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Why American Health Care Costs So Much

Posted By Lewis Mehl-Madrona, Thursday, April 7, 2011
Updated: Friday, June 10, 2011

We spend so much more time talking about how to pay for health care in the United States than we do wondering if what we get is worth what we pay or how to make health care more cost-effective. My fields are family medicine and psychiatry, and, to my chagrin, rarely do the two specialties communicate. Here’s an example that cost the health care system enormously. These kinds of situations arise commonly.

Recently a mother became concerned about her son who was feeling sad. She talked to him enough to learn that he was being bullied at school and that sometimes he wondered if it wouldn’t be better not to be here. She took him to their family doctor who said he didn’t do mental health and she would have to take her son to the emergency department at the hospital so he could get services.

At first this sounds crazy, but in our health care systems, the fastest way to get an appointment at the community mental health center is to go to the emergency department. Otherwise, one waits months for an appointment (at least where I work). It’s more questionable for the family doctor to say, "I don’t do mental health.” We have extensively training in handling mental health issues during our three year residency. In Canada, where residency training is only 2 years, family doctors are expected to manage all mental health issues with psychiatrists available only as consultants, and actually do so.

So, the mother took her son to the emergency department. They waited five hours to finally see a physician. He asked the son a few questions. The coup de grace came when he asked the boy if he ever felt as if it would be better if he were there. The boy agreed. Sometimes he thought that way. The physician left the room for an hour and returned to announce to the mother that he was transferring the boy to the regional psychiatric center by ambulance, because of his suicidal ideations. The mother objected. "I can take my son in our car to somewhere else to be evaluated, just like I brought him here.” The physician left the room and returned with a social worker and two security guards who told the mother that she would be arrested and detained if they interfered with the transfer of her son by ambulance and that Child Protective Services would be involved because of her failure to recognize the gravity of the situation and that her son needed immediate treatment. She acquiesced and followed the ambulance in her car. By now, her son was terrified.

At the Regional Psychiatric Center, they waited another 5 hours before they saw a social worker who took the history. Then a physician in training (called resident physician) came to talk to the boy and her. After a total of eight hours at the Regional Psychiatric Center, they were allowed to leave with a prescription for 5 mg of escitalopram, a selective serotonin reuptake inhibitor (Brand name, Lexapro) and some names of some private therapists to call in their home community. Imagine the charges stacking up. The family doctor billed for an office visit. The emergency department charged almost $2000 for their evaluation. The Regional Psychiatric Center charged $2500 for their evaluation. The ambulance transfer had cost $500. The prescription cost eighty dollars.

At the Regional Psychiatric Center, the social worker and the resident physician had managed to figure out that the child had no plan to kill himself, but only sometimes wondered if it would be better to cease to exist. In fact, until his encounter with the psychiatric system, the child had not actually considered that people really killed themselves. His concept had been more wistful and fanciful as he wondered if it would be better not to exist. Presumably others have wondered the same thing without benefit of Regional Psychiatric Care. The mother’s observation was that each time she was transferred her caregivers seemed younger and less experienced. At the same time, with each transfer her son was becoming more and more frightened.

In the end, after an extra $6000 in billing and probably the worst day of this mother’s and this child’s life, the end result could have happened in the family doctor’s office. He could have listened to the mother and the child and could have made a determination that these thoughts were not connected to a plan or to an intent to die, but rather an expression of how miserable the child felt. He could have written the same prescription since this drug is widely detailed to family doctors with instructions on its use. He could have given the mother names of psychotherapists in the community to call. In an enlightened office, he could have had a therapist on call for his office or visiting on a regular basis each week to handle these kinds of situations.

Why didn’t he? One explanation is fear of malpractice. That drives much of the insanity in American health care and is not so nearly a problem in other countries. These other countries have social networks to care for people who are injured in medical mishaps. We don’t. The only choice available to our injured patients is to sue. Another explanation is the silo model of American medicine. Each specialty keeps to its own domain somewhat exclusively. Internists don’t talk to psychiatrists and don’t treat psychiatric disorders. Similarly, psychiatrists don’t talk to internists and don’t treat medical disorders. However, the body is one. The arbitrary separations we create do not actually exist in nature.

If we are going to actually afford an accessible health care system, we will need to address these questions of how care is delivered. Failure to do this will bankrupt our healthcare budget.

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Restorative Justice: A (Surprising) Example of Collaboration in the Justice System

Posted By Troy Sanders, Thursday, March 31, 2011
Updated: Friday, June 10, 2011

The idea of working collaboratively has obvious merits in the healthcare field; after all, the purpose of all healthcare providers is to improve the outcome of their patients. Patients or consumers should be seen as natural partners in their own care, especially in the realm of mental wellness as the efficacy of many treatments can depend entirely on what a consumer communicates to their friends, family and healthcare providers. Full and honest communication is essential in this context, as difficult as that can be at times.

