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Somatization: From Biomedical to Sociocultural

Posted By Wendy Bradley, Thursday, November 15, 2012

One of the biggest challenges in any health care setting is how to manage somatic symptom disorders. Studies show that one third to one half of all visits to primary care have no identifiable primary cause. These visits cost the US health system over 100 Billion annually due to overuse. Presenting concerns often have components of some sort of pain or a check for some odd symptom.

Often the most frustrating aspect of this condition is the presentation in clinic. These encounters often include:

  • High levels of dissatisfaction and overall distress,
  • Vague and dramatic reporting of medical history,
  • Reactions to psychosocial distress with physical symptoms,
  • Frequent moves from complaining of one symptom to another,
  • Seeking care from multiple providers, failing to keep appointments,
  • Denying psychological influences and referrals to therapy,and
  • Disappointment and frustration when nothing is found.

A fundamental attribution to this dilemma is the overarching perception of what ‘health’ is. "The ‘usual’ medical system and patient expectations have evolved into an ‘evidence based’ system for the physical body where if the right tests are ordered, the right diagnosis made, and the right medications prescribed, health will follow” (Eby, 2011).

Southcentral Foundation logo

As Southcentral Foundation is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships.

Through listening to our patients and examining our own behavior we have discovered that we have reinforced the idea that it is the health care team’s responsibility to ‘fix it’. This has become a set up for both providers and patients---as both have difficulty tolerating ambiguity because of this expectation. As long as we make the focus about "physical solutions” to these complex issues we will continue to prescribe new medications, take more tests and make referrals to specialty clinics to find out what is ‘wrong’ with them. We will continue to be frustrated with the patient for not listening to us. As long as we are working harder to ‘fix’ them, we leave no space for them to take responsibility of their own health and begin to learn how to manage the symptom or the distress surrounding the symptom.

As Southcentral Foundation (SCF) is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships. This philosophy has created the foundation for how we approach our patients that visit our system the most and have unexplained somatic symptoms. Instead of seeing those patients as a "problem to be solved” we focus on working with that patient to determine the "context” that a condition is occurring in. The focus moves away from trying to figure out the symptom to supporting the patient in learning how to manage the distress the symptom is causing. This approach has resulted in us taking a step back and assessing the entire picture of health

We have been practicing full integration for over 8 years in a level 3 medical home model and it has taken time for this philosophical shift about what ‘health’ is to take place, for both ourselves and our patients. We have learned that managing those patients with somatic symptom disorders cannot fall on the integrated behavioral health consultant alone. Care becomes fractured and teams respond out of frustration and a sense of helplessness. We had to move towards a seamless approach that involved our entire management and clinical staff to use a very different and expanded skill set from the ‘usual’ medical practice.

In response, we designed a process that the main emphasis is on how we communicate and work towards a relationship built on shared responsibility. Teams needed to learn how to effectively manage "dilemmas” (when there is no known medical diagnosis to treat or when what the customer wants what can’t be done safely or is necessary) and move away from trying to "solve the problem”. We provide skills and tools that allow teams to truly engage customer-owners while staying objective. We challenge them to look at what they bring into the exam room that influences outcomes (i.e. countertransference, frustration). We intentionally train and coach teams to listen to and acknowledge the ‘fears’ behind the patient visit and have honest conversations about what is happening. They then use encouragement and questions to support the patient and family to develop a plan on how to manage the condition or distress.

We continually encourage teams to have conversations that encourage health ownership. We found that we needed to spend time discussing expectations. Conversations revolve around who is responsible for what and which parts of ‘health’ the team can support and which part the patient will need to make choices about. It also means having intentional discussions about all factors that impact health and what outcomes are possible. Though the behavioral health consultant is still heavily involved, the entire team practices and reinforces the same approach.

Ultimately, we know that while this approach may not ‘fix’ the dilemma of somatic symptom disorders, we can alter the way ‘usual’ medical care is delivered thus expanding the range of opportunity and options that can influence health outcomes. Through placing our emphasis on the whole person, putting the physical, behavioral, emotional and spiritual back together rather than pulling them apart and our continued engagement in long term, trusting, personal relationships with our patients, we can offer the space for health and wellness to happen.


Wendy Bradley LPC is clinical improvement advisor at Southcentral Foundation in Alaska. She developed and provided clinical oversight to behavior health integration in primary care--the program has been successfully established for the past 8 years.

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CFHA Annual Conference: What's in it for students?

Posted By Jodi Polaha, Thursday, November 8, 2012

Each Fall I teach a course called "Primary Care Psychology 1” to our doctoral students at East Tennessee State University (ETSU), covering the gamut of current health care policy, rationale for integration, models, research, innovation, and administration. Each Fall, I ask my Department Chair to offset some of the CFHA travel costs for the students in the course. The conference is a perfect content match, and they love hearing talks given by the authors of their readings! This year, once again, Dr. Dixon came through, and that, combined with scholarship and volunteer opportunities within CFHA, made it possible for three class members to attend.

A little seed money for student travel and conference costs goes a long way. Isolated "course content” is transformed by a "culture” of professional engagement: when we arrived in Austin, we were joined by two recent ETSU graduates and two advanced students, most of whom attended in prior years on this patched-together "gift trip.” On Friday night, the eight of us had dinner with two ETSU faculty from Family Medicine. What a delight to sit and reflect on what we’d all learned that day! As you will read in the reflections below, the students in our program struggle with professional identity: "Are we psychologists or behavioral health consultants?” " "How do we be both?” The CFHA annual conference was a place for them to explore this creatively and with the supportive sounding board of "comrades” from their home institution.


Matthew Tolliver

Matthew Tolliver

As a second year student in a clinical psychology doctoral program with an emphasis on rural integrated care, I am beginning to develop my own sense of professional identity. Attending the CFHA conference furthered that development, inspiring me to think critically about the role of the Behavioral Health Consultant (BHC). In particular, I was surprised to hear several BHCs identify more closely with Family Medicine and the provision of primary care than Psychology or mental health services. I found myself asking questions such as: What are the ethical, legal, and professional implications of the shift in professional identity that comes with working as a BHC in primary care? What implications does this have for training BHCs? In what ways can BHCs who are just starting their careers develop a strong sense of professional identity, especially those who work in rural areas and who may have limited contact with their peers? I was fortunate to participate in a lunch discussion with Dr. Patricia Robinson and discuss some of these questions. One particularly salient suggestion that Dr. Robinson raised involved the need for and value of mentoring BHCs in order to foster a strong sense of professional identity. Overall, I plan to take what I have learned at the conference back to ETSU to promote increased collaboration between students in psychology and other academic health sciences. The conference was a great experience, and I am especially grateful for the volunteer and scholarship opportunity, which allowed me to attend.

Courtney Lilly

As a doctoral student in a clinical psychology with a special focus on rural integrated care, I found the CFHA conference to be highly rewarding. Some concepts were familiar, such as integrated healthcare models and the function of a behavioral health consultant. Other topics were new to me, such as electronic medical records, legal issues, and specific ethical considerations. I learned a great deal; however, a few things stand out. The first of these is the lack of standardization for integrated care models and the role of the BHC, which seems, in some cases, to vary in critical ways by primary care context. As a student in rural east Tennessee, my future work as a BHC will likely differ greatly from a BHC in an urban area. Given the importance of contextual factors, in what ways should the role and training of a BHC be standardized? A second point that stands out relates to the use of technology to advance integrated care. I greatly appreciated the focus on social media and technology as means for patient and provider engagement. The idea of provider consultation via technology was especially new to me. Within smaller integrated care networks (especially in rural areas), it is likely that the BHC will be relatively isolated having few opportunities for consultation on difficult cases. Technology allows for communication between providers worldwide, which can improve both job satisfaction and patient outcomes. A final focal point for me relates to ethical standards and guidelines. As integrated care and technology become standard components of behavioral healthcare there will be a vital need for more research and guidance in this area.

