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

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

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

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

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

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


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

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

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




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

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

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

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

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

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

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

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

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

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

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


Today:
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.

Tags:  family therapy  medical 

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Medical Family Therapy Intern, Part 1: How Did I Get Here?

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

November 2010:

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

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

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

Rewind several years:

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

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

Back to November:

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



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

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How Having my Team at My Healthcare Home Helps Me

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

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

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

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

Here are the benefits of having a healthcare team:

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

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





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"A Little Cheese with your Whine?"

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

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

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

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

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


Family Health Blog

Jennifer Hodgson, PhD, is a licensed Marriage and Family Therapist, Associate Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University, and President of CFHA.

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

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

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

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

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

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

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

Below is a letter written by a client:

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

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

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

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

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


Your soon to be ex-friend.


Peter Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.

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Cacophony Healthcare

Posted By Ben Miller, Thursday, May 5, 2011
Updated: Wednesday, May 25, 2011
Think about it.

During the healthcare debate, after the healthcare debate and all in between, there have been voices whispering (or yelling) their opinion on healthcare.Nowhere is this more prevalent than in discussions around the integration of mental health and primary care. These are two worlds of healthcare delivery that are in desperate need to intersect.

There are many voices speaking up on what they believe needs to be done, but is the loudest voice getting the most attention? Is this an example of cacophony challenging our ability to hear healthcare innovation? When resources are scarce, does infighting and, in turn, wars start to trump the community’s needs?

While mental health integrationwas not a topic discussed openly during the reform debate, it is an underlying issue that, like the 400 pound purple gorilla in the room, cannot be ignored.
States, like Virginia, are not providing adequate mental healthservices for children. Iowa is reforming their $1.3 billiondollar mental health system because it is flawed. And it goes on and on and on and on.

It is time to harmonize. It is time to "clean out our ears” and start to listen to the needs of the community. There is a broken system out there that needs our attention. Mental health is in need of innovation. Healthcare might be willing (and dare we say able?) to take on this task of integrating mental health. What will this look like? How will we do it?

Innovate, but please don’t yell.


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




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Questions of Collaboration at a Distance

Posted By Kenny Phelps, Thursday, April 28, 2011
Updated: Wednesday, May 25, 2011
Professionals in the collaborative field often speak of moving from silos to co-located and eventual integrated care, especially within the patient-centered medical home. I had the privilege to "come of age” as a therapist in integrated primary care settings. My clinical placements were alongside dieticians, health educators, nurses, physicians, and other health care providers. I found myself intrigued with intervening to control HbA1cs and BMIs through systemic interventions as much as assisting with couple and family discord.

An advantage of this training was to increase my awareness of systems of care and the full biopsychosocial picture. It also taught me about effective (and ineffective) collaboration. A disadvantage of this training was fewer instances of needing to collaborate at a distance. This would be understandable since colleagues were often in the room or down the hall, co-creating treatment plans. However, my acceptance of a position in an academic psychiatry context pulled me away from my primary care roots, as well as the easy access to these providers.

Certainly, my current role includes a great deal of multidisciplinary teamwork under the same roof, including psychiatrists, psychologists, family therapists, social workers, rehabilitation counselors, families, and patients. One could argue that mental health centers serve as the patient-centered medical home for many with chronic and persistent mental illness. This has been the impetus for integration of primary care providers into these environments. However, many individuals treated in our academic clinic present with acute clinical problems, such as adjustment disorders, major depression, panic disorder, or couple and family strife. In these circumstances, patients typically identify the primary care setting as their "home” for medical care. This fact has necessitated creative ways of linking care between primary and specialty care, as to not fall victim to the "out of sight, out of mind” problem.

On a systems level, we are integrating some of our providers into OBGYN, Family Medicine, and Pediatric settings to improve screening and treatment. We also have plans to use telepsychiatry to provide effective care at a distance. I have been involved with giving lectures on The Role of the Consultant Psychiatrist in Integrated Care, thereby increasing our residents’ exposure to the burgeoning efforts to meet patients were they are. While systems level changes are surely essential for improved healthcare, I believe that individual provider must take initiative to link with others while delivering care. Thus, I have developed a few questions that assist me in my clinical practice:

WHO needs to be talking to provide the best care possible?
This first question is the foundation for good collaboration in my opinion. The answer will likely be as divergent as patients’ presenting problems. For instance, a child with oppositional behaviors, asthma, and Asperger’s might warrant collaboration between a therapist, pediatrician, and school teacher; whereas, an adult with panic disorder, hypertension, diabetes, and significant suicidal ideation might warrant collaboration between a family physician, psychiatrist, therapist, and nutritionist. Thus, this is a question I ask myself and will also ask the patient during an encounter. The answer to "Who do you think needs to be talking to provide you the best care possible?” is often answered with "maybe you should talk to my husband, pastor, or friend.” I believe this reiterates the importance of including patients and their support systems on the health care team.

