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CFHA Facebook Debate #1: Generalists versus Specialists

Posted By Administration, Thursday, February 9, 2012

CFHA has hosted a number of debates on our Facebook page ("like" CFHA today to participate!). This post is the first in what we hope will be a series of debates that went viral on facebook and were brought here for further commentary. Please add your perspective to today's debate.

You're starting an integrated team from the ground-up. Would you hire 3 mental health clinicians who view themselves as generalists (e.g. 3 LPC's or LCSW's) or would you prefer to have clinicians with some form of specialty focus (e.g. 1 MedFT, 1 psychologist, 1 addictions counselor)?

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The Pros and Cons of Patient Portals: Can Integrated Electronic Health Records Help Empower Patients?

Posted By Peter Y. Fifield, Friday, February 3, 2012
Providers spend a significant amount of time with patients problem solving effective ways to manage chronic health issues. Through the use of Motivational Interviewing for example, providers focus on increasing patient self efficacy; "how do I guide this patient in owning their own health?".

With the rapid grown of Health Information Technology (HIT) I'm optimistic that HIT, specifically the use of patient portals, will provide more tools for not only improving patient satisfaction and reducing costs, but also in addressing another real issue in healthcare: Increasing patient autonomy.

Patient portals become a window of opportunity for managing our own health. Metaphorically speaking it is like maintaining our car with the use of that dusty paperback in the glove compartment: The vehicle maintenance log. We resource the maintenance log to see what work has been done in the past and as importantly, what work needs to be done in the future. To compliment this log, we use the gauges on the instrument panel. We read the tachometer, the gas gauge, and the engine lights to understand what the vehicle needs. These data complete the feedback loop so we now know how to act: Get gas, inflate tires, flush your transmission.  You get the idea.

A patient portal could act in a similar way. Medications, appointment times and blood pressures could all be accessed via the encrypted portal and assist the patient in being a better manager of his or her own body. I can hear it now "there's an app for that"...imagine remote blood sugar sent from the glucose monitor to our medical record via the patient portal. Diet and exercise routines could be managed daily, calorie counts entered at each meal; all of this managed on your own medical portal (and possibly complimentary smart phone applications). Most important, it can all be updated and facilitated in real-time by patients or their HIT devices. There is a market here just waiting to explode.

With such potential, why is it then that so many providers have an issue with the use of patient portals? I heard one physician say: "not on my watch" and a BHC say: "I'm unsure of the benefits here" regarding initiating a patient portal access initiative at a local primary care clinic. In the spirit of investigating this enigma, I have listed a few key components of patient portals below that I think provide the most fodder for the cannon in terms of eliciting arguments from both camps. Just to clarify, in this blog I am referring to patient portal access to the patients own electronic medical record (EMR) not the "never-used" Electronic Health Record (EHR) that are typically little more than a hi-tech headache.

1. Patient portals can be thought of as a gateway to patient data, health record content, and web services associated with the hosting provider. Patients get secure, encrypted access via use of a patient ID and password; a similar process that allows clients access to other very sensitive information such as online banking. Unlike with online banking, medical information is often sensitive information and keeping unwanted eyes from seeing your portal could prove difficult. As this one article shows, the views on confidentiality are mixed.

2. Providers grant patients access via their username and password and through the patient portal, the patient may be able to perform the following tasks:
  • Check their appointment schedules and requests an appointment
  • View lab results and basic patient information such as BMI, BP, and weight
  • Examine medical and billing statements
  • Request prescription refills
  • Complete new patient intake forms and registration information
  • Complete ongoing assessment forms such as PHQ 9, GAD7, DUKE 17, etc.
  • Correspond with medical personal via encrypted email services
An interesting philosophical question here is that if the medical chart really belongs to the patient, why is it the provider that is granting access? Who is really driving the bus here? This may be a reflective residue of the slowly fading paternalistic role providers have played in the past. It could be argued that until the patriarchal paradigm is shifted to give power to the patient, they simply will not have it.

