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The Collaborative Care Sorting Hat: Gryffindor or Slytherin?

Posted By Randall Reitz, Thursday, September 1, 2011
Updated: Tuesday, May 8, 2012

A tangent to get us started. I'm one of the few people I know who is just getting started with Harry Potter. I read the first book about 7 years ago and loved it so much, that I knew that I would want to read the series with my, then, newborn daughter. We tried to start  reading them during our bedtime reading when she turned 6, but even the more vanilla "Sorcerer Stone” proved too intense for her. About 7 months ago we tried again and it has since consumed much of our daddy/daughter time. We started out with her reading 1 paragraph per page and me picking up the rest. We're now starting Year 5 with a combination of shared and individual reading.

One of my favorite characters from the book is the Sorting Hat. As each new first year student arrives at Hogwarts School of Witchcraft and Wizardry she or he is assigned to 1 of the 4 houses of the school: fearless Gryffindor, devious Slytherin, friendly Hufflepuff, and analytical Ravensclaw. Click here to see which house fits your temperament.

This ritual occurs to great fanfare in front of the entire school at a ceremonial dinner. 1-by-1 the first years sit on a chair and has a floppy, snaggle-toothed witch's hat placed on his/her head. The hat has a mind and a mouth. The mind analyzes the student and intuits fit between the student and the typology of the 4 houses. The child wearing the hat can hear the reasoning of the mind. Then, the mouth announces the assignment to the breath-bated mass in the banquet hall. You can see Harry's experience with the Sorting Hat here.

The Sorting Hat

Sorting through the hats. As a collaborative clinician employed as the Director of  Behavioral Sciences in a family medicine residency, I have developed my own Sorting Hat technology. Unfortunately, my hat's intuition is still foggy, its mind confused, and its mouth glitchy. Hopefully putting pen to paper will help to work out some of the bugs.

In this professional role I wear numerous hats—sometimes consecutively, but usually concurrently:

  • Educator—This is my primary role, either in didactic sessions or through staffing cases in the precepting room and exam rooms;
  • Evaluator—After supervised appointments or behavioral science learning days I prepare formal evaluations of the learner's skills and professional development;
  • Remediator—I serve on a committee that employs both carrots and sticks to assist residents struggling in identified areas (e.g. medical knowledge, professional behavior, curriculum completion, biopsychosocial health concerns);
  • Supporter—Residents are scheduled with me on a 1-to-1 basis about every 2 months and many residents pull me aside to discuss personal issues;
  • Colleague—I have the fortune of a psychologically-minded residency and my faculty colleagues will often seek me out to consult or to cathart;
  • Clinician—I carry a small individual caseload, co-facilitate group medical appointments, and see numerous patients on-the-fly when invited out of the precepting room by medical providers;
  • Supervisor—We have an integrated mental health team (therapists, case managers, doctoral interns) that I supervise clinically.
  • Patient—My family receives our primary care at the residency clinic.

I love being a faculty member and usually wearing the multiple hats is a great job perk. For example, about 6 months ago (hopefully not as a result of Harry Potter), my oldest had a seizure. I found her lying on the floor at 6 a.m. already in the post-ictal phase with no idea as to the etiology of her altered mental status. I put on the patient hat, drove to the residency clinic, found a favorite resident, and got her seen without appointment. Within minutes the team narrowed in on a seizure diagnosis, and rushed us off to hospital. We benefitted from excellent technical care from the ER doctor and compassionate and patient-centered support from a resident and attending physician throughout our inpatient experience. As a bonus, this attending physician is my personal doctor and her partner is one of Grand Junction's few neurologists. To this day, when I put on the patient's hat in the clinic our family doctor answers my questions and offers quick phone consults with the neurologist.

My Mind and Mouth. Despite these benefits, it is not hard to predict that wearing multiple hats often troubles my mind with double and triple role conflicts. For example, when I see patients with residents the clinical, teaching, supportive, and evaluative roles overlap: If the resident is struggling with behavioral patient skills do I leave on the teaching hat and only observe the difficulty, or do I switch to the clinician hat and take over care? When debriefing after the appointment do I approach it with the supportive hat or the evaluative hat?

