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Let's remove the policy barriers to integrating care

Posted By Benjamin Miller, Thursday, December 29, 2011

Treating behavioral health and physical health separately has resulted in poorer outcomes, higher costs and fragmentation at almost all levels in health care. Scientific evidence shows it doesn't make sense to proceed as if the brain and behavior are separate from the body. That's why there are numerous efforts underway to promote "integrated primary care services" in Colorado and elsewhere.

In short, integrated primary care is a model of health care delivery that engages individuals and their caregivers in the full range of physical, psychological, social, preventive and therapeutic factors necessary for a healthy life. Yet, while integrated primary care services improve patient health and provider morale, many providers have encountered difficulties implementing the model due to reimbursement constraints and the complex nature of billing health plans.

Recognizing that most programs that integrate physical and behavioral health struggle with financial sustainability, the Colorado Health Foundation partnered with the Collaborative Family Healthcare Association (or CFHA) to launch the Promoting Integrated Care Sustainability (or PICS) project. PICS is a statewide effort that aims to identify the financial barriers to integrating physical health and behavioral health care services and to implement Colorado-specific solutions to move integrated primary care into the mainstream of health care.

The PICS team surveyed clinics and practices across Colorado that integrated behavioral health into a primary care setting or primary care into a behavioral health setting. By conducting interviews with providers who integrated behavioral and physical health care in other states, PICS developed preliminary policy recommendations and considered "next steps" to support financially sustaining integrated care services across Colorado. The analysis of the PICS project findings will be finalized and shared later this year, but the preliminary data tell us that integrated care services in Colorado are primarily grant funded. On average, those who provided integrated care recouped only 20 percent of the costs associated with the services. In fact, many integrated care services simply are not reimbursable by today's standards.

On Nov. 7, PICS released preliminary policy recommendations at a summit convened by the Foundation and CFHA. The recommendations are intended to help providers generate some revenue from integrated care in the short term. In the long term, the tactics aim to gather robust cost data and move the health care system away from a fee-for-service, volume-based, payment structure towards more global payment strategies. Here are the recommendations:

  • Clarify current billing regulations and train integrated care sites to optimize the use of existing revenue sources to provide cost efficient, medically necessary care.
  • Resolve confusion about the ability of behavioral health and physical health providers to bill for services provided to the same patient on the same day and pursue efforts to reduce administrative barriers.
  • Examine the viability of health plan payment for health and behavior assessment codes to provide health behavior services for self-management of chronic illness.
  • Test and analyze the viability of global funding strategies, defined by a single or enhanced payment for all care received, to financially sustain integrated care services.
  • Plan and implement a standardized statewide data collection system to document financial, operational and clinical outcomes and costs of integrated care services.

These are exciting times in health care. However, many challenges still lie ahead for integrated primary care services. To keep fragmentation from prevailing, we must build upon the many collaborative and innovative health care efforts in Colorado and across the country to support appropriate payment for integrated care services. Let's hope these preliminary recommendations will provide a good starting point for accomplishing that important goal for Colorado's health care system.

Benjamin Miller, PsyD, is a clinical psychologist and an assistant professor in theDepartment of Family Medicine at the University of Colorado School of Medicine.

Blog Disclaimer

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Integrate This: Evidence-Based Practice in Integrated Primary Care

Posted By Elizabeth Horevitz, Thursday, December 22, 2011

This October, I attended my very first CFHA conference. As many others have already described, I experienced that sense of "professional Zen” that comes from being surrounded by like-minded practitioners, researchers and students coming together because of a shared belief in and commitment to integrated/collaborative health care. We spent the weekend discussing the best ways to break down the old silos of health and mental health services, and integrate mind and body in whole-person, patient-centered health care. One of the clear take-away messages was that in order to effectively "accelerate the adoption of collaborative care” (the theme of the conference) research will increasingly play a centralized role in CFHA.

This resonated with me. As a doctoral student at UC Berkeley, the importance of evidence-based practice (EBP) has been drilled into me for the past four years. Evidence-based health care refers to "use of best current knowledge in decision making about groups and populations” (Gray, 2001). EBP requires critical thinking about claims of knowledge, and a willingness to reject false claims of knowledge or truth.

In contrast to evidence-based practice is authority-based practice, which relies on claims based on authority, tradition, popularity or consensus, rather than subjecting claims to "critical tests of their accuracy” (Gambrill, 1999, p. 346).

Now comes the hard part.

What if one of the key cornerstones of collaborative health care "best practices” might actually be authority-based?

The culprit? The Warm-Handoff.

For those of you not immersed in the world of collaborative care/integrated primary care, the warm handoff refers to a referral practice wherein the medical provider introduces the patient to the behavioral health consultant in real-time. Although there is no specific one way to do a warm handoff, it is generally agreed upon that behavioral health consultant can, at the time of the referral, offer a brief intervention if the patient is in acute distress, or at the very least engage in a "meet and greet” to assuage any patient concerns about behavioral health treatment. If you Google it (go ahead), you willl find thousands of hits describing the central role it plays in collaborative care, links lamenting the inability to bill for this "cutting-edge” same-day service to clients, and videos demonstrating how to properly make a warm handoff referral in primary care.

As a behavioral health consultant in a Federally Qualified Health Center, I can tell you I love the warm handoff referral. It makes intuitive sense: a personal introduction to the behavioral health consultant by the medical provider is thought to help increase engagement, reduce stigma, and enhances continuity of care. It is a standard part of collaborative care practice, and, I can tell you from experience that nothing will lull you into believing in the power of collaborative care like a well-executed warm handoff.

But the warm hand-off has never been rigorously tested. We have no proof of its effectiveness in enhancing follow-up to behavioral health treatment.
While there is mounting evidence for the benefit of specific stepped-care interventions for depression, anxiety and management of other co-morbid conditions in primary care (see for example: the IMPACT trials and the CALM studies referenced at the end of this entry), very little research has been done on what actually gets patients to the door of behavioral health treatment in integrated settings.