WHAT information should be shared with my collaborators?
The amount and type of information shared when collaborating at a distance often depends on the recipient. Considerations for this question include: What information is relevant to my collaborator? What can I share given limitations on confidentiality? What can I share given the amount of time to collaborate? Too much or irrelevant information may be met with frustration by collaborators, whereas relevant and pertinent information can improve treatment plans. Beyond shared information, the question "What information do I need from my collaborators?” is vital as well.

WHEN should collaboration occur? I typically try to contact collaborators when there has been a significant change to my treatment plan or I have the sense that there have been significant changes to their treatment plan. Beyond the frequency of collaboration, the specific time to collaborate can also be important. For example, I typically do not phone school teachers in the middle of their academic day, but either first thing in the morning or directly after school has been dismissed. If there are specific collaborators that I need to speak with regularly, I might ask "When would be the best time to reach you?” to avoid the familiar and frustrating game of phone tag.

WHERE are collaborators located? Since I prefer face to face collaboration, sometimes I like to ask where my collaborators are located. Collaborative care is a relational process and building these connections is an important piece of any practice. Thus, I will sometimes ask a family physician across town that shares 4-5 patients with me to meet for lunch or will ask a pediatrician if I can stop into their practice on a Monday morning to chat about our shared patients for a few minutes prior to starting our respective responsibilities for the day. While this is not always feasible, I am surprised that colleagues are often 5 minutes down the road.

WHY should I bother? This is probably my favorite question. Historically, I have worked with behavior change in my clinical work. This has involved talking at length with patients who may be precontemplative or contemplative about changing habits of smoking, overeating, or medication nonadherence. I am certainly not exempt from these stages of change either. There have been many instances where I was precontemplative about having to pick up the phone or write a summary letter to a colleague. Thus, asking oneself "Why is this important?” can be especially useful. Even utilizing strategies such as advantages/disadvantages analysis can spin us into preparation or action stages of change.

HOW should I collaborate? Once I am aware of the who, what, when, where, and why elements of collaboration, the final step often involves how I should collaborate. Commonly used strategies include phone consults, summary letters faxed or mailed, or creating a notebook for the patient or family to carry from appointment to appointment. In our setting, we have developed a simple form that includes the patient’s name, appointment date, DSM diagnoses, medication changes, vitals, and other comments (goals, strengths, follow-up) that can be easily completed and faxed to the primary care office after a first appointment. Formulating protocols or forms such as these can ease the process of collaboration at a distance.

While delivering clinical services in an integrated care system has clear advantages, elements of our health care system will always operate at some distance. Electronic health records could significantly diminish this dilemma. Until these technological advances take hold, individual providers can go a long way to improve communication and the overall cohesion of care. I leave you with one last question: "Why did you decide to do what you are doing?” For many of us, it was to provide patients and families with relief from their medical or psychological struggles. In order to do so, we need to collaborate no matter the distance…whether next to one another in an exam room or many miles away.


Kenneth W. Phelps, Ph.D. is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina. He was trained as a Medical Family Therapist at East Carolina University.  Dr. Phelps has been a member of CFHA for many years and currently chairs the Membership Committee.


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Beyond a Fad: How Integrated Care Can Swim to the Mainstream

Posted By Cassidy Smith, Thursday, April 21, 2011
Updated: Friday, June 10, 2011
The concept of "integrated care” seems to have joined the ranks of smartphones and iPads. Like those nifty devices, integrated care is innovative, effective and sought-after -- yet, not everyone can afford it.

In plain English, integrated care is a way of providing health care services that engages individuals and their caregivers in the full range of physical, psychological, social, preventive and therapeutic factors necessary for a healthy life. Within health circles, integrated care has become "all the rage” in Colorado. To illustrate the proliferation of integrated care, the Colorado Behavioral Healthcare Council mapped some of the numerous efforts underway to integrate physical health and behavioral health care services.

Supporting the delivery of integrated care has been a funding priority for the Colorado Health Foundation in recent years. Yet, while grantees rave about the positive impact integrated care services have on patient health and provider morale, they consistently report it is difficult to maintain these kind of services due to reimbursement limitations and the complex nature of billing health plans. National data tells a similar story. A 2010 article in Psychosomatic Medicine by Roger Kathol, MD, concluded that correcting disparate physical and behavioral health reimbursement practices is crucial for the survival of integrated care.