Where the idea of collaboration tests our Western notions is the field of law. Our justice system (and this applies both in Canada and the United States) is predicated on two uniquely Western (i.e. owing their origin to the Greco-Roman concept of dualism) principles: 1. our rights system is centred on the individual and 2. our system is constructed in an adversarial fashion. In this light, medicine and law could scarcely be farther apart in their philosophical orientation.

However, when we examine judicial practices of other societies and traditions, we find another lens through which to aid our search for justice. These principles state the community, not the individual, is the centre of the social and legal structures. It then follows, if a community is composed of many people, that each person is not an insular individual but one of many community members. With this framework, one can use the medical analogy of a community being "the body” while the community members are the disparate parts of the body – organs, limbs, skeleton, neurological network, etc.

This organic understanding of community and people immediately challenges our current legal regime. The heart does not exist separate from the lungs, nor brain, nor mouth from the stomach. All are connected and work together, not in competition. These are the central themes of Restorative Justice (or RJ). Participants work together, communicating, each sharing their concerns and wisdom for the benefit of the larger whole. RJ does not say "A law is broken, thus comes punishment”. RJ states "someone has harmed another and by extension, the community”. A conversation then develops among the person(s) who have made a poor choice, those who have been harmed and other members of the community. It is essential to note the action (or choice) and not the individual is judged.

With honesty and compassion, the group examines what went wrong (regarding the incident itself but also within the person’s life) and what led to their poor choice. The person learns who has been harmed, how they have been impacted and through this process, learn how their actions affect others. The process reinforces the sense of community as well as allowing the person a chance at sober second thought and reflect on their mistakes. The talk then leads to ways the person can heal the harm. Again, this is not punitive. Sometimes, when a wrongdoer learns how they have hurt others, they proactively ask what they can do to make things right. Where one system would have crafted adversaries, RJ can, at its best, forge new alliances and strengthen everyone impacted in the end. RJ sees conflict not as something to eradicate, suppress or "deal with”, rather, it is a catalyst for personal growth.

We thus have a working model for collaboration in two critical fields in our society. This is an excellent start, but not without radical challenges. In a society structured around a competitive, "me first” mentality, "do your best” is often confused with "be the best”, while the ends too often justify the means (we will forgive winners for minor mistakes sooner than noble losers who failed to succeed). Frankly, in a society eager to infuse Sun Tzu’s The Art of War into new areas of public life, it is a wonder how any seeds of collaboration could grow in this hostile field of abject narcissism. It has taken far too long for science to see nature and nurture as anything but an either/or problem, an excellent example of the tendency to default to such dualistic thinking.

Any attempt in our society at working collaboratively runs against the grain. This is unfortunate but true. Yet this must always be kept in mind, especially by those of us who have fully embraced collaborative practices. It can be easy to give up when fighting layers of bureaucracy rooted in competitive assumptions. Privacy laws assume information will be used for the gain of one and at the expense of another. Never would we assume information would be shared among partners working collectively with one in need. Instead of building bridges to communication, we erect impenetrable silos as "protection”. We fail to see the void between silos as gaps too many fall into, never to recover.

Yet as difficult as it is to work together, there are thousands of years of wisdom which encourages us to do so. Many elements of RJ (and theories of collaborative practice in general) find roots in indigenous customs millennia old. These teaching models grew from resilient cultures who saw communities as central figures, yet valued each community member for the contributions they add to the whole. Working with one another came much easier to them – forging not only an enlightened environmental awareness, but also a social awareness in much the same way. We spend so much time proving the value of collaboration not because its value is questionable, but because we have forgotten we live in a social ecosystem, connected to everyone and everything else. When our first reaction is focused on the collective instead of the individual, everything will change.

When we ask "how can I help the community I am a part of” (whatever community means at that moment) instead of "what’s in it for me” our treasury of collective wisdom will explode exponentially and our ability to help one another will grow in equal measure.

Troy Sanders is a mental health consumer working with ADD, Depression and Social Anxiety. He holds both a B.A. and a L.L.B., degree; although he chooses not to practice law. He recently discovered a deep interest for Restorative Justice; a collaborative parallel to mainstream judicial processes and he has been an RJ practitioner for close to 5 years now. Writing is a passion of his.

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For Patients' Sake... Let's Get on with Collaboration

Posted By Roger Bland, Thursday, March 24, 2011
Updated: Tuesday, April 12, 2011
Primary care, provided that it is accessible and available, improves population health. Primary care includes but is not limited to family physicians. In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder. Of that 35%, 93% were seen by a family physician and had a major diagnoses of an anxiety disorder, mood disorder, substance use disorder, schizophrenia and psychosis or cognitive impairment.  
 
