally have a ready "network” of specialists to whom to refer, frequently at University Medical Centers, for various severe conditions. (In the case of behavioral disorders, however, scheduling for appointments can take weeks or months.) Because of these commonalities, finding necessary components of rural integrated care implementations may be more feasible.

During our Nebraska experiences in implementing integrated behavioral health into 17 rural primary care practices, we have had our share of successes and disappointments. The remainder of this blog will discuss some components that we feel are necessary for successful integration of behavioral health into primary care and we will provide some examples of factors that seemed to undermine our attempts. First, a necessary component, in our experience, is the establishment of positive relationships by the behavioral health specialist with not only the primary care physicians but also office staff (nurses, billing clerks, receptionists, etc.). In one of our first replication attempts, some office staff initially viewed our presence as a "burden” and would frequently neglect to notify our behavioral health provider of patients in the waiting room. After "earning her spurs” by successfully treating one of the children of a support staff member, however, relationships improved markedly and staff became some of our greatest supporters. Lesson learned: be sure to develop relationships with staff by chatting, bringing "treats” on occasion, and providing reinforcing comments for cooperation and services provided, no matter how menial. With physicians, reinforcing the "appropriateness” of referrals and information about treatment successes greatly contributes to relationship building.

Secondly, communication with primary care physicians and staff is paramount for establishing a consistent flow of patient referrals when implementing integrated care. In many cases, physicians are unaware of the types of services and skills that are possessed by behavioral health providers. During their training, most primary care doctors receive one to two months of rotations in psychiatry during their residency years. Depending on their experiences during these rotations, primary care physicians frequently place behavioral health providers into a single category, dealing with only the most severe disorders. Communication about the "types” of services that can be offered should occur during the first 6-12 months of program implementation. Noon conferences, presentations to local hospital "rounds,” and "sitting in” on patient sessions can all be forums for providing information to physicians and staff. Recently, by way of example, a family presented in a new clinic with a behavioral concern about "head banging” by their four-year-old child. Following the physician’s citation of the percent of children who engage in this behavior and reassurance that the child would eventually outgrow this activity, our behavioral health professional was able to indicate having some skills in reducing potentially self – injurious behaviors and was able to "solve” this problem in only two sessions using parental differential attention and timeout. Following this episode, the number of "warm handoff referrals” (a la Kirk Strosahl) increased. Other methods for increasing communication include timely intake reports, discussions of combined medical and behavioral plans, notes about when an outside referral needs to be made, offering assistance in behavioral diagnostics, and monitoring of psychotropic medication effects.

It is important to note that communication can best be achieved through physical proximity and seeing patients in examining rooms in the primary care practice. In one instance, an office manager, in an attempt to provide better "clinic space,” assigned a room at the end of the hall to our behavioral health provider. While accommodations were better for seeing patients, contact with physicians, nurses, and office staff was reduced and referrals dropped markedly. Using examination rooms on physicians’ days off allows contact with other doctors as well as providing access to support staff.

A third critical component in implementing Integrated care, in our estimation, relates to the "economics” of primary care practice. Behavioral health providers need to have enough "business acumen” to understand the financial pressures and incentives in primary health care. A number of models of funding for behavioral health reimbursement exist (and may increase with the implementation of the Affordable Care Act). Capitated care, fee for service, Medicaid, co-pays, sliding scale payments, HMOs, and insurance panels are all examples of how behavioral health services can be reimbursed. Providers need to understand the number and "mix” of patients being seen in the primary care practice according to payment source and reimbursement allowed. Negotiating "overhead” costs for space and staff support should also be taken into consideration. These factors help determine estimates of potential income and number of patients that need to be scheduled. Consideration of the economics for primary care providers should also be a point of awareness for integrated behavioral health providers. Initially, we recommend keeping staff demands and supports at a minimum until the overall "value” of integrating behavioral healthcare into primary care physicians’ practices is established. This can be done by the behavioral health provider transcribing his/her own notes, handling return schedules, making reminder calls, and performing billing and collection functions. As the benefit of having behavioral health available in the practice, many of these functions can be absorbed into the day-to-day activities of support staff.