3. Through reviewing provider satisfaction research, one of the most often heard complaints is that the providers do not have enough time with patients. Period! In addition, providers spend significant time discussing symptoms and providing medical advice that they do not bill for. Simply stated, there are too many things to address aside from the Chief Complaint. Through the use of the portal providers and support staff can communicate back and forth with the patients and send messages such as appointment reminders, electronic statements, and lab results.

Historically, part of the provider-patient relationship included correspondence via phone. We could consider the patient portal a very high tech, and easy to facilitate version of that same information exchange, however; it would be more informative for the patient and much easier and less time-consuming for the provider.

4. The patient can complete much of the patient visit information and yearly paperwork prior to the visit. Existing patient intake and medical forms can be uploaded onto the website for the patient facilitating the process for not only the patient and provider, but for the support/office staff as well.

5. All of the interaction on the patient portal can be set to directly integrate into the chart. Although I disagree with this on a philosophical level [see above], pragmatically the medical practice is the ultimate authority regarding how much data is conveyed to the patient. Said otherwise, the patient does not have access to all of the doctor's records at any time. Patients only see what doctors want them to see and thus the physician note remains protected.

Portals could provide more patient access to a very valuable resource: Provider knowledge

Ideally, using a high quality patient portal allows the patient to upload their records to a central repository. The continuity of care between different doctors of different specialties, in different locations, becomes a reality for the self-efficacious consumer.

6. The portal is accessed through the practice’s web site. Educational material [including pdfs, photos videos etc] and links to other websites [,,] can be posted on the web site as well to provide adjunct services and supports. Many practices post educational information such as diabetes information, exercise options, support service information, times and dates of groups being held, diet/meal planning suggestions, and medication information, etc. on their practice web site as a service to their patients.

With the HITEC Act in place, it is reasonable to say that more and more providers will continue to venture into the world of high-tech charting. Patients could have far more access to their provider's vast knowledge by complementing the face-to-face visit with portal access and thus create a more interactive relationship with their medical record.

I see this as exchange of information via patient portal as a compliment to the face-to-face appointment; an extension of the office visit, if you would. Providers are the keepers of an infinite amount of medical knowledge and currently there are 2.7 physicians per 1000 people in the US. The informational bottlenecking lies in the finite space in time providers have to transfer that information to the patient. In a 15 minute visit we all know this is impossible. The patient portal could act as an expansion of this 15 minute window and would allow for more patient access to a very valuable resource: Provider knowledge.

Patient portals are obviously no panacea for the health care crisis. Ultimately nothing replaces patient accountability when it comes to overall health outcomes. However; the patient portal could function as an integral tool in increasing patients’ motivation for healthy living by giving patients access to their own information.

Inevitably technology will continue to play a role in patient care and most likely patient portals will be more widely used.

My question is, why not now? I'd be curious to hear other opinions out there regarding the pros and cons of using patient portals. Is there anyone out there in the CFHA audience already using them? How has it worked? What are your thoughts?

Pete Fifield is the Manager of Integration and  Behavioral Health Services 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.

Tags:  CFHA  health information technology  Integrated Health  patient portal 

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A Non-clinician's View - From Wingspread to...Where?

Posted By Bill Steger, Saturday, January 28, 2012

Thanks to Dave Seaburn for telling our story that began with Wingspread. We all need to be reminded of how this ball of energy started rolling. For me, what started as a part-time, strictly business, gig with the Collaborative Family Health Care Coalition (CFHCC) soon evolved into getting hooked on the passion and commitment of the people in the organization, especially the quiet but captivating nature of Don Bloch. Talk about ‘walking the talk', this group devoted countless hours meeting, writing, and pitching the organization to colleagues and students, collaborating with other organizations, and putting on bi-annual (initially) conferences with only volunteer time on a shoe-string budget, and one part-time staff guy. Truly amazing!

Today the Collaborative Family Healthcare Association (CFHA) is a membership driven organization but our coalition building has never stopped. Our conferences have grown as has our membership but, more importantly, the idea of collaborative/integrated care has caught on nationally and internationally. Many are now understanding that care delivery needs to be patient centered with considerations beyond just the medical or mental health aspects but the whole package, including the patient's living/support environment, or their ‘family' in an extended sense.