The World Health Organization has nevertheless drawn attention to this "treatment gap"; the high proportion of people even in developed countries who have a treatable disorder but do not get treatment. The severity of cases and the diagnoses of those seen in primary care differ from those seen in specialist care yet the diagnostic systems and criteria are more oriented to specialist practice than to primary care. Family physicians in Canada have highlighted problems with the mental health system including lengthy delays for consultations, inaccessibility of psychiatrists and poor communication following referral.

The Canadian Psychiatric Association and the College of Family Physicians of Canada have worked together to improve care for patients with a mental health disorder and have strongly advocated for shared care or collaborative care where psychiatrists and mental health practitioners work closely with primary care physicians and services. There are several goals associated with this which include facilitating early treatment, achieving better outcomes, reducing stigma and ensuring that patients are receiving the most appropriate service in a timely fashion in a setting that is congenial and avoids stigma. Considerable effort has gone into ensuring that specialists services support primary care and primary care physicians rather than meeting the needs of specialist programs.

"In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder."

Several different models have emerged.  One model uses a relocated consultation service.  Although it may perhaps be the simplest concept it has not necessarily proved to improve services or outcomes.  Another type of service includes placing mental health workers into primary care practices. Reports on this are variable depending on whether the services are designed to collaboratively support primary care or just be embedded in primary care but doing their own thing.
 
One of the better models seems to be where a psychiatrist and/or other mental health professionals are attached on a full or part-time basis to a primary care practice or practices and provide ongoing formal and informal consultation and support along with other aspects of psychiatric patient care. Integral to any of these services is that the individuals involved need to get to know each other and build trust and confidence. It is clear that when the various components are well coordinated it is reflected in how the patients feel about the service with greater satisfaction.
 
Research evidence is available but limited. Where a particular disorder, for example depression, is being treated with a standardized protocol and ample supports it is clear that patient outcomes are improved. Often the research project ends and those involved do not continue to follow the same protocol. Where there is close collaboration patient satisfaction studies tend to show positive results which is also often the case when additional service availability (for example counseling or housing services) are built in to primary care setting. Clearly role definitions are important.  Specialty mental health services will continue to play a significant role in the management of difficult cases--specifically those where patient needs are very high which are often associated with psychoses and dementias.

For cooperation to succeed there needs to be strong positive attitudes on the part of the practitioners involved and good administrative support including financial support from those bodies responsible for funding health care. The rapid growth of collaborative care arrangements in Canada suggests that there is a strong belief that this approach can help those with mental health problems.

Roger BlandDr. Bland is Professor Emeritus and former Chair of the Department of Psychiatry at the University of Alberta. His research interests have included epidemiological studies, long term outcomes and mental healthcare utilization including collaborative care.  He has served as a CPA member of the CWGSMHC for the last decade.

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Supported Self-Management of Depression and Anxiety

Posted By Dan Bilsker, Wednesday, March 16, 2011
Updated: Friday, June 10, 2011

After spending 25 years as the psychologist in an emergency psychiatric unit, as well as treating depressed individuals with Cognitive Behavioural Therapy, it has become clear to me that our North American health system does a poor job of sharing knowledge regarding effective methods for individuals to manage their own psychological difficulties. Our systems are heavily focused upon delivering treatments, generally pharmacological ones, and often leave patients in a passive role. If all we expect a depressed individuals to do is be adherent to prescribed medication, we are missing the boat in terms of the potential for collaboration between healthcare provider and recipient.

It is worth noting that antidepressant medication, the most widely applied treatment for depression, is not particularly effective for milder cases, although it does have the same worrisome level of side effects. Given the high rate of sexual dysfunction associated with antidepressant medication, one would like to be confident that the benefit outweighs the risks of reduced quality of life, impaired self-esteem and damaged relationships. At least within the Canadian system, the vast majority of depressed individuals have no practical access to evidence-based behavioural interventions. It is crucial that healthcare providers have training and support to deliver behavioural interventions. One such alternative is the intervention we refer to in our research unit asSupported Self Management (SSM).

In SSM, the health care provider (typically in the primary care system) serves as a facilitator and "coach” for the patient in learning and applying mood self-management skills. There is a significant amount of outcome research supporting this approach. Our research unit has conceptualized this as a form of collaborative knowledge exchange between policymakers, researchers, health care providers and care recipients—we have focused our investigative efforts upon methods for fostering this kind of knowledge/practice exchange among key stakeholders. We developed a depression self management tool (Antidepressant Skills Workbook) that is available for free download from our website as well as several variants for particular contexts and populations: depressed adolescents (Dealing With Depression), depression in the workplace (Antidepressant Skills at Work); and depression or anxiety difficulties associated with chronic illness (Positive Coping with Health Conditions). The basic adult workbook is available in several languages and as an e-book – all of these tools are free. Also available on this website is a relaxation training audiofile and self-help guides for dealing with suicidal thoughts.