Catherine Rowe

My experiences at CFHA bolstered my conviction that I have chosen to engage an exciting field, burgeoning with new opportunities for mental health professionals and new promises to improve the quality of care for many in our country. As a doctoral student in psychology ETSU, I am being trained in integrated primary care for rural areas. This emphasis is both challenging and inspiring. Many sessions at CFHA helped me close my own mental "gap” between the traditional approach to clinical psychology and the application of these principles to the primary care setting. There were numerous sessions that focused on real world problems that behavioral health consultants may face in their journey for fully integrated care that gave shape to many of the questions that I sometimes find myself asking. One of the highlights, for me, was the opening plenary by Sarah Kliff regarding the opportunities that are currently developing for further integration of mental and behavioral health services into primary care. Ultimately, my experiences at CFHA left me feeling very aware of critical problems in our current healthcare system as well as aware of the potential solutions.

Hooray for growing traditions … we’ll see you next year in Denver!


Jodi Polaha is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.

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MENTORING is the Cat’s Meow…The Bee’s Knees… (am I showing my age?)

Posted By Deborah Taylor, Thursday, November 1, 2012

Dr. Taylor's post is the final installment of a 5-week collaborative series hosted by the blogs of

Please read all the previous posts.


One of my greatest professional joys has been my connection to STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF) steering committee. Most "seasoned” behavioral science educators remember the "jump and build wings on the way down” training model for our discipline. The BFEF is an effort to create a more supportive/less isolated model to increase retention and career satisfaction. As with most acts that appear altruistic, those of us on the steering committee quickly found ourselves experiencing increased energy/enthusiasm and dedication to our work. In promoting a fellowship model of mentorship intended to be an offering, we receive far more than we contribute.

The term "mentor” has its roots in Homer’s epic poem, The Odyssey. In this myth, Odysseus, a great royal warrior, has been off fighting the Trojan War and has entrusted his son, Telemachus, to his friend and advisor, Mentor. Mentor has been charged with advising and serving as guardian to the entire royal household. As the story unfolds, Mentor accompanies and guides Telemachus on a journey in search of his father and ultimately for a new and fuller identity of his own.

Mentor Jar
The term
"mentor” has
its roots
in Homer’s
epic poem,
The Odyssey

At times, throughout the story, Athena, goddess of wisdom, who presides over all craft and skillfulness, whether of the hands or the mind, manifests herself to Telemachus in the form of Mentor. The account of Mentor in The Odyssey leads us to make several conclusions about the activity that bears his name. First, mentoring is an intentional process. Mentor intentionally carried out his responsibilities for Telemachus. Second, mentoring is a nurturing process, which fosters the growth and development of the protégé toward full maturity. It was Mentor’s responsibility to draw forth the full potential in Telemachus. Third, mentoring is an insightful process in which the wisdom of the mentor is acquired and applied by the protégé. Some argue it was Mentor’s task to help Telemachus grow in wisdom without rebellion. Fourth, mentoring is a supportive, protective process. Telemachus was to consider the advice of Mentor, and Mentor was to "keep all safe.”

I was surprised to learn that mentoring begins to appear in the professional literature only in the last 15-20 years. Mentoring is now clearly identified as an important influence in professional development in both the public and private sector, including health care. Documented benefits of mentoring include increased performance, retention, commitment to the organization (local and sponsoring), and the presence of paying it forward by mentees.

I am consistently struck with the opportunities we have to "walk the talk” about mentoring’s value -- the mentor as teacher, as counselor, as a "travel” guide and one who promotes the development of others. I encourage you to reflect on the myriad mentoring opportunities that present to us as members of residency programs, family medicine departments, health care organizations, and regional/national professional development groups like STFM and CFHA. Be open to seeking mentoring relationships as well as offering your expertise and professional friendship, and "promote” others in need.

I hope you have or will enjoy being on the giving and receiving end of some valuable mentoring in your life – it has been my "cat’s pajamas” and my "bee’s knees” (my mom’s 2 favorite descriptors)! Thanks for engaging – I really appreciate your time.

Deborah Taylor
Dr. Deborah Taylor has been a Behavioral Science Educator and Associate Program Director at Central Maine Medical Center FMR
(a community based program with a rural training emphasis) for the past 20+ years. She received her PhD in Clinical Psychology from the U. of Kansas and has worked in medical education for the past 25 years. Deborah currently serves as the Co-Director of the STFM Behavioral Science/Family Systems Educator fellowship.

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The Joy (and Jostling) of Team-Based Care

Posted By Barry J. Jacobs, Thursday, October 25, 2012

Dr. Jacobs's post is the fourth in a 5-week collaborative series hosted by the blogs of

Please check back
each week.


In the early-‘90s, at the outset of my career as a psychologist in medical settings, I spent 5 years at a physical medicine rehabilitation hospital on what I was sure was a team of perennial all-stars. During our weekly clinical meetings, daily curbside dialogues in the hallways and cafeteria, and co-care in the PT gym and patients’ rooms, I always marveled at the competence, youthful confidence and innumerable skills of the doggedly optimistic physical and occupational therapists, canny speech therapists, hardy nurses and street-smart social workers on my assigned squad.

At the head of this team was usually a gray-haired, white-coated physiatrist, wizened and patient, offering subtle guidance to team members but generally allowing us to practice our crafts. Not that harmony always reigned. We would have table-pounding debates about treatment plans. Rivalries simmered about who best evaluated cognition or ambulatory status. But the team worked proudly and effectively and patients usually thrived.

Barry J. Jacobs
I like the interdisciplinary spirit embodied in the phrase, "All for one and one for all.”

I eschew the
trans-disciplinary credo of
"All are one.

I’ve been waxing nostalgic recently about those years because of family medicine’s ostensible move toward team-based care. The Patient-Centered Medical Home is intended to be a collaborative, integrated, multidisciplinary place where family physicians work shoulder-to-shoulder with behaviorists, pharmacists, case managers, social workers, medical assistants and administrators to deliver improved, cost-effective, chronic disease management. But the culture of family medicine, in my opinion, is not yet team-driven. What is second nature in physical medicine rehab is of necessity first nature for us—a new set of spiffy dress-up clothes without the well-worn comfort of habitual garb. I think there is much we can learn from rehab medicine’s decades-long experience with teams:

--:”Multidisciplinary” isn’t "interdisciplinary”: An oft-cited truism in the field of integrating behavioral health services into primary care is that "co-location isn’t integration”--that is, proximity by itself doesn’t lead diverse clinicians to work in tandem toward better patient outcomes. I think this truism extends to team-based care in general. A multidisciplinary PCMH just connotes different disciplines under the same roof which are working on their own respective and possibly divergent goals. Rehab was distinctly interdisciplinary—different disciplines working on commonly agreed upon goals. I believe that the PCMH likewise needs to be interdisciplinary in order to best blend the talents and skills of multiple specialists striving together. That means, like rehab, there needs to be processes in place for ongoing team communication and decision-making. (An EHR alone, in my opinion, won’t suffice.) That means somehow creating team meeting times out of the hectic primary care work flow

--"Interdisciplinary” shouldn’t become "trans-disciplinary”: In my years in brain injury rehab, we experimented with "trans-disciplinary” care—clinicians from different disciplines taking on aspects of each other’s jobs to reinforce one another’s interventions in order to better achieve clinical goals. For instance, the physical therapist might counsel the stroke patient about his depression. I might reinforce ambulation techniques with that patient when he walked back and forth to my office. While this model seemed promising in theory, in practice it led to a diffusion of team member roles that exacerbated underlying rivalries. It seemed we all needed some protected territory we could stake out as our own. While the integrated PCMH certainly requires some delegating of responsibilities—e.g., having the medical assistants and not the behaviorists administer a depression screening instrument—we ought to maintain the kind of role distinctions that allows us to protect our professional identities (and egos). I like the interdisciplinary spirit embodied in the phrase, "All for one and one for all.” I eschew the trans-disciplinary credo of "All are one.”