I guess that's where Family Systems Theory has played to our strength (here's where my non-clinical shows). In a role likened to Johnny Appleseed, we have been spreading the collaborative care model seeds, starting in Washington, DC and then on the road to Clearwater, FL, Chaska, MN, Seattle, WA, Newport, RI, Asheville, NC, Denver, CO, San Diego, CA, Louisville, KY, and Philadelphia, PA. As we move on to Austin, TX this October, the cycle then starts over with Denver in 2013, Washington, DC in 2014, and the process of harvesting hopefully begins.

In a role likened to Johnny Appleseed, we have been spreading the collaborative care model seeds...

What has changed since we started as CFHCC is the healthcare environment with pressing issues of affordability and access and a sense of urgency to deal with coverage issues at the federal level. There are also now a growing number of diverse organizations acknowledging that integrated care promises less overall cost and better outcomes. The collaborative/integrated ‘market' is getting crowded but we can take satisfaction in that this is probably because we have been true to our mission.

The challenge now is planning for what we should probably consider as the next phase in our growth. We are at the point of a typical business life cycle where the growth curve becomes steeper in a shorter period of time. We have an increasing base on the membership side and we are evaluating an increasing number of collaboration opportunities with other diverse organizations on the coalition side. Another aspect of our growth is our expanding ‘staff' including Steffani Blackstock, another part-timer managing our conferences, and the addition of a part-time Executive Director, starting with Steve Snow, to Randall Reitz who significantly increased our productivity, to our newest and almost full-time ED, Polly Kurtz who will be the enabler of our next phase of growth.

So, what is our future? That will be determined by our membership and the wisdom of our leadership. The opportunities appear to be many, the need is certainly there, and there is the desire to be relevant. Volunteerism still is the linchpin of CFHA and as we head down this road to the future, there are still some seats up front. Become involved if the spirit moves you!

Bill Steger, MBA has been the Business Manager for CFHA since 1998 with past relevant positions as Director of Marketing and Oncology Department Manager for Highland Hospital of Rochester, NY and Operations Manager for Highland Family Medicine. He is a principal in Quality Services & Products, LLC, a business management consulting company.

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Eight Steps for Creating Successful Behavioral Health and Primary Care Partnerships

Posted By Cheryl Holt, Thursday, January 26, 2012
There are numerous initiatives underway that address the primary care needs of people with behavioral health disorders. It is heartwarming to see the silos begin to develop cracks, allowing the primary care folks and the behavioral health folks to engage in serious conversation about how they can work TOGETHER to serve this vulnerable population.

It isn’t easy for two disparate groups to work together. It takes considerable planning, patience, and commitment. Despite the fact that both primary care and behavioral health are healthcare fields, they have vast differences. Their cultures, funding streams, philosophies, and overall approaches to treatment vary greatly. Therefore, it is not an easy task for these two groups to collaborate together to serve individuals with behavioral health disorders….yet they are doing just that! The mission is far greater than are the differences! It is worthwhile to devote the necessary time, energy, resources, and focus to develop strategies for streamlining the integration process. Whether the services are provided in the primary care clinic or in the behavioral health clinic, working collaboratively provides enhanced results.

For a successful behavioral health – primary care partnership, these eight steps that were adapted from "Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, will provide the foundation for success:

It is vital for both organizations to sit down together and create a shared vision. This will likely require a merging of goals into a partnership mission statement. This mission statement must be communicated with everyone involved in the partnership. The success of the partnership will depend on frontline champions. They need to be identified and empowered from the onset. They will provide the energy to motivate other team members.

Primary Care and Behavioral Health speak different languages; therefore, a common language must be identified. Clarity of communication enhances mutual understanding of cultures, roles, and expectations. While these differences might not seem important at the onset, it will become increasingly important as the partnership progresses. Most likely, each partner has a different language for many things. There are notable differences between contract deliverables, medical records, coding, management structure, procedures, and even the language used in describing the clients/patients/consumers/members/individuals served.