As a researcher interested in health and mental health disparities, particularly among Latinos, I decided to conduct my dissertation research on predictors of follow-up to depression treatment within an integrated primary care clinic (where I also work as a behavioral health consultant). After all, what good are all of these evidenced-based interventions if no one shows up for treatment?
I can tell you from my preliminary analysis that the warm hand-off may not be all it is cracked up to be.

My findings suggest that at best receiving a warm handoff (as opposed to a "cold handoff” wherein no personal introduction is made) is ineffective (it is not a significant predictor of follow-up for depressed Latinos). At worst (for English-speaking Latinos), receiving a warm handoff has the exact opposite effect from what it is intended to do: English-speaking Latinos with depression who receive a warm handoff are significantly less likely to attend a first visit with the behavioral health consultant as compared to those who receive a cold handoff.

As a behavioral health consultant, these results are pretty hard for me to believe (I've been in the room! I've seen it work with my own eyes!). The colleagues with whom I've shared this information have also been stunned. The next questions people usually ask me are:

  1. How big was your sample? (431)
  2. Did you account for [insert various patient demographics, comorbidities and provider characteristics here]? (Yes, and I am happy to share them with you. All of my methods and analyses will be available for scrutiny in an upcoming published article (in preparation)
    And…
  3. WHY? (I don't know, but I am currently conducting in-depth interviews to find out).

Certainly, preliminary results from one study at one clinic are not enough to warrant a referendum on the warm handoff. This information should, however, raise questions about what we are doing and how we are doing it.

Undoubtedly every integrated clinic has its own take on the warm handoff (how and when it is done), but most integrated clinics practice some form of it. Some may have better outcomes than others, and some populations/cultures may respond better than others. All of this underscores the need for better understanding…a need to break open the "black box” of how we engage patients into care. While the integration of behavioral health services into primary care undoubtedly improves access to behavioral health services, the extent to which the warm handoff helps engage people (in this case, Latinos) into care beyond the mere existence of co-located services merits further study. There are many possible reasons for my findings (maybe meeting the behavioral health consultant is so effective that folks don't feel they need a follow-up visit?), but we don't yet know enough to say.

I'm left wondering, though, what do we do with this information?

References:

Gambrill, E. (1999). Evidence-based practice: An alternative to authority-based practice. Families in society, 80, 341–350.

Gambrill, E. (2005). Evidence-based practice and policy in California: Choices ahead. Power point presentation. Leadership Symposium on Evidence-based practice in the human services, Sacramento, California

Gray, J. A. M. (2001). Evidence-based healthcare. Elsevier Health Sciences.
Manoleas, P. (2008). Integrated primary care and behavioral health services for Latinos: A blueprint and research agenda. Social work in health care, 47(4), 438–454.

Roy-Byrne, P., Craske, M. G., Sullivan, G., Rose, R. D., Edlund, M. J., Lang, A. J., Bystritsky, A., et al. (2010). Delivery of Evidence-Based Treatment for Multiple Anxiety Disorders in Primary Care. JAMA: The Journal of the American Medical Association, 303(19), 1921 -1928.

For a listing of evidence for IMPACT depression trials, check out: http://impact-uw.org/files/IMPACTPublicationsList.pdf

Elizabeth Horevitz, MSW, is a doctoral candidate at the University of California, Berkeley. She is interested in the integration of behavioral health services in primary care settings with a particular emphasis on research and dissemination of evidence-based interventions for Latinos and other underserved populations. Concurrently, she is interested in the preparation and training of social workers for practice in integrated behavioral health/collaborative care settings. Her dissertation examines follow-up to depression treatment among Latinos at Community Health Clinic Olé in Napa, CA, where she also works as a behavioral health consultant. When she is not researching or working, she enjoys hiking and biking in the Bay Area and, until she can adopt one of her own, spending time with other people's dogs.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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What A Conundrum: Confidentiality And Integrated Care--Part Two

Posted By Sandy Rose, Thursday, December 15, 2011


Our preliminary conclusions are as follows: For the most part, we believe federal and state laws and regulations do allow for easy flow of information and practice, in the true spirit of integration. But, not for all of "us.” If you are an alcohol and drug specialist, or code psychotherapy vs. health and behavior codes, then at least in some states, we are not all equal in the eyes of the law to our medical colleagues, and integration is not so easy. As many know, the Federal Alcohol and Drug Confidentiality law (42CFR Part 2) has specific provisions for consent and confidentiality for those designated covered "programs.” Also, as in NH and numerous other states, there are licensing laws quite explicit asto what kind of informed consent must be provided that applies to mental health practice. Medical providers are not subject to this law. We also believe that if your patient can reasonably expect you are doing psychotherapy regardless of what you call yourself or bill for, you are subject to these licensing laws for mental health provision. How does your referring primary care provider introduce you prior to your warm handoff or intake, and what credentials are alongside your picture or on your staff listing that might provide a reasonable impression that you are a mental health provider?

Given clear expectations for behavioral intervention alone, billing consistent with behavioral consulting, and limiting documentation to non-sensitive information, we believe integration may well be permitted the way it was intended to be. You can chart along with your medical colleagues, release information using your health center policies and have a unified informed consent in the patient handbook at patient registration. However, this has never been tested, and for those in states where provisions for mental health practice are prescribed with respect to these issues, you are in uncharted (so to speak) territory.

One last (integrated) worry: Did you know that any of your records (mental health or otherwise) which are received from specialized "programs" under the Federal Alcohol and Drug Confidentiality law (42CFR-Part2) cannot be re-released without specialized releases? HIPAA compliant releases are not enough. And if you indeed would like to treat alcohol and drugs as a specialist in your health center, (important given the prevalence of this problem in primary care), you are covered under Part 2 and subject to those set of provisions for consent and confidentiality provision.

As recently noted in the calming SAMHSA (October, 20112) article "Don’t Be Spooked” (http://www.integration.samhsa.gov/about-us/esolutions-newsletter/october-2011#spooked) , there are in fact quite reasonable solutions to a number of these concerns. For example, where applicable, agencies can expedite communications using Qualified Service Organizations and Organized Health Care Delivery Systems. However, as stated even in this reassurance, "Your state mental health code or state alcohol and drug abuse agency may impose additional confidentiality protections that must be addressed. These must be linked with the HIPAA and 42 CFR Part II to create an overarching policy for information sharing”. Although the article describes two progressive state efforts to address confidentiality regulations to facilitate integration, we have found the vast larger majority of states still lagging behind.