On April 8, the Colorado Health Foundation along with the Collaborative Family Healthcare Association, the Colorado Psychological Association and the Colorado Academy of Family Physicians convened a summit of nearly 100 Colorado primary care and behavioral health providers, health plan administrators, nonprofit leaders and policymakers to talk about the challenges associated with sustaining the delivery of integrated care services.

Here are some of the conclusions summit participants reached on how to make integrated care the expected standard of care for all Coloradans:

  1. Change culture of behavioral health -- Negative judgments of those with a mental health condition or substance-use disorder persist among the general public as well as health care and social service providers; despite knowing these conditions can be treated and prevented like any other health condition.
  2. Train providers to deliver integrated care -- Most physical and behavioral health providers have not been trained to work together in teams to provide integrated care services.
  3. Test new payment models – Current reimbursement practices hinder the ability of physical and behavioral health providers to work effectively as teams to deliver timely care to patients.
  4. Get support of the business community -- As employers, businesses are significant purchasers of health care services and can benefit the most from positive health outcomes and cost savings associated with integrated care.
  5. Encourage public to demand change – Many individuals have not had the opportunity to experience integrated care. Therefore, they do not know that it is the optimal way to deliver care.

The Colorado Health Foundation is partnering with the Collaborative Family Healthcare Association to take a closer look at the financial barriers impeding the delivery of integrated care services. Over the next year, Collaborative Family Healthcare Association will work with a broad group of Colorado stakeholders to summarize the financial barriers to integrated care delivery; identify potential policy fixes; and build a financial case for changing current reimbursement practices.

Hopefully, this new effort will help move integrated care from "the next cool thing” to the normal way of doing business.

Cassidy Smith is a public policy officer at the Colorado Health Foundation where she works with a broad group of stakeholders to advance public policies to improve access to quality, affordable health care services. Before joining the Foundation, she was special project coordinator in the Medicaid office at the Colorado Department of Health Care Policy and Financing. Cassidy earned her master's degree in Health Policy and Administration from the University of Illinois School of Public Health.

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It's Not Compulsive If it's Helpful, Right?

Posted By Randall Reitz, Thursday, April 14, 2011
Updated: Wednesday, May 25, 2011
OK, true confessions. When engaged to marry as an undergrad at Brigham Young University (at BYU you’re either married, engaged, or actively pursuing engagement) I took a course titled "preparation for marriage”. The class content was outstanding, and included a mixture of communication training, family-of-origin orienting, sexuality awareness raising, and expectation lowering.

Despite the bounty of helpful science that was shared, only one off-hand comment remains specifically lodged in my consciousness. The teacher, a slender woman in her 60’s, made the observation that if a person only puts on 1 pound per year after marriage, by mid-life he or she will be overweight, and before dying will be morbidly obese. I did not want to be morbidly obese.

That being said, awareness of a potential problem is rarely sufficient for avoiding said problem, see: overweight doctors, stressed-out therapists, and bankrupt accountants. Ten years (and a divorce, remarriage, and child birth) later I found myself exactly 10 lbs heavier than when I sat in that fateful class.

While the premarital education hadn't had its intended effect, the moment of epiphany did. For the first time in my life I started jogging regularly. I began by running 2 to 3 miles around a local park a few times each week. In the process I found a partner who shared my running cadence and my interest in centrist politics, post-modern Mormonism, and raising children to be nerds. Six a.m. runs became the highlight of my week.

To keep track of my progress I started a simple spreadsheet for recording how often I ran, times in races, and occasionally a weight. Eventually I added graphs to the spreadsheet because I found the downward slopes motivating. Over time the spreadsheets became more sophisticated, including an automatically tallied point system for all forms of exercise, and monthly goals for points (100), days with at least 1 point (90%), and ratio of running vs other forms of exercise (1:1). I was in heaven (see: "raising children to be nerds” above).

Over the first few months I lost the 10 pounds and over the next 5 years my weight was homeostatic. As every first-year systems therapist learns, homeostasis is not stagnancy, but variation within limits. My limits were up or down about 2 pounds. When I moved to Frisco, Colorado my weight dropped another 5 pounds, I believe because of higher metabolism from living at 9,000’.

In the last months of my mountain years my work demands had become so consuming that I discontinued tracking my exercise and weights. Then, I moved back to Grand Junction and started my current job where I have unfettered access to free food in the hospital cafeteria. Within 6 months of stopping the spreadsheet, my weight was back up the 15 pounds that I had lost, and I was back on my way to the dreaded pound per year.