Approximately 100,000 copies of these various workbooks have been downloaded from the website over the past six years. With support from healthcare agencies, we have trained over 500 family physicians to deliver SSM to their depressed patients. We carried out an implementation study to determine the degree of update one could attain using sophisticated knowledge exchange strategies: we studied 85 family physicians who each received a one-hour training session and access to the workbook for enrolled patients (an envelope the patient could return for a copy of the workbook). These physicians distributed the request envelopes to 1300 patients over a six-month period, and 55% of these patients sent back the envelope to request the workbook. This degree of adherence to a prescribed therapeutic action is comparable to the adherence to prescription of antidepressant medication. Given the minimal cost in time and financial resources of this system intervention, we consider this to be an impressive outcome. The bottom line is that dissemination and support for psychological self-management should be a core component of all mental health systems. Collaboration in mental health care should include not only primary and specialist care providers, but also care recipients.

References

Bilsker, D., Anderson, J., Samra, J., Goldner, E.M., & Streiner, D. (2008). Behavioural interventions in primary care. Canadian Journal of Community Mental Health, 27, 179-189.

Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S & Lovell, K. (2007). What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychological Medicine, 37, 1217-1228.

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Canadian Mental Health Shared Care: A Beginning

Posted By Gary Mazowita, Thursday, March 10, 2011
Updated: Friday, June 10, 2011

The upcoming Halifax Collaborative Mental Health Conference both exemplifies and showcases the kinds of changes that are currently taking place in the Canadian healthcare system related to mental health. After a decade of "talking about” the changes necessary to ensure ongoing sustainability in the face of an ageing population and evermore expensive and sophisticated tests and treatments, things are finally happening in visible fashion, in virtually all areas of the country.

A cornerstone of change in all locales is "collaboration”. Such collaboration is not narrow, but rather attempts to engage a broad swath of society at large: family doctors, specialists, other healthcare providers such as nurses, nurse practitioners, psychologists, pharmacists, social workers, and perhaps most importantly, families and patients.

In many ways, mental healthcare has been the "crucible” of change…..perhaps largely because the need was so pressing, and the existing delivery models so stretched, and even dysfunctional.

Fascinating to me has been the apparent willingness of the mental health consumer population to accept, and even endorse, certain aspects of the "medical model of care”. Historically, the term "medical model” has conjured up values of paternalism, dogma, and elitism. Now, it seems, there is exciting openness to some of the "good” things possible from certain aspects of this model, particularly in the domain of "chronic disease management”. Elements include active patient engagement, self-management, goal-directed choice, recall systems, planned proactive management, attention to routine primary care, and a range of collaboratively-oriented providers.

It is fair to say that there is now more interest in mental health, and in collaborative mental health models of care specifically, than has ever been the case in Canada.

If this "cultural change” continues (and it surely will, if we expect to enjoy the benefits of our publicly funded healthcare system) then the next decade will likely witness a transformative change in mental health service delivery, and in stigma reduction as well.

In my province alone (British Columbia), some noteworthy developments have been:

  • Tools and supported office change for family doctors and their Medical Office Assistants (MOA). These have been extremely well received, and are available under "Practice Support Program’ at www.gpscbc.ca. One particularly exciting element of the "Adult Mental Health Module” is the provision for MOAs to take the "Mental Health First Aid Course”. This course helps to educate and sensitize MOAs with respect to prioritizing appointment-making, waiting room environment, signage, conflict resolution, etc. This truly brings MOAs into the "collaborative team”.
  • Building on the above, more and more shared care models between family doctors and psychiatrists, and more recently psychologists, pharmacists, and nurses, are being discussed, or being planned, or exist. There is an expectation that this direction will continue, and will expand.
  • The "Bounceback” program of peer cousellors, who connect to patients by phone, has been well-received, and is expanding.(www.cmha.bc.ca/bounceback).
  • A "Child and Adolescent Mental Health Module” is nearly complete, and will complement the adult module, and likewise encourage collaboration. It should eventually be available on the gpsc website.
  • Payments to family doctors and psychiatrists are increasingly being aligned to support collaboration. We believe this will not only ensure sustainability of our publicly funded system, but improve the patient journey, and provider work-life. Still largely outside the publicly-funded umbrella are psychologists and others, although creative solutions are beginning to appear.

Similar initiatives are ongoing in other parts of Canada, and venues such as the Halifax Conference allow us to learn from each other, and both drive and spread change. On behalf of the Shared Care Mental Health Committee (College of Family Physicians of Canada, and Canadian Psychiatric Association) we are happy to engage in dialogue with our American colleagues.

To quote an old American proverb: If you don’t believe in cooperation, watch what happens to a wagon when one wheel comes off.

Together, we are stronger.

