Posted By Laurie Ivey,
Friday, February 1, 2013
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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 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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Posted By Catherine Jones-Hazledine,
Thursday, January 31, 2013
Updated: Monday, February 4, 2013
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|Cate's blog is the |
last post in a
care in rural settings.
Read the entire
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
are dying to move to
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.
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.
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
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
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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Posted By James L. Werth,
Thursday, January 24, 2013
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blog is the
Read the entire
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
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.
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.
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
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Posted By Joe Evans and Rachel Valleley,
Thursday, January 17, 2013
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|Joseph and Rachel's |
blog is the third post
in a month-long series
on integrated care in
Read the entire
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
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
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 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
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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Posted By Jodi Polaha,
Thursday, January 10, 2013
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|Jamie and Jeff's |
blog is the second post
in a month-long series
on integrated care in
Read the entire
Tedder, M.S.East Tennessee
always viewed the stepped care approach (e.g., see Bower & Gilbody, 2005)
to mental and behavioral health service delivery as being like a relay race
where the participants are various health and mental health providers. The professionals at each stage provide
treatment within their area of expertise and within the constraints of their
practice before "passing the baton” to the next provider. This was the image I had in mind when I
walked into my first external placement; a rural pediatric clinic with a
co-located mental health specialty service. I was to practice population-based care -- the
first runner on the mental health relay team.
few patient contacts I realized I was more like the Lone Ranger than a relay
racer. I felt many of my patients could
benefit from more lengthy and frequent treatment than I was able to provide in
population-based model, but the co-located service and the community mental
health center in town is typically "booked out” about 8 weeks. The nearest "next best” referral source is
over 30 miles away. By the end of that
first day I was overwhelmed, to say the least.
are no easy solutions for the challenges, such as this one, that are raised in
a rural setting. This year, we are
experimenting with a creative solution that builds in technology. Thus, one day each week I travel about 60
miles to the rural clinic described above, in Rogersville, Tennessee, to
provide behavioral health consultation services. Three other days a week I (along with my
colleague, Jeff) staff a telehealth clinic based out of Johnson City, where we
are based, at East Tennessee State University.
Several rural primary care clinics across the state have access to our
services through the telehealth clinic, including my site in Rogersville. This allows me greater flexibility to
schedule follow-up visits for patients who need more frequent treatment, longer
sessions, or who simply can’t make it into the clinic on the day I’m
there. I also access supervision and
consultation through telehealth as needed.
New and innovative treatment modalities such as the one described above
give rural behavioral health consultants more options in underserved areas, and
decrease the feeling of professional isolation often experienced by
practitioners in rural areas.
my graduate training, I have had the opportunity to work on-site as a
Behavioral Health Consultant (BHC) in two rural Appalachian primary care
practices and via telehealth at several others.
These experiences have shown me that, while every primary care clinic faces
unique challenges (e.g. the types of patients seen, the physical space
available, the workflow, etc.), the lacking availability of community resources
is a constant challenge among rural practices.
As a BHC in non-rural settings, I have enjoyed my role as a component in
a stepped care approach, where more intensive outpatient services are available
to patients who do not benefit from brief, problem-focused treatment in the
primary care setting. In rural
communities, however, I quickly learned that lacking specialty services made
such referrals impossible. Thus, in rural practice I feel a pull to treat
a much broader spectrum of problem types and severities than would ideally be
the case in population based mental/behavioral health care. It is a challenge to navigate
this dilemma, allocate clinical time, and prioritize clinical services to make
the greatest impact.
attempts to make this dilemma more manageable have led us to experiment with a
variety of possible solutions, some novel and innovative and others
common-sense. One way that we have risen
to this challenge has been by developing a telehealth infrastructure in the
clinics in which we provide service.
This has allowed us to allocate more of our time to clinic coverage (due
to reduced travel time to and from these rural clinics) and has reduced the "lone-wolf”
feeling when we are providing on-site services (because of the potential to
access additional consultation, supervision, and support via video).
We have also experimented with setting aside
dedicated time each day for brief appointments with patients requiring longer
term management (e.g., specialty services) while making it clear to providers
that appointments can be interrupted for consultation and warm handoffs as
needed. Although we have had some
success with interventions such as these, rural practice as a BHC is a daunting
calling and one that begs persistence, flexibility, and creative thinking at
Ellison and Jamie Tedder are advanced students in the doctoral program
in Clinical Psychology at East Tennessee State University, which has a
rural, integrated care.
