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Surviving Where The Grass Is Browner: A Story Of Integration In Tennessee

Posted By Parinda Khatri, PhD, Thursday, July 14, 2011
When most people hear that I live in Tennessee, they tell me they have traveled through Smoky Mountain National Park. It is, after all, the most visited national park in the country. Some tell me they have always wanted to visit Graceland, home of Elvis, or that they love Tennessee barbecue. A few ask if I’ve run into Keith Urban and Nicole Kidman (sorry, we don’t travel in the same circles). I also hear with alarming frequency, "We can’t integrate. We can’t be like Cherokee Health Systems. It is too difficult. It is not possible.” Here is the interesting thing: Tennessee is a state rich in culture, beauty, and warmth but not in wealth. Poverty is present hand in hand with low literacy and poor nutrition in many communities from the hills of the Appalachian Mountains in the eastern portion of the state to inner city Memphis on the western border and many points in between. Limited resources for health and education are stretched well beyond capacity. Healthcare coverage for underserved populations and reimbursement for healthcare services have been cut dramatically. Demand for health care services, particularly for the underserved, invariably outstrips supply. Sound familiar?

I work as Director of Integrated Care at Cherokee Health Systems (CHS), a comprehensive community healthcare organization based in east Tennessee that blends behavioral health and primary care as its model of care. At CHS, our CEO Dennis Freeman has always maintained that the organization goes "where the grass is browner.” Not surprisingly, the organization has expanded at a dramatic rate to meet the needs of our communities. CHS moved into counties where primary care and behavioral health resources were scarce and often nonexistent. People routinely asked us what grant and team of experts we used to plan our model of integrated care. They are surprised when we answer "No grants. No planning.” We simply responded to the needs of our patients who showed up on our doorsteps, asking for comprehensive care for a wide spectrum of needs.

People presented with a plethora of physical, behavioral, and relational issues so intertwined we could not tease them apart to fragment care even if we tried. So, we put behavioral health clinicians in the middle of primary care. We brought primary care to our "behavioral health” patients, many of whom had previously untreated diabetes and cardiovascular disease. We set up multidisciplinary treatment teams to collaborate and co-manage care with the patient and family. When we could not find enough providers to travel to remote clinics, we set up telehealth equipment so primary care and behavioral health providers could beam into clinics and schools to increase access to care. When people ask, how in the foothills of the Smokey Mountains, with few resources, did we develop a system of integration that is now is fairly well progressed, our answer is simple, "Our patients led the way.”

We are not alone. Safety net clinics in Tennessee have initiated collaborative efforts to improve the health status of their communities. Matthew Walker Comprehensive Health Center in Nashville holds a monthly "Diabetes Day” when patients see a primary care provider, behaviorist, ophthalmologist, dentist, and podiatrist, all of whom work together to improve the patient’s management of diabetes. Matthew Walker’s high- risk pregnancy clinic has a behaviorist who sees every pregnant woman as part of the OB visit (come hear Dr. MaryClare Champion talk about her work in this program at the CFHA conference in Philadelphia). Perry County Health Center in middle Tennessee brought a behaviorist into their rural primary care clinic who became, and still is, the only licensed mental health provider the county has ever had. East Tennessee University in Johnson City developed a PhD program in Rural Primary Behavioral Health care to help build a workforce for the rural safety net health care community.

The Tennessee Primary Care Association has been a stellar leader in integration efforts in Tennessee. They have teamed with health centers to advocate for changes in billing, coding, credentialing, and policy to foster and sustain integration efforts throughout the state. They have organized representatives from a variety of health centers to work together to advance integration on both clinical and administrative levels. Every TPCA clinical conference now has an "Integrated Care track” for both primary care and behavioral clinicians. Just this year, TPCA successfully lobbied the state government to pass a resolution supporting primary care and behavioral health integration.

It may be no fluke that innovation and collaboration emerged from such an impoverished landscape. Without significant extramural funding, little access to specialty resources in public nutrition, mental health, and health education, clinicians committed to the underserved communities realized that they should, well, work together….as a team…with the same mission. Because, in effect, we, as a team and community, were all we had. Several years ago, a team from a well known policy center in D.C. visited Tennessee as part of their research for a white paper on Integration. As they traveled with us to clinics in the mountains of rural east Tennessee and inner city Knoxville, one visitor observed that innovation often emerged in communities with few resources. To paraphrase the famous saying, they had to invent out of necessity.

As we move forward in these challenging times, with continued budget cuts in our state (as likely in yours), I am reminded of an article I read years ago written by a journalist who visited the lush wine regions of France. After touring beautiful vineyards ripe with plump grapes, the guide took the group to view vines in a remote area with rocky and dry terrain. Few grapes were produced from these scrawny vines that had to overcome the adversity of poor soil and climate. However, it was these grapes that yielded wines rich in clarity and complexity of flavor. It was these grapes, he explained, that had the potential for greatness.

Those of us committed to integrative and collaborative care continue to be faced with walls to climb and obstacles to overcome. But we can never say "This is impossible” or "We can’t do it” because if it possible in one place, then it is possible anywhere. In fact, we can and we are doing it. So, the next time you are driving through the Smoky Mountains, check out the local health center and learn about the cool stuff they are doing. Who knows? Maybe you’ll run into Taylor Swift on the way.