--Leadership is a skill-set: Past STFM president Perry Dickinson and his colleagues at the University of Colorado-Denver developed well-conceived competencies for family physicians to lead the interdisciplinary team. They include setting expectations for performance and change, sharing information and being receptive to others’ ideas, and managing interpersonal issues. But these will remain little more than abstract and somewhat daunting concepts to family medicine residents unless we give them practical real-life experiences. As part of their training to become physiatrists, PM&R residents spend abundant time observing their attending physicians leading team meetings. Later, those residents lead the teams themselves. They come to know well the nuances of the various specialties around the table, as well as the ebb and flow of team dynamics. Family physicians need that kind of socialization to step into the team leadership role.

--Follow which leader?: The 2010 "Joint Principles for the Medical Education of Physicians as Preparation for Practice in the PCMH” calls for "physician-directed medical practice”—i.e., physicians as leader of the clinical team. This was always the case in rehab as well. But others have questioned whether physicians needs always take the lead. In a workshop at the 2012 Collaborative Family Healthcare Association conference, Jeri Hepworth, immediate past president of STFM, and Susan McDaniel of the University of Rochester Departments of Family Medicine and Psychiatry suggested that team leadership can be handled in more egalitarian fashion by rotating leadership among team members. They contended that this flattens team hierarchy and ultimately leads to more trusting, cohesive and coordinated team care.

--Bring patients and family members on board: Because rehab medicine is to a large degree about transferring skills to enable patients to better function in their home environments, PM&R teams work intensively with patients and their family members to provide them with education, hands-on experience, and emotional support. If patients and family members aren’t quite full-fledged clinical team members, then they are fully deputized partners in care. Family medicine’s approach to teams needs to likewise embrace patients and family members. This goes beyond "patient activation” or reflexively documenting patients’ goals for medical visits. This means including patients and family members in team deliberations through regular communication and feedback loops. It also means involving patients and family members in the running of our PCMH practices by asking them to serve on advisory boards and volunteering to assist us with our quality improvement projects. The measured performances of rehab teams rest firmly on the quality of the lives of patients and family members. The performances of family medicine teams—interdisciplinary, prevention-focused, functionally oriented—need to as well.


Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA and a CFHA board member. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Loved Ones While Helping an Aging Parent.

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Aligning our Efforts to Transform the System

Posted By Rob Cushman, Thursday, October 18, 2012

Dr. Cushman's post is the third in a 5-week collaborative series hosted by the blogs of

Please check back
each week.


As a long-time member of STFM and the incoming President of CFHA, I am both excited and a bit anxious about taking on this role at this time, because we are truly at a critical juncture. As healthcare providers and educators, we offer clinical services in a "system” that is about to either continue making important strides forward toward becoming a true SYSTEM achieving meaningful outcomes, or to slip backward into the free-for-all chaos that has complicated delivering good, patient-centered care for decades. We need to work together as members of STFM and CFHA to navigate through these twists and turns, or plow through some obstacles, so that we, our trainees, and our patients and communities, come out in better shape on the far end.

I want to share one of the "clinical pearls” I learned in my residency, which has served me well as a "compass,” and which I have quoted (with attribution!) many times to my own trainees as I precept them in the hospital and the office. I offer it now because it is applicable beyond the direct patient care process. I can still hear Tom Campbell saying, "When you’re stuck, expand the system.

He of course meant to explore more into the patient’s family and community context, gathering the perspective of some of those folks that make up that social network, or enlisting their assistance in changing parts of that context in order to achieve change for the patient. He also meant to ask for input and additional, new and different perspectives and suggestions from one’s professional colleagues, both diagnostically and for interventions. This approach has proved hugely valuable to me, repeatedly. And I think the current emphasis on team-based care is a result of a collective recognition that this systemic approach is valuable and more effective than "going it alone.” Rob Cushman
We need to invite others who are not yet fully aware of
the models we
are implementing
to join us and
learn along with
us as we change
our systems.

I want to challenge us all to continue to "Expand the System” in three ways. I want us to Expand our Concept of Teams, to Expand our Measurements of what we’re doing, and to Expand our Reach. Let me elaborate briefly on each of these.

First, Expanding our Concept of Teams. Too often we lapse into thinking of the team as the "clinical team”, those who are based in our practices and/or in other agencies. I would encourage us instead to remember that every patient needs to be at the center of the "team” that coalesces to address their physical and mental health needs. The person that is that patient/client/consumer should be thought of as a co-captain in setting the agendas for the team. Only then will our primary care practices have truly become Patient-Centered Medical Homes. I fear that label is currently thrown about far too liberally, and unconsciously shortened to "medical home” because being truly patient-centered is way harder!

Second, we need to Expand our Measurements. By this I mean that we need to more consistently, more systematically collect, track, and analyze meaningful data about what were are doing (our processes) and the impacts we are achieving with and for our patients and their families and communities (our outcomes). Some folks emphasize measuring outcomes over process, and that has some validity in the long run. However, while we are in the middle of striving to find the best ways to do things, collecting information about process may help us to determine more rapidly which aspects of different approaches we try may be the critical components in determining the success or failure of an approach. The outcomes measures are then important for making the case that that change is ultimately worth doing.

Finally, we need to Expand our Reach. By this I mean that, as CFHA and STFM members, we need to expand our conversations about collaborative, integrated care to others in our workplaces and communities. We need to invite others who are not yet fully aware of the models we are implementing to join us and learn along with us as we change our systems. We need to decide how we can best coordinate and partner with each other and other organizations who share many similar values and positions, in order to join our collective voices in advocacy, and even to undertake joint initiatives to help "make our case.” We need to share our success stories, and be able to provide the data coming from our own, and our collective, measurements and research about the value of this holistic model of care. This is what advocacy is, distilled down: telling illustrative stories, backed up by data. Each of us has a role in advocating for the continued expansion of collaborative, integrated care. Together, we can make this happen.

So, don’t just expand the system when you’re feeling stuck. Instead, let’s strive to Systematically Think (and Work) Systemically.


Robert A. Cushman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Connecticut School of Medicine and Saint Francis Hospital and Medical Center. He has been an active member of STFM since 1987. He was consistently active in the Group on Family and the Group on Community Medicine, and served on the Steering Committee for the Group on Family, including serving as Conference Chair for the STFM Conference on Families and Health in New Orleans in 2008. Since that time he has become increasingly involved in CFHA, as well, and joined its Board last year as Treasurer and President-Elect. The text above is adapted from his inaugural address as CFHA President.

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Without Collaborative Care--The PCMH Fails

Posted By Gene "Rusty" Kallenberg, Thursday, October 11, 2012

Dr. Kallenberg's post is the second in a 5-week collaborative series hosted by the blogs of

Please check back
each week.


I want to tell you a story that is both personal and also parallels the evolution of primary care and collaborative care over the past decade and predicts its future.

I arrived in San Diego to take over the Division of Family Medicine at UCSD in the fall of 2001. I came from "the East” where I had been at George Washington University Medical Center and School of Medicine for the preceding 20 years.