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A Personal Invitation to the 12th Canadian Conference on Collaborative Mental Healthcare in Halifax, Nova Scotia

Posted By Ajantha Jayabarathan, Thursday, March 3, 2011
Updated: Friday, June 10, 2011

It is now recognised that one in five Canadians will experience mental illness in their lifetime. In actual fact, all Canadians are affected, because mental illness has or will touch each of our lives through a family member, friend, co-worker or employee. "Unlike any other part of the healthcare system, family caregivers play a pivotal role as a service provider. Similarly people with lived experience must be at the centre of the mental health system as , in most cases, they are the best judge of what will, or will not,be effective in treating their illness. Therefore, to be effective, a collaborative mental health system must include family caregivers and people with lived experience at its core.” These are inspiring words from Senator Michael Kirby, who now heads the Mental Health Commission of Canada.

To help overcome challenges posed by the lack of access to quality mental health care in our communities, our upcoming Collaborative Mental Health Care Conference, aims to build bridges between mental health consumers, their families and health care providers. This summer, interactive presentations, innovative workshops and exciting new networking opportunities will highlight the richness of working collaboratively in the mental health care field, at the World Trade and Convention Center in Halifax, Nova Scotia during June 23rd, 24th and 25th.This is the 12th Canadian Conference on Collaborative Mental Healthcare, but is unique in its approach to meaningfully engage mental health consumers and their families in the future development of collaborative care. Our goal is to have twenty percent representation by mental health consumers as presenters and participants.

Our keynote address by the Meriden group from the UK speaks to a new era in engaging families as "carers”. New Position papers from the Canadian Psychiatric Association and the College of Family Physicians of Canada, on Stigma and the Future of Collaborative Mental Health care in Canada will be launched at the conference. The Mental Health Commission of Canada and research groups interested in treatment of mental illness in primary care will be participating and conducting key workshops. The emerging role of Health Informatics in evaluative and treatment strategies in mental healthcare delivery, integration of addiction prevention and treatment services, early psychosis intervention, new areas in child and adolescent mental health along with the powerful use of creative arts to present the mind and its development are some of our offerings. Our scientific submissions to the conference will showcase an international and local array of innovative projects.

We have developed interesting venues during which you can network with presenters as well as the "other experts” attending the conference, namely participants like you! Nova Scotia is well known for its informal warmth , friendliness and beauty. The spiritual nature of the setting of the conference in downtown Halifax, nestled between the Historic Town Clock perched on Citadel Hill and the shimmering, blue waters of the Atlantic harbour holds the promise of feeling rejuvenated and connected to your surroundings. Many who attend conferences here come prepared to stay and travel across its stormy seashores, emerald green highlands, seaside villages and mysterious fossil cliffs with friends and family. Our website, www.sharedcare.ca will continue to hold updated information on the conference details. Soon we will be also be sending out e-mercials that further showcase key topics in our conference with links to www.destinationhalifax.ca that can further assist with your travel plans.

Finally in the words immortalised by the song, "Colors of the Wind” in Walt Disney’s Pochahantas,

"You think the only people who are people ,Are the people who look and think like you,But if you walk the footsteps of a stranger,You’ll learn things, you never knew , you never knew.”

Come walk with those who will be strangers to you but once, learn about what you do from different perspectives, immerse yourself in a place that has withstood the test of much adversity and engage in what is the most viable future of mental healthcare: collaborative practice that involves an assortment of providers, consumers and their families in a partnership built on equality and mutual respect.

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The Integrated Care Learning Community--A New Hampshire Experience

Posted By Bill Gunn, Thursday, February 17, 2011
Updated: Friday, June 10, 2011

I work in a community health center and a family medicine residency program in New Hampshire. Along with many in the Collaborative Family Healthcare Association (CFHA) I have wanted to be able to "group up” and find ways for those doing collaborative work to get together and share their successes and barriers. The CFHA has been trying to stimulate regional efforts through conferences and summits; enlisting interested stakeholders to meet as part of the annual conference. I have noticed however that there are many more out there who don’t write about what they do, they don’t meet at regional summits and they don’t go to conferences, they just do great things! We all want to avoid isolation and add to the momentum to cause a "tipping point” effect for integrated/collaborative care.

Five years ago in New Hampshire, a relatively small state known for conservative politics and primaries, there was a significant effort to define what mental healthcare reform could look like to bring the state from its current "D” rating back to its previous "A” rating a few years ago. I served as co-chair along with the Executive Director of NAMI, Mike Cohen on a workgroup focused on integrated care. We met for two years with physicians, consumers, behavioral health practitioners and administrators to produce a document that reflected our summary and recommendations about what needed to happen to integrate care. The results were published and through a meeting with the governor and many legislators we all learned more about improving our current healthcare status. The bumper sticker read "Mental Health is part of Overall Health”. The ball moved a bit forward.