Parinda Khatri, Ph.D., is Director of Integrated Care at Cherokee Health Systems. She is a Clinical Psychologist with extensive experience in Behavioral Medicine. She earned her doctorate in Clinical Psychology at the University of North Carolina at Chapel Hill and completed a Post-Doctoral Fellowship in Behavioral Medicine at Duke University Medical Center. Dr. Khatri has led Cherokee's integrated care implementation at a number of primary care sites.  Dr. Khatri has presented extensively on integrated care and is involved in training and consultation in this area as well. She serves on the organization’s Clinical Leadership team, which provides oversight and guidance on clinical issues.  Dr. Khatri is involved in program development and supervision of several of the organization’s health and wellness initiatives and leads Cherokee's APA Accredited Psychology Internship Program.

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What Collaborative Care Can Learn From Chaos

Posted By Peter Y. Fifield, Thursday, July 7, 2011
A client once told me, "Humans pray for outcomes and God laughs. Now that’s chaos”

Chaos Theory is paradoxical; sort of like when you see an object clearer in the dark when you don’t stare directly at it. Chaos theory for me reminds me of this concept. It comes more into focus the less and less I try to figure it out. The mathematics behind chaos theory are extremely abstract and difficult to conceptualize and I’ll be the first to admit quite frankly they are way over my head. That being said, in my interpretation the basic premise is simple: We need not waste time seeking control of a system, instead we seek order within the system.

Generally we humans think in a very linear fashion. Schools, are organized by the born on date of the student, factories by what products they make, hospitals by triage needs, organisms by phylum and genus, mental illness by diagnostic criteria etc. The list goes on. It seems that we find it very difficult to live in an environment that we do not control: A world that is not classified in a way that allows us to make sense of all its parts. Vexing as it is, we tend to have difficulty grasping nature’s reluctance towards linearity. In the name of ‘education’ and the need for classification we conversely limit our divergent thinking ability. As contradictory as it may seem, I am convinced that via our own "advanced” education, nourished by underlying Newtonian philosophies we are limiting our mental potential.

Although it may just take some good old fashion ‘out of the box’ thinking a different approach to seeing and working within our world may prove to be helpful. Chaos is not chaotic, it is actually a series of events made up of numerous reiterations that when seen as a whole, actually displays innate order. These ‘events’ are quite formulaic and result in a system of data that is fed back into that system over and over again. Graphically these reiterations result in fractals; a wonderful display of order.

This new science reminds us that ALL systems exist in chaos. Although superficially these systems appear ordered, they are actually in constant state of internal flux. Typically a few guiding formulas dictate the initial setup and organization. These formulas are designed to maintain structure within the system by a constant feedback process. Importantly, each variable has a high level of autonomy working within the well ordered system. Now this is collaboration!

Chaos transcends mere theory. However, actualizing the theory into collaborative practice is not easy. Sometimes the sticky wicket is around the collaborators needing to possess a level of curiosity and a view point that is never convinced that it knows anything. When creating a new collaborative network it is important to create a system of standards; a calculus that defines the roles and actions of each player. Once an algorithm of flow has been created, and the roles of key participants have been defined an integral next step has to be taken--the creation and maintenance of relationships. Collaboration is all about creating and fostering bidirectional relationships. These relationships create conduits of communication that facilitate how information (about the patient) gets back into the system (not only in the Electronic Medical Record but w/ personal interactions such as hallway consults as well). This is an example of a simple chaotic reiteration.

When primary care providers, medical assistants, behavioral health consultants, case coordinators, administrators, front desk staff etc., all collaborate and operate at the upper limit of their scope of practice, then patient centered care happens. When accurate feedback is provided into the system a greater sense of confidence arises. Providers are then allowed to stay informed AND stay curious. The providers, now playing the role of change agent, feel comfortable letting go of the wheel and allowing the patient to drive the bus. Patient autonomy is gained and they subsequently become responsible for their own health. This in turn, not only reduces the provider's anxiety but as important, frees the provider to offer what they do best--direct medical services.

So in the end, chaos is not chaotic. There is always some semblance of order hidden within. We as providers of whole person health care are best utilized when we realize that control is an illusion yet order is a certainty. We often will find that systems best work when in flux and when all members are operating at the height of their scope of practice. As we become more comfortable operating as such we realize that we can let go of the control. Not only control over patient outcomes (the age old myth of non-compliance) but as importantly control over the who, what and where of how we function within the care giving system. Furthermore we find that when we create, foster and maintain environments where learning and sharing are the constant and we the observers are colleagues co-creating new environments; then we are all are free to seek the innate order in the system. Chaos theory can provide a tenable environment, a nurturing place where mysticism meets hard science.

Peter 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.

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CFHA: Heed the Prophet; Clinician: Corrupt Thyself

Posted By Randall Reitz, Thursday, June 30, 2011

Like religions, academic fields are led by both prophets and administrators. Collaborative care’s prophet is undoubtedly CJ Peek. His prophetic bona fides include his Yoda-like gravitas, his universal devotion from our movement’s founders, his unmatched ability to distill arcane doctrines into teachable articles of faith, and his usage of language that is equally inspirational and apocalyptic.