My clinical primary care practice fortuitously shared a waiting area with the outpatient mental health team. It was a short walk to the therapists’ offices and in the course of wandering over to seek help on various patients I met a clinical psychologist with whom I developed a close working and collegial relationship. When I needed help with a patient I would seek his counsel and/or refer the patient over to the group with an "Attention to Pat” comment on the referral. I ended up hiring him to be the psychologist in our new family medicine residency program; we did an international consultation together for an Eastern European country’s developing academic family medicine program; and he introduced me to the concept of motivational interviewing among other things.

I began to realize that without this kind of key help the practice of primary care/family medicine would be a lot harder. I began to talk with a psychiatrist who headed the 3rd year clerkship about deeper collaboration, but then circumstances changed more significantly at GW and I decided to move. Long story made short I ended up taking up the leadership of the UCSD Division of Family Medicine.
Rusty Kallenberg
This began our decade-long effort to "do good” rather than just talking about studying how to do good.

One of the most pleasant and propitious surprises on arrival was that there was an outstanding group of academic teaching PhD marriage and family therapists from the University of San Diego (USD) who were in discussions with our UCSD Psychiatry Department about transferring their activities to UCSD from the Sharp Family Medicine Residency which, unfortunately, was winding down to closure. Todd Edwards and JoEllen Patterson were the dynamic duo I was privileged to meet. Unfortunately these discussions were mired down with our Psych folks in what seemed like a circular and non-progressing research oriented discussion. Being the new kid on the block I was able to ingratiate myself with the Chair of Psychiatry and got him to "let our people go” and actually set up a clinical operation where we could deliver co-located care along with directly observed behavioral science teaching sessions (fondly referred to as "BS Sessions”) within our family medicine offices.

This began our decade-long effort to "do good” rather than just talking about studying how to do good. And the journey has reflected every aspect of the maturation of collaborative care that I have witnessed during my 15-year tenure with CFHA. I had the privilege of being at the founding meeting of CFHA in DC in 1996. One of my colleagues at GW, Karen Weihs, was a skilled researcher-clinician, an FP-Psychiatrist who was one of the first-generation conceivers of CFHA. I was intermittently active for the next 5 yrs. before coming to San Diego, and once we began to deliver collaborative care I became more involved and have been a regular CFHA attender since Seattle, where we presented on our initial UCSD efforts. During this period STFM extended a key organizational avuncular helping hand as CFHA adopted the mantel of the sun-setting Family in Family Medicine conference and its faithful attendees.

Our system has been somewhat unique all along in that we use trainees from USD’s Marriage and Family Therapy Program along with both a supervising PhD MFT and psychologist who are both on our DFM faculty. This solves some of the financial challenges and is a disseminatable component of what we’ve built. In short, we bill patients co-pays only for student and intern visits, which respectively either contributes to supervision costs or for paying the interns their nominal hourly pay. If patients wish to see a licensed person we have them see the supervisors and bill insurance accordingly. Medicaid patients are seen by students/interns on a reduced-fee sliding scale. Additional supervision costs are borne by our clinical budget as a justifiable expense for having this clinical service – which clinicians recognize the benefits of and are willing to pay just like they do for general nursing support.

The system of collaboration we built initially relied on physician education and orientation, physician referral of patients they identified needing help with common mental health and family issues and a paper referral system, which actually introduced our faculty to "genograms” as a baseline referral data requirement (pretty sneaky, eh?). Therapists shared space in our offices and saw patients in exam rooms mostly and offices sometimes if needed and available. Each of these elements has seen substantial evolution over the ensuing years as our national discussion, experience and knowledge about collaborative care has grown and been shared largely through CFHA efforts. I will detail these a bit.

1. Culture – We started with surveying faculty and residents about their views on the importance of mental health and behavioral health issues; their ability to engage and assist patients with these problems; their need for help in such efforts; and their belief that these problems in fact could be helped. We went from "Who are these behavioral people?” to a now universal awareness of how ubiquitous such mental/behavioral problems are in primary care and what such team mates and colleagues bring to the table in successfully caring for the whole patient. We now tout our collaborative care team as a selling feature of our practice to potential faculty and to candidates for our FM residency.

2. Affiliation/Space – Initially our interns were employed by the Psychiatry Dept. and when we hired our first supervising faculty MFT – Michele Smith – and our first clinically active psychologist – Bill Sieber – we had to do so with approval from Psychiatry. Over the course of the first few years we wrested that control from Psychiatry and have directly hired and overseen all our licensed folks and interns within Family Medicine. As we have grown we have dealt with space wars about who should be seeing patients in increasingly limited exam room space to now incorporating our collaborative care needs into our most recent building plans for new office construction.

3. Medical Records/Communication – We computerized our practice in 2005 with the EPIC EMR system and converted our referral system into the computerized medical record. We now do all referrals through the EMR which has increased both use and tracking efficiency. However, as many have also experienced, we lost our genogram abilities, but we hope this is temporary and are working on ways to re-computerize this most useful social data recording function. We dealt with the HIPAA challenges and achieved the ability of our therapists to write their notes in a reasonably unrestrictive manner within the EMR so that they included enough useful data that would appraise collaborating family docs of the issues, therapeutic approach and progress being made on their referred patients. Our docs are universally cc’d on ALL notes from collaborative care. In fact, this initially decreased oral and interpersonal communication for a while, but this has since rebounded even more strongly under our new T-Care system (see below).

4. Referral Process/T-Care – Under the new leadership of Zephon Lister we have developed T-Care – a more directed effort at identifying patients who may benefit from CC. Rather than just allowing the docs to identify patients needing referral we now have collaborative sessions where MFT students work with docs in their assigned exam rooms to review the roster of patients together and determine who might need CC services. Sometimes the MFT student goes in ahead of time and sometimes with the doc, and sometimes even staying after a while with the patient. These initial shared collaborative sessions intimately teach the doc and the MFT student about each others’ mental/behavioral health and communication abilities, help identify problems and issues that were NOT known to the doc beforehand, and facilitate follow up referrals to our CC Team. The time to "collegial level peer relationship” between new MFT students and our physician staff has been cut dramatically through these T-Care joint sessions. Initially each MFT student spends a couple sessions with each doc "getting to know each other”. By rotating around between docs everyone gets to know everyone in a few months rather than a year or more previously. Once the MFT students get to know everyone – they can provide T-Care services for 2-3 docs a session, identifying patients on all their schedules who might benefit from CC services.

5. Screening – Finally, with this structure of care in place and with our ability to use data from our EMR we were able to respond finally to the new US Preventive Services Task Force recommendation for universal screening for depression if and only if the care system has a way to respond to those patients identified by screening. We had spent years developing our service arm and it was time to complete the work by embarking on the task of identifying ALL the patients in need of such services. We were able to initiate universal PHQ2-PHQ9 sequenced screening on all our patients over an amazingly short 3-4 week period this past spring. We are now preparing to add anxiety screening as well. Each of these efforts involves teaching our MAs new skills, developing EMR data recording capabilities and back-end data analysis reports to evaluate our efficiency and measure outcomes (referrals to CC, diagnostic labeling of problem list, medication prescribing and effects on medical co-morbidities). We are excited to further expand our efforts to cover all common mental and behavioral health issues in our practices.

What this progression details is the inner workings of our development of increasingly sophisticated Collaborative Care and how important this has been to our practice. This has been true with regard to specifically providing mental/behavioral and family therapy services for our patient population. But even more important going forward is how effective this effort has been in generating a GENERAL TEMPLATE for incorporating additional team members’ efforts within the new practices we are trying to build today. Now collectively referred to as the "Patient Centered Medical Home” (PCMH) and supported by STFM and all primary care specialties, this concept is solidly built on the concept of team-delivered care – with many different health professionals working together to provide the care that any patient population needs to care for their chronic illnesses and to stay as well and functional as possible.