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Posted By Jodi Polaha,
Thursday, January 3, 2013
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|Natasha and Alysia's |
blog is the first post
in a month-long series
on integrated care in
Read the entire
The following highlights
insights from two pre-doctoral interns working in rural, integrated primary
care clinics. Their doctoral programs
differ in foci of training, but do overlap in their focus on providing care to
rural, underserved populations. They are
both currently on internship thru a novel "grow your own” model at Stone
Mountain Health Services (SMHS).
Natasha Gouge, MA
|Cummings, O’Donohue, and
Cummings (2009) put it best: "integrated behavioral/primary care is like a
pomegranate: overwhelmingly people say they like it, but few buy it” (pg.
6). I read this statement a few years
ago while reviewing literature for a term paper, and these words have been
engrained in my mind ever since. The
statement, although originally associated to the economic hurdles associated
within integrated care, is not limited to health care costs or
Within my own graduate
training program, which is tailored to train clinicians to work within
integrated care settings and/or among rural populations, several individuals
"don’t buy it”. Despite the program’s
mission offering an appealing training specialty at the onset, as students get
exposure to integrated care and working within rural areas their commitment to
the model and region often seems to wane.
So I might add a similar statement like, "integrated care and working
within rural areas are like vegetables:
overwhelmingly people recognize they are needed, but few enjoy eating
them every day”.
The ideals of integrated
care and of offering services to underserved areas are generally supported in
theory. However, supporting those ideals
and working in the service of those ideals are two very different tasks. And the result? Turnover.
Students, interns, post docs, residents—the list goes on, embark on
clinical experiences in line with these ideals, only to seek other career
opportunities after their initial obligation is over. So after the 9-week rotation, or semester
practicum, or yearly internship comes to a close, some individuals decide they
no longer have a taste for their vegetables.
(Or worse, in the case of rural underserved regions, this realization
occurs after an individual has received their loan reimbursement installments!)
About Stone Mountain
Alysia Hoover-Thompson, MS
My path to liking vegetables
was a long one, as I suspect is the case with many other clinicians in
integrated care. I had an undergraduate
double-major in physics and anthropology (seriously…what was I going to do with
that combination?) and worked in IT staffing and boarding school admissions
prior to applying to Master’s programs in Counselor Education. I loved my Master’s program, but felt that
pursuing a doctoral program that offered more intensive clinical training, as
well as the opportunity to conduct research, really appealed to me.
My doctoral training
program, which has a focus on rural mental health and additional emphases on
cultural diversity, social justice, and evidence-based practice in psychology,
is designed to train generalists in rural mental health. During my final year as a practicum student,
I had the opportunity to work at a Free Clinic doing integrated care. Beyond coursework and readings, I had limited
exposure to the world of integrated care, prior to this opportunity. I vividly remember my first day at this new
site - I could work in a fast-paced environment, seeing patients alongside
medical providers, doing more than just traditional mental health and someone
would eventually pay me for this? Sign
me up for a vegetarian diet!
While integrated primary
healthcare is right for me, it is certainly not the right fit for
everyone. Along the way, I have often
been asked- "How can you see someone in 15 minutes?” "Don’t you miss really
getting to know your clients?” "How do
you work without an office?” Yes,
these are very good questions but are easy to answer for someone who fits in
this model of care. Do I miss having a
cushy couch to nap on over my hour-long lunch break? Yes.
Do I wish that I could go home every day and not have blisters on my
feet from running around the office in impractical heels? Yes.
Would I trade this vegetarian diet for something less PETA friendly? Definitely not.
The farm that produces our
vegetables is SMHS, a Federally Qualified Health Center that consists of 11
primary care clinics in rural, Southwest Virginia. The mission of SMHS is to promote and
provide quality primary health care that is accessible, affordable, and
community-based for the people of Southwest Virginia. Following from this
mission, the organization’s vision is to be the recognized leader in the
provision of accessible health care in our communities, through integrity,
excellence and diversity of services. Services offered by clinics include:
family health care, black lung, assistance in obtaining medication, x-ray and
laboratory, dental and behavioral health counseling. In 2011, SMHS, in conjunction with East
Tennessee State University and Radford University, created the pre-doctoral
internship to address the needs of this patient population.