So, I brought back the spreadsheets, and for the first-time, I started weighing myself everyday. I was quickly able to re-gain my sporting lifestyle and re-lose the weight. With this close observation, the weekly average for my weights narrowed to a 1-pound range. Proof positive of the axiomatic, "that which is tracked moves in the desired direction”.

Admittedly, I do more than just track. I’m also 1.5 years into a habit of only drinking water and milk. When my weight gets 2 pounds over my goal weight I don’t eat sweets for the day and remind myself of this deprivation by writing "NST” (no sweets today) on my hand with a marker. This common medical acronym is cause for concern for my colleagues who are unaware of my habit and of laughter and reassurance for the previously initiated.

I had it all figured out.

And then, one day I was in the precepting room of my residency program—consulting with the young doctors regarding the behavioral issues of their parents. I felt a twinge of pain in my lower left flank. I quietly got up, did a lap around the clinic and returned to the precepting room massaging my side and walking with a slight hitch. One of the more brilliant faculty physicians looked up from her computer saw my gait, observed "you have a kidney stone”, and went back to her computing. Within 5 minutes I was writhing on the exam room floor, getting a rushed testicular exam from a colleague (evoking thoughts of how adolescent girls must feel in the back seat) and limping off to get a CAT scan while clutching a vomit-filled garbage can.

My wife still gets upset when women tell her that kidney stones are worse than labor pains.

Looking back, I make sense of this occurrence as the defining moment of when healthy, fastidious habits devolved into compulsive behavior. According to the DSM-4, repeated thoughts and behaviors aren't classified as obsessions and compulsions unless they cause distress or disruption in the person’s life. Or, more technically: "The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.”

Sometime in the previous 6 months, I had become so committed to maintaining the weight that I wanted, that I had taken up a bad habit. As my spreadsheet only included the lowest weight for the day, on days when I didn't like my morning weight I would put off eating and drinking in the morning and weigh myself again before lunch. Worse, on weekends my lowest weight was at the end of a long trail run. If I didn't like the weight before the run, I wouldn't drink much water during the run and then wouldn't re-hydrate until I got back on the scale.

In recounting, these steps are embarrassing, but worse, I’m convinced that they contributed to my developing kidney stones. This same family doctor who diagnosed me has helped with my on-going treatment. She informs me that one of the most important steps in preventing new kidney stones is to drink large amounts of water. Ugh!

One year later, I’m still as meticulous about tracking exercise and weights, but I've made an accommodation to ensure that my approach is more healthy. I now weigh myself only 1-time per day—first thing in the morning before breakfast or any exercise. This, then stimulates extra water drinking because I find that it helps fuel my exercise and temper my appetite.

What on earth does this have to do with collaborative care?

Well, as a therapist in an integrated family medicine residency, I’m constantly aware that it is a compulsive milieu:
  • We track all our warm introductions, joint appointments, and inter-disciplinary consults for grants;
  • The EMR and patient registry "tickles” us to pay attention to minute details of patient care;
  • Fear of a bad outcome or a litigious patient prompts extra tests and images;
  • We’re now sigma six and "lean” trained to practice healthcare using the same processes that pilots use to avoid crashes;
  • Meeting the accreditation requirements for graduate medical education requires that we document each aspect of our curriculum and our residents’ evolving competency.
Like my spreadsheets, this attention to detail is helpful. It helps to ensure efficiency, patient safety, and fidelity to our healthcare model. But, at some point the demands pile-up to an extent that one barely has time to look up from the computer screen to collaborate with a colleague or to motivate a behaviorally-challenged patient.

For example, our new EMR is so time-demanding that laptops are now ubiquitous at our resident education days. At last week’s session 19 of the 20 participants were only nominally aware of the presentation because they were "working their boxes”.

Pursuit of best practices can result in worst practices.

A wise man once asked: "If a son shall ask bread of any of you that is a father, will he give him a stone? or if he ask a fish, will he for a fish give him a serpent?”

Obviously, people who choose to practice in primary care, do it to offer our patients bread and fishes: we aren't in it to offer stones or serpents to the unwell. But, neither did I start tracking my weights to give myself a stone.

When we find ourselves with a stone, we need to step back, re-calibrate, and return our focus to the pole-star. As we consider the excitement of each new healthcare innovation (PCBH! PCMH! ACO! EMR!) we do well to remind ourselves that the indelible center of healthcare is the relationship between the patient, the family, the community, and the clinicians who have the privilege of joining them in the pursuit of wellness.

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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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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.