We have used our successful collaborative care template to replicate introduction of pharmacy services, acupuncture/TCM services and RN care-management services. We are, in fact, now planning the introduction of health coaching services, to complete the full range of team skills for our PCMH practices. For these coaching services we will actually employ our MFT students in true behavioral health counseling roles in addition to more traditional mental health roles. Thus our CC efforts have really led and guided our efforts to develop a fully functional, one-stop-shopping Patient-Centered Medical Home.

We believe, from our own experience and from the influential work CFHA leadership has done leading to the successful incorporation of the requirement to attend to mental/behavioral conditions in order to qualify for PCMH status - as certified by the National Center for Quality Assurance (NCQA), that collaborative care will be central to the new PCMHs primary care is developing all across the nation. This is why we agree wholeheartedly with the words of the past CFHA President, Frank deGruy, "Without Collaborative Care – the PCMH fails!


Gene "Rusty” Kallenberg MD is a long-time member of both CFHA and STFM. He is UCSD School of Medicine Division Chief of Family Medicine and Vice Chair of the Department of Medicine and Preventive Medicine.He received his medical degree from the University of Cincinnati College of Medicine in Cincinnati, Ohio, and completed his internship and residency in Family Medicine at Los Angeles County Harbor-UCLA Medical Center, Torrance, California.

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As Rosie the Riveter Says: We Can Do It—Collaborative and Facilitative Leadership

Posted By Jeri Hepworth, Monday, October 8, 2012
Updated: Tuesday, October 30, 2012

Dr. Hepworth's post is the first in a 5-week collaborative series hosted by the blogs of

Please check back
each week.


As STFM President-Elect, I attended my first meeting of CAFM and Working Party. Forgive the funny names, but they represent the Council of Academic Family Medicine organizations (STFM; ADFM, the organization of departments and chairs; AFMRD, the residency directors; and NAPCRG, the primary care researchers). The Working Party includes the CAFM organizations, plus the American Academy of Family Physicians (AAFP), the American Board of Family Medicine, and the AAFP Foundation. Together, the organizations work to ensure coordinated positions and grapple with vision and leadership of family medicine. These meetings represent ideal examples of Covey’s work of being both important and not urgent, of taking the time to consider what family medicine is accomplishing, and very powerfully, what should be the next steps.

Not surprisingly, attending my first meetings of these groups was intimidating. But, on the first morning, I received this email from my husband, Robert Ryder: "You are not a non-physician. You were elected to represent the educators in family medicine. So you represent the future of family medicine. Go do good work.” I must say, I walked a bit taller after that email, and over the last couple of years of leadership within national family medicine, I take these statements very much to heart. And I want others to recognize these truths.Jeri Hepworth
"I have a
commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions."

Behavioral science clinicians and educators have the skills needed for leadership in our departments, in our health care systems, in our agencies and policy-making arenas, and in our national organizations and advocacy efforts. We know how to listen and include others. We can elicit divergent views and withstand conflict. We know how valuable it is to include the views of those who feel less powerful in systems. We can tolerate the anxiety that emerges in systems under stress or facing change. We know how to help groups create goals and vision, though we sometimes need help determining whether differences actually emerged. So we know we need collaborators, and generally we know how to play well with others. If we have been successful in working in settings in which our professions were the minority, we have learned these skills. And they are exactly the skills needed for effective leadership.

I truly enjoyed giving talks as president of STFM. Unlike presentations about my work, I learned that I didn’t need to hold back, because I wasn’t talking about me. I was representing something greater than me. To be grandiose, and also accurate, I was able to talk about a future and vision of compassionate, effective health care. It wasn’t a form of bragging about my work or ideas; it became a responsibility to do the best I can to help achieve our common goals. I was given a wonderful platform and support to do so.

And the beat goes on. I will still take the opportunities to advocate for family medicine, for primary care, for integrated health care systems that are focused first on patients and families and that require the collaboration and skills of many. But I also have a commitment to encouraging others to stand up and participate in advocacy and leadership for our common visions. The Collaborative Family Healthcare Association and STFM create wonderful platforms for us to advocate. Let’s not waste these opportunities.


Jeri Hepworth, PhD LMFT is professor and vice chair of the Department of Family Medicine at the University of Connecticut. She is the immediate past president of STFM. Her professional work has focused on families and health, psychosocial issues in medicine, and managing personal and professional stress. Among her publications, she is co-author of 3 books: Medical Family Therapy, The Shared Experience of Illness, and Family Oriented Primary Care.

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Live Blog of Saturday Plenary: Purposeful Engagement

Posted By Frank deGruy and Jennifer Hodgson, Saturday, October 6, 2012
 This morning's live bloggers are Frank deGruy and Jennifer Hodgson.
Please follow along during the plenary and add your thoughts in the comments.
You can email your comments for uploading to
Frank deGruy and Jennnifer Hodgson 


Jennifer 8:45am Opening Thoughts. Engaging patients in their journey through a health event is a skill that is often challenging for providers. It means tapping into the very thing that we are taught to contain as we are trained in our professions, our emotional connection to patients. This plenary will invite attendees to listen and absorb patient stories and reflect on their work of engaging patients, families, and communities in healthcare.


Frank 8:45am Opening Thoughts. The depth and sophistication of the presenters at this meeting has improved tremendously. This morning we will hear from a panel of presenters who will help us think through how to incorporate patients, clients, consumers more deeply into the collaborative partnerships we are trying for here. This should be threatening, exhilarating, enlightening, and edifying.


Jennifer 8:54am. Purposeful engagement in patient-centered practice does not mean more time but better use of our time. It takes effort and energy not to listen or to ask about the patient and family experience. So, what would happen if we learned to use that energy in ways that help us to get to "health" faster?

Parinda Khatri (moderator) is introducing the panel of plenary speakers: Danny Sands (primary care physician), Kerri Morrone Sparling (patient blogger), and Laverne Miller (attorney). I am excited to hear their stories!


Frank 9:00am. Parinda Khatri is moderating. She sets this up as a conversation not about whether we engage with patients and consumers, but how. Danny Sands, MD, MPH: HIT and participatory medicine. Kerri Sparling: Type I DM since childhood, active blogger whose personal story doesn't define her but helps explain her. Laverne Miller: Attorney at Policy Research Associates with a bug about advocacy, particularly for the disadvantaged and vulnerable.


The plenary panel


Jennifer 9:00am. Dr. Sands opens with a description of his journey and lessons learned along the way. He shares his story about his enculturation into medicine how providers are often trained not to be wrong or are afraid to admit not knowing. He learned how important it is to ask patients questions. Why are some providers so afraid to talk to patients about what they think is going on? Is it really about time or is it about being afraid of not knowing the answers.  


Frank 9:10am. Danny heard early on how learners were reluctant to show what they didn't know. He had an early mentor who upbraided him for not asking about what he didn't know. Learned early on to ask, not presume or pretend to know. At Boston City Hospital learned how important the home environment was to how patients ultimately did. Fortunate to have early team-based care experiences, and mentoring by Tom DelBanco, who said, "Nothing about me without me." Heard early on,"The single most important resource in patient care is the patient." These are powerful formative experiences that can shape a life attitude.
Because of the accident of colleagues (with whom he frequently emailed) also being patients, learned early on the value of email to patient care; this flowered out to encouraging patients to use email, access the web, and otherwise use technology to stay connected and learn about their conditions.