White papers are great and there are lots of them. But how do you keep the ball rolling? Enter the learning community! The terms "learning collaborative” and "learning community” have been used by many including the Institute for Healthcare Improvement and the National Council for Community Behavioral Healthcare. Learning communities are more grass roots and open to all interested parties Our first meeting with thirty interested stakeholders, met for three hours without a break and created a significant local "buzz”.

Since that first meeting in October of 2008 we have continued to meet bi-monthly for the past two years. This year we have reorganized and are having a fall and spring meeting each with a local guest presenter. Last fall, Craig Jones, medical director of the Vermont Blueprint for Health was a guest speaker and he talked about the critical importance of his state’s incorporation of behavioral health professionals in their health reform pilot projects. Medical (Health) home projects all over the country are learning the lesson that incorporating behavioral health is a key component. Following are some key points that may facilitate creating an Integrated Care Learning Community.

1. Actively engage those individuals who are already moving ahead with some form of integrated care.

2. Engage as many different ‘world views” as possible. We had CEO’s and CFO’s of several local mental health centers as well as community health centers, behavioral health consultants in community health centers, academic researchers, primary care physicians in private practice and in community health centers, state administrators from Health and Human Services, (Nancy Rollins, state deputy commissioner was the co-leader of this initiative) and substance use administrators and clinicians.

3. Create a mailing list to function as a list serve so members can communicate with each other between meetings.

4. Keep the initial focus on sharing knowledge and best practices. While the Antioch NE research project (mentioned below) was an ongoing project, busy professionals can lose sight of the primary purpose of this group by creating to much of a "to do” list. This can be a natural outgrowth later.

5. Keep the idea of policy advocacy at the forefront. As state legislators or medical home pilot projects become more interested in this effort, membership of the learning communities can be a way to become involved in these more comprehensive efforts.

These learning communities are a great way to informally organize. They could even be seen as state or regional chapters of CFHA to increase contact between national meetings and try to keep up with the expanding knowledge in the field. I look forward to hearing more stories about other efforts to create these around integrated care.

Here are three examples of integration projects happening here in NH that you will likely not have heard about.

Mid-State Health Center located north of Concord in Plymouth NH. Here psychologist Vince Scalese and physician Fred Kelsey had been working in parallel practices for 30 years. Through work and over the occasional beer, they often revisited the idea of "Wouldn’t it be nice if we got together in practice”. So five years ago, Vince agreed to merge his practice with Mid-State for which Fred served (and continues to serve) as the Medical Director. The Electronic Health Record that has been in place since 2003 was tweaked to include templates for behavioral health services. This was done so patients would have a truly shared record that was designed for the way the both clinicians documented. The CEO of Mid-State, Sharon Beaty, worked to break down administrative and financial barriers for them, built a new building with behavioral health in the center of the action and together Mid-State is making it happen.

Antioch University New England located in western New Hampshire. Psychologists Jim Fauth and his colleagues received local funds to provide support in evaluating local projects in five community health centers in the state. Representatives from all five heath centers joined the learning community and reported on the populations on which they were focused and ways in which they were trying to improve care delivery to those populations. Four of the five centers have embedded behavioral health services and have benefited from the efforts to participate together in a joint evaluative project.

Avis Goodwin Community Health Center in Dover, New Hampshire. In partnership with Great Bay Mental Health, leaders of the project worked with Intermountain Health Care to secure a grant that would put psychological and social services together with medical services. They used protocols and processes that Intermountain has employed for several years. Sandy Rose, PhD, psychologist and owner of Great Bay recently shared her research with the learning community on the use of informed consent forms to be used in primary care.

This is just mention of a few examples. There are many more and the capacity to follow and advise these projects has been very stimulating…………but you get the idea. The excitement over finding like minded folks who were local was a great thing!

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"The Integrated Care Learning Community--A New Hampshire Experience"

Posted By Bill Gunn, Thursday, February 17, 2011
Updated: Tuesday, April 12, 2011
I  work in a community health center and a family medicine residency program in New Hampshire.  Along with many in the Collaborative Family Healthcare Association (CFHA) I have wanted to be able to "group up” and find ways for those doing collaborative work to get together and share their successes and barriers.  The CFHA has been trying to stimulate regional efforts through conferences and summits; enlisting interested stakeholders to meet as part of the annual conference. I have noticed however that there are many more out there who don’t write about what they do, they don’t meet at regional summits and they don’t go to conferences, they just do great things!  We all want to avoid isolation and add to the momentum to cause a "tipping point” effect for integrated/collaborative care.

