Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT,
Thursday, June 23, 2011
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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
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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.
This post has not been tagged.
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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Posted By Ben Miller,
Thursday, May 5, 2011
Updated: Wednesday, May 25, 2011
| Comments (1)
Think about it.
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.
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
challenging our ability to hear healthcare innovation? When resources
are scarce, does infighting and, in turn, wars start to trump the
mental health integration
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.
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
Innovate, but please don’t yell.
|Ben Miller is a daily blogger at
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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Posted By Kenny Phelps,
Thursday, April 28, 2011
Updated: Wednesday, May 25, 2011
| Comments (1)
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.
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.
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
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?
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?
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
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.
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.
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.
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.
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.
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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Posted By Cassidy Smith,
Thursday, April 21, 2011
Updated: Friday, June 10, 2011
| Comments (1)
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
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
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
- 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.
- 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.
- 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.
- 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
- 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
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Posted By Randall Reitz,
Thursday, April 14, 2011
Updated: Wednesday, May 25, 2011
| Comments (2)
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.
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.
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.
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.
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).
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’.
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.
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
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.
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.
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.”
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!
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;
the accreditation requirements for graduate medical education requires
that we document each aspect of our curriculum and our residents’
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
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.
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?”
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.
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.
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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