Important mentor was Tom Ferguson, who helped develop patient portals. All culminated in founding the Society of Participatory Medicine. This is worth checking out.
Jennifer  9:15am. Dr. Sands talked about a placement he worked at where lots of providers worked under the same roof and side by side. Had a mentor who said "Nothing about me without me." This was in relation to a patient bill of rights. What a powerful statement! Empowering patients is a critical part of healthcare reform. He goes on to say that he learned the single most underutilized resource is the patient. So, he employed patients in his setting and in the early 90's started communicating with patients via email. He co-authored the first guidelines on using e-mail to communicate with patients {insert link}. This decreased the distance between his patients and him. Amazing access!
Frank 9:17am. Kerri introduces herself as "just a patient," in a sea of people with letters after their names, but it's clear that she sees that as sufficient credibility to speak knowledgeably about her experiences in a way that helps us be better at what we do. She's a blogger! She's out there (here). I'll have to track this down.  Here's the link to her blog.
The panel
Frank 9:23. Laverne Miller: What a brave woman! A young professional with a bright, promising future as an attorney, then dealing with mental illness, and facing the prospect of huge losses of career, professional network, income, prestige. She describes an early experience with a therapist who cried with her—made herself completely vulnerable—and thereby opened up the possibility of an actual shared experience. A partnership. She can "tell" when a professional actually understands her—gets her, and will thereby be helpful to her.
Great question. Medical clinicians get too busy, too narrowly focused to actually get the big picture that is essential to grasping the problem fully. Can't be helpful or effective without a full picture. Behavioral clinicians frequently add that dimension.
Jennifer 9:25am. Laverne Miller (attorney) opened up about how she is speaking from the perspective of a consumer and how her experience of her mental health changes started back as a child. She noted that her mental health was never the focus of her visits to her primary care provider, yet she was struggling. She felt different but no one asked her how she was feeling and coping. She did not want a label but wanted to be able to express her experience emotionally, cognitively, and socially. In her culture and community admitting mental health issues was not done. She felt alone. This is a powerful argument for routine screening in primary care and integrated care visits. If only someone would have asked, "How are you doing?"
Frank 9:30am. Kerri is funny! She describes her relationships with health professionals as though they are part of her personal circle, who remain there only if they act like there is a meaningful relationship going on. Human to human. Dispassionate, objective posture just won't do. She'll fire you if you come at it like that.
This business about knowing and being known: We're hearing from the professional side of the river (Sands) that clinicians aren't necessarily up to revealing themselves as people who have feelings, don't necessarily know the answer, are real people. We socialize that out of professionals, and we need to get it back in.

Kerri wonders why this isn't obvious, since we professionals all go the the doctor, and we want to be treated as people by people there.
Jennifer 9:32am. Laverne said we are not a "monolithic" community and we need to be accountable to practicing from a culturally sensitive lens. We need to understand how different cultural groups make healthcare decisions, come to healthcare visits as a group, and perceive use of medical interventions and diagnostic labels. Dr. Sands agreed that we need to be training providers how to engage patients and set up patient and family advisory boards. We need satisfaction surveys. Kerri asked "Don't doctors go to the doctor?" What a powerful challenge to get providers to think about it from what they would want for themselves, their loved ones, etc.
Jennifer 9:37am. The question is posed to the panel on how do you engage the patient who does not want to or appear to want to engage? Kerri said to call patients on it but be willing to be called on back if you are not engaging back. Dr. Sands said that you have to try using technology. Laverne said you need to ask about the side effects of medications and how that may be a cultural and practical reason for patients to not want to engage. She also said people are bringing to the table the sum total of their experiences. Some have trauma stories and they don't want to be touched and are often not asked what they need to feel safe.Their visit is often not orchestrated around what they need but rather what the healthcare system thinks they need.
Frank 9:40am.  Kerri is so thoroughly imbued with the necessity of having a human-to-human relationship! She likens it to dating: "I went to a new primary care physician, and we called each other out on engaging and taking responsibility for our respective parts of the relationship; it was kind of hot. This could be a great relationship."
Frank 9:45am. What a balanced panel! All bright, equal floor time, different perspectives, provocative questions from Parinda.  Laverne has this exquisite ability to lay out for us how just a tone, just an attitude of superiority, can be so damaging to a healing relationship. She is convincing me that we really need to sit still, listen, and get inside the others' story before good work can be done.

Jennifer 9:48am. Laverne, wearing her attorney hat, said to make sure to explain to patients know who their information is being shared with, why, and how. Patients who do not want to share information may benefit from peer specialists to help explain why it is so important. Dr. Sands challenged that he should have the right not to take care of a patient who will not let him or her have access to her medical record. He provided the example of providers not having access to mental health records and how that is complicated and can prevent good care.

Who owns the patient record? Kerri thinks the patient should have full access to their record. What are the limitations around full access?


Frank 9:50am. Parinda! Raises the difficult issue of a patient's unwillingness to give permission to disclose personal information (I.e., ETOH consumption) to all the members of a team. Interesting discussion about winning the confidence of other team members, HIPAA's requirements that actually allow disclosure of records that affect care, etc. Daniel makes the case that we just have to share that stuff in order to avoid bad outcomes. Kerri argues that they are her records and she can decide who sees what, but thinks her care depends on all the clinicians talking to each other with full information.


Jennifer 9:52am. Parinda posed the question to the audience on what is one thing we can do differently to move this conversation of engagement forward.

Kerri: Said we are having these discussion in a bubble. Leave the conference and hold yourself accountable to looking your patients in the eyes. Be human!

Laverne: Said go back and step up. Demand change! Focus more on practice-based evidence and go out and observe and take risks....walk the walk in all your interactions.

Danny: Influence your office by changing policy to get patients and family input. Open up patients' records to them. Lower the barriers for patient engagement.


Frank 9:52am.  Parinda: Engagement 2.0. What can we go home and do that will cause our conversation to be more advanced, more effective next year. Kerri says don't go home and do the same thing you've been doing. Go home and look patients in the eye. Let them know you have a heart and eat apples. Be more human.

Laverne says step up and move to practice based evidence—observe, take risks, be vigilant, be brave.

Danny says if you can influence your practice to make sure you get more patient input. Put patient advisory boards in place, lower the barriers to access. Be at least as available to family input as your vet is.
Frank 9:55am. Kerri just keeps insisting that she is a person, needs to be treated like a person. For example, she is a person with diabetes, not a diabetic. Her family needs to know what's going on with her health so they can have a better life.
Jennifer 9:57am. Danny talked about the Annuals of Family Medicine published an article this week about Open Notes...check it out here!
Frank 10:00am. Laverne closed us with a reminder that she is not fragile, she is not broken, she is resilient and sturdy and capable of participating! Good one!

Jennifer Closing Thoughts: I learned from this presentation that I need to be more accountable and purposeful in the way I train providers to engage with patients and families, include them more in my writing and presentations, and focus on their perspectives more in my research. I also value the act of looking at them in the eyes and realizing that I need to more culturally aware of the systems outside the office that support and challenge them. What an amazing panel representing a diverse sets of experiences all unified by one theme: we need change the way we think about healthcare to be more inclusive.

What are you willing to do to purposefully engage patients and families more in the healthcare experience?

Frank Closing Thoughts. This was an exceptionally well balanced panel that took us beyond where we were. Perhaps we should bake this plenary (this kind of plenary) into our subsequent meetings.

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Live Blog of Friday Plenary: The Great Debate

Posted By Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield, Friday, October 5, 2012
This morning's live blog is hosted by Laura Sudano, Stephanie Trudeau-Hern, and Pete Fifield. Please follow along and add your thoughts in the comments section.