It would sure be nice to have a single or reasonably understandable source of accessible information that can help the average administrator or clinical director understand where their behavioral health providers might fall with respect to the laws and grasp the growing options for meeting the challenges of these ethical issues. It is a costly effort to navigate these issues:
The excellent LAC guide to this law is $89.00 (see http://www.lac.org/index.php/lac/183#pubs) for starters, not to mention the legal expenses and staff time in getting up to speed. It would sure be nice if there was a primer and open forum for those of us who chose not to go to law school and who do not have a year or two to devote exclusively to policy making for these purposes alone. There are excellent resources including the SAMSHA website, the National Council, the Legal Action Center, and the NACHC. We have had some very helpful discussions with staff from these agencies, including Attorney Katie O’Neill form the LAC, and Mike Ladierre from the National Council’s VP of HIT and Strategic Development, and formerly from the NACHC. But more educational assistance is needed for those starting out and even those who are beyond beginners in the field.

We hope that agencies such as SAMHSA might continue to assist with ongoing FAQs that can clarify ambiguities in the laws such as who is covered under 42CFR and what a typical FQHC might fall with respect to a "program”. We hope that national guilds such as the ASPPB can help guide the state licensing boards to understand integration and behavioral interventions as distinct from mental health practice and afford protections for those who are licensed and working in behavioral health settings wanting to be truly integrated. We believe strongly that the laws have a long way to go to reflect the movement as it was intended specialty care. We hope our members can help educate legislators about the benefits of accessible information and procedures in integrated settings, and disseminate model statutes such as in Washington, to help guide the process.


In the meantime, we hope that our research can inform others wanting to ensure their practices and policies and procedures are grounded not only in theory, but the realities of regulation around them. We hope this study will shave off a little of the learning curve for colleagues in developing best practices for their health center. Finally, we hope that this will begin a larger discussion that can serve as a forum to discuss questions and maybe even reduce the Xanax you ingest during your own program development.

The recent release of SAMHSA's FAQ can be found at: http://content.govdelivery.com/bulletins/gd/USSAMHSA-21733b



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





The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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What A Conundrum: Confidentiality And Integrated Care--Part One

Posted By Sandy Rose, Thursday, December 8, 2011
People accuse me of being a closet-lawyer-wanna-be.  I vehemently deny these charges.  My obsession over ethics statutes has far more to do with my anxiety disorder than any career ambition (although Lord knows, I certainly would not mind the money).  

As one who transitioned from specialty care to a fully integrated FQHC setting, I was bound to get nervous in uncharted waters.  It was not the role change or frantic pace that got me going.  It was confusion: How could I integrate into a medical world that was held to different ethical standards and licensing laws?  No medical colleague I ever knew was required to provide the specific language for informed consent prior to starting treatment that is mandated in our licensing law.  In NH, we have very specific language, amounting to pages of information, which licensed psychologists must provide prior to mental health treatment, in addition to informed consent requirements that apply to all health workers.  Nor did my medical colleagues appear to do much beyond securing the HIPAA general consents for release of PHI  prior to collaborating outside the practice:  They routinely picked up the phone and talked with their colleagues using only general releases.  Unlike HIPAA’s provision for exchange of information for health purposes, the ethical standards for mental health providers require specific releases rather than general consents before communication to external providers.  

Don’t get me wrong:  I harbor no masochistic tendencies and do not relish the response of the medical records and front end staff faced with endless releases and four page consents that were so (relatively) easy at my former specialty practice site.  Most importantly, I would not be here at an FQHC if I did not wholeheartedly believe in the need for full access to my records by the primary care providers and operational efficiency of my center.  I also know that our viability as a profession requires us to be on par with the healthcare providers in optimizing efficiency and accessibility of our practice.   I just wasn’t sure that the laws and ethics caught up to this need.  If I did "behavioral intervention” vs. "mental health” care, how much do I have to comply with my state laws and regulations intended for "mental health practice?” How much is "enough” informed consent for a warm handoff?  Do behavioral interventions, even if billed using H&B codes vs. the CPT therapy codes, make me immune from having to provide full informed consent as mandated by my state licensing law? Do patients expect more privacy from us, and does this set us apart from our medical colleagues in all the above?  Am I a covered "program” under 42CFR Part 2 because I diagnose and treat alcohol and drug problems in the health center, but do not "hold myself out” as a specialist?

It turns out that I found little clarity or even discussion of these topics in the integration literature.  And, not many really wanted to talk much about this either. I used to take the unanswered emails personally, but have since concluded that few like to talk about something so messy. Go figure.  It was also clear that there were different approaches to this vacuum--As one successful administrator responded, "It is better to ask forgiveness than permission” when practicing in areas of ambiguity. Alternatively, one could simply stick one’s head in the sand until policy, at least in my state, catches up with integration.

Fortunately, there were others confused just like me, and we bonded over our drinks and questions at last year’s CFHA conference.  These colleagues (Cathy Hudgins, Pete Fifeld, and Steve Arnault) came from various aspects of integrated care—education, service provision and administration.  We decided to see what we could learn collectively through a systematic course of study, from all our perspectives.  Our goal was to  develop a research base to guide practice relating to informed consent and confidentiality in integrated settings: Our plan of attack was as follows:
  1. Identify all the  federal and state statutes, regulations, and discipline-specific ethical guidelines for psychological interventions that we could find on informed consent and confidentiality for behavioral health service provision.
  2. Survey key national agencies and stake-holders including the National Council, NACHC, LAC, SAMHSA for guidance and  interpretation of ambiguous laws.
  3. Survey the literature (books, articles), provider list serves, and practice manuals to identify patterns of practice.  
  4. Consult with lawyers we knew who could assist in interpretation of any remaining ambiguities. 
We presented a manic overview of our findings at a 20 minute presentation at last month’s CFHA conference in Philadelphia.  We are preparing a full report of our findings and analysis for an upcoming article on this topic.  It will include a compilation of state and federal laws impacting confidentiality and informed consent for comparison and analysis.  We have been most interested in how these laws and regulations are different for BH providers than for medical providers, and what this means for integration. Can we truly have one informed consent that covers all disciplines, and are there differences in the regulations (rather than theory) that set us apart when it comes to chart entries?  We have drafted a "best practices” protocol based on our findings and will include this in our discussion next week in part 2 of What A Conundrum: Confidentiality And Integrated Care.  