We both desire to remain
working in rural primary care after the completion of our internship. Are we the norm among doctoral trainees? Probably not.
Most interns uproot themselves and their families for a 1 year training
experience and then move on. To provide
consistent, doctoral-level providers, SMHS created a "grow our own” model. Two
interns began in August of 2011 and they are now both psychologists within the
organization. We began in August of 2012
and hope to also be offered positions to stay on board. To date, we have seen over 300 patient
contacts (in addition to all of our hours of supervision and didactic
Organizations that wish to
train or employ psychologists who enjoy a daily dose of those rural integrated
care veggies, have quite the challenge!
SMHS recognizes that psychologists who desire working in integrated care
can move to a rural region and lose interest in maintaining their position due
to a lack of resources professionally (e.g., referral options for their
patients) and personally (e.g., academic or extracurricular opportunities for
their children); likewise, psychologists who desire serving the underserved, do
not necessarily want to work within primary care settings. With internship opportunities, employment,
and funding ever in flux, how can a better match between an organization and
applicants be found? Well, SMHS has
taken a novel approach: seek out the
vegetable-friendly professionals already residing in the region and grow them
into vegetable connoisseurs.
Alysia Hoover-Thompson is a doctoral candidate at Radford University in the Counseling Psychology PsyD program. She received her MS in Community Counseling from Radford University in 2009. Her research interests include: women’s issues, body image and rural practice.
Natasha Gouge is a doctoral candidate at East Tennessee State University in the Clinical Psychology PhD program. She received her MA in Clinical Psychology from ETSU in 2011. Her professional interests include dissemination and implementation science; program development, innovation, and evaluation; primary care, rural practice, and pediatrics.
Cummings, N.A., O’Donohue,
T.O., & Cummings, J.L. (2009). The
financial dimension of integrated behavioral/primary care. Journal of Clinical
Psychology in Medical Settings, 1-9. DOI 10.1007/s10880-008-9139-2
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Posted By Lauren DeCaporale,
Thursday, December 27, 2012
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When I was interviewing for graduate school, I was asked if I thought my dual major as an undergraduate in sociology and psychology would be "detrimental” to my career as a geropsychologist. Evidently, it was the interviewer’s belief that systems had little to do with the individual adult. I have often reflected on that moment and recognized the critical role it played in my professional development. It is difficult for me to imagine working with an older adult and not knowing his or her background, not exploring the interplay between one’s social structure and sense of self, and not integrating families and other professionals into a patient’s care. However, there are many that do not know the benefits of this work or how it can be done, particularly as it pertains to older adults.
As I participated in this year’s CFHA conference, I was surprised by how few people I met expressed interest in geriatrics. In fact, I was alarmed. It was disheartening to hear Doctors Blazer and Martinez report on the "silver tsunami” and the Institute of Medicine’s report on the limited number of workforce prepared to care for this rapidly growing population.
I wondered: how could this be? Is it a lack of funding? A lack of educators? A lack of awareness? And the answer seems to be: All of the above. So how do those of us who are passionate about our work with this population demonstrate that it is a worthwhile endeavor desperately needed in our current culture?
The numbers alone should demand our attention:
- 72.1 million: the number of older adults projected by 2030 in the US alone (Administration on Aging, 2011).
- 7 - 8%: the number with severe cognitive impairment (Freedman, Aykan, & Martin, 2001).
- 5 - 10%: the number of older adults seen in primary care suffering from major depression and dysthymia (Lyness et al., 1999).
- 20%: the number of older adults with chronic disabilities in the US (Manton & Gu, 2001).
- 29%: the number of the US population providing care for a chronically ill or older adult family member (National Alliance for Caregiving, 2009).
Though these numbers are powerful, they do not capture the full story of our aging population. There are many families who invite us into their lives to share their experiences of successful and sometimes less than successful aging. Recently, I was meeting with an aging patient and her friend. They both expressed gratitude to me for not shouting and talking down to them as if they were children, noting that this was so often their experience with others. I was reminded during this encounter of the stigma attached to aging. Why is it that we assume we must shout or that an aging individual must be suffering from cognitive impairment? These assumptions are unhelpful.