8:55am: The anticipated intensity of this debate was such that it may have altered the actual "Ways” of the Universe and subsequently caused one of the debating members to be absent. Yes folks, we have already lost a presenter. Well lost necessitates a "found” and to that matter, he was found in the airport at Grand Junction, Colorado. The reason: his plane had a flat tire. A plane with a flat tire, sounds a bit like "the dog ate my homework”. We hope sabotage isn’t involved in this unfortunate event.

Dr. Randall Reitz, Dr. AJ [Ajantha Jayabarathan], and Dr. Eduardo Sanchez take the stage with music to welcome them to the great debate. Shaking hands, each take their respective podium to open up with their position statement.

9:00am: Dr. AJ opened up her position statement with a reference to the Triple Aim. The Institute of Medicines focus on access to high quality care, care that results in improved health outcomes and the care must be sustainable; all of these happening all together. Dr. AJ, an eloquently and soft yet direct spoken Canadian physician, speaks of the Canadian Rubiks Cube to demonstrate the micro, meso and macro levels of systems care. She urges for U.S.A. to adopt this as their own model.

9:07am: Dr. Reitz speaks towards the historical connections of the nascent nature of collaborative care. Relative historical physician interactions as Reitz have included, removing humors, enemas and leeching. We now are in a new phase of care, one that he would admit needs to be aligned over the Three World View:Clinical, Financial and Operational.

9:15am: A metaphor has arisen already that may represent this debate. Dr. AJ during her opening statements referenced s a graphic of what she described as a "Rubiks Cube”. Dr. Sanchez has referenced multiple times his love of baseball; perhaps his Dominican roots are showing--Yogi Berra being his favorite philosopher. Although Dr. Reitz, arrived in his red U.S.A. sweat jacket, tear-away warm-up pants, and donning boxing gloves, I can’t help but think that the Xbox version of this boxing idol may be a more accurate representation of American ways (and subsequent health level). Is it possible that these three icons represent us well? Rubik’s Cube, the Intelligent Canadians, Baseball, the athletic Dominicans and Virtual Boxing, the lazy Americans? In many ways, we need to put away the game controller and act. I might have missed on this one but you may get where I’m going.

Dr. Sanchez, focused heavily on behavioral and mental health related co-morbidities as one of the most significant players in the ill-health of America. Sooner than later, the financials of this situation will come to realization. We are headed towards collaborative care because of the financial models.

Dr. AJ disagrees and states that to make an omelet, you have to crack some eggs. If the omelet is collaborative care, you’re the egg. How are you going to feel about "being broken” if you are the egg. Currently the "Rub” comes at an individual level [PCP] and we must create. I want to be the quarterback that counts; you must change my mind at the individual level

Dr. Sanchez recommends we create an omelet without eggs? Possibly. They do agree that it needs to change. He uses the concept of a team that changes to the game; to meet the new rules. The opposite of this approach is changing the entire team to meet one player; please reference Tim Tebow’s offense to challenge to this idea.

Randall states that commercial insurance is to collaborative care as condoms are to pregnancy: They are 92% effective at prevention.

Dr. Sanchez questions what we are paying for is evidence based (EB). There are PCMHs out there that are not PCMHs but we are going to call them one. Us bloggers question, "Is that a misunderstanding of the definition or an abuse of system?” The dollars are going to drive this change more so than people gathered around a podium bantering.


The debaters 


9:28am: Barry Jacobs, audience member, states that collaborative care is not going to happen. Treatment via a care management approach, not necessarily treating the mental health illness connected to the problem.

Dr. AJ comments that Political Will and a Leadership Socialist approach are what Americans are afraid of as a possibility. Triple Aim reference to treatment being local and grass root generated. She discusses the Canadian use of office redesign; something that they created out of a grassroots collaborative care model – every person needs to make small changes and expand their own scope of practice within each professional position.

9:31am: PCMH are words that are used, doing Integrated care before it had a label.Overall, it is recognized as a team approach. Practice medicine the way football was played 50 years ago, you really can be a one person team back then. Primary care is a team, health team, driven endeavor. W

9:37am: Dr. Reitz points out that our medical system lacks a general contractor. Medical care has too many outlets in their "home” because the electrician makes a lot of money for each outlet he installs. We need a GC. Through federal CPCI initiative, clinics in nine states will earn a $20/per patient per month for collaborative care. Put BH in primary care and it will be paid for.

AJ continued to speak towards the micro level of change; the grassroot generated individual impetus for larger change. If every office, every worker made small changes, it would collectively make a more significant change. To follow the football analogy, it would be like having every player on the team be more universally trained [say simply in MI or trauma focused care] , than having "special teams”.

9:43am: If you have a safe place but people are not honest, that does not work out that well. Honesty in this case is driven by finances.

9:45am: Dr. Sanchez states that in Texas they are working on a system of payment that focuses on bundled payments. The model's first draft showed that the MH community became very nervous; fearing being "cutout” of the process. Second, when a plane comes down when the wheels just touch ground, you get the traction "we love this” but a bit of a jerk because it is scary. The pushback was around "we cannot do it” not because of the lack of unity in the idea, but there are no true systems to make or even allow it to work. We cannot get a new model without fracturing the process.

The "Culture of Shared Benefit” is it really a question of Health vs. Wealth?

Those with the money and power are not interested in collaboration.

Dr. AJ points out the Mental Health Commission: Canada--they are transition funds and incentives for treating the behavioral side

The question by moderator, Ben Miller, asks if Integrated Behavioral Health costs more - is this correct? Dr. Sanchez responds with no, it is cost-effective. Dr. Reitz states that it doesn't cost more, but does cause significant cost shifting.  Counties with a higher percent of primary care always have lowest overall healthcare costs.

AJ: You Americans put the man on the moon w/ a focus on the change, once again, we are a shining model for the rest of the world but we have to put a focus on it at an individual level.

An audience member asks if there are any Financial Benefits managers and large corporations in the room. Crickets. The member goes onto state that they are the ones who pay for care. If we are going to change this (have collaborative care carry on), we need them. They are trying to control cost; not pay more to the people and not cost more at the end. The payers need to understand we bring something to the table that helps them. We need to talk to the benefits managers.

Another take home message: If we really do want to push this forward, who is not at the table: Employers? Who else?

9:57am: One main point of this discussion around the future of collaborative care (whether we will be a mainstream healthcare model CC by 2022) is that we need to look around the table and realize who is not there. Mainly, invite those to the table who can help us move the field forward. Dr. AJ challenges people to stop being onlookers and become motivated to seek out others. She asserts her stance on changing others at the microlevel.

Dr. AJ states that for all of the eggs out there, in every end there is a new beginning. We (U.S.A.) put man on the moon, the Rubiks cube with the traffic lights, a very robust depiction of how to do this micro and meso levels; now we need to move on to the macro.

Onlookers, we pass the flame on to you: support collaborative care and disseminate the word. 2022.

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Live Blog of Opening Plenary Session: Sarah Kliff

Posted By Benjamin Miller and AJ Jayabarathan, Thursday, October 4, 2012
 Tonight's Live Blog is hosted by AJ Jayabarathan and Benjamin Miller. 
Check back often to read their posts and to add your comments. 
You may also email your comments for posting to
Ben and AJ


A.J. 6:25pm. Sarah: NEJM carried a paper that looked at a comparison between states that expanded medicaid and others that did not....the population health outcomes clearly favored the states that expanded medicaid. Sarah's response to a question about changing human it possible with the current emphasis on education ex. calorie labels being affixed to fast foods? Would making a big mac more expensive be the true way to change behavior and therefore manage health outcomes...Humana is presently looking at making healthier choices easier and incentivised to affect human behaviour.