Five years ago in New Hampshire, a relatively small state known for conservative politics and primaries,  there was a significant effort to define what mental healthcare reform could look like to bring the state from its current "D” rating back to its previous "A” rating a few years ago.  I served as co-chair along with the Executive Director of NAMI, Mike Cohen on a workgroup focused on integrated care. We met for two years with  physicians, consumers, behavioral health practitioners and administrators to produce a document that reflected our summary and recommendations about what needed to happen to integrate care.  The results were published and through a meeting with the governor and many legislators we all learned more about improving our current healthcare status.  The bumper sticker read "Mental Health is part of Overall Health”.  The ball moved a bit forward.

White papers are great and there are lots of them. But how do you keep the ball rolling?  Enter the learning community!  The terms "learning collaborative” and "learning community” have been used by many including the Institute for Healthcare Improvement and the National Council for Community Behavioral Healthcare. Learning communities are more grass roots and open to all interested parties  Our first meeting with thirty interested stakeholders, met for three hours without a break and created a significant local "buzz”.

Since that first meeting in October of 2008 we have continued to meet bi-monthly for the past two years.  This year we have reorganized and are having a fall and spring meeting each with a local guest presenter.  Last fall, Craig Jones, medical director of the Vermont Blueprint for Health was a guest speaker and he talked about the critical importance of his state’s incorporation of behavioral health professionals in their health reform pilot projects.  Medical (Health) home projects all over the country are learning the lesson that incorporating behavioral health is a key component.  Following are some key points that may facilitate creating an Integrated Care Learning Community.

1.  Actively engage those individuals who are already moving ahead with some form of integrated care.

2.  Engage as many different ‘world views” as possible. We had CEO’s and CFO’s of several local mental health centers as well as community health centers, behavioral health consultants in community health centers, academic researchers, primary care physicians in private practice and in community health centers, state administrators from Health and Human Services, (Nancy Rollins, state deputy commissioner was the co-leader of this initiative) and substance use administrators and clinicians.

3.  Create a mailing list to function as a list serve so members can communicate with each other between meetings.

4.  Keep the initial focus on sharing knowledge and best practices.  While the Antioch NE research project (mentioned below) was an ongoing project, busy professionals can lose sight of the primary purpose of this group by creating to much of a "to do” list.  This can be a natural outgrowth later.

5.  Keep the idea of policy advocacy at the forefront.  As state legislators or medical home pilot projects become more interested in this effort, membership of the learning communities can be a way to become involved in these more comprehensive efforts.

These learning communities are a great way to informally organize.  They could even be seen as state or regional chapters of CFHA to increase contact between national meetings and try to keep up with the expanding knowledge in the field.  I look forward to hearing more stories about other efforts to create these around integrated care.

Here are three examples of integration projects happening here in NH that you will likely not have heard about.

Mid-State Health Center located north of Concord in Plymouth NH.  Here psychologist Vince Scalese and physician Fred Kelsey had been working in parallel practices for 30 years. Through work and over the occasional beer, they often revisited the idea of "Wouldn’t it be nice if we got together in practice”.  So five years ago, Vince agreed to merge his practice with Mid-State for which Fred served (and continues to serve) as the Medical Director.  The Electronic Health Record that has been in place since 2003 was tweaked to include templates for behavioral health services.  This was done so patients would have a truly shared record that was designed for the way the both clinicians documented. The CEO of Mid-State, Sharon Beaty, worked to break down administrative and financial barriers for them, built a new building with behavioral health in the center of the action and together Mid-State is making it happen.

Antioch University New England located in western New Hampshire.  Psychologists Jim Fauth and his colleagues received local funds to provide support in evaluating local projects in five community health centers in the state. Representatives from all five heath centers joined the learning community and reported on the populations on which they were focused and ways in which they were trying to improve care delivery to those populations.  Four of the five centers have embedded behavioral health services and have benefited from the efforts to participate together in a joint evaluative project.

Avis Goodwin Community Health Center in Dover, New Hampshire.  In partnership with Great Bay Mental Health, leaders of the project worked with Intermountain Health Care to secure a grant that would put psychological and social services together with medical services.  They used protocols and processes that Intermountain has employed for several years.  Sandy Rose, PhD, psychologist and owner of Great Bay recently shared her research with the learning community on the use of informed consent forms to be used in primary care.

This is just mention of a few examples.  There are many more and the capacity to follow and advise these projects has been very stimulating…………but you get the idea. The excitement over finding like minded folks who were local was a great thing!

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Advancing Healthcare Through Provider/Patient Partnerships

Posted By Tai Mendenhall, Monday, February 14, 2011
Updated: Friday, June 10, 2011

Healthcare as we know it is changing fast. As hospital and clinic systems redesign themselves to better facilitate collaboration among providers representing a variety of disciplines, our patients and their families are benefiting through increased access to coordinated and reciprocally informed services. As our training sites across graduate and medical education prepare future healers to enter these more complex work environments, we are seeing yesterday’s interdisciplinary tensions regarding whose field is better (e.g., Psychology vs. MFT) change to contemporary mutual respect and valuing of our colleagues’ contributions to a whole that is more than the sum of its parts. At the same time, policy makers, system administrators and 3rd party payers are working to advance ways to financially sustain new ideas and methods of care-provision.