It is very important to temper expectations within the partnership. Establishing regular meetings will help to promote ongoing communication. Mutual goals and disappointments should be continually communicated so that they can be addressed immediately. The partners must remain flexible in order to sustain a healthy partnership.

The decision makers must be open to new ideas and problem solving. Developing shared solutions maximizes organizational efficiency and capacity. Everyone must have skin in the game! Compromise is important for success.

The project should first be piloted to allow for evaluation and for adjusting expectations to ensure that both partners are on the same page. Internal conflicts are inevitable and should be discussed openly. The partners must address differences of opinions on an ongoing basis. Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization.

Face-to-face meetings are essential for establishing and maintaining trust among partners. Be sure to focus on building trust at all levels. Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels.

Success is dependent on the involvement of everyone. This requires empowering champions at all levels to move the mission forward. This empowerment develops buy-in among staff. Communicating with everyone and soliciting feedback ensures ongoing focus on the mission. Be sure to create a forum that allows both positive and negative feedback.

Establish the outcomes to be measured early in the project. Be prepared to modify outcomes as needed. Don’t overlook the benefits of partnership that include more efficient allocation of resources, less duplication of services, increased choice among clients, and the synergistic effect of the partnership resulting in enhancing the lives of those we serve.
Following these eight steps will assist in bridging the innate differences between behavioral health and primary care to ensure a successful partnership. Far too many promising partnerships have been derailed due to poor communication and lack of planning. Careful preparation at the onset will ensure a productive partnership that will ensure a focused mission aimed at addressing health disparities among people with behavioral health issues.

Cheryl Holt, MA, NCP, BCCP currently serves as the Director of Training and Technical Assistance with SAMHSA-HRSA Center for Integrated Health Solutions for the National Council for Community Behavioral Healthcare. She is moderator of the Behavioral Health – Primary Care Integration Listserv, manages the Behavioral Health Integration blog, and is active in social media: Twitter, @cherylholt and @BHPCIntegration; and Facebook, Behavioral Health Integration

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.

Tags:  family medicine  health policy  Integrated Health 

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The Wingspread Conference

Posted By David B. Seaburn, PhD, LMFT, Monday, January 23, 2012
On January 27-30, 1994, a group of approximately thirty-five health and mental healthcare professionals lead by Don Bloch met in Racine, Wisconsin at the Frank Lloyd Wright designed Wingspread Conference Center. From this Robert Wood Johnson Foundation sponsored meeting, the Collaborative Family Healthcare Coalition was born. I was honored to be part of that birthing group. At the time, I was a faculty member in the Department of Family Medicine at the University of Rochester Medical Center working alongside Susan McDaniel, Tom Campbell and others trying to develop effective models of family-oriented collaborative care in a family medicine residency program.

It was a heady time. Don was editing the journal, Family Systems Medicine (now Families Systems and Health) the vanguard publication for collaborative family healthcare. Susan, Jeri Hepworth and Bill Doherty had published Medical Family Therapy two years earlier. Still a fledgling movement, I recall knowing personally almost everyone in the country who was doing this work. We were a small and highly motivated group. I had organized the Working Group for Family Therapists Practicing in Medical Settings in 1992. In a matter of two years, I was sending informal newsletters to over four hundred interested health and mental health professionals. As you likely know, there were no formal training institutes or degree programs for family-oriented collaborative healthcare at the time. We were creating the models as we did the work.

In the late winter of 1994, at the Family in Family Medicine Conference at Amelia Island, Fla., Don Bloch invited some of us to his condo to discuss the future of the collaborative family healthcare movement. The notion of a planning meeting came out of that gathering. In the fall of 1994, a smaller group met in Rochester, NY to plan the Wingspread Conference. This included Mac Baird and Bill Doherty (who had written the seminal work, Family Therapy and Family Medicine, in 1983), Don Bloch, the father of the collaboration movement and our convener, Lyman Wynn, one of the founders of Family Therapy, Theodora Ooms, Virginia Rutter, and Susan McDaniel, Tom Campbell and myself (together we had published the first edition of Family-oriented Primary Care, in 1990).