I am fortunate enough to have learned many lessons on aging from all four of my beloved grandparents and my parents who provided them with much of their care. I was taught to live and breathe the idea of respect for my elders, but it was more than that: it was a message of providing the aging people around me with dignity and a listening ear. It was from them that I learned how to grieve and on some days, how not to. I learned how to be flexible, as they gracefully made transitions and altered their expectations when necessitated by medical and physical need. I learned perseverance as my grandmother insisted she was not old, not ready to die, and kept taking the stairs rather than using an elevator at the age of 90. When I wasn’t learning from them, 30 older adults and their professional caregivers at adult daycare facility were teaching me every summer during my adolescence about the power of gentle touch and laughter as sources of healing.
I recognize that others are not as fortunate as I, who had the wonderful opportunity to know all four of these people until my early adulthood. But I challenge all providers who have not had such opportunity to listen to your older patients, to hear their stories, and to learn from them. Geriatric educational programs might not be accessible to all of us, but these patients are abounding, and ready and willing to teach us. Let us take a moment to be educated through their experiences, their voices, their families, and their lived-wisdom.
Lauren DeCaporale, PhD is a second-year postdoctoral fellow in Primary Care Family Psychology with a specialization in geriatrics/internal medicine at the University of Rochester Medical Center, Institute for the Family, Rochester, NY.
Administration on Aging (2011). Profile of older Americans. Aging statistics. Retrieved from http://www.aoa.gov/aoaroot/aging_statistics/index.aspx
FreedmanVA, AykanH, MartinLG.Aggregate changes in severe cognitive impairment among older Americans: 1993 and 1998.J Gerontol B Psychol Sci Soc Sci.2001;56:S100-S111.
Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disorders in older primary care patients. J Gen Intern Med. 1999;14:249–254.
MantonKG, GuX.Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999.Proc Natl Acad Sci U S A.2001;98:6354-6359.
National Alliance for Caregiving (2009). Caregiving statistics. Who are Family Caregivers?. Retrieved from http://www.thefamilycaregiver.org/who_are_family_caregivers/care_giving_statstics.cfm
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Posted By Zephon Lister,
Thursday, December 20, 2012
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What experience in your professional or personal life was
most influential in your development as a family-oriented behavioral healthcare
John Rolland: Near the end of medical school
I debated between family medicine and psychiatry and ultimately decided to go
into community psychiatry and public health. There have been both personal and
professional experiences that I believe have influenced my development as a
family focused practitioner. Personally, I was influenced by two experiences
during my psychiatric residency. First, my mom had a stroke, which became one
of my first close encounters with how families and the healthcare system
interacted. Later in my residency my first wife developed and later died of
cancer. I remember there being no advice or support provided to the family. I
saw how marginalized the family was, and that there was little effort to reach
out to those outside of the "patient”, who were also suffering.
As I reached
out to the providers and my professors for insight and understanding, I began
to realize that there was no road map given to help individuals, couples, and families,
navigate these situations. No one had anything to offer to me in the situation. Almost everything was pathologizing. There
was no guidance on whether what I and we as a couple were experiencing was
normal or dysfunctional. I remembered how I felt during that experience and knew
I wanted to help families not go through what I went through. I also wanted to
help providers do a better job of understanding the importance of family and
how illness impacts the entire family system.
saw how marginalized the family was, and that there was little effort to reach
out to those outside of the 'patient', who were also suffering." |
Professionally, some of the
experiences that had a significant impact on my career path were my exposure to
early system thinkers such as John Weakland and Don Bloch. One of the first papers
that excited my interest in family and illness was John Weakland’s, "Family
Somatics”- A Neglected Edge” (1977). In addition to my personal family
experiences with illness and readings, I was strongly influenced by my primary mentors, Betty Carter in family
life cycle and Dan Levinson in individual life cycle development. They informed and inspired my conceptual
thinking about how illness, family system, and individual family member’s
development interact across time. Don Bloch was another very influential person
that led to my focus on health and the family. He had the vision of the field
and its potential. I remember how he was
able to bring "kindred spirits” together from different disciplines to collaborate
around family systems and healthcare. These collaborations led to foundational
and lasting contributions to the field of family systems in healthcare especially through the establishment of the
journal Family Systems Medicine, now Family, Systems, and Health and the
Collaborative Family Healthcare Association (CFHA).
ZL: What do you consider your most important contribution to the
family systems in healthcare field or literature?