Many of our efforts, however, appear to be missing something that I think is important to consider: attention to the role(s) of our patients and their families. Whether it is in the research studies that I peruse, clinics and hospitals that I work in or collaborate with, mission statements that I read on care facilities’ walls, pamphlets or brochures, presentations that I listen to, or professional conversations and forums that I participate in – almost everything that is "out there” frames professionals as the carriers of knowledge/wisdom and providers of services vis-a-vis patients/families who are relatively passive.

It is my (and several of my colleagues’) opinion that the greatest untapped resource for improving health care is the knowledge, wisdom, and energy of individuals, families, and communities who face challenging health issues in their everyday lives (Doherty, Mendenhall & Berge, 2010). Consider, for example, the following questions: How does somebody recently diagnosed with diabetes really overhaul his/her lifestyle (and stick with it) across diet, physical activity, and disease management- arenas? Where is ‘the line’ between supportively reminding someone to check blood sugars and being a ‘nag’? How can a partner avoid burning out from supporting a mate whose pain is chronic and progressive and whose complaints are never-ending? How does a partner attend to his/her own health and needs as his/her partner continues to decline? How do couples handle the sometimes intrusive roles of health professionals, social services and/or insurance companies?

Our system is set-up (and evolving) in a way that enables providers to talk with each other more than ever before, but patients still sit straight-forward in our waiting rooms reading outdated magazines in comparative isolation. Social prescripts keep their interactions superficial, and we are not allowed to encourage anything more. HIPAA laws restrict us from connecting a patient who has learned how to effectively manage a chronic illness with somebody who was just diagnosed and is struggling with a great deal of fear and ambivalence. Privacy mandates prohibit our introducing the spouse of a patient who has been taking care of her brain injured husband for 10 years to the spouse of another patient who just sustained a similar injury. Outside of structured group visits (which still tend to be top-down and expert-driven), opportunities for patients to share their wisdom are scarce.

Patients’ and families’ wisdom are similarly absent from many of our conventional methods of designing, implementing and/or evaluating interventions. We, as the professionals, decide what is important to teach, how to teach it, and what is important to measure. At a recent forum I was invited to participate in to discuss a clinic’s transformation to a "patient-centered medical home,” I was simultaneously taken-aback and not surprised by the fact that there were no patients at the table.

As large national and international organizations focused on health (e.g., Agency for Healthcare Research and Quality (AHRQ); National Institutes for Health (NIH), World Health Organization (WHO)) have systematically called for – and advanced funding to support – community driven and collaborative efforts to address complex health and social problems ill-suited for conventional top-down service delivery and research endeavors, community-based participatory research (CBPR) has been put forth as a way to partner with our patient communities – and thereby create and implement supportive care systems that neither providers/researchers or patients/families could create on their own.

Several key assumptions permeate CBPR projects, including: 1) recognizing that the community is the principal unit of identity; 2) partnership that is democratic and equitable between all project members (e.g., patients, providers, researchers) through every stage of knowledge- and intervention- development; 3) identifying and building on the strengths and resources already within the community; 4) promoting capacity-building and co-learning between and among project partners; 5) deep investment in change toward improving the lives of members in a community or practice; 6) an iterative process in which problems are identified, solutions are developed within the context(s) of the community’s existing resources, interventions are implemented, outcomes are evaluated according to what participants see as most important, and interventions are modified in accord with new information as necessary; 7) project members are both humble and flexible to accommodate changes as necessary across any part of a project; 8) disseminating new knowledge to and by all partners and constituents in the investigative process; 9) recognizing that CBPR can be slow and messy (especially during its early/initial phases); and 10) long-term engagement and commitment to the work (Bradbury and Reason, 2003; Doherty, Mendenhall and Berge, 2010; LaVeaux and Christopher, 2009; Mendenhall and Doherty, 2005; Scharff and Mathews, 2008; Strickland, 2006).

Care systems have slowly been experimenting with CBPR since the 1990s because of its ability to inform understanding of patients' experiences, generate or improve services, facilitate community outreach and engagement, enhance education and learning, and improve cultural awareness. These efforts have effected improvements in asthma, the management of preoperative fasting, patient problem-solving skills, dental and mouth care practices, overall physical well-being, patient-practitioner communication, and patient and practitioner satisfaction. My and my colleagues’ (Bill Doherty and Jerica Berge) work in Minnesota in "Citizen Health Care” (a model designed purposefully for medical and mental health professionals who work with families in community settings) has seen marked improvements in diabetes, obesity and smoking cessation (Berge, Mendenhall & Doherty, 2010; Doherty, Mendenhall