Posted By Parinda Khatri, PhD,
Thursday, July 14, 2011
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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.
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
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.”
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.
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.
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.
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.
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
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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Posted By Peter Y. Fifield,
Thursday, July 7, 2011
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A client once told me, "Humans pray for outcomes and God laughs. Now that’s 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
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.
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.
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!
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.
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.
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
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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Posted By Randall Reitz,
Thursday, June 30, 2011
| Comments (2)
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:
care is clinically inappropriate it fails.
care is not operationalized properly, it also fails.
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.
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.
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.
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
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
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
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:
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”.
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.
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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Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT,
Thursday, June 30, 2011
| Comments (1)
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.|
Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT,
Thursday, June 23, 2011
| Comments (0)
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.
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.
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.
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.
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.
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.|
Posted By Lisa Zak-Huner,
Wednesday, June 15, 2011
| Comments (0)
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.
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.
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
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.
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.
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.
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
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.
Posted By Lisa Zak-Hunter,
Thursday, June 9, 2011
Updated: Friday, June 10, 2011
| Comments (0)
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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Posted By Brandi Hilbert,
Thursday, June 2, 2011
| Comments (1)
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
- 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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Posted By Jennifer Hodgson,
Thursday, May 19, 2011
Updated: Wednesday, May 25, 2011
| Comments (1)
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!
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.
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.
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.
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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Posted By Peter Fifield,
Thursday, May 12, 2011
Updated: Wednesday, May 25, 2011
| Comments (2)
We are all aware of the dangers of smoking. Yet the
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.
exposure is not the only danger.
and the newly implicated
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.
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
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
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.
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:
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.
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.
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.
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.
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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