I must admit that I was star-struck by the leaders in the field that I met at Wingspread, including such early pioneers of primary care collaboration as Barry Dym and Michael Glenn. We had an ambitious agenda for the conference, dividing our work among three key areas: practice, training and research. Groups met to develop ideas for each of these areas and then reported back to the whole. From the beginning it was clear that the heart of this approach was: collaboration between mental health providers, healthcare professionals, patients and families. The issue of including family members in collaboration (especially with chronic or life-threatening illness, psychosomatic illnesses, and health problems that required family members to provide care) was discussed at length in those years and it became apparent that the influence of family was so great in most circumstances that not partnering with them could be detrimental to care.

The most important development from the Wingspread Conference was the recognition that we had a critical mass of committed professionals that needed its own organization. We left the conference with a new name---The Collaborative Family Healthcare Coalition. Yes, Coalition, because we saw ourselves as bringing together many different voices, many different organizations that were committed to the same cause. It was only later that the name was changed to Collaborative Family Healthcare Association to meet the growing demand for a membership organization.

The goal at that time was to facilitate a shift in healthcare nationally, from acute to chronic and preventive, from inpatient to ambulatory care, from top-down to collaborative, from individually focused to family-oriented, from exclusively biomedical to biopsychosocial systems. We felt that these should guide our practice, training, research and systems organization. I think that vision is as sharp and fresh now as it was then. It was the driving force behind the Collaborative Family Healthcare Coalition and became the foundation of the Collaborative Family Healthcare Association in all its endeavors.

I left the University of Rochester Medical Center in 2005 to initiate collaborative approaches to mental healthcare in a public school setting. I had not been to a CFHA Conference in many years when I attended the meeting in Philadelphia. It was invigorating to see so many people who are committed to this work. And it was exciting to hear new and old ideas coming together to shape the future of family-oriented collaborative healthcare. It was clear that the spirit of the Wingspread Conference was alive and well.

David B. Seaburn, PhD, LMFT was Assistant Professor, Psychiatry and Family Medicine, at the University of Rochester School of Medicine (1986-2005) where he was Director of the Family Therapy Training Program (Psychiatry) and Coordinator of Psychosocial Core and Psychosocial Rotation (Family Medicine). Seaburn was also Director of the Family Support Center Spencerport Central Schools until he retired in 2010. He has written three novels, most recently, Charlie No Face.

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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Collaborative Family Healthcare Association: Value Added For Canadians

Posted By Ajantha "AJ"Jayabarathan, Thursday, January 5, 2012

Kentucky had settled into the month of October in 2010, when I arrived there to attend the 12th annual CFHA conference. It was not only my first visit to Kentucky but also my first attendance at the conference and I was ready for an adventure. I expected to hear, see and learn much that was different from my home city of Halifax Nova Scotia.

 People spoke with a distinct drawl that was friendly; the skyscrapers loomed; the city blocks hosted an interesting array of monuments and storefronts; the downtown core was both inviting and somewhat dangerous in its layout; and I plunged into this journey of discovery.

I sat with three hundred and fifty other participants at the conference and happened to be the sole visitor from Canada. The candid, direct styles of the keynote speakers and the bold imagination in their ideas grabbed my interest. The sessions were equally rich and thought provoking. I found myself volunteering my comments, answering questions, getting easily acquainted with other participants and even hosted a lunchtime discussion on Compassion Satisfaction!

The members of the CFHA board and their executive team appeared genuinely interested to make my acquaintance and learn about their sister organization in Canada (National Working group on Shared Mental Health Care). And to top it all off, they invited me to join their membership committee, so that we could work towards strengthening ties between our respective organizations. Before too long, I was invited to write a Blog for the CFHA (V-Forming Healthcare), they joined forces with the planning committee in Halifax which was organizing the 12th Canadian Conference on Collaborative Mental Health Care, an entire month was dedicated to blogs written by Canadian authors and they sent email invitations to their membership, promoting the Halifax conference.