Data that we have collected over the years indicates that primary care pediatricians spend literally double the amount of time on behavioral referrals as compared to acute care episodes or well – child visits. When collectible fees for providing behavioral health services by physicians were analyzed in one of our studies, physicians unable to utilize mental health codes in their billing. This resulted in reimbursements that were only 45% of "typical” collections for acute and well – child care. Following this logic, physicians should be able to be 15-20% more productive with time freed up when a behavior specialist is available to deal with mental and behavioral health issues within the practice. In our experience, once the that physicians recognize the amount of time savings, economic benefit, and improved diagnostic and treatment capacities resulting from having a behavioral professional in the practice, referrals flow steadily and benefit all parties: primary care physicians, behavioral health professionals, and patients.

Finally, and possibly the most important component in preparing behavioral professionals for primary care practice, is knowledge and skills necessary to treat behavioral problems presenting in primary care physicians’ offices. Unfortunately, there is not a direct correspondence between graduate education in many behavioral health graduate training programs and medical practice in the community. Training in addressing the most common behavioral problems presenting in primary care is a necessity. Most psychology training programs are not located in, nor do they collaborate with, colleges of medicine. In integrated pediatric primary care, by way of example, behavioral providers need to be able to accurately assess and treat the most commonly presenting problems of childhood and adolescence.

Specific protocols for diagnosing and providing therapy for sleep disorders, feeding disorders, thumbsucking, nocturnal enuresis, learning disabilities, ADHD, habit disorders, childhood depression, aggression, anxiety, school motivation problems, medical compliance, and the psychological effects of chronic conditions such as diabetes, epilepsy, cystic fibrosis, and genetic conditions should be mastered in order to be successful in integrated pediatric primary care practice. We recently had a student in a pediatric practice in an underserved, high need poverty area. Her training did not include education in many of the behavioral conditions noted above and she spent a good deal of her time doing assessment and then referral out of the practice. This simply added another "layer” of delay between the physician and eventual treating agent. Similarly, we have had students who are well trained in standardized and "manualized” therapeutic programs requiring consistent attendance at 10-12 consecutive sessions. In primary care, this is a practice that is rarely successful and often leads to treatment failure. In our estimation, short – term, evidence – based, protocol driven and prescriptive therapies are the "norm” in pediatric integrated primary care practice.

In summary, as educators of future integrated behavioral health specialists, we are very interested in sharing and hearing the experiences of others, both positive and negative, who have been successful in implementing integrated care programs. We have attempted to share some of our successes and "tales of woe” that will hopefully be of benefit to you in your future endeavors.

 

Joseph Evans
Dr. Joseph Evans is a Professor at the Munroe-Meyer Institute (MMI) and in the University of Nebraska Medical Center's (UNMC) Department of Pediatrics. He is the Director of the Psychology Department at MMI and the Division Director of Pediatric Psychology in the UNMC College of Medicine. Dr. Evans administers a staff of eleven Psychologists, nine Doctoral Interns, five Post-doctoral Research Associates, four graduate students in Applied Behavior Analysis, and support staff. He is an active clinician and manages the ADHD Clinic conducted at MMI as well as serving as a staff psychologist for the DHHS Children with Special Health Care Needs program.

Rachel Valleley
Rachel J Valleley, Ph.D., is a licensed psychologist in the Department of Psychology at the Munroe-Meyer Institute for Genetics and Rehabilitation and Associate Professor in Pediatrics and the Munroe-Meyer Institute at the University of Nebraska Medical Center.  Her research and clinical interests revolve around behavioral health in primary care. Specifically, she is interested in the impact that behavioral health problems have on primary care, demonstrating the effectiveness of the integrated model on behavioral health, and the unique contributions that behavioral health specialists can have upon primary care. She is currently Coordinator of MMI’s Outreach Behavioral Health Clinics, overseeing 13 rural clinics, 7 Omaha area clinics, and 4 collaborating sites. She has published nearly 20 scientific papers and chapters related to children with behavioral health and academic concerns.


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