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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,


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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What’s in a Name?

Posted By Lisa Zak-Hunter, Friday, September 30, 2011
Whats in a Name? I found myself pondering this question as I walked away from a session in which I introduced my current patient to her new therapist. As an intern, I had a time-limited appointment as a behavioral healthcare provider. My patients knew this, but that did not always make for a smooth transition. Admittedly, I was less concerned about this transfer. To the delight and dismay of her providers, the patient had made remarkable progress and I assumed she would be discontinuing services soon. I was unprepared for how concerned she was to be working with the new therapist. I quickly suggested the three of us meet at our next session, but she remained undecided. During the next session, I ran this idea by her again, but she insisted the decision was mine and that she was ‘fine’ either way. I opted to bring in the new therapist. When it was just the two of us again, her once passive and seemingly nonchalant attitude vanished and she thanked me exuberantly. She had indeed wanted to have a transfer session to help establish trust with this provider. She noted that although she knew and liked him from another clinical setting that individual therapy was different. She pointed out a few times that he had a rather strange last name and that frightened her the most.

I thought about all the variables I had assumed were in place to make this a smooth transition 1) the patient was familiar with the new provider and had expressed liking him; 2) the patient had been making such wonderful progress, I anticipated she would not need the same degree of mental health services as before; 3) the patient would continue at the same clinic with the same healthcare team; 4) the patient would have a familiar and trusted translator, who also served as a community leader. I had not assumed that the new provider’s name would be the biggest sticking point. The new provider and I were both dismayed by this. It reinforced the old adage that one never stops learning.

In the world of medical training institutions, transfers occur every few years once the physician has completed residency. Patients have a variety of reasons for choosing a residency as their primary care site- referred by members of the community; grew up at that clinic; enjoy working with residents whom they believe are more willing to spend time understanding and investigating their condition; feel safer in an institution that may be connected with a university wherein their physician has access to the latest research and technology. For most, this outweighs the downside of cycling through care providers- although there are still a plethora of reactions to this cycle.

As the time approaches, each physician has his/her own way of telling patients about the upcoming transition. There may not be time to address patient’s concerns about a new provider, the patient may not feel comfortable voicing them, or there may be distractions. The patient may leave wondering whether the new physician will address their needs in the same way, will be able to handle their complicated health history, is someone the patient can trust and feel comfortable discussing treatment goals and plans. In the case of my patient, she may have left feeling terrified of her new provider based on his last name. This is likely not a concern she would have voiced with him. If the patient has difficulty establishing trust and confidence in a new provider, it can affect treatment compliance, no-show rates, and the patient’s understanding of his/her conditions. Overall, the patient’s health may be negatively affected and the new physician may wind up feeling frustrated and helpless.

Enter the importance of a team-based approach to healthcare. As we transition into the patient-centered medical home, the impact of provider changeover can be lessened. Other providers are available to discuss these issues, increase communication, provide suggestions for a new provider, and brief the new provider on the patient’s medical and social history, thereby helping establish a provider-patient relationship before the two even meet. Patients’ concerns can be addressed on a more individualized level. Outside this model of care, each physician or institution has more leverage in handling provider turnover, which may not necessarily meet patient needs. Often a general letter is sent to all patients indicating their physician is leaving and the name of the new provider/s who are taking his/her patients. It is impractical to conduct a hand-off to the new provider/s, especially when the physician’s panel includes hundreds if not thousands of patients. A collaborative model allows us to address both these issues: general patient healthcare and individualized healthcare. Patients come from a variety of backgrounds with different medical concerns. In a more traditional medical setting, patients’ individual needs and social contexts may not be consistently addressed.

Now there is a saying that one must not lose the forest for the trees. In non-collaborative healthcare, this may be translated as the need to follow what approach works best for the most patients. I would argue that one must know what types of trees grow in the forest and how to best care for them in order for the forest to flourish. For some patients, the importance of easing provider transitions may be greater than we realize or than patients communicate. This transitioning can be handled in a more responsive manner in a collaborative setting. So, what’s in a name? Quite a bit apparently.

A special thank you to Gregg Schacher for helping ease the transition for many patients!

Lisa Zak-Hunter, MS is a doctoral candidate specializing in marriage and family therapy at the University of Georgia. She completed a behavioral medicine internship through the University of Minnesota’s Department of Family Medicine and Community Health. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

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Why Integrate Behavioral Healthcare into Primary Care?: The Neglected Role of Systematic Quality Improvement

Posted By William O’Donohue, Ph.D, Thursday, September 22, 2011
In the past decade there has been a notable increase in the amount of interest of redesigning healthcare service delivery so that "fractionated” care is changed into "integrated care”. The quotations marks are meant to indicate that it is none to clear exactly what these terms mean. How do we understand the reasoning behind this interest in integrated care? Is it simply a fad—perhaps even a passing one? Is the reason because some sort of change in an expensive, inefficient healthcare system is needed and integrated care seems as good as any? Is part of the reason rhetorical—"fractionated” sounds bad and "integrated” sounds much better? Ought integrated care be pursued for its own sake—is there something about it that is an unalloyed good—like kindness or a goodwill?