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

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.


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INTRA-Disciplinary Care: Can Mental Health Professionals Work Together in Primary Care?

Posted By Jennifer Hodgson , Thursday, December 1, 2011
Updated: Thursday, December 1, 2011
The burgeoning success of integrated care brings with it a complicated by-product. The diverse range of behavioral and mental health professionals are stepping up to the plate. Many of these professionals, trained under the "old guard” as competitors in the market, are now tasked to re-align in the context of a new paradigm. The following represents insights from a year-long conversation (tongue in cheek) between two friends and colleagues, one a clinical psychologist and the other a medical family therapist who are in search of a model of intra-disciplinary collaboration.

Dr. Jodi Polaha, Most Awesome Clinical Psychologist (and humble too):

Last fall, I sat through an uncomfortable board meeting. I was charged to work with a Clinical Social Worker, Licensed Practicing Counselor, a Counseling Psychologist, and a Licensed Nurse Practitioner to develop an integrated care training program as part of a rural workforce development project. Whose students could provide treatments in behavioral medicine? Whose students could help develop programming? Whose students understood research well enough to do program evaluation? "Ours!” I said, smiling.

So did the other professionals in the room.

"NOT!” I shouted in my mind. I tried to keep my facial expressions in check, but it was hard. Everyone knows social workers help people get food stamps and find support groups, right? Everyone knows our counseling friends deal mostly with life-adjustment issues, right? And everyone knows that clinical psychologists are superheroes, trained in the scientist-practitioner model, who REALLY CAN do everything…RIGHT?

I was challenged by this conversation, and recognized my long-held, inaccurate stereotypes of other mental health disciplines, including my own. Still, some questions made me itch: Can mental health professionals from various training backgrounds work harmoniously in integrated care? If so, could their roles be interchangeable? Should they be?

I took my questions to Dr. Jennifer Hodgson. Who would know better than the president of CFHA? Granted, she is a marriage and family therapist (or medical family therapist as she calls herself these days), so she lacks the finely-honed analytical skills of a clinical psychologist. She can pick out a cute suit, though, so I felt it was worth a try.

Dr. Jennifer Hodgson, Supreme Marriage and Family Therapist:

First, I would like to say, when Jodi Polaha approached me with questions about intra-disciplinary collaboration, I had to hide my confusion. Why would a clinical psychologist be concerned about this? Don’t they mainly do testing and inpatient work with serious and persistent mental illness? Isn’t their training mainly in one specific area of health or mental health? What are they doing in primary care? I would not want a foot specialist operating on my eye, after all! How does she figure she is a team player with the likes of medical family therapy, who, we all know, leads the field in advancing integrated care! I know what is going to happen, she just wants psychologists to take over the leadership of this integrated care movement. Arguably, they do have Medicare in their back pockets, but so do social workers. Does that mean though that they are better integrated care clinicians?

There are so many inaccuracies in how different mental health disciplines are trained that perpetuate the ideas that others are less well trained simply because of their degree. Why can’t a social worker, pastoral counselor, professional counselor, or family therapist (had to get my field in there somehow) run an integrated care service with a blend of professions present? Of course we can work harmoniously Jodi, but we first have to be willing to be vulnerable and willing to learn from one another in the field.

I have gotten to a place where I just want all mental health disciplines to stop figuring out who is best based on degree and to start taking classes together, training in the field together, and promoting policy for parity together. We would be even better together…if only we knew how to share the space. It is the old adage of those who have power want to hang on to it and those who want it are working hard to get it. I tell my students that there is plenty of room in the sandbox so no need to throw sand to create space.

Most healthcare professionals just want someone who can do the job and cannot understand why some mental health providers cannot work together easily. I go back to how people were trained, Jodi, and I believe strongly that we can be retrained to learn models of integration that embrace multiple disciplines in the same location. We can share the work, divide the responsibilities, and promote one another’s strengths. We can embrace hiring someone not because of the degree, but because he or she meets the patient population’s needs and has the core competencies (to be determined) to provide integrated care services.

It starts at the training level and I believe CFHA is the place where we can drop our labels and learn the core competencies needed for the work. I know my calling is to train the next generation to behave differently, but it starts with me and sometimes I struggle with it too. I want to understand why we cannot just drop the entitlements...but as a systems thinker I know that change happens slowly, thoughtfully, and organically (with a smidge of encouragement from associations like CFHA).

Dr. Jodi Polaha

It’s funny, in spite of my reaction to that board meeting last year, this year in Philadelphia, I had so many positive interactions with professionals from so many varied disciplines. In that forward-thinking environment, Jennifer, it was truly effortless to meet the spirit of your ambition for all of us. I learned from social workers, public policy people, and physicians. I exchanged cards with a school psychologist from Florida, with similar research interests to my own. The energy in this mixed group was incredibly engaging and specific credentials, training history, and even experience seemed to fade away. In another week, I am off to a clinical psychology conference and, reflecting back, I feel I was more among "my people” at CFHA than I will be there.

It occurs to me that the mental health professionals involved in integrated care have so deftly cast off the old guard notions about the 50-minute session, the cozy psychotherapy room, and even the term "mental health.” I’d like to see your vision become a reality, Jennifer. Perhaps, the stereotypes and competitive dispositions will be the next to go.


Jennifer Hodgson, PhD, is a licensed Marriage and Family Therapist, Associate Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University, and outgoing President of CFHA. She has over 18 years clinical experience and has served on numerous boards and committees related to healthcare and mental health care issues. She is co-author to the first doctoral program in medical family therapy in the nation.


Jodi Polaha, Ph.D. 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. In addition to her work, she spends lots of time with her husband and two young boys swimming, biking, and hiking in the surrounding mountains.


The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.