This is exacerbated when a resident is referred to the remediation committee. My participation during the tense interactions with referred residents can blunt a resident's willingness to confide in me during supportive 1-to-1 sessions. And conversely, it is not clear to me how information that was shared with me in semi-confidence while wearing the supportive hat should affect the proceedings of the remediation committee. Or worse, how would it affect our relationship if a new resident made a mistake in offering care to my family and it resulted in a bad outcome or a referral to the remediation committee?

My mouth is the behavioral manifestation of my mind's hat sorting quandaries. When an ethical or inter-personal dilemma arises from a multi-role relationship, the first response that is usually expected comes through my mouth. In faculty meeting when we discuss a situation with a resident, all eyes will often turn to me to provide insight into the resident's emotional constitution, cognitive faculties, or behavioral eccentricities. When I'm brought in to meet a new patient I feel heightened need to provide a pithy intervention so that my teaching opportunities later in the week will seem credible.

Toggling between mind and mouth while fumbling numerous hats requires 2 under-appreciated skills: delay and vagueness. Delay helps by slowing down the discussion to allow my mind to offer a reasonable solution to my mouth (i.e. "Let me think about this and talk with Resident X before I weigh-in”). Vagueness allows me to wear multiple hats simultaneously without violating their competing ethics. For example, I can respect confidentiality by making a broad statement such as "I think Resident Y might struggle with self-doubt stemming from a difficult experience during her first year”).

My Blog Colleague: My guess is that Sorting Hats are ubiquitous in collaborative settings, especially in collaborative teaching settings. Rather than my idiosyncratic head ornament, Sorters are endemic to our field. How does your Sorter fit?

  • When is your Sorter comfortable? When does it provoke a rash?
  • How do you balance the competing aspects of collaboration?
  • Which aspects of your personal life do you bring to the professional setting, which aspects do you leave at home?
  • Is there any video clip that depicts dual-role relationships better than this one?

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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Who Says You Can’t Choose Your Family?!

Posted By Helen Royal , Thursday, August 25, 2011
So I’m running around, doing whatever it is that I do at a fast pace all day long; seeing patients, supervising behavioral health providers, consulting with medical providers, reviewing unanticipated outcomes, trying to incorporate our behavioral health work into the new electronic health record and uh-oh, my blog is due. As I start preparing to write about the parallel process of change for patients and staff as we transition to an electronic health record and an increasingly complex world, I keep getting interrupted by some kind of patient need. I get pulled away from writing about life in integrated care, to the reality of patient care. That darn patient who relies on us for so many unusual services keeps stopping by. He needs his pill boxes filled, and can we check on his dental appointment time? He’s feeling stressed and suicidal, can we talk to him? He’s got medication questions, and he needs help in figuring out the letter he just got from unemployment. Do we have anything to feed him because he missed breakfast in order to catch the bus… and just in general, can we make time for him when there often just isn’t time? It struck me that this is what you do with family; shift your priorities and make time to focus on what’s important. Of course we’ve got time. My blog theme just morphed…

One of the values of the Collaborative Family Healthcare Association is involving family members in patient healthcare. However, in many areas, and in the life of many patients, their families aren't available, or aren't even a great source of support if they are available. In the rural resort region where my non-profit clinic for un/underinsured, low income patients are served, we rarely see patients who've grown up here or who really have any strong family ties. Often they "escape" to the area due to unhealthy family situations or an inability to fit into a traditional lifestyle.

These patients, perhaps more than those with traditional families, need providers to expand their definition of family to provide comprehensive healthcare. Care providers need to challenge our notion of family. What is family? People connected by duty, blood, history, values? Is there a way to engage community members in this same manner? What does a supportive family provide? Companionship, understanding, compassion, honest opinions, help with life's day to day and big time struggles. Communities can do that...
Ask Ty! He is that darn needy patient who says: "I can't figure it out, but everywhere I go people know me and say hello and are nice to me."

Ty is a middle aged male who is currently involved in many services in our community. He's suspected of having cognitive impairment his whole life as evidenced by his employment history, law enforcement involvement and overall poor decision making. Prior to his biological family's passing, he had a "safety net" to help him redirect his actions, face the consequences for the poor decisions and keep on track financially. After his parents passed, the pattern of substance use escalated and he suffered a series of medical complications. From that point on the road got steeper. Have you ever tried to find a job, apply for food stamps, keep stable housing, keep your beloved pet, stay sober, keep track of medication and manage the daily stressors of life without transportation and without family?