I propose that the fundamental reason for integrating care is that it—if done correctly—is that it can improve the quality of healthcare services. That is, integrated care needs to be understood in terms of an overall context of quality improvement. If not understood in this context, a much weakened, and perhaps even unsuccessful, integrated care system will be instituted. An implication of this is that integrated care is not good in and of itself—it is only as good as the QI process it represents.

The Neglected QI Agenda in Behavioral Health.

Behavioral health has and has had a serious quality problem. This problem is poorly recognized, harms patients and wastes money. Physical medicine received its wake up call around a decade ago with the Institute of Medicine’s 2001 Crossing the Quality Chasm (which should be required reading for anyone in this area). This report found that physical health care was dangerous, deadly, inefficient, and did not have the needs of the consumer in mind. It called for a radically new healthcare system around the following quality parameters:
  • Safe—avoiding injuries to patients from the care that is intended to help them.
  • Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).
  • Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
  • Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.
  • Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy.
  • Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

When we examine standard contemporary behavioral healthcare, what evidence exists that it meets the criteria above? How often do patients receive care that is based on clinician’s irrational beliefs about effectiveness instead of evidence based treatments? How often are patients misdiagnosed? How often are patients given less safe and less effective medication regimens instead of safer more effective psychological treatments. How often do patients die because of the poor quality of behavioral healthcare? How much money is wasted on poor quality "care”?

We as a profession have been poor at recognizing the quality problem in behavioral health and taking systematic responses to it. Integrated care can be a step in the right direction, but if done without sufficient attention to systematic QI, can suffer from most of the quality problems found in specialty behavioral health care. The integrated clinician can prescribe interventions that have no evidence base. Diagnoses can be missed or false positives can be made. There can be an over-reliance on medications, etc.

Our professional organizations are largely part of the problem—not part of the solution. They have done little to lead on this issue, but instead trumpeted guild issues such as increasing payment to practitioners for the same old problematic services—instead of trying to raise salaries by improving the value proposition we offer. There has been little to no leadership on taking quality seriously. It is a good sign that President Obama has appointed Donald Berwick as head of the Centers for Medicare and Medicaid Services as Dr. Berwick has been one of the leading thinkers on bringing systematic QI into healthcare.

What Can be Done?

First and foremost our profession needs to be educated in the philosophy and technology of systematic quality improvement. QI is not a slogan and most importantly it is not a rhetorical phrase meant to impress or persuade. Rather it is a systematic approach to understanding what consumers need, the extent to which data can be continuously collected to see the extent to which these needs are being met; and continually innovating to meet or exceed these needs all the while driving price down. QI never ends. Honda has a saying "The reason why our customers are satisfied is because we never are”. We can look at the innovations in physical medicine and adopt some of these training programs and innovations—they are ahead of us and making some excellent progress. We need to get on board as soon as possible.

Integrated care can be an important step in QI. Many customers want one stop shopping. By identifying the behavioral health pathways impacting medical presentations, patients can become healthier and costs can go down. Integrated care can increase diagnostic accuracy and the treatments offered can be evidence based. Or integrated can be the same sloppy, non-consumer oriented, set of services in a different setting. We must make sure it is the former not the latter. We must learn quality improvement, collect quality data, establish benchmarks, have a deep understanding of the processes that produce key outcomes, and continually innovate.

William O'Donohue, Ph.D. received his doctorate in clinical psychology from the State University of New York at Stony Brook. He is currently Professor of Psychology at the University of Nevada, Reno and the CEO of OneCare Health Solutions, LLC ( He has published 70 books and over 150 journal articles.

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The Lone Ranger Rides No More

Posted By Brian Bonnyman, Thursday, September 15, 2011
I finished my residency in family medicine in 1993, and returned to my hometown to start work in private practice. My office was located in an affluent suburb, and my patient population reflected that affluence. The patients were generally well-educated, insured, and motivated, and I thoroughly enjoyed caring for them. I had several excellent colleagues in my practice, but we generally worked as solo practitioners under the same roof, only consulting each other on occasional cases. I call this the Lone Ranger model of providing primary care, which is typical for most private practices, and represents the traditional and time-honored way of doing things.

After 15 years of work in this setting, I left that practice and started working across town, at a large urban community medicine clinic. The zip code of my office location changed by one digit, from 37922 to 37921, but those sites are worlds apart. Now my practice includes many homeless people, refugees, recent immigrants, and ex-convicts. The psychosocial disease burden in this population is astonishing, especially compared to my prior practice. As one person put it, the main problem for patients at our clinic is not medical in nature, but that their lives are broken. I have had to dramatically adjust my expectations for patient compliance and outcomes, and change the way I practice medicine. Among the many adaptations I have made in this transition, one of the most pleasant is working as a member of a team (rather than as a Lone Ranger), side-by-side with psychologists. In my old practice, if I thought a patient would benefit from therapy, I would have to give the patient a phone number of a good therapist. I call this referral method sending a message in a bottle, given the low likelihood that the patient would follow through on the recommendation.