Tags:  CFHA  family medicine  family therapy  Philadelphia 

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CFHA in Philadelphia: A Field Trip for ETSU Doctoral Students in Clinical Psychology

Posted By Jodi Polaha, Wednesday, November 23, 2011
As a school girl, I always loved going on field trips, what kid doesn’t? What I know now is that it is just as fun, and maybe even more so, to guide one.

A few weeks ago, I took five students from East Tennessee State University (ETSU) to Philadelphia to see the Collaborative Family Healthcare Association in action. The students are in their second year in our doctoral program in clinical psychology, which has an emphasis on rural, integrated care. This semester, the students are taking my course, Primary Care Psychology; devoted to learning the language of contemporary healthcare, understanding the rationale and research behind integrated care, and evaluating models for its administration. Overall, the conference was a great way to bring to life the great potential and actual effects of their "book learning.” In particular, I was pleased to see that the content was not redundant with classroom-based knowledge, but advanced what they have learned. And, it was exciting for them to have employers asking, "When will you be finished?” with a position in integrated care in mind!

I thought blog readers might like to hear from these up-and-coming professionals themselves, so I asked them, "What impressed you most about the conference?”

Laura Maphis
I chose to earn my Ph.D. in psychology at ETSU, because I was hoping to learn how to "do” integrated care. What I have learned so far is that there is no instruction manual for "doing” integrated care, that it is a pioneering endeavor, and that the more I learn, the more questions I have. For instance, how are we going to do this in primary care when primary care has its own unique problems (e.g., fewer physicians seeking generalist careers)? How are we going to do this with multiple insurance/coverage barriers? How are we going to do this with little legislative support? As a graduate student new to the integrated care frontier, I felt the excitement of this "frontier” enhanced by the vastness of it (so many questions!), as well as the isolation of having only a small minority of U.S. care providers on-board. I am super impressed with how the 2011 CFHA conference was able to give shape and form to this vastness by honing treatments for specific disorders, treatment modalities, issues inherent in working with special populations, ethical concerns, billing and reimbursement considerations, cultural considerations, issues at the provider level, and education and research as they pertain to integrated care. Moreover, the collaborative nature of the CFHA conference made me feel, if only for a few days, part of a majority. As a result, I feel more capable of navigating this frontier in the future, and know that I will be in good company.

Sheri Nsamenang
My trip to CFHA happened right when I needed better shape to my career aspirations. Aside from the things I learned from listening to talks by renowned leaders in the field, the mentoring opportunity, the friendliness and the willingness of conference attendants to discuss the practicality of collaborative care, I was inspired by the informative research presentations at the poster sessions. While I have increasingly become conversant with the clinical practice of collaborative care, I have been less familiar with conducting research in primary care settings. As I visited various researchers and learned about their projects, I was exposed to a plethora of research topics, ideas, and designs. Although I did not necessarily leave the conference with an idea to research, I left with ideas on how I could design studies, examine interventions, and how to examine non-conventional data such as patient charts in a primary care setting. Off additional importance, I left feeling that there was an audience for primary care research. A highlight moment for me as I walked from one poster to the next, was meeting researchers from Japan. As an international student, this encounter made me realize that, CFHA was an association I could rely on in the future if I were practicing collaborative care somewhere in Africa.

Alishia Foster
At this conference, the model I had become accustomed to reading about had taken on new life. I felt I was part of a dynamic process of change and that the struggles of integrated care are also my own struggles. For example, sustainability was a prominent topic, and I found myself debating with my fellow students over pitching integrated care to insurance companies, the use of H&B codes, as well as the reality of current dependence on grant funding for many programs. Amidst the brainstorming over those few days and after, I felt that we are the generation rising up to follow in the footsteps of those we’ve read about such as Strosahl and Blount and be the innovators for a changing age of health care. The conference was an enlightening and encouraging experience, reassuring me that I am on the right track!

Jamie Tedder
What impressed me most about the conference was the "boots on the ground” mentality that was such a pervasive theme across so many of the sessions. It was exciting to hear about various integrated care research and projects that are having an impact and helping people in the here and now. I felt like I could easily take the information I gathered at the conference and immediately apply it to my own clinical and research experiences. During the First-Timer’s Orientation, CFHA’s outgoing president Jennifer Hodgson made the remark that CFHA is where she feels rejuvenated professionally and I certainly now echo that statement. The new perspective I gained from the conference has completely reshaped how I view my current program of research as well as the direction I would like to see my professional career take in the future. This grad student has definitely been inspired to lace up my boots and hit the ground running!

Jenny Barnes
Of the many impressive aspects of this conference experience, I would like to address the outstanding sense of community. It was such a great feeling to engage with like-minded up-and-comers and professionals who are truly committed to high quality care. Though the different healthcare disciplines may have their differences, one would never know from observing the interactions at this conference. It can be easy to think only in terms of one’s own "bubble,” so it was refreshing to see that the push for collaborative care is happening nationwide, and not just on paper, but in real, boots-on-the-ground applications. As well, the passion at this conference was palpable, and speaking of passion, I could not think of a better way to kick off the conference than with Dr. Brenner’s opening plenary session! Overall, this conference was a great learning experience and I’m glad we made the trip from east Tennessee. This is a conference I definitely plan to attend in the future as I stay abreast of the newest innovations in integrated care.

In closing, it’s worth mentioning that I am grateful to CFHA, who provided a scholarship to each student to defray the registration cost. I am also grateful to my Department Chair, Dr. Wally Dixon, who provided funds to cover transportation and hotel costs. Without this support the field trip wouldn’t have been possible… and that would have been a real loss for the students considering all they gained at the conference in Philadelphia … not to mention the cheesesteaks!


     Left to right:                                                            
     Sheri Laura, Jamie, Jenny and Alishia

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.



Tags:  CFHA  collaboration  ETSU  Philadelphia 

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Open Letter to a Student

Posted By Randall Reitz, Friday, November 18, 2011
Dear New Collaborator:

I pen this letter on an airplane flying westward across our fare land—from Philadelphia to Grand Junction. I’m leaving the CFHA conference where it was announced that CFHA had hired my successor as executive director, the fantastic Polly Kurtz. So, the mood of my flight from the bustle of the CFHA conference and back to my day job at the St Mary’s Family Medicine Residency is frankly nostalgic.