While prophets generally only preach one world-view, collaborative care is sufficiently pluralistic that our prophet is best known for his three-world view:

  1. "If care is clinically inappropriate it fails.
  2. If care is not operationalized properly, it also fails.
  3. If care does not make reasonable use of resources, the organization, its patients, or society eventually go bankrupt and thousands of patient-clinician relationships are disrupted” (Peek, 2008).

This dark prophecy is fulfilled daily in collaborative care settings where the financial corrupts the operational and the operational corrupts the clinical.

Allow me to explain myself. Just like any church, the collaborative care pews are filled with fervent believers, practicing adherents, and devilish apostates:

  • Front-line clinicians are the true believers. We are the ones who have enough faith in the cause to work outside of our areas of training for less money than could be made for less effort elsewhere. Had we practiced 2000 years ago it would have been said of us: "it is harder for a clinician to leave a collaborative clinic as a rich man than it is for a camel to walk through the eye of a needle” (Matthew 19:24).
  • Operational administrators are the practical adherents. They find that our model makes sense even if the reimbursement pays only cents. However, they distract our daily pilgrimage with banalities like efficiency and HIPAA compliance.
  • Financers are the devilish apostates. I propose a corollary to the Peter Principle, which I’ll call the Judas Judgment. It states that "Clinicians keep the faith until they are advanced in their careers enough to hold the money bag.” Then all they decree is "no margin, no mission” as they cut collaborative care positions. It’s worse at the governmental and healthcare payor levels where the virulent vestiges of carve-outs eviscerate our sustainability.

This same corruption happens on a personal level. Collaborative care is very demanding operationally. It’s not enough to have great clinical acumen, we also need keen operational awareness. Before entering the primary care world, I would regularly attend clinical conferences: AAMFT, narrative therapy intensives, the Erik Erickson symposium. Since entering primary care, I have only been to operational/financial conferences like CFHA. I fear that if I weren’t teaching the behavioral sciences to family medicine residents that my clinical skills and knowledge would have atrophied completely.

Wait, a minute…did I just describe CFHA as an operational/financial conference? Now there’s a heresy. Well, look at last year’s Louisville conference: The plenaries were political (Jonathan Cohn), corporate (Grundy/James) and operational (Scherger). Similarly, of the 5 pre-conference workshops only the counselor and physician orientations could be described as remotely clinical. All this being true, I’m not convinced it’s proof of CFHA’s apostasy.

Just as I have needed to focus more on the operational and eventually the financial as my career has developed, our field has needed to follow the same developmental path. CFHA’s archives reveal that our association was founded at a meeting of family therapists and family physicians who attempted to answer the question "No matter how financed, what should a thoroughly modern healthcare delivery system look like at the clinical level?” No matter how financed? Really? Now, there’s a mantra for a congregation of true believers. While it served us well as we coalesced our vision in safety-net and academic settings, this myopia limited our growth to these same settings.

However, in the larger healthcare system, it’s not only money that matters, there’s also size and science.

Size matters—a movement based on the combined efforts of family therapists and the family physicians who like to collaborate with family therapists is bound to be a small movement. That being said, once the circle is expanded to include other like-minded (though not doctrinally pure) groups, the model invariably evolved. For example, just as CFHA’s conference is not really about clinical skills anymore, it’s also not really about family. In the heart of this family therapist, this is a real loss. Similarly, collaborative care has swung above its weight by aligning itself with other movements—most notably the patient-centered medical home (PCMH). While PCMH shares many of our tenants, in its current formation the language is far too physician-centric to appeal to the nurse practitioners and some of the more ardent behaviorists amongst us.

Science matters—and will also corrupt our model. The problem for true believers is that faith and science have clashed for centuries. While collaborative care will never be financially sustainable without a strong empirical case, when we engage in honest science we surrender control of what the evidence reveals. For example, by my count 1st-tier medical journals (JAMA, NEJM, BJM) have only published 2 or 3 articles on our model. However, while the authors of these articles called what they studied "collaborative care”, a close reading reveals that they are care management models that don’t make prominent usage of any sort of behavioral therapist. While their strong findings advance our cause beyond "no matter how financed” idealism, it is markedly different than what the founders envisioned when they first asked the question.

So, there we have it, to survive in world of money and science we need to leave the church and gain comfort in the world of publicans and sinners, and dare I say Republicans and rich corporate winners. But, in this challenge, I’ll cast my lot with the true believers. CFHA and collaborative care were built by clinicians and we will be the ones to justify our movement’s place in the healthcare mainstream. However, as Brother CJ predicted, our clinical skills are insufficient in this endeavor. As clinicians become leaders, we need to corrupt our clinical purism with the realities of operations and finances. In our role as leaders we’ll need to wield our motivational skills in the unholy pursuits of lobbying politicians and negotiating with insurance companies.

As we move away from orthodoxy and orthopraxy, how will we know when we have completely lost our way? I suggest that a reasonable test is to compare the models we currently practice with the model described in CFHA’s mission statement:

"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”.

In comparison to the question at the heart of our founders’ vision statement, I believe this is a mission trip that all of us true believers can continue to take every day.

Randall Reitz , PhD, LMFT is the executive director of CFHA and the behavioral science faculty at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.