The concept of medical home is, in a nutshell, a hub of compassionate, comprehensive care. We are the core family. We are the ones who don't give up, no matter how annoyed, busy, frustrated or confused we may become. We may be charged with continuing to manage and encourage patient engagement and access to services. Sometimes we too need "family" help. Our colleagues and network of providers can fulfill that for us if we remember to look for it; to challenge that notion of "family". Can we bring others into the medical home web? Find out who has your patient connected to? Maybe an employer or a child's daycare provider. Food stamp administrator? Bring them into the web! Find who can help you model those healthy connections?

If we get stuck with the traditional view of "family" in collaborative family healthcare we miss the rich opportunity to engage communities in helping its members feel that sense of belonging and connectedness that we strive for with our patients. We need to challenge ourselves to engage with our patients and help them create families who can be active members in their healing process.

This means really listening to what's important to them. Yes, Ty, you want to live independently, yes you want to keep your dog, yes, you want to have some power over how the little money you have is used/spent. No, you don't want to live in assisted living with a bunch of people waiting to die. You don't want to be pushed into decisions, you want to be heard. And you want the darn sore on your arm to go away! Well OK then. When do you do well? When do you struggle? How can your "family" help with this? Who do you consider part of your family around here? I asked Ty that very question today and here's what he offered up:

Social Services caseworkers
Medical Clinic: MD, clinic assistants, front desk and Behavioral Health providers
Workforce Center
Billing person at the hospital
Security Guard at the hospital
Peer Support at Mental Health Center
Therapist at Mental Health Center
Bus drivers on free bus
Regular bus riders

As I was still letting the concept of extended "family" roll around in my mind, I was driving around doing errands and saw Ty and a young child, who I later learned was a neighbor child. They were walking down the side of a busy road, Ty on the outside, so the kid stayed on the safe sidewalk. I watched them walk together for quite a while and then Ty took him into a store where his mom was working. Off to his next destination.

What a great symbol of paying forward that caring, compassionate connection that always seems to puzzle him from his "extended family".

Helen Royal is a Colorado State Licensed Professional Counselor and Director of Behavioral Health at Summit Community Care Clinic in Frisco Colorado. She has worked in community mental health for 20 years as a clinician and quality improvement manager and is currently
Project leader for an integrated care grant working on integrated primary care. She is passionate about equine assisted psychotherapy!

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Finally, the Fruits of Our Labor! Bringing Integrated Care to Rural Communities in Southern Appalachia

Posted By Jodi Polaha, Ph.D., Thursday, August 11, 2011
Summer gardens everywhere are kicking out crops at last. Just yesterday I pulled six cucumbers from a vine and set three more tomatoes on the kitchen windowsill. Hmmm… with balsamic and oil? Mozzarella and basil? Decisions, decisions!

The Psychology Department at East Tennessee State University (ETSU) is at a similar point. About ten years ago, a grant from HRSA provided seed funds to develop an idea: a doctoral program in Clinical Psychology with a special emphasis on rural, integrated care. About five years ago, the program accepted its first cohort. This fall, the program will have a full complement of students including three attending internship. It’s been a long growing season and we are excited to see the fruits of our labor!

ETSU is nestled in the foothills of the Appalachians. We’re a gorgeous one-hour drive through the mountains to Asheville, NC or to dozens of other communities nowhere near as populous, gentrified, or well-served. The University has established a niche in serving rural communities across multiple disciplines with, for example, an award-winning program in Rural Family Medicine. That our new doctoral program would serve rural communities was a given.

Integrated care boasts particular advantages in rural communities where travel and stigma are top barriers to behavioral health care. So, it made sense to our program’s forward-thinking founders*, that the integrated model should be a strong component and we developed a program with graduated didactic and experiential rural and integrated training elements. This includes interdisciplinary courses with other health professionals, courses in our department exclusively focused on integrated practice, and out-in-the-field experiences in integrated care at the observer, externship, and, if chosen, internship levels. This year, two of our three students will complete internships in integrated care settings.

That said, the shortage of behavioral health providers is perhaps the most significant barrier to care in rural areas and simply training our students to provide integrated care is not enough to address it. In developing a program with a rural focus, we have had to grapple with how to use the integrated model in innovative ways to get services to remote places and to recruit students to locate to rural communities, particularly in our underserved region. This is where working in the garden gets really fun. To extend the metaphor, it is a little bit like moving beyond simple plant-and-pick gardening to learning how to preserve seeds, use cuttings to start new plants, or can crops.