I recently turned 39. By my calculation, this allows about 1 more year of relevance to the rising generation of collaborative clinicians. Our field is fast-evolving and in the very near future my ideas will seem quaint and my experiences obsolete. Given that my stock is eroding faster than the US economy, please allow me the timely presumption of sharing my CFHA story as a model of how this association can benefit your own professional development.

My journey is a trail of serendipitous turning points that connect extended periods of intentional activity and ambition. CFHA was a catalyst for advancement at each of my turning points.

My affinity for CFHA began years before I attended my first conference or formally joined the association. In the fall of 1996, as a family therapy student at Indiana State University, I attended my first professional conference: AAMFT in Toronto. The steps I took to attend on a very limited budget will sound familiar to many:
  • Unable to afford the registration fee, I procured free attendance through volunteering;
  • The ISU cohort crammed into a minivan borrowed from one of our parents and drove 12 hours overnight to Toronto;
  • 8 of us spooned in 2 hotel rooms "within walking distance” of the conference hotel;
  • I brought along an electric frying pan to save on at least 1 restaurant bill each day.

My last duty at the conference was to assist in breaking down the exhibit hall. I spent most of my time in the Basic Books booth. At the time this imprint published the best literature in our emerging field. As a thank you, the exhibitor game me an unlimited pick of the unsold books. I squeezed at least 15 books into the minivan, including Medical Family Therapy, Models of Collaboration, The Shared Experience of Illness, The Body Speaks, Collaborative Language Systems, Conversation, Language, and Possibilities, and Beliefs: The Heart of Healing in Families and Illness.

I had no idea of the treasure-trove I’d stumbled upon. Having a younger brother with diabetes, I was interested in family dynamics with chronic illness, but had no idea that the collaborative care movement was being formulated by the authors of these books and that they were also founding a professional association (CFHA) to unify their efforts.

I read just about every word of these books in the next few months. I quickly discovered that the author of "Beliefs”, Dr Wendy Watson, was an RN therapist on Brigham Young University’s MFT faculty—the school I hoped to attend for my doctoral studies. We began an email correspondence that resulted in my acceptance in the program.

While I was preparing my literature review for my dissertation, a large percentage of the articles I reviewed were published in Family Systems Medicine and Families, Systems, and Health—CFHA’s official journals, including my favorite clinical article of all time: Michael White’s treatment of Sneaky Poo in "Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles”.

Within a few years I was seeking out a doctoral internship site. I was granted interviews by John Rolland’s program in Chicago and Susan McDaniel’s program in Rochester, but didn’t secure either of these positions. I returned to my cache of books from CFHA-affiliated authors and sent out emails regarding possible internship sites. Melissa Griffith, a co-author of "The Body Speaks” forwarded me a CFHA email blast regarding a job-opening at Marillac Clinic in Grand Junction, CO.
 
It turns out that Larry Mauksch had just completed a year-long sabbatical at Marillac where he had trained the medical staff in collaborative care and had successfully applied for a 4-year RWJ grant to hire 3 mental health clinicians and a case manager. I was the first hire for this grant and ended up staying with the clinic for 5 more years after my internship. Larry’s years as president of CFHA and chair of the Seattle conference overlapped with my time at Marillac. Larry became my beloved collaborative care mentor. We published research together and presented together at the CFHA conferences in Minneapolis and Seattle. Since that time, at every major turning point I have sought Larry’s advice. He was a reference when I applied to be the behavioral science faculty at my residency and he wrote my nomination letter when I applied to be a member of the CFHA board.

Six weeks into my board term, CFHA’s newly hired, first-ever executive director died at a young age from a heart attack. I was on the highly unsuccessful task-force to hire a new ED. After 8 months of frustration, and out of sheer desperation, Frank deGruy asked me to consider leaving the board and joining the staff as a "half-time” executive director. Splitting time between leading CFHA and continuing my commitment to the St Mary’s Residency has been my biggest, and undoubtedly most rewarding career challenge. I’ve never sent as many 4 a.m. emails in my life. I’ve never had a role that required such creativity, determination, and discernment.

As in previous experiences with CFHA, the richest aspect has been the collaborative relationships with CFHA people. The board of directors and committee members are wonderful, visionary, generous people. I especially want to tip my hat to Jennifer Hodgson and Ben Miller who have been my early morning email co-conspirators. The staff, Bill Steger and Steffani Blackstock, are shockingly good at what they do. My dear friend Pete Fifield has created an amazing blog that stimulates conversations across the nation each week.

As this is a letter to the next generation of collaborators, I will end it by observing that my experience with CFHA is far from unique. The association is full of people who have committed themselves to a cause and have been richly rewarded for it—people who saw beyond the walls of their own disciplines to create a vision for a healthcare system where people actually enjoy working with the colleagues and family members who inhabit our medical homes and healthcare neighborhoods.

Yes, last week’s conference was again the annual nexus of collaborative care, but the vast majority of the creativity and energy will be created outside the conference. Just like my experience with my first ever professional conference back in 1996, you stumbled upon great caches of information at the conference, but the most important connections you will make will come from sending out follow-up emails, from getting involved on a CFHA committee or work group, or from contributing to the conversations at our blog. If you will make these small steps, you will discover that at each turning point of your career, there will be a CFHA person there to guide you, to promote you, and to buoy you up.

Warm Regards,

Randall

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Now Is The Time For CFHA

Posted By Ben Miller, Thursday, November 10, 2011
Now is the time for CFHA. Now is the time for collaborative care. Isn’t it time for our collaborative care revolution? Isn’t it time for us, we the collective, to occupy healthcare?  CFHA is more than a conference. CFHA is a movement.  We are disruptors. We are innovators. We are change.

As president of CFHA, I want to focus on three areas:

The first is Policy – some of you may have noticed on your CFHA bags that the word research was written. While CFHA has not always been known as a research conference, we know that in order to help inform policies we are going to need research with our amazing stories. We are going to need research on integration and collaboration to be a strong part of our conference. With the creation of the research committee and the Office of Collaborative Care Policy (OCCP), we have an opportunity to combine the increasing amount of research we are doing with our efforts to change policy.