A.J. 6:18 pm. Audience member question: There are many demonstration projects and pilots going do they all fit together?

Sarah: I don't know how they are going to fit together, however with everyone moving towards value based, high quality care, the hope is that it moves people along in a positive direction which will effect positive change.

Audience member (Dr. Sanchez): We have the highest number of uninsured people in Texas....just like we have a lot of bats...and our Senator has announced that Texas does not need to expand medicaid. However, a reputable economist is soon to refute his position with strong evidence to the contrary.

Sarah: Wait until the election happens. Right now it is easy to say these things, but should President Obama be re-elected, there will be a powerful force for change afoot.


Ben 6:16pm. Sarah taking questions now. This has been a good (and fast) plenary. I am thankful that there are really smart policy people out there who can write (and talk) about this. The information that Sarah brought was grounded in evidence and rationale in its delivery. There are very few out there covering health policy that do it as well as Sarah Kliff. Using up to the date research (and amazing graphs), Sarah helps explain some of the most complicated issues around healthcare policy in a very easy to understand way. For example, here write up last week on "Increased obesity is wiping out most health benefits of less smoking” used one graph to describe this phenomenon and why it is happening. This is one blog to have in your RSS feed (plus, how many reporters will integrate the Simpson’s into their work?). Thank you Sarah for an excellent plenary session. 


A.J. 6:13pm. Closing anecdote: Doctors salaries were tethered to quality of care determinants. A check list of deliverables were developed. In the first month 3 doctors got bonuses, then 12 ...etc, etc. It set up a positive competition amongst the group of surgeons that stayed, and it was felt that this shifted direction. Sort of like atheletes being paid for performance???? 


A.J. 6:09pm. In all fairness, the subject matter is dry and full of numbers! Study after study after study after study.....mind numbing! Is it any wonder, we glaze over like donuts after some time?


Ben 6:06pm. Sarah discussing the state of Oregon and healthcare innovation. However, a state, very similar to Oregon is Colorado. In Colorado, we have a wonderful innovative community known as Grand Junction. To really know why Grand Junction matters, you have to look under the hood and examine the engine.

"Unlike in most communities, where doctors are paid less for Medicaid patients than insured ones, physicians here agreed among themselves to charge a little less for regular patients and a little more for Medicaid patients. That way doctors would be happy to treat all comers.’”In effect, we created a community health system,’ said Steve ErkenBrack, president of Rocky Mountain Health Plan.”

The engine in this case is a nonprofit health plan willing to take some risks to delver better care. The reasons of this may be lost on many initially, but think about it for a second and I will return to this.

And again, we are back to the need for transformation in our payment systems.  


A.J. 6:05pm. Organizations are stepping forward and taking on the challenge to reform provision of services...and they are "sticking" out their necks it seems and taking on risks. How come? Because at the micro, meso and macro level, "everybody knows" (check out Leonard Cohen's song...very apt) that the current system is doomed. So, those that want to be saved and save their systems of care are strapping on the parachute of "Obamacare" and jumping before the aircraft crashes...


A.J. 6:00pm. 2014 heralds the start of the affordable care act...the biggest expansion to medicare since 1965. A new set of acronyms to define unicorns it seems, creatures that no one has seen before?

Nay, the act seeks to lay down new foundations (no matter how boring and dull they sound) that will grow new outcomes. Because it is more strategic, more comprehensive, much more grounded in the reality of the population health issues that face 314 Americans every day.


Ben 5:56pm.  Sarah just brought up the magical unicorn, ACOs. Accountable Care Organizations are partnerships between healthcare providers designed to be accountable for the quality and cost of the healthcare they provide in return for financial incentives. How these partnerships are implemented may vary, with some focused purely on primary care, while others include sub-specialists and hospitals. In all cases, primary care is expected to form the core of these organizations, the center of the wheel, and base for the ACO.

ACOs are risk-bearing entities and require capitalization. To this end, hospitals and other healthcare professionals like physician groups are partnering with insurers to form these entities. The partnerships that participate in the MSSP will likely cross over into commercial plans, and Medicare will not be the only health insurer to benefit from the cost reductions realized by ACOs.

There are indeed interesting opportunities within ACOs for collaborative care.


Ben 5:51pm. Sarah just nailed one of the most important points about healthcare – we have an irrational system that rewards bad behavior in healthcare. We have a system that pays for healthcare through fee for service that often rewards behaviors whether or not they work. As Dr. Peek has taught us, we must change healthcare in three worlds simultaneously (clinically, operationally, and financially).

A.J. 5:50pm. Health care spending is the primary driver of the National debt. But despite spending more, fewer people are covered for health care needs. Covering fewer people with more money, is NOT the objective for the it?

The rate of insurance has actually gone down because of the affordable health care act policies...for those younger than 26.
The kindergarten approach expecting all health care providers to cooperate is an important element that needs to happen in order for silos of care to change.
Doctor's roles are determined by how the system of care is set up and they follow them...however, what is irrational is how they don't work in unison! What gives?

A.J. 5:44pm. The affordable health care act asks fast food places to post the calorie labels on their food. When Sarah asked a consumer of fast food at MacDonalds what their reaction was towards this, he remarked that this made sense and should be part of what Government is doing to improve health care!!!!! When informed that it was part of "obamacare", he appeared to loose interest in the matter.

Ben 5:44pm. Sarah just told us about a story about McDonalds and talking to people about healthcare policy. She mentioned a gentleman who believed that something was in PPACA that was in reality not in the law. And it’s true, there is a substantial need for accurate information in healthcare policy. Finding the most accurate source of information is hard and made even harder by the fact that we have our own opinions and political biases.  


Sarah Kliff at #CFHA2012

A.J. 5:35pm. Austin hosts 1.5 million bats as a colony housed under the bridge over Lady Bird Lake. 84% (ballpark) of the audience watched the presidential debate last night. Ben Miller 's interest is in the policy development of healthcare. Sarah Kliff covers healthcare policy in her writing and has a remarkable grasp of data as it pertains to healthcare. However, "The dream of reason did not take power into account" , so, this talk is perfectly poised between the presidential debate last night and the elections to come 


A.J. 5:30pm.  We heard from Dr. Eduardo Sanchez, Lynda Frost and Katherine Sanchez about the numerous initiatives in Texas that have further the field of Collaborative care at a grass roots, horizon and blue sky level. The Hogg Foundation, Amerigroup Real solutions, VA Health Care, Blue Cross Blue Shield of Texas, American Psychological Association, Forest Institute, St. David's Foundation, The Meadows Foundation have provided sponsorship and support for this conference to be held in Austin, Texas!


A.J. 5:10pm. Journalists are the story tellers of our time. Instead of campfires of yore, we huddle with our mobile devices for the warmth of human company and the draw of the "narrative” element of storytelling. But how closely does media portray reality? How much reality can we handle? If you asked someone who has experienced mental illness, domestic violence, bankruptcy or their family member, the raw emotion of pain and suffering is tangible. And, our story tellers use these elements to sell their stories. Tonight I look forward to hearing from a "truth teller”. Sarah’s pieces carry the simplicity of fact and the review of relevant evidence to help put stories in context. Tonight I look forward to seeing and hearing her.

Ben 5:00pm. Healthcare policy is always moving. It is a complex adaptive system constantly interacting with all kinds of other components. Tonight’s plenary speaker, Sarah Kliff, begins her talk telling her story. It is a story about becoming involved in politics and the complexity of politics and healthcare policy. It is a story that often highlights the differences between public perception, our politicians, and law. It is a story that highlights how disconnected we can be in healthcare policy from that which actually happens on the ground with our patients.

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Contact Us

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

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.