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A Call to Engage Youth in Collaborative and Integrated Care: Part 2

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 30, 2011
Last week In my previous blog entry, I advanced a call to purposively engage youth in our efforts in collaborative and integrated care. As I have spoken-up regarding this topic across a variety of forums with colleagues, most have initially responded with a strong sense of enthusiasm, followed by a want for evidence that such efforts can be effective.

I have been involved in several community-based participatory research (CBPR) projects in health since beginning my current position at the University of Minnesota, and have seen time-and-again how professionals and patients learn new ways of working together that are different from conventional top-down/service-delivery models of care-provision (i.e., wherein professionals learn to function as citizens of the research process (vs. rigid leaders of it), and patients learn to not instinctively look to professionals for leadership or answers (and to instead work to tap resources within themselves and their communities that have heretofore not been tapped)). Generally this process evolves over several months as a new project begins and/or for new members to orient and function within CBPR-principles. However, I have noted that young persons appear to learn and adopt these principles very quickly (usually faster than adults), and they do extraordinary work.

The SANTA project (Students Against Nicotine & Tobacco Addiction), for example, is a health initiative that engages local medical and mental health providers in partnership with students, teachers, and administrators in a Job Corps training site/community to reduce on-campus smoking. The project has endeavored to better understand the causes of students’ smoking behaviors; change the campus environment in ways facilitative to stress-management and boredom-reduction; revise the manners in which smoking cessation and support services are conducted; and establish the project as a sustainable and stalwart presence on-campus. Every facet of SANTA’s efforts is owned-and-operated by its students, which is a driving force behind its sustainability and integration into campus culture. Since its establishment in 2005, campus-wide smoking (including new and established students) has decreased from almost 60% to 36%, and evaluations across several cohorts of students show that smoking rates decrease significantly with prolonged exposure to SANTA interventions (Mendenhall, Harper, Stephenson et al., 2011; Mendenhall, Whipple, Harper et al., 2008).

The ANGELS project (A Neighbor Giving Encouragement, Love & Support) is a health initiative through which adolescents and their parents who have lived experience with diabetes (called "support partners”) are connected with other families (called "members”) who are struggling with the illness. These efforts begin at the time of diagnosis, which occurs almost universally in the context of an emergency hospitalization. It is during this time that the initiative’s teens maintain that they want the ANGELS to connect with members, because the motivation to adopt healthy lifestyles is the highest at a time of crisis. Support partners and members meet in a variety of combinations (e.g., adolescents with adolescents, parents with parents, families with families), and they continue to meet off hospital grounds (or via telephone, e-mail, internet discussion boards) after initial hospitalization. Sometimes members simply need a pep talk; other times ongoing support is offered for several months (Mendenhall & Doherty, 2007; Mendenhall & Doherty, 2005).

Other arenas that I and my colleagues have worked in to engage youth in health care include physical activity, obesity, teen pregnancy, and interpersonal violence. Across all of these initiatives, our youth have risen to the challenge of taking an active part in their own health (Berge, Mendenhall & Doherty, 2009; Doherty, Mendenhall & Berge, 2010; Mendenhall, Berge, Harper et al., 2010; Mendenhall, Doherty, Baird et al., 2008; Doherty, Mendenhall, & Berge, 2010).

So why is it that teenagers appear to have less difficulty in learning how to work with providers in the PCMH and/or in CBPR? Is it because they have not yet been socialized into the conventionally passive patient-roles that are so consistent with conventional Western health care and/or "standard” education? Is it because they have not yet been socialized to presume that "real change” (however defined) takes a long time?

Honestly, I am not sure that it matters. What is important is that we not leave our youth on the sidelines as we advance our efforts in collaborative and integrative care. As we work to engage them, we will bestow in our youth the honor and confidence that they can take responsibility for their health and well-being. Their voice(s) and involvement represent an essential piece to a larger puzzle, and they are up for the task.


Berge, J., Mendenhall, T., Doherty, W. (2009). Targeting health disparities though community-based participatory research. Family Relations, 58, 475-488.

Doherty, W., Mendenhall, T., Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 389-402.

Mendenhall, T., Berge, J., Harper, P., GreenCrow, B., LittleWalker, N., WhiteEagle, S., BrownOwl, S. (2010). The Family Education Diabetes Series (FEDS): Community-based participatory research with a Midwestern American Indian community. Nursing Inquiry, 17, 359-372.

Mendenhall, T., Doherty, W. (2007). The ANGELS (A Neighbor Giving Encouragement, Love and Support): A collaborative project for teens with diabetes. In D. Linville and K. Hertlein (Eds.), The Therapist’s Notebook for Family Healthcare (pp. 91-101). New York: Hayworth Press.

Mendenhall, T., Doherty, W. J. (2005). Action research methods in family therapy. In F.
Piercy, D. Sprenkle (Eds.), Research Methods in Family Therapy (2nd Edition) (pp. 100-118). New York: Guilford Press.

Mendenhall, T., Doherty, W., Baird, M., Berge, J. (2008). Citizen Health Care: Engaging patients, families and communities as co-producers of health. Minnesota Physician, 21(#12), pp. 1, 12-13.

Mendenhall, T., Harper, P., Stephenson, H., Haas, S. (2011). The SANTA Project (Students Against Nicotine and Tobacco Addiction): Using community-based participatory research to improve health in a high-risk young adult population. Action Research, 9, 199-213.