I will work towards CFHA becoming more involved in policy at the state and federal level.
The second is presence. If we, CFHA, are not at the table for conversations around healthcare, we have missed a chance to influence. To impact policy, we need to be consistently present.
As, one of my policy mentors, Dr. Margy Heldring reminded me yesterday, we must practice perseverance in any and all efforts we have around policy and changing healthcare.
 
The third area is around creating a community contagion for collaborative care. We want to have the community start to demand more from healthcare. They, the community, expect fragmentation but we can give them integration. We want to create leaders in our communities to rise up and ask for everything we have to offer.

In this room, we represent everything that is right about health. We are a living representation of change. We are perpetual combaters of fragmentation and proud of it. We are change agents on a mission.

So in summary, CFHA, this community, is a strong one. I described it yesterday as a place for me to go to recharge my batteries. A place for me to come and feel like I am home. A place for me to grow, and a platform for us all to work together on change.


The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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CFHA Members of the Board, Founders, Members, New Members/Guests, and Students

Posted By Jennifer Hodgson, Thursday, November 3, 2011


It is with great respect that I stand here today to thank you for this wonderful year as President of CFHA. When Frank deGruy called me several years ago and asked me to consider this position, I has just had my third child and was working hard to grow a newly established doctoral program at East Carolina University. My love for CFHA overrode any hesitancy I had because I saw who I would have the privilege to work alongside during my presidential year. My belief is that if you want a successful outcome you surround yourself with smart, talented people. You cannot be afraid of great ideas or ideas that may change the direction of your organization because both of those events are what take good associations to great. Most of you in this room aspire for great and CFHA is a professional home for those who want to make healthcare great in our country…one context at a time! 

I would like to share with you some of the accomplishments of your CFHA board and members this year. I cannot believe we have done as much as we have with a group of volunteers who in their day jobs are already stretched thin but who find the time to not only make the difference but be the difference. 

Since we last reported to you at the conference in Louisville KY, our membership has increased by 24%, and is still growing. Today we are at 530 members! We are averaging about 100 new members a year! As far as our financials, we are $82,000 ahead of budget and much of this is due to an increase in our membership, sponsorships for the conference, conference attendance (which is also up by about 100), and grants. These resources are being used to grow our association and the staff support needed to maintain it. This year we have been awarded a contract through the Colorado Health Foundation. Several of our members Sam Monson, Randall Reitz, Ben Miller, and Laurie Ivey have been critical to its success. It has allowed us to help make the case for integration through a statewide assessment of integrated care in Colorado including the current solutions and obstacles to sustaining it. The next step would be to take this to the policy makers in Denver and help transform healthcare delivery to a more integrated system of care. 

Colorado is a starting point for CFHA’s leadership across the country in integrated care policy. This year your board created the Office of Collaborative Care Policy chaired by Ben Miller. We also established a new committee, the research committee, of which Chris Hunter and I will co-chair. These committees will help organize CFHA’s development in the areas of collaborative care research and healthcare policy. These new committees will work collaboratively with the events committee to ensure that cutting edge research and discussions about healthcare policy are a part of our annual meetings and help us to advance the scientist-practitioner model. It is important that our association reflects all the vital components to advancing collaborative and integrated care: clinical, operation, financial through training, research, and policy. Change is not sustainable without attention to each moving part. 

Highlighted today at this awards luncheon are mechanisms of change and transformation that reflect the future of CFHA. We have been trying to find ways to keep members connected to our association and the "medically unexplained symptoms” working group lead by Norm Rasmussen is one of the ways members are organically rising up to network throughout the year. Several other working groups are in motion and this is exactly what the board was hoping for by the time this year’s annual conference began. We are also proud to have initiated the first research fellowship awarded to Lindsey Lawson. CFHA stands behind the future of the association and it is with students and new professionals. They are responsible for much of our growth in membership. This effort is due to the energy of the membership committee lead by a new professional himself, Kenny Phelps. We have also instituted several other membership benefits, one for our retiring members who may now invest in a lifetime membership that will make paying for membership dues post retirement easier. We have also implemented institutional memberships to encourage entire departments and agencies to join CFHA together at a discounted rate. We are an association that we know all of you will add on to your main professional association so we are trying to make this affordable and meaningful to your work. 

Lastly, our events committee, led by Barry Jacobs, not only implemented a planning committee for the 2012 CFHA conference in Austin TX but led us to commit to 2013 in Denver CO and 2014 in Washington DC. Planning this far in advance not only allows us to secure the best venues but allows us to form the recruit high profile conference chairs and form the most talented planning committees. 

Given all that CFHA has accomplished this year, we attribute much of this success to one key person who we will recognize here today. Dr. Randall Reitz has served as our Executive Director since 2009. He has been a major contributor to many of the advancements in our association that I reported above. This year he decided that the job required more than a 50% staff role, he has grown us to that level of need, and because of his love for CFHA he respectfully recommended that we recruit for a new ED who could do this job full time. Randall has a full time job as a behavioral science faculty at the St. Mary’s Family Medicine residency program in Colorado. This month we have successfully completed our search and hired Polly Kurtz into this new role. Polly is going to take CFHA to the next level and comes with years of experience vital to the position of ED of CFHA. Information about Polly Kurtz will come to our membership soon via the webpage and email but we would like for her to stand now and be recognized. 

Randall I am not through celebrating you though. Randall has gone above and beyond in his position which is true Randall style. He never misses a detail, deadline, or opportunity to think of what others need to do their job well. He is known to work late into the night and be up early in the morning to get the job done. One of the things that draws me to certain collaborators is their work ethic and passion for the mission of CFHA. Randall cares about CFHA and to show Randall how much CFHA care about him I would like to present to him the following award in honor of his exemplary service to CFHA. Please know that Randall is not going anywhere though...we would not allow it. Randall will be overseeing our association’s social media initiatives which include the website, blog, and facebook page to name a few.
 