Never before, had I experienced such like-minded dedication to promote, advocate and develop the concepts embedded in Collaborative Mental Health care; and it was happening to benefit both Canadians and Americans.

In Canada, the essence of Collaborative Care is currently being embedded in many provincial re-organized health systems as well as the Mental Health Commission of Canada. It is defined in the newly launched 2011 position paper from the Canadian Psychiatric Association and College of Family Physicians of Canada as Mental Health, addiction and primary care practitioners working together, with people and their family members, to ensure that an individual reaches the services they need, when they need them, with a minimum of inconvenience. It is;

  • Built on personal contacts
  • Based on mutual respect and trust
  • Based on effective practices
  • Responsive to changing needs with openness to new ideas
  • Shaped by context, culture, local resources, shared goals & local solutions
  • Contingent upon five key components – Effective communication, Consultation, Coordination, Co-location and Integration

In Canada, this model of care started with psychiatrists and family physicians working together to provide care differently than established traditional models in the mid-1990s. In 2005, this model was expanded to involve 12 other partners in the work of the CCMHI (Canadian Collaborative Mental Health Initiative); pharmacists, nurses, occupational therapists, social workers, psychologists, dieticians and first voice/consumers/people with lived experience.

Meanwhile, in March of 1993, 15 colleagues from the fields of family medicine and family therapy met to develop a better healthcare paradigm in the USA. This model aimed to address pressing clinical and economic problems.
Naming their vision the "collaborative family healthcare model", they formed an organization to bring together those interested in this innovative approach. In July 1995, CFHA held its first national conference in Washington, D.C. It was well attended and received glowing reviews. The Collaborative Family Healthcare Coalition was up and running.

CFHA is a member-based, member-driven collaborative organization. Collaboration isn't just a word in the organization's name; it defines who we are, how we interact with each other and other organizations. We believe deeply that collaboration is an essential element necessary for re-visioning healthcare, specifically, and society, generally.

CFHA promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities.CFHA achieves this mission through education, training, partnering, consultation, research and advocacy. We not only host a leading-edge conference every year, we also are active in every other aspect of healthcare change: development, design, delivery and assessment.

October 2011 found me in Philadelphia at the CFHA's 13th annual conference. A new city to discover, new colleagues to hear from, a new set of keynote speakers to present material to evoke and provoke new directions in evolving models of care. I presented the 2011 Canadian position paper alongside Dr. Roger Bland one of the other co-authors, and was one of five Canadians at the conference. The Canadian organization and its work were presented as part of the exhibitors, mirroring CFHA's presence at the Halifax conference earlier in the summer.

Collaborative practice is about how we practice together….how we treat each other….how we benefit from each other's perspective and the partnership that we bring to the table so that people and their families are served to their benefit. It is different from traditional team based approaches. To truly "experience” what it feels like, one has to be open to the ideas and diversity of people involved in this model of care.

Your attendance at the annual CFHA and Canadian conferences could serve as a starting point for you. Robust information and the evidence base for this model of care are available on their websites: and  Consider looking at the material on these sites. Consider attending the conferences. Consider these alternative models of care in your practice of primary care and mental health care, and imagine what it could be like……..and you may find yourself in Vancouver, British Columbia in the summer of 2012 and Austin Texas in the fall of 2012…..ready for an adventure……and return awash with new ideas that have fuelled your hidden passion to work collaboratively….and you will have found what now energizes my daily practice of medicine!

Ajantha Jayabarathan (AJ) is a Family Doctor practicing in Halifax, Nova Scotia. She is well recognized in the Atlantic region of Canada due to her columns on television. She is an Assistant Professor at Dalhousie University and co-chaired the organization of the 12th Canadian Conference on Collaborative Mental Health care in Halifax 2011. She also co-leads the advocacy coalition,

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.

Tags:  Canadian Collaborative  CFHA  family medicine  primary care 

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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)
  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?


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:

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” ( , 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 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:

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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