Mendenhall, T., Whipple, H., Harper, P., Haas, S. (2008). Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Developing novel interventions in smoking cessation through community-based participatory research. Families, Systems & Health, 26, 225-231.

Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program, and holds an adjunct faculty position in the UMN's Department of Family Social Science. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

Tags:  Behavioral Health  family therapy  medical 

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A Call to Engage Youth in Collaborative and Integrated Care: Part 1

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 23, 2011
The call for interdisciplinary collaboration in health care is a longstanding one, and our collective efforts to do this are evolving across medical- and mental health- training programs and care facilities today more than they ever have. Recent advancements in the Patient Centered Medical Home (PCMH) movement are arguably pushing team-based approaches in continuous and coordinated care toward the middle of the bell-curve, wherein someday soon our integrated models will represent the rule (not the exception) to how health care is done.

My experiences as a clinician and researcher in this exciting time in health care have exposed to me to a variety of definitions of what "integrated”, "collaborative”, or "medical home” sequences looks like, and efforts by the CFHA and others to standardize and clarify these characterizations are presently underway. However, while common themes throughout these descriptions encompass the collaboration between professionals who represent different disciplines (e.g., a family physician with a marriage and family therapist) and/or the collaboration between professionals and patients (i.e., encouraging and facilitating patients to take active roles in their own health), most hallway conversations, formal presentations, research studies, professional literature, and clinical work that I have taken part in (or am aware of) around the PCMH frame patients as adults.

I believe that it is important to extend our call to engage "patients” in collaborative and integrated care to purposively include children and adolescents. I support this call on two primary grounds:

• First, many of the most prevalent and difficult presentations in health care today (defined as those that are the most common, most expensive, and/or most connected to co-morbidities and death) begin early in life. Diabetes, for example, is highly correlated with cardiovascular diseases (which represent the #1 cause of death in the United States), kidney disease, reduced or lost vision, amputations, and depression – and is directly connected to the rising epidemics of childhood obesity and sedentary lifestyles of America’s youth. Smoking is similarly correlated with cardiovascular diseases (as well as asthma, diabetic retinopathy, optic neuritis, influenza and pneumonia) – and most smokers (up to 90% of them) begin as teenagers or young adults. Put simply, then, it is easier to prepare than it is to repair. By engaging patients in health-related activities early in life, it is more likely that they will avoid experiencing commonplace troubles later on down the road.

• Second, the advancements of the PCMH and parallel efforts in community-based participatory research (CPBR) bring with them a sharing of responsibility between providers and patients. While providers maintain responsibility for learning and appropriately using knowledge in the prescribing of medications or performing medical procedures, for example, patients maintain responsibility for managing their diets, physical activity and other health-related behaviors. This is important to note because it transcends conventional provider/consumer models in which passive patients are rendered care (i.e., "fixed”) by all-knowing/all-powerful providers. And just as adult patients must assume responsibility for their own health within the PCMH, so to should children and adolescents. As we encourage and facilitate our youth to do this, a new generation of active (not passive) patients is born.

As I have advanced the call for active engagement of youth in health care across a variety of formal and informal meetings with colleagues, almost everyone has agreed that the idea carries a great deal of face-validity. They add that, too, that oftentimes kids (read: teenagers) will listen to each other more than they will to an adult, and that facilitating care sequences and/or supportive interventions that allows for this may offer a great deal.

But it’s when my colleagues ask about evidence of such efforts being effective that I really light up. Beyond the (admittedly limited) articles that any of us could find through a literature review regarding youth-engagement in health, I have been involved in several such projects since beginning my current position at the University of Minnesota. In my next blog entry, I will highlight some of these projects – and the extraordinary work our youth can do as we facilitate their active participation in care.

*This is the first of a two part blog on engaging youth in collaborative and integrative care.

Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program, and holds an adjunct faculty position in the UMN's Department of Family Social Science.  Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

Tags:  Behavioral Health  community health  family medicine  Integrated Health  medical  Youth 

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Medical Family Therapy Intern Part II: How do I Help?

Posted By Lisa Zak-Huner, Wednesday, June 15, 2011
November 2010:

It’s a typically non-typical day at the family medicine primary care clinic. ALL my morning patients show up. That must be a record! More often than not, my patients no-show. That’s just one of the changes I’m getting used to working here. As I’m working to fulfill my university’s graduation requirements for clinical hours, I sometimes feel stressed when patients do not show. Other times, I am quite relieved to have some time to write case notes, consult with other providers, process, and maybe catch a bite to eat. It feels like a roller coaster.

After this morning, my head is as full as my caseload. At maximum, I have about 5 minutes between sessions to digest what just occurred with one patient and prepare for the next. This particular day, I’ve switched therapy rooms twice- conducting therapy in two of the faculty physicians’ offices. The clinic serves a very high needs population- low income, immigrant, severe psychosocial stressors, complex health concerns (diabetes, chronic pain, GI problems, renal failure, obesity etc), non-English speaking, severe mental health issues (PTSD, severe depression, severe anxiety problems) etc. So, I sometimes pray for the days in grad school where a couple’s ‘only’ problem was infidelity.