JR: I think my most important
contribution to the field of family systems in healthcare is the Family Systems
Illness model I initially developed during the late 80’s and early 90’s, which ultimately
culminated into my book Families, Illness, & Disability: An Integrative
Treatment Model published in 1994. It has been gratifying to see how well it
has been received among mental health professionals and some healthcare
disciplines, such as Family Medicine and Nursing. However, it was also my hope to
expose these ideas more to other medical disciplines, especially those who are
less familiar with systems thinking in relation to family and illness (i.e.
physicians, family educators, healthcare administrators and policy-makers).
ZL: What do family-oriented behavioral health clinicians most
need to move into the mainstream of healthcare?
JR: I would say a greater effort on visibility
and marketing. Medical family therapy is not just a discipline but an
orientation and way of practice that is not limited to family therapists or
providing just family therapy. Personally, in medical settings, I prefer to
identify myself as a "family-oriented behavioral health consultant.” Certainly
as a psychiatrist, this is more acceptable to patients and their families, who
have no prior exposure to mental health professionals. Outside of my practice
or a mental health clinic setting, I have always found the term "consultant” an
easier entry point to a relationship with patients/families.
Regarding visibility, I believe
the family-oriented behavioral healthcare field has done a pretty good job
integrating into primary and secondary care settings. The next step, I believe,
is expanding the family systems training in current curricula across mental
health disciplines to incorporate the skills needed for better integration into
tertiary, quarternary, and home/community healthcare environments. My own work
has always centered more in this area. To me, there is a huge opportunity for family-oriented
behavioral health clinicians to provide services in chronic illness-based and
specialty medicine. Some of the areas I
think family-oriented clinicians should give increased attention to include: oncology,
cardio-vascular disease, diabetes, rehabilitation medicine, pediatrics, obstetrics
and gynecology, and palliative care/hospice.
Since it is by definition
family-based, the burgeoning field of genomics is particularly well-suited to our
skills. Many of these settings have a collaborative team ethos and structure
that is just not family-oriented enough and lacks a team member with advanced family-oriented
behavioral health skills. Greater access
to medical in-patient services would be terrific. It is typically a crisis-point in healthcare,
where patients and their families are vulnerable, biomedical providers often
need behavioral healthcare support, and all are usually brought into closer
While it is important to continue
to develop the field of family-oriented behavioral health practitioners across
professional disciplines, in terms of the MFT discipline specifically, I think
there is a unique opportunity to train its practitioners to be more integrationist.
At this point of the field’s development, instead of focusing energy on
describing how different MFT’s are as a discipline and potentially isolating
themselves, I would suggest, take the skills that MFTs have cultivated and
collaborate more with other healthcare disciplines and environments to demonstrate
how MFTs fit into a broad range of multi-disciplinary healthcare teams and
I think that fields that are ripe for integration with
MedFTs would include disease specialties, hospice/palliative care, and genomics.
MedFTs should make a more concerted effort to attend and present at
professional conferences outside of their discipline (e.g. Psychosocial Oncology,
Behavioral Medicine and become more involved in non-guild organizations, such
as the American Family Therapy Academy (AFTA) and the National Council on
Family Relations (NCFR). They should also write towards journals in other healthcare
areas, emphasizing the application and benefits of a family systems perspective
and the role of MedFTs within various healthcare contexts and illnesses.
ZL: You have been successful in collaborating with various organizations to
promote and implement funded family-centered care approaches, what advice or
suggestions would you have for young family-oriented behavioral health clinicians
who wish to pursue similar collaborative relationships?
JR: The first step is helping other
healthcare professionals understand what family-oriented behavioral health clinicians
do and then helping them understand how you can help in their particular
healthcare environment. It is important to be able to concisely describe how
your presence will benefit the organization in the short and long term in order
to get buy in. Often, to gain initial access to a clinical service or
organization, it is useful to provide services at a lower cost and intervene
with complex cases to demonstrate your effectiveness. I think that a couple
underutilized resources are forging relationships with family (e.g. National
Family Caregivers Association, Well-Spouse Foundation) and illness-oriented consumer-based
organizations (e.g. MS Society, American Diabetes Association). More attention
should also be given to the executive team, such as medical directors, administrative
leadership of healthcare systems of care, and benefits directors. These are the
individuals that have or know how to access financial resources to support
integrated care services. Forging an effective relationship with a clinical
service’s/center’s medical and nursing directors greatly benefits overall development
and implementation of family sensitive service delivery models.