Lastly, I want to recognize and introduce your new President, Ben Miller. Ben is always working to advance collaborative care and integrated care policy. He also has a passion for making sure the research is available to make this happen through his leadership over the Collaborative Care Research Network. Those who know Ben knows that he has several grants going at all times and is quickly building an army of post docs to assist him in this work. He has quickly risen to a place within several associations of critical importance. He has a love for policy and affectionately refers to himself as a "policy wonk.” He is a full time faculty member at the University of Colorado Denver and an esteemed frequent flyer on several major airlines. His pride and joy though is his family and he will quickly tell you that the best thing he has done is being a father. I got the chance to know Ben better while on a trip to Nova Scotia this summer and it was clear to me that he is not only committed to the outcome, he is a systemic thinker who appreciates how important it is to have all key players at the table for change to occur. He has a way of making sure everyone around him feels important and drawn into the cause. I have full confidence in Ben as my successor and it my honor to present him as your 2011-2012 CFHA President.


Jennifer Hodgson, PhD, is a licensed Marriage and Family Therapist, Associate Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University, and President 
of CFHA.


The views expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Talk About Situational Stress: Multigenerational Living is on the Rise

Posted By Peter Y. Fifield, Thursday, October 13, 2011

My two sons attend a daycare in the same building as a nursing home which has a multigenerational program integrating the wee tots with the geriatric populations. They pass the time singing songs, playing games and I’m sure, laughing at each other’s idiosyncrasies. My wife and I purposefully chose this daycare for this reason. We felt that there, both the young and the old had a lot to offer one another and that it would be a wonderful learning experience for our two young boys who unfortunately do not live near either set of their grandparents.


My personal story is a bit unusual. I am the youngest of seven biological children; added to the fray, I have a very sweet adopted Cambodian sister. This bit is actually not THAT unusual but you might find the rest is a bit odd. At the ripe old age of TEN I moved into a nursing home. Fortunately for me, it was not due to early onset dementia but to the fact that my mother inherited a rather quaint old colonial home from my grandmother, complete and equipped with 12 elderly persons. Out of necessity to "be closer” to the business my father built an apartment addition on the "Austin Nursing Home” and Shazam!, instantly l was engulfed in a multigenerational living situation.


Although it took some getting used to, I adapted and quickly decided that going with the flow was easier than trying to swim upstream. The first thing I had to adjust to was the olfactory delight of Pine-Sol, old mothballs, smoked tobacco and rose perfume. The second adjustment came with an increased pain threshold for my cheeks were constantly red and sore from being pinched by any given resident at any given time. The worst part though was that with every pinch of the cheek came the gooey grossness of "you’re so cute”...Bobby or Donny or Jimmy or even Beth or Dot seemed to follow. Due to their old age, dementia or Alzheimer related memory issues, I was sentenced to be identified by some non-gender specific "given name” other than my own. I quickly learned to pick my battles and decided that responding with, a simple "yes ma’am/sir” was easier than trying to explain that my name was actually Peter.


The days of living in the nursing home have long since passed. Although the land has been subdivided and the nursing home handed over to new owners the multigenerational living continues in the "Fifield compound”. On my parents "compound” [the use that term is somewhat accurate] there are three quaint yet well-kept homes. In total they are occupied by five, count them five generations: my grandmother (at age 102), my parents, two of my sisters, two of my nieces and three of their children. Why is this such a big deal you ask? It really isn't but it has me thinking about what I have witnessed a lot more of here at work.


I now am a Behavioral Health Consultant for an FQHC in the Seacoast region of New Hampshire. Approximately 80% of our patient population is either uninsured or under-insured. Due to our unique population, even before this current national financial crisis, a significant number of my patients were managing through their financial difficulties. In our therapeutic setting I have observed a correlation between our country’s current financial crisis and what seems to be a spike in reported multigenerational living. More and more patients report "having to” move in with another family member. Whether it is a single mother moving in with a son or daughter, a couple moving back home with the parents after losing a job or a son or daughter who is "not a fully functioning adult yet”, they all have a similar story. The consensus seems to be one of distress, desperation and despair.


According to an article in US News Money the downward trend of multigenerational living has happened since the end of World War II when, at that time, about 25 percent of families lived in multigenerational households. Due to many factors ranging from a growth-oriented capitalistic paradigm and the "Mobile society” to more recent influences such as the current mortgage crisis and collapse of home values, a decline in multigenerational households has happened ever since. Regardless, since the latter part of the 20th century we have become imprinted to fly the coop and make it on our own.


From so many of my patients suffering from any form of depression and/or anxiety, I have heard them voice the cause of their guilt as "I used to be responsible” or "I should be succeeding in the world”. My challenge to them is to rethink success. Our egocentric need for privacy and drive for success may have caused us to forget the gift of sharing in an extended household and thus isolated our dwellings to the nuclear family. Interestingly enough it was not long ago that our ancestors lived in "dwellings” that didn’t even have rooms, it was just one open area. For that matter, the majority of the world still lives that way. The challenge then as I see it is how do we Americans learn how to play in the sandbox again with others (in our family).


There are many websites (this one with extensive links) that openly offer ideas about the rejoining of multiple generations under one roof. According to one website the current percentage of multigenerational is on the rise: 16%--that is 50 million Americans. I wonder what the cultural break down is here. My personal observation has been that many more ethnic minorities still commonly practice multigenerational living here in the US and abroad compared to their Caucasian counterparts. I wonder if the observed local "surge” has anything to do with the fact that I live and practice in an area that is 90% Caucasian. Regardless, the core issues seem to be the same. We need to relearn how to share and this is not as easy as it sounds.


Sometimes living in a single family home is hard, never mind living in a multigenerational family, but what seems to be the trade-off is the richness gleaned from the old and the young living under the same roof. I will never forget the lessons I learned from all 12 of my beloved grandparents at the Austin Home. Sometimes it was hard, sometimes it was outright embarrassing but with learned patience, tolerance and dealing with a lot of "could you repeat that I can’t hear you sonny”, it always worked out. The other day my wife went to pick up our two sons at day care and the one-year old was upstairs. She found him up there with one of the daycare workers nearby "talking” with Gunther, an eighty year old resident. She said, "You should have seen the smiles on both of their faces. It was priceless”!



Pete Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.


The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Contact Us

P. O. Box 23980,
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14692-3980 USA
info@CFHA.net

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.