In the past four hours, I have worked with someone who has severe depression, anxiety, and alcoholism. The depression is so severe that we mostly sit in silence. The patient struggles to make eye contact and stutters out a few short sentences while staring out the window. The safest topics to discuss include children, the weather, sports, and plans for the weekend. I feel like it’s a combination of an interview and an awkward conversation with a stranger. I wonder how this has been helpful for the past 5 weeks. My head tells me this must be or the patient would probably not keep coming. Regardless, I feel uneasy. Even with all my knowledge of projection, transference, and counter transference, I can’t help but feel depressed and anxious as we leave the office.

Another patient is struggling with chronic pain from an old injury. She retells the same story about medical mismanagement of her pain. I can almost recite the ten year history with her. Most of session is spent validating feelings of mistrust, deceit, hurt, and skepticism. I think back to Arthur Kleinman’s book Illness Narratives. Conceptualizing her story from this perspective helps guide our sessions, my suggestions to her physician, and my sense of competence. The anxiety and depression from session one has waned. Instead, I want to feel comfortable with the repetition and make sense of it. I come back to the same question. Am I helping? How? It certainly doesn’t feel like I’m pulling much from the different models of family therapy I learned that are supposed to guide my interventions. No time to process that- the next patient is here.

I spend the next two hours in another crash course on Hmong culture. One patient’s depression and suicidality have decreased, but perhaps only me and her primary physician notice. The depression remains severe. I go with my gut on this one. Teach me about your culture, I ask. If I don’t understand what guides your interpretation of past and present experiences, therapy won’t be the most effective. The patient’s normally flat affect disappears a little and I see a small amount of brightness. Even though we’re working through an interpreter, (which normally seems to slow down the process) the session flies by. I’m soaking up everything I’m learning, and the patient is very interactive. I’ve gone from feeling uncertain and somewhat uncomfortable about the first two sessions to feeling like I’m on track.

The next patient is new and not really sure what I do and how I can help. It ironically parallels my own general feelings this fall. We talk (again through an interpreter) about what the primary physician recommended for treatment and how she’s described my role. The patient is not very clear, and my explanation does not seem to clarify anything. However, since the physician has said I can help, she is more than willing to keep returning for future sessions. Right now, I’m not sure where to head with her case either.

The rest of the day flies by. I try to make sense of what happened during the morning. Over lunch I balance supervision, food, case notes, and more spontaneous consultations with other clinic staff. During the afternoon, I switch gears. I’ve gone from provider to teacher. I walk into the precepting room to see which resident I have not shadowed and evaluated. I ask one if I can tag along for the afternoon to help him get his patient-centered evaluations out of the way. We don’t know each other well since our time at the clinic hasn’t overlapped much. I don’t know what to expect or how he might view a mental health intern serving as a mental health preceptor for the afternoon. I’m acutely aware of the power dynamics- I am younger, female, an intern, and a mental health professional. I’m also still learning what I can offer in the world of medicine and how to do it. Everything I’ve learned in theory is being tested. In all, we see about ten patients ranging from well-child checks to chronic pain, tension headaches, and diabetes management. By the end of the day I am exhausted. I’ve gone up and down, riding a roller coaster of stress, emotions, and feelings of incompetence versus competence.

This blog feels long, overwhelming, pressured, and too detailed. Perhaps it’s the perfect way to communicate my experience. I can’t edit these days. They occur in full force- fast, detailed, and sometimes overwhelming. I’ve learned how to ride the roller coaster a bit better. I’m far from being comfortable, but I know how to hold on and not get sick. And every now and again when it takes an unexpected turn, I get excited. I don’t panic. I hold on tighter, lean into the curve, and look around. Just as the roller coaster drops, I relax a little. Through this, I see how I can help and am reminded of why I enjoy this work.

Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. 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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Medical Family Therapy Intern, Part 1: How Did I Get Here?

Posted By Lisa Zak-Hunter, Thursday, June 9, 2011
Updated: Friday, June 10, 2011

November 2010:

The 6:00am alarm goes off too early Monday morning. Over the weekend, I put in about 20 something hours at my second job as a PCA in a group home for mostly non-ambulatory and non-verbal adults with complex developmental and physical disabilities. My brain is switching gears from playing games, doing crafts, singing songs, and providing complete personal care, feeding, and medication regimens. Feeling sluggish, I take about as much of a B-vitamin complex as I can handle and grab some breakfast to eat on the go.

The cold air slaps my face as I get near my car, reminding me what Midwestern winters feel like. After spending time in the South for graduate school, I’ve gotten spoiled. On the drive in to work, I crank up the radio in an attempt to relax and enjoy my long commute. I feel my mind struggling to get lost in the music. Instead, I’m already focusing on what my clinic schedule looks like and trying to fight the feelings of incompetence and stress. The familiar tension headache and general fogginess start to set in as my mind picks up speed.

Graduate school did not prepare me for this. After all the classes, training, and clinical work, I figured I had a decent idea of how to conduct therapy. I’ll always be learning- but I didn’t imagine my internship would feel like completely starting over. Even the days I’ve questioned my abilities and feel stuck in my growth, I’ve felt like it’s ‘good enough’. Now, my theory of therapy seems like it was written by another person, in another dimension. I struggle in and out of the office to find ways to apply my knowledge to work in a family medicine residency site and the social, medical, and metal health complexities of low-income and immigrant patients. After a few months of working at my internship, I feel like a first year grad student again. I feel like it’s so much learning on the go (building the ship as we sail it- as my supervisor has said) that I barely have time to process between patients or even between work days! It is perhaps the most stress I’ve encountered in a long time; hence the fogginess, headache, sleep deprivation, feelings of inadequacy and a host of others. Yet I’m still here. I haven’t turned my car around. I haven’t tried to ‘get out of this’. Deep down, I know I love this and I thrive on it.