In recent years, I have become
increasingly interested in funding for family-centered prevention models of
integrated behavioral healthcare. This means both providing family-oriented
behavioral healthcare to individuals/families at high risk for a condition,
such as diabetes, and families entering the world of chronic illness, such as
cancer, cardiovascular disease, or dementia.
I have had most success implementing brief family psychoeducation
consultations that can be incorporated as a family-oriented behavioral
consultation in routine intake protocols, or multi-family groups
psychoeducational "modules” (e.g. 4 evening sessions or a weekend ½ - 1 day
skills-building format). The latter is very cost-effective, identifies
higher-risk families, and networks families facing the same disease. I have found prevention-based models of integrated
behavioral healthcare to be more challenging in terms of getting the buy-in
needed to access the financial and administrative resources to establish an
effective program. Ultimately, I think these types of prevention-oriented
initiatives would need support at the government and policy levels if any real
impact is going to be made long term.
ZL: What areas do you believe family-oriented clinicians are not taking full
advantage of in the areas of research and practice and how could the field
improve upon these areas over the next 10 years?
JR: Reflecting on the points made in
questions 3 and 4, I think making a deliberate effort to expand into tertiary,
quarternary, and home/community healthcare environments as well as being more
intentional in integrating into other organizations. I also believe we should
place a greater emphasis or both clinical and cost benefit research. While it
is difficult to demonstrate how integrated family-oriented care can increase
revenue short term, research should seek to identify how the use of our services
reduce cost more long term. In general, we need more empirical support for systems-of-care
and disease specific family-based interventions.
John Rolland, MD LMFT is internationally recognized for his Family
Systems-Illness model, clinical work, and research with families facing serious
physical disorders and loss. His book,Families, Illness, and Disability:
An Integrative Treatment Model (Basic Books), was
nominated for book-of-the-year by the American Medical Writer’s Association. He
is currently co-author of a new book, Individuals,
Families, and the New Era of Genetics: A Biopsychosocial Perspective (Norton). He has given over 250
national and international presentations on topics related to his work.
Zephon Lister, PhD LMFT earned his doctorate in Marriage & Family
Therapy from Loma Linda University with an emphasis in Medical Family
Therapy and completed his post-doctoral training at the Chicago Center
for Family Health an affiliate of the University of Chicago. His
clinical and research interests have focused on the recursive influences
of family relationships and chronic health conditions and the
integration of behavioral health into health care settings. Dr. Lister
is the director of the UCSD family medicine integrative collaborative
care program where he facilitates behavioral science training for family
medicine residents, supervises MFT clinical training, and facilitates
learning groups with medical students.
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Posted By Barry J. Jacobs,
Thursday, December 13, 2012
Updated: Wednesday, December 12, 2012
| Comments (0)
In the evolution of
healthcare, demographics will shape our destiny. On the horizon is the so-called "silver
tsunami”—the increasing prevalence of aging Baby Boomers using more and more
healthcare resources. But there’s a
dearth of American healthcare professionals interested in geriatrics. And there are relatively few collaborative,
team-based programs focused on the needs of aging adults.
|Psychologist Sara Honn
Qualls, Ph.D. has spent her career integrating the evidence-based
gerontology with both elegant and pragmatic formulations of family
thinking. The Kraemer Family Professor
of Aging Studies and the director of the Gerontology Center at the
of Colorado, Colorado Springs, she is one of the country’s leading
writers and educators about families in late-life. Her latest book,
Caregiver Family Therapy (co-written by Ashley A. Williams) was
recently published by APA Books. It should
become a foundational text of not only medical family therapy academic
but of all family-oriented healthcare training.|
I had the privilege of
working closely with Dr. Qualls for a year-and-a-half as members of the APA
Presidential Task Force that produced the Caregiver Briefcase, a web-based
resource on family caregiver research, practice and policy. It was good to hear
her quick, incisive voice again as she talked with me about her new book.
BJ: What has led you to focus your career on aging families?
SHQ: My family-of-origin had exposed me to a lot of aging
families. Then, while I was an
undergraduate during the late-70s and early-80s, I did a workshop in
gerontology for which we went out in the field.
I was hooked. I just got it. I became interested in the psychology of aging
families but there wasn’t much information out there. At the time, however, there was a rich family
therapy literature that was mostly based on families with young children. It was fascinating for me to try to translate
those early family therapy models into ideas about families of older adults in
which there was a lot more ambiguity about what family roles could or should
be. When I started working as a
psychologist in the aging field, it was clear to me that family is the key
social and service context for older adults.