One example includes the development of the Southern Appalachian Children’s Telebehavioral Health Clinic. Funded by HRSA (Office for the Advancement of Telehealth**), this Clinic is staffed full-time to provide behavioral health consultation to patients in five pediatric clinics in rural Tennessee and one school-based health network in rural North Carolina. Equipment is located in primary care clinics and "open access hours” allow physicians on-the-spot consultation and the capacity for warm hand-offs which, sometimes occur at a rate of 5 to 8 in a day! We are experimenting with all kinds of interesting seeds and it is thrilling to see some of them sprout and grow.

Another example is the initiation of the East Tennessee/Southwest Virginia Predoctoral Psychology Internship. Few local internship opportunities for our students meant that some of them would have to move away from the region for a year and the possibility that they might not return to grow the local workforce. Recently, Dr. Kay Matlock of Stone Mountain (an FQHC based in rural Southwest Virginia about one hour northwest of ETSU) was awarded HRSA, Office for Workforce Development funding to develop behavioral health professions training at their site, using a truly integrated model. Co-directed by Dr. Jodi Polaha (ETSU) and Dr. Jim Werth (Radford University), this predoctoral internship will see its first trainees begin on August 15th. This reminds me of our strawberry plants, whose runners leap from garden boundaries about this time of year. We cut them and plant in another bed, providing a whole new crop in the Spring!

It has been a pleasure to write this blog entry, to take the time to appreciate all we’ve grown, and to anticipate our "fall garden” which will be very full indeed! Now, out to the garden with all you readers! You can never put enough water down in August, and, for a readership of forerunners in integrated care, I’m guessing you’ve got a few baskets of your own veggies to harvest!

*Dr. Peggy Cantrell, Director of Clinical Training; Dr. Wallace Dixon, Jr., Department Chair; Dr. Bruce Beringer, Office of Rural Health
** The project described was supported by grant number H2AIT16623 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.”

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.

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Families are Messy, Complicated, and Silent Partners in Healthcare

Posted By Jennifer Hodgson, Thursday, August 4, 2011

Primary care settings are rich with all types of patients, diseases, diagnoses, celebrations, and providers. As defined by the Patient-Centered Primary Care Collaborative (PCPCC), "The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family” ( The key question that I want to pose in this blog is "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”

I can think of countless times when the family (defined by the patient) has been the missing piece of the healthcare puzzle. The family was the one thing not accessed that helped put things into motion or helped providers realize why there was no motion. Family boundaries can be either enmeshed (no new members in or out), disengaged (no connection to one another), or permeable (new members allowed in and current members allowed out). This information is critical to providers because it may help make sense on why patients are not showing up for appointments, nor following treatment plans, or why some patients, conversely are model healthcare citizens. Of course, attending to the family and their unique dynamics is not the holy grail of medicine but neglecting the family may be another chasm interfering with the quality of care.

For example, a patient presented to his PCP with homicidal ideations. He was in constant pain, clinically depressed, and was waiting to hear whether his final appeal for social security disability was going to be accepted or denied. He scared his PCP with his voiced ideations, plan, and intent. At this point the PCP called in the Behavioral Health Provider (BHP) to collaborate. Both providers were quite convinced of the patient’s intent when he said that if he lost his appeal he was going to follow through with his suicidal plan. Taking necessary precautions the PCP and BHP collaborated and had the patient hospitalized. Surprisingly, the patient was voluntarily committed. Continuing their collaboration the PCP and BHP corresponded with the inpatient psychiatric unit attending to ensure that he had all the information needed and that duty to warn was enacted. The PCP and BHP knew that the patient would eventually be discharged and return to primary care for follow up.

One week later, he was back in their outpatient clinic and one week after that he was having ideations again. Quickly the integrated care team, with the BHP at the lead, contacted the patient’s spouse and brother. The PCP and BHP encouraged the patient to bring them into his therapy sessions. He complied and together they developed a plan for how the patient would be monitored for escalation of ideations. They were educated about his pain, diagnoses, pharmaceuticals, and psychotherapy plan. The family had been scared for years, watching his mental health decline, and did not know what to do. He had seen several psychiatrists and mental health providers, but he never attended more than a few sessions at each. This was the first time since he was injured 5 years ago that he continued with care and that anyone invited his family to be a part of his care. Without the family, the work of the integrated care team would not have resulted in successful management and care for this patient’s medical and mental health needs. Thankfully the patient is continuing to do well, as it has been over a year. Note: His social security disability was declined.