Rewind several years:

As a child, I always wanted to be a ‘doctor’ (although, my parents will tell you my very first career aspiration at age 2 or 3 was to be a cashier). I refined that dream to pediatric oncologist when I was 12 and held on to it through the beginning of college. As much fun as the courses in biology, physiology, anatomy, and biochemistry seemed, I knew I didn’t have the heart to go through other pre-med coursework that disinterested me. I turned to psychology as an outlet, focusing mostly on courses in psychopathology, neuropsychology, and biopsychology. Eventually, I took a counseling course and fell in love. I held on to my interests in medicine and health, uncertain of how to incorporate them with counseling. As a senior in college, I was introduced to medical family therapy. It clicked. You mean there is an actual field that incorporates mental and physical health care? Encourages collaboration with other healthcare providers?? Would allow me opportunity to teach and learn from physicians, nurses, social workers, and pharmacists etc WHILE counseling patients and families??? Eureka!

Through an undergraduate internship, I learned quickly that my passion lies in helping people cope emotionally, psychologically, relationally, and intimately with illness. Some of that is clinical work, some is teaching, and some is research. An important piece includes working with, teaching, and learning from other healthcare professionals about the biopsychosocial milieus of illness. It is actively collaborating with someone’s physician, social worker, diabetes care coordinator, and the patient to increase the patient’s sense of well-being, health, community, and control. Throughout my graduate studies, I read all about medical family therapy/collaborative family healthcare. I have done guest lectures on it and class presentations. I soaked up as much knowledge as I could in my specific interests. I thought I had at least a decent idea of what I was stepping into.

Back to November:

Yet here I am at 7:45am, turning on my computer to review my schedule, and already feeling behind. A couple of different coordinators pop in my office to consult on cases we share. One of the interpreters and medical assistants talks with me about citizenship forms and writing advocacy letters. I send a couple of messages to residents to give them updates on patients we share. I grapple to remember what I last covered with my morning patients as I review my case notes and any other medical visits they’ve had since I last saw them. One of our front desk staff comes in with the fee ticket for my first appointment. Since there are more mental health providers than mental health rooms, I search out another space for morning therapy. A physician’s office will do for today. I head to the waiting room.

Lisa Zak-Hunter, MS is a doctoral candidate specializing in family therapy at the University of Georgia. She is currently completing a behavioral medicine internship with the Department of Family Medicine and Community Health at the University of Minnesota. 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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How Having my Team at My Healthcare Home Helps Me

Posted By Brandi Hilbert, Thursday, June 2, 2011
Hello, my name is Brandi. I am a native of Grand Junction, Colorado and I enjoy crafts, writing, and working with other people. I live with 4 birds and a boyfriend. Since I was a young child I have lived with many hardships, including my parents’ bitter divorce, a family history with alcohol problems, numerous medical problems, and frequent thoughts of self-harm.

Since my high school years I have participated in treatment for these problems, such as counseling, groups, medications, and meeting with my family doctor. I have seen numerous counselors in many different settings. So many, that it is difficult to remember who I saw, where, or when. These problems have also made it so I have been to several hospitals on numerous occasions, and there was a time when I was going to the ER or admitted to the hospital weekly or monthly.

This all started to change when I finally was able to have a family doctor who paid attention to both my needs and wants. I first met Dr. Mathwig in 2008 when she was a family medicine resident at St Mary’s Hospital in Grand Junction. I felt that she listened to me and met me halfway. Through her help many of my hardships and my need for high-level services improved.

Over time my healthcare team has grown. It now includes a family therapist named Dr Reitz and a psychiatrist named Dr Venard. Dr Mathwig has now graduated and my current resident is Dr Carlson.

Here are the benefits of having a healthcare team:

  • Less confusion
  • More confidence in myself and the team that treats me
  • Less afraid of what any given doctor may say or do with my treatment
  • I feel more important and validated
  • It helps me take a deep breath and realize that I have a team who is dedicated to helping me continue to be a success.

My message for other people dealing with hardships is that I’ve realized that hardships are only temporary, so keep your chin up and do your deep breathing. I feel lucky that I’ve been able to assemble a good healthcare team, and therefore, I encourage you to take your time and work with your providers and to insist that everybody works together.

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"A Little Cheese with your Whine?"

Posted By Jennifer Hodgson, Thursday, May 19, 2011
Updated: Wednesday, May 25, 2011
These days I do not indulge on the libations of fermented grapes much but I feel the hangover of working full steam with minimal stops. Why is it that collaborative people tend to become so enthused by the great buffet of work? Most people who are collaborative care types are the ones you see championing new ideas, training ridiculous numbers of people to do the work, writing and researching the merits of systems thinking, and working tirelessly to advance healthcare while pushing a boulder the size of Aunt Rita’s meatballs uphill!