Families ought to be key members of the integrated healthcare team but
are often considered outside the pale and are left outside team deliberations.
BJ: Why write the book Caregiver
SHQ: In the field of gerontology, family caregiving
interventions have had a focus on the individual framed mostly in a stress and
coping paradigm. But what struck me
while talking to caregivers in our clinic is that most of them didn’t seem to
think of themselves as individual caregivers dealing with stress so much as they
saw themselves as part of families in late-life transition.
We wrote the book because there was a need to
integrate various caregiving interventions into a systemic framework that isn’t
addressed in the stress and coping paradigm.
How do we help family members walk through an illness trajectory while
identifying the transition points that challenge the whole family’s
organizational structure. How do we help
family members make the transitions they need to make while supporting the
development of all family members? All
these types of changes require a systems frame to understand and intervene.
BJ: You focus in your book on "naming the problem.” What do you mean by that?
SHQ: Families come into treatment because something isn’t
going right for them. Their name for the
problem is often not what the healthcare system calls it. That’s a disconnect. For example, caregivers may call me to see
their mother for depression when it’s clear to me that their mother also has
cognitive changes, possibly dementia. As
a professional, I have to gather all the assessment data and integrate it and
make sense of it. And then I have to
offer that understanding to the family in a way that will be useful to them so
that it matches their value system and cultural context and positions them to
respond to the practical health and well-being needs of their elder.
BJ: You also focus on what you call "role structuring.” How do you help family caregivers shift into
SHQ: We have to increase their awareness of the transitions
that are required to deal with aging and illness, especially dementia. We then have
to figure out the barriers that are keeping them from smoothly making those transitions. In our clinic, we use role plays or imagery
exercises to help family members understand what would be a more effective
strategy and to make real the risks they run if they insist on playing the same
roles they’ve always played.
BJ: You engage family caregivers in problem-solving. What evidence do you have that that kind of
cognitive process is effective?
SHQ: Insight is necessary
but rarely sufficient, especially when it comes to changing fundamental aspects
of our roles across generations. By
engaging family members in problem-solving, we are more likely to elicit the
real barriers to action or transition—e.g., guilt or fear of conflict with a
sibling. The power of change is in
helping family members see the problem in a new frame and exploring new resources.
BJ: How can family-oriented healthcare professionals improve
their effectiveness with family caregivers?
SHQ: By asking family caregivers to collect clinical data
about the patient for us—say, through using reporting scales-- healthcare
professionals may become aware of problems that we didn’t even know about. This will lead us to ask ourselves different
questions about how to help our aging patients and their devoted family
Barry J. Jacobs,
Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family
Medicine Residency Program in Springfield, PA and is the author of The
Emotional Survival Guide for Caregivers.
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Posted By Bill Gunn and Julie Schirmer,
Thursday, December 6, 2012
Updated: Monday, December 3, 2012
| Comments (0)
What the heck is a "learning community?” The definition we
are using is: a group of like- minded individuals working
together to learn what’s working, what’s
not working, and how to change our systems
to be more collaborative.
This collaboration is necessary with patients, families, health care
teams and systems.
Management consulting guru, Peter Vaill,
describes the constantly changing world we are in as being in "constant white
water”. There are no pools to
recover and rest before the next set of rapids.
We just need to learn how to paddle the boat better through the white
water of change. Rather than just
working harder, Vaill proposes strategies of working smarter, specifically
working "reflectively smarter” and "collectively smarter”. The learning community model uses both
strategies. The integrated care "river” is moving forward all over the
country. In the aftermath of the
election and the move towards population-based "accountable care
organizations", we all need to work "collectively smarter.”
"There are no pools to recover and
rest before the next set of rapids.
We just need to learn how to
paddle the boat better through the
white water of change."
There are other organizations using this strategy. For example, The Institute for Healthcare
Improvement (IHI) sponsors ” learning collaboratives”, bringing in hospitals, clinics and other
organizations to provide technical assistance for their change efforts. The National Council of Behavioral Healthcare
sponsors learning communities among behavioral health organizations, which
provide integrated primary care health services for the severe and persistently
We need to look for partners in our local systems and in our
geographic regions to share sustainable models, influence new policies, and
collect mutually agreed upon data to discern the impact of different models of
care. CFHA has been a leader in conducting national meetings held in regions
where there is strong interest and activity in integrated care. Each of the meetings has held a local
"summit” that has brought together leaders from the region to learn together
and ideally create integrated care workplans.