Researchers back the importance of the family role played in patient care and numerous therapeutic models exist for working with families. What we lack is strong policy and insurance incentives to make families a greater part of a patient’s care. We have more barriers than pathways (e.g., privacy laws, exam room size, appointment times, and lack of training). Families can be messy and very complicated but notwithstanding they are silent partners to any PCP/BHP team. They are there in the room with us whether we choose to see or talk to them. Most of the time, unbeknownst to us, they are either reinforcing or discouraging treatment plans. Most importantly, family members often feel like they have important information to share with us but have been told that we cannot hear it nor respond to it. While some may abuse this privilege, most just want to help and be helped.

Again I present to you the following question, "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”

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. 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.

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Salud 2.0 Part Two: Broadening the Collaborative Web in Healthcare and Emerging Technologies.

Posted By Gonzalo Bacigalupe, Thursday, July 28, 2011

The second day at the Salud 2.0 Euskadi in Bilbao was as rich in content and participation as the first. Manuel Armayones, lecturer and researcher at Universitat Oberta de Catalunya and president of a rare disorder association, and Carlos Luis Sanchez Bocanegra, e-health and system administrator with the government of Andalucía, spoke about research and development from the perspective of rare disorders. Like the e-patients during the first day, Manuel and Carlos also transformed their personal plight into actively contributing to communities of patients. They are the paradigmatic situations in which professional-patient boundaries are tested, Manuel told us. A core dimension of these connected communities is the ability of patients to shape research and development. We know that social networks and the easy access to health research information makes the lives of families, with a member diagnosed with a rare disorder, less unbearable. Being able to overcome geographical barriers to reach for emotional support, medical expertise, and tailored research are central. Most important, however, is the potential for unifying across the same barriers towards eliciting clinical trials, developing new collaborations in research, and venturing into the development of innovative treatments. Several social media examples were given and the dilemmas of social participation, the role of the professional, and the funding difficulties were outlined in this presentation. Two must read books were mentioned by Carlos: e-Patients: How They can Help us Heal Healthcare by Tom Fergurson and Unlearning: Incomplete Musings on the Game of Life and the Illusions That Keep Us Playing by Alejandro Jadad.

Miguel Angel Manez financial vice-director of the Alicante-Sant Joan Health Department, reported on the efforts related to creating a social network for the professionals in the system and to coordinate all the web efforts of the health department. The challenges of moving from a 1.0 scenario to a 2.0 dynamic are not about the technological tools, but about organizational cultures. We have to be clear about what we want to achieve. Leading the transition should not be left to the information technology employees, but those in tune with the strategic goals of the organization. He utilized the songs of Coldplay to challenge us not to be afraid of the new media and to help us move a government department into a 2.0 environment. Some of the advice included: motivating people to do new and different thing, not to interfere with the free flow of information, find the natural leaders who can motivate others, and do not rely on the myth that the internet will resolve everything. He also suggested that the tools are about finding solutions collaboratively utilizing the cloud with some incentives. Miguel Angel suggested that fear of imposition, suspicion, and lack of skills are intrinsic in organizations, but this should not stop us from innovating. Finally, he reminds us that health is communication.

The Basque Country health system has been a leader at implementing a strategic plan that acknowledges chronic illness prevention and treatment as a central undertaking for the healthcare system. Economist Carolina Rubio, program director at Innobasque, acknowledging her own chronic illness has been leading the implementation of a social network for chronic illness patients to share information and support. Kronikoak Sorea relies on the notion that caring for others is also healing. Carolina mentioned that to accompany, to be flexible, to learn, and to build are key in the planning of a social network platform for chronic patients. One of the most innovative aspects of this project is the special focus on the emotional state of patients instead of the illness per se in designing the social platform to ensure participation.

Two primary care physicians, Ignacio Basagoiti at the Polytechnic University of Valencia, and Salvador Casado, assessed the adoption of technology by doctors and patients. Ignacio spoke about how doctors have to adapt to new technologies amplifying traditional social networks. If I am not an excellent physician to begin with, the social media tools will not make me an excellent one in the end. But can these tools make us better professionals? According to Ignacio, the answer is affirmative. He explored each of the tools that are freely available. He described Fernando Casado (not related to Salvador and also a primary care physician, the presenter in this panel) use of twitter to inform patients about appointment delays or useful health tips. Ignacio emphasized the amplifier role of social media to communicate, a means to relay specific goals.