There are so many factors to consider in the change process, and our dear friend CJ Peek nailed it when he crafted the words "Three World View.” Just like a car, healthcare will not move without money to put gas in the tank and maintain it, a place to drive the vehicle that is not in the way of existing transportation, and people skilled enough to do it well. However, it also takes a commitment to retraining providers, patients, families, and countless others which is where the cheese comes in because there will be lots of whining happening when we start the change ball rolling.

We are creatures of habit and movement is not about the lack of a great idea but the willingness to stop and turn the wheel and head in a different direction. The first step is to sometimes step back and take inventory of what is existing in that space. Retain what is going well and slowly introduce change that is in partnership with the system that will be impacted by it.

If you want to lessen the whine, serve great cheese that the system wants! A model that works in Colorado may not work in its pure form in North Carolina. However, the idea of the Colorado model shared with colleagues and patients may generate a hybrid version that has promise. This work is messy, time consuming, and not for the impatient types. In the eyes of a patient though, they do not see all of the mess, although sometimes they might, but they feel the effort of a system who is trying to improve upon itself.

The title of this blog is really ambiapplicable. Those whining can be those doing it, as well as, those impacted by it. Either way, change is challenging and movement can be slow but progress is addictive. Perhaps this blog has the flavor of my last grant, substance abuse, or is a product of how I feel after a long semester in academia. What I want people who read this to know is that your work and your efforts are making the difference! You are inspiring people each day by your commitment to your philosophy of what healthcare can look like now and in the future.

Family Health Blog

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.

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Goodbye Old Friend, I've Known You Far Too Long

Posted By Peter Fifield, Thursday, May 12, 2011
Updated: Wednesday, May 25, 2011
We are all aware of the dangers of smoking. Yet the CDC reports that in the United States over 46 million people (20.6%) over the age of eighteen and 2.7 million (17%) of all high school students are current smokers. Out of the 46 million adult smokers, the CDC reports that over 40% of them tried to quit in the past year. The implication here is that to some degree they wanted to quit, but were unable to to actually stop smoking. It is hard, very hard, to separate oneself from the addictive nature of nicotine.

First hand exposure is not the only danger. Second hand and the newly implicated third hand smoke exposure endangers a much higher number of individuals; putting even the innocent at risk for many acute and chronic health conditions. The knowledge of these hazards is not new. We have been well aware of them for years yet about 21% of our adult population continues to puff away.

There is no doubt that everything we do, we do for a reason. Therapeutically as a Behavioral Health Consultant in a primary care office I see behavior as less of an issue regarding right or wrong but more so does it or does it not work. So with the known risks of smoking there must be a pretty good reason why people continue to smoke, right? Nicotine has psychoactive properties that are very addictive; most likely related to how it effects the brain’s pleasure/reward center---the mesolimbic dopamine system.

Smokers smoke because it works! Some say it "relieves stress”, even though it is a stimulant. Some admit they smoke for "something to do” when they are "bored”, Others report that they smoke when they are "feeling down” and depressed and even when they are "feeling great”--a reward system for feeling both crappy and wonderful. People smoke when they drive, they smoke when they sit at the computer, they smoke when they are having coffee, tea or a beer with a friend. Some even smoke because "as sad as it is, smoking is really the only thing in my life I enjoy doing”.

After many years assisting patients in the smoking cessation process, I have becoming more convinced that most individuals, even though they are not consciously aware of it, relate to cigarettes as a friend—an unconditional friend that is always there when they need them. What I find most interesting is the one sided, almost masochistic nature of this obliging yet very pernicious friendship.

Tobacco use is the single largest cause of morbidity and mortality in the United States; as touted by the CDC "the only legal product that when used as directed will kill one-third of users”. Each year smoking cigarettes accounts for 1 in 5 deaths--that is about 438,000 people. Just to give you a relative benchmark, deaths related to alcohol and illicit drug-use combined total 44,000 per year. This is surely a dubious friendship but it is one that comes with minimal conditions. It is a relationship that for most has no perceived incentive to change.

Below is a letter written by a client:

We've been friends and co-dependents for a very long time, 46 years to be exact. I remember the first time we met...I was five and boy did you get me in a lot of trouble. First I climbed high to reach you and then I gave you a try. I got yelled at and spanked because your partner burned my mummy's rug.

My mom knew you first and I wanted you to be my friend too. You seemed to be liked by my mom and almost all of her friends, but I was forbidden to associate with you...until 5 years later when I was 10, I snuck you away from my mom and we bonded in the basement. We lived in the projects. It made me cool with the other kids to be your buddy. You hung around until I couldn't get rid of you...but I didn't want to because you felt good, you calmed me and you made me look cool. Little did I know you were the controlling one in our sick relationship.

It took me years to realize that we were unhealthy together but I seemedto overlook it. Even when my mother cut her ties with you; when she begged me to do the same, I refused. I tried but you were stronger than me.

Today I want to tell you that..."you're killing me" and I don't want to have anything to do with you anymore. Very soon you can rest assure that I won't let you send me to my grave. I can't take the pain I've seen you cause so many other people.

In a nut shell I want to say "watch out" because you'll soon lose out in this friendship. I can't wait for the day I say...NICOTINE-I QUIT!!!

Your soon to be ex-friend.

Peter 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.

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