We know that many folks from other parts of the country think that in
New England "good fences make good neighbors”,
but our experience with integrated care has shown this not to be
true. We have created a steering
committee and workgroups around training, advocacy and quality improvement with
representatives from Maine, New Hampshire, Vermont, Massachusetts, Rhode
Island, and Connecticut. We have had
monthly steering committee phone calls, two face-to-face meetings, and plans
for more to work on projects of common interest in the region. These projects are in the areas of training,
advocacy, and quality improvement.
There is another organization, the Family Medicine Education
Consortium (FMEC), whose mission is to move important primary care health
projects along and to promote family medicine.
The goals of FMEC and CFHA overlap around integrated behavioral health
care. The two organizations sponsored
two preconferences in the fall of 2011 and 2012 on Supporting Sustainable
Integrated Care. The 2011 meeting kicked off the New England Learning
Community. The 2012 meeting in
Cleveland, Ohio set the stage for a state-wide Ohio Learning Community and
planted the seeds to bring together the 4-5 Pennsylvania integrated care
state-wide organizations in the fall of 2013.
The Ohio proceedings included
lessons learned from providers, administrators, funders, and foundations.
Jennifer Hodgson started the meeting with an overview of the impact of the
Accountable Care Act on behavioral health integration and the cutting edge advocacy work taking
place in North Carolina. The panelists
and discussions were very dynamic. The meeting ended with learning community
strategies for the states represented at the meeting. The Ohio group has
created a listserve and is approaching a couple of groups in northern Ohio to
"house" a state-wide learning community, connecting it to the good
work of Janice Bogner and colleagues at the Health Foundation of Cincinnati
Susan Labudo-Schrop at the University of Ohio College of Medicine Family
Medicine Department (NEOMED).
One of the surprise outcomes of this Ohio meeting was
identifying the North East Learning Community Theme Song. We had not yet read Randall Reitz's blog
regarding a theme song for the CFHA. So, although we "ain't got much
money", we do have fun AND a theme song!
If you are at all curious, click here to view the original Youtube
version. We really like the chorus. It's
catchy, great to dance to. Yet we need to rewrite the rest of the lyrics As with behavioral health integration, we
aren't satisfied with the traditional organization of the song. An integrated
care transformation is needed to benefit patient satisfaction, clinical
outcomes and cost! Maybe selling the
rights to the new lyrics will bring in money to support our efforts. Stay
In southwest Virginia, another regional effort is taking place,
sponsored by Radford University and the primary care clinics in that area. Cathy Hudgins and Bill McFeature have
organized an annual conference and provided technical assistance to clinics and
behavioral health organizations in that area.
Through the North East, our hopes are to connect these
efforts: informing our care, strengthening our ability to learn from each
other, uniting to influence policies to improve care, and "taking it to the streets". We have
an assumption that there are many more efforts local and regional efforts to
promote integrated care and we hope this blog will encourage others to let us
all know what you are doing.
Bill Gunn PhD is a
faculty member of the NH/Dartmouth Family Medicine Residency in Concord, NH and
holds a clinical appointment at Dartmouth Medical School. He is a
board member of the Collaborative Family Healthcare Association. Bill is a co-author of Models of
Collaboration (2006) and The Collaborative Psychotherapist (2009).
He coordinates with Julie Schirmer, LCSW an integrated care "learning
community” in New England which meets regularly. He is membership co-chair of CFHA, and
co-chair with Nancy Ruddy, PhD of the Division 38 primary care subcommittee.
Julie Schirmer, LCSW is Director of Behavioral Health at the
Family Medicine Department of Maine Medical Center and Assistant
Director of the Family Medicine Clerkship at Tufts/Maine Medical Center
School of Medicine. She is Co-chair of the North East Regional
Integrated Care Learning Community, Past President of the Family
Medicine Education Consortium, and upcoming Director of the Behavioral
Science/Family Systems Educator Fellowship of the Society of Teachers of
Family Medicine. She is author and co-editor of Behavioral Health in Primary Care: A Global Perspective(Radcliffe, 2010).
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