Salvador Casado, after taking his shoes off, talked in a very personal way about humility. Patients want someone who cares and will help them find solutions. What do the physicians want? The same, a shoeless Ignacio told us. Patients want to wait less and to suffer less. He mentioned the usual challenges and villains in the healthcare system with the obvious consequence: burn out. Communication seems to be the solution and the social networks could be helpful. However, face-to-face communication really makes a difference. The magic of being together, like the participants in the conference who knew each other virtually, but for the first part can be together in the same room. Salvador challenged us to think of change from bottom up and to use the web 2.0 tools to address this via seven proposals: take care of yourself, humor, talk with your peers, innovate, slow medicine, eliminate the bureaucracy from your office, and flow. Casado’s talk was probably the most applauded of all and he deserved them. His call for personal accountability was clear.

The last part of the course addressed the perspective of journalists as well as how health care communications and public relations can be managed with the new media. Alain Ochoa, a journalist at Diario Medico used a photo of a sinking Titanic to demonstrate where journalism is. He called for no excuses to figure out how to move forward. The cartoon by Jesús Martínez del Vas, where two kinds of journalists look at each other, the techno savvy and the ones still caught in the traditional print outlet, synthesizes well the central point in Alain’s talk. The techno savvy see the others as dinosaurs and the traditional reporters see the others as extraterrestrials. Alain framed the new scenario not as an excuse to go back to a nostalgic form of journalism, but to embrace the digital form as a way of reaching readers. However, the implementation of any new technology could backfire and for that Alain made an analogy based on the film Robocop.

Imma Grau, researcher at the Hospital Clinic of Barcelona, described the forumclinic experience as a form of handling communication by a large hospital. The approach is based on the notion that satisfied patients will handle their chronic illness better. Imma reaffirmed the power of patient communities and their role in making healthcare collaboration a reality. Her work reminded us of how much we need systematic research related to the impact of healthcare social media tools. The health system needs to use research evidence in making decisions about how to utilize resources. Imma shared the story of patients who propose themes to deal with. Patients organized around specific illness make sense because it focuses the discussion on a common interest. What really matters to the patient emerges through the social network medium and not necessarily via the physician-patient relationship. In analyzing the data, one of the main findings is for the institution to adapt based on the patients’ conversations.

Journalist Elena Escala, from Diario Medico and TEDxSol, outlined the ways in which communication is not unidirectional and how the dialogue with readers can be uncomfortable and difficult. To witness or to be around is different from true participation. For Elena, joint collaboration and creation are the focus of the new way of doing journalism in the 2.0 era. As an example, she announced the publication of a free book in Spain: The New Health and New Patients in the Web 2.0, a joint effort that did cut through disciplines and professional silos. She challenged the audience to move the innovation out of the garage to make change sustainable. Innovation is occurring at the margins of organizations; we need to include it in the organization and with its support. 2.0 need to be more than the result of a small group of people in each healthcare institution. Incentives are needed to mainstream these innovations.

Responding to the need for creating an instrument that facilitate continuous improvement in quality of chronic illness are in healthcare Andres Cabrera, a mathematician at the Government of Andalucía and lead person at OPIMEC, the Spanish Observatory of Innovative Practices for Complex Chronic Disease Management, presented the project that utilizes many of the most innovative 2.0 technologies. The initiative born in 2008, intends to bring together communities of knowledge and practice. The pharmaceutical industry was also represented at the course. Juan Carlos Esteban, communications director at Amgen, acknowledged the difficulty that some may have at viewing a positive role for pharma in social media. According to Juan Carlos, there are obvious advantages in participating in social media, for instance with adherence to treatment (medication) in which there are applications being developed and tested. The social networks are an opportunity to educate patients and he reiterated some of the same ideas shared by others during the course. According to him, however, the fear towards entering the social media sphere varies, with institutions being very interested in implementing initiatives. The pharmaceutical industry in Spain has been much more cautious than other industrialized countries in joining social networks like Facebook or building virtual games.