If I successfully convince the patient of the benefit of seeing a mental health specialist (which is part of the art of medicine), I can now have a therapist see the patient in the very same exam room after me. I can get immediate feedback and additional history from the therapist. For mental health diagnoses, we collaborate on reaching an assessment, with appropriate treatment and follow-up plans. With this arrangement, we estimate that 80% of behavioral cases can be managed without further consultation. This is not too different than the 90% figure that I always heard represents the percentage of cases seen in primary care that can be managed without further consultation.

I see a significant improvement in the quality of care that I now provide, thanks to working in a team environment with behavioral health specialists. Now, if I have a patient that is non-compliant with diabetes, for example, I can enlist the help of the behavioralist to help treat a medical condition. Patients that are ready to address their substance abuse problems can enroll in a treatment program run by the psychologists. Likewise, I can get patients easy access to treatments that I have read for years are beneficial for a variety of difficult-to-treat conditions, but I could never offer my affluent, insured patients at my prior practice. Motivational interviewing for substance abuse and cognitive behavioral therapy for fibromyalgia are two examples.

Just having another person get additional historical information from the patient can improve quality of care, with little additional cost. Since about 80% of the data I need to arrive at a diagnosis comes from the patient’s history, every bit of information helps. For example, a psychosocial condition unrecognized by me, but detected by the psychologist, can be the key to getting the correct diagnosis of a challenging case. The patient with hypertensive crisis who admitted his cocaine use to the behavioralist (but not to me) comes to mind. Rather than work him up for some obscure cause of malignant hypertension, we could concentrate on his substance abuse. To paraphrase the old medical saw, I have learned that when I hear hoofbeats in the hall, it is more likely to be a horse with a behavioral problem, rather than a zebra!

As a clinician experienced in the ways of the Lone Ranger model, working in a team setting can be difficult in some ways. In a conservative field like medicine that has a history of less-than-nurturing educational methods, teaching an old dog (like me) new tricks can be hard. At times, the learning process can be a challenge to one’s ego, as when I find that my assessment of a psychiatric condition is off base. Recognizing that the correct diagnosis is in everyone’s best interest (especially the patient’s!), and seeing these moments as opportunities for learning help minimize potential embarrassment. Having supportive mental health colleagues is a big plus since their communication and collaboration skills are miles ahead of many of my MD friends, who aren’t used to working in teams. I now realize how much of my medical education revolved around intellectual one-upmanship, and appreciate the importance of creating a mutually supportive collegial environment in the office.

Overall, though, giving up the Lone Ranger role to work as part of a team makes sense, both for providers and for patients. Heck, even the Lone Ranger had a Tonto!

Brian Bonnyman works as a family physician with Cherokee Health Systems in Knoxville, Tennessee. He enjoys treating patients of different cultures, who cannot easily obtain care elsewhere. Habla un poquito de español, tambien.

Tags:  Cherokee Health  family medicine  Integrated Health  primary care 

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Labor Day Question: Does the American Workforce like or Understand American Healthcare?

Posted By Benjamin Miller, Monday, September 5, 2011

How satisfied are we with our current healthcare system? How satisfied should we be?

In a recent Deloitte report, the American public does not seem to believe the hype that the US has the best healthcare system. From the Hill's Healthcare Blog:

"The survey found negative attitudes at nearly every level. For example, despite lawmakers' frequent claims that the U.S. has the best healthcare system in the world, only 24 percent of Americans view it as even among the world's best systems."

When you rank 37th in the world, eventually someone might start paying attention, asking questions and wondering why the US healthcare system "ain't doing so hot". Usually in the political arena someone says - "but we have such a unique system, international comparisons aren't helpful." From NEJM:

"Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the United States, the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?"

Description: some ways, it is good that the public is less and less inclined to believe that our healthcare system is the best. While we do have some of the best healthcare providers out there, the system in which they have to operate is broken, expensive and consistently fragmented.

Another telling statistic from the report:

"Most consumers do not have a strong understanding of how their health care system works. Consistently across the 12 countries surveyed, with the exception of Portugal (17 percent) and Luxembourg (16 percent), around one in three consumers felt they understood the system well. Three in four U.S. consumers (76 percent) feel they do not have a strong understanding of how the health care system works; this perception has not changed in recent years (77 percent in 2010, 74 percent in 2009)."

So not only are we dissatisfied, we often don't understand how our healthcare system works.

Will the community rise up and begin to demand more from their healthcare system? Only time will tell, but studies like this show that maybe the public is ready to question the healthcare "system".

Collaborative care is no exception when it comes to satisfaction.

Is the community demanding more "integrated care” from the system? Does the community see the value and importance of better integrating mental healthcare into the fabric of healthcare?

Based on the above information, I am beginning to wonder if I should trade in all my degrees for one in marketing.

Game On Blog
Ben Miller is a daily blogger at and his tweets can be followed at @miller7. He is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine. He is the President-Elect of CFHA.

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