The last interventions attempted to predict the future (always a difficult task, but the organizers tried) with an audience that was still fully engaged in conversation. Javier Bikandi, one of the host organizers proved that it is not only necessary, but feasible to work on innovation with the government. Mapping the social media players, Javier invited participants to review the Basque blogosphere map. Javier mapped the Basque social media landscape and the use of LinkedIn and Facebook by the government health care institutions. A community of knowledge that includes all the professionals in Osakidetza is being implemented as well as other simple web 2.0 tools like wikis. Javier pointed out to what I believe was a consensus in the meeting: the most significant challenges that innovation faces are not in the technological front, but the cultural. We have the tools; the question is how to mainstream their adoption to improve health outcomes and better the systems of care.

Gonzalo Bacigalupe, EdD, MPH (standing third from right in the front row) is an Ikerbasque Research Professor with the Vulnerability to Stress and Resilience Research Team at the College of Psychology and Education, University of Deusto Bilbao; Associate Professor, Department of Counseling Psychology, College of Education and Human Development, University of Massachusetts Boston. Gonzalo is co-senior editor of Family, Systems, & Health. His webpage is at:

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Salud 2.0 Part One: Healthcare Collaboration, e-Patients, and Social Technologies

Posted By Gonzalo Bacigalupe, Thursday, July 21, 2011
For two days in July, The University of Deusto Business School in Bilbao hosted the course Salud 2.0 Euskadi. More than 160 healthcare professionals, administrators, researchers, and business leaders, came to learn and discuss what emerging digital media offers to patients, professionals, and healthcare organizations. The Basque Institute for Healthcare Innovation (o+berry) and TEDxSol organized the conference with Luis Luque (a health informatics doctoral candidate at the University of Tromso) and Manuel Armayones, a researcher from Cataluña. Since most of the contributions to the course were in Spanish as well as the archived stream, interviews, and visuals, with this entry I share my summary of the terrific contributions and ideas for readers in the United States. I believe this is especially significant since the healthcare experts in Spain deal mostly with quality of access and patient care rather than first worrying about insurance access (health access in Spain is written in the Constitution as a citizen right).

Two American "starts” participated: e-Patient Dave deBronkart, a well-known inspiring patient advocate, and Manny Hernandez, founder and director of the Diabetes Hands Foundation. Their work is widely available on the Internet and since it is in English, following their links should be more informative than attempting to synthesize their engaging talks. Appropriately, being patients themselves, they were the ones who kicked off the conference calling for clinicians to listen, stay curious, and be transparent. Dave asked us to advocate strongly for patients to have access to their own health data. His mantra, Gimme my Damn Data, is the subject of a popular and compelling TedTalk.

The Blue Button for Health Data initiative is being promoted by the Veteran Administration and the Medicare and Medicaid Services.

Beginning with their personal histories, surviving cancer for Dave and living with diabetes for Manny, their talks transmitted a contagious resilience. Participating in patient care is the responsibility of everyone, not just those in the healthcare professions. Communities of patients telling their story and utilizing new media productively are not only possible but also sustainable and rich in possibilities. The video Do the Big Blue Test on World Diabetes Day is a great testimony to the potential that social technologies offer in fostering healthcare collaboration and reaching large segments of the population. Their call for networking across the healthcare professional, governmental, business, and citizen spectrums was refreshing and percolated through the whole course. It was also in sync with Kronikoen, the Basque Health System strategy to deal with chronic illness.

Julio Mayol, innovation director, and professor and surgeon at the Clinic Hospital of Madrid and Jorge Juan Fernandez, e-health and health 2.0 director of the Sant Joan de Déu Pediatric Hospital of Barcelona, reported on their efforts to get hospitals closer to patients’ needs. It seems like an oxymoron but often hospitals practices are not designed to collaborate with patients. In the family health systems movement we have discovered that institutions are often designed to prevent collaboration among professionals and to reinforce the expert medical role versus a passive patient one. Innovation is not easy in hospital settings despite the urgent need for reorganizing around family and patient health rather than purely around illness. Julio, citing Shahid Shah, reminded us: "People want more time with their physicians and don’t really care who manages their chart”. Good ideas, as he reported, are not valuable unless someone uses them. Shah provided many examples of how to use social media effectively for research and development in healthcare. He insisted that concerns about reputation are overrated and should not stop us from introducing change.

Jorge Juan spoke about the "liquid” hospital—how a hospital has used information communication technologies to integrate patients as active stakeholders. The liquid hospital is just one of many initiatives that his institution has implemented for 4 years. The information revolution has been disruptive and two variables changed: time and space. What I heard was that we are moving fast towards virtual interactions demanding a change in the doctor’s role; a change not necessarily welcomed. His hospital intends to facilitate the sharing of information to open up new conversations with patients, and to publish its results in the name of accountability. To achieve these goals this private hospital has embraced most but not all the popular social media outlets to share hospital and medical news, to ease patient attention, obtain funding, market new services, and to attract human resources.

Luis Luque and I grounded this conversation in the ethical and social challenges that arise with the mainstreaming of emerging media. Luis addressed some of the ethical problems that arise as patients have access to the same technologies. He showed the example of eating disorder patients who reinforce and normalize their pathology, tobacco consumers that map bars welcoming smoking, and more generally the potential disinformation related to finding appropriate information on the Internet. A YouTube video of a patient at a hospital bed complaining about how he was mistreated by the healthcare personnel created some controversy. For Luis, the video demonstrated the negative side of patient ability to go public bashing health services. For others, me included, the video highlighted the ability of patients to make accountable unresponsive professionals and healthcare organizations. Privacy in patient communities was also mentioned, including the danger of inappropriate use of genetic information. Luis’ questions challenged healthcare professionals to think about privacy of healthcare professionals and of patients.

My presentation asked participants to reflect on issues of health access and quality and the digital divide. The potential of emerging technology is clear, initiatives like PatientsLikeMe and TextforBaby are good examples of social media platforms that can facilitate collaboration in health, and thus the alleviation of health inequity. Does the introduction of social technologies enhance the well-being of all the populations and decrease health disparities? Furthermore, could the integration of Information Communication Technologies in the healthcare setting solidify or widen the healthcare gaps? Vulnerable populations, the ones needing the most increase in access and quality of healthcare, are also those left behind in the adoption of new technologies. Health literacy and digital literacy seem to go hand in hand. Like access to healthcare does not necessarily correlate with quality; access to digital tools does not immediately mean that the user can use them effectively. Often in the implementation of e-healthcare innovations the early adopters are more privileged and typically the ones who benefit the most from the innovation. The implementation of social media initiatives in healthcare requires careful thinking of how to incorporate the less literate and the most vulnerable. In other words, we need to think not of the early adopters, but those often left behind--the most vulnerable.

Introducing e-health into the system of care should be more about health outcomes and less about the technology. This is not a novel idea, but one forgotten in social media healthcare circles. The now head of the Centers for Medicare and Medicaid Services (CMS) Donald Berwick, in article in JAMA (2003) suggested that technology should translate into improved patient outcomes. In Bilbao that morning, indeed there was consensus that technology should be at the service of health and not the other way around. In the afternoon, my workshop on ethical and social dilemmas reaffirmed both the creativity in implementing innovation on the ground and the difficulties we still have in addressing the core issues of access, cost, quality, and health outcomes. There is definitely a hunger for learning about social media, electronic medical records, and other health information communication innovations, but also a lot of fear and lack of support to experiment with them. We heard, for instance that whole health systems are experimenting with the possibilities of social networks (Facebook) to outreach and connect with patients and professionals. Paradoxically, however, the same institutions have imposed filters that prevent doctors, nurses, and administrators to use Facebook in their offices.

The comments of those in the audience with a twitter account (#Salud2eus) and the ones watching on their computers added to the richness of our face-to-face conversation. The engagement was certainly horizontal; similar to the one we lived through the conference face-to-face. The live stream and the virtual discussion that accompanied the presentations gave testimony to the possibilities, but also the challenges ahead of healthcare innovation. The design of the conference demonstrated too that the collaborative conversation with the elimination of professional silos could occur in a respectful as well as rich critical way.

Photo Link 1:

This is part one of a two part series on integration and social technologies. Read part two of Salud 2.0 next week.

Gonzalo Bacigalupe, EdD, MPH (third from right in the bottom row) is an Ikerbasque Research Professor with the Vulnerability to Stress and Resilience Research Team at the College of Psychology and Education, University of Deusto Bilbao; Associate Professor, Department of Counseling Psychology, College of Education and Human Development, University of Massachusetts Boston. Gonzalo is co-senior editor of Family, Systems, & Health. His webpage is at:

Tags:  health information technology  Social Media  technology 

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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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Contact Us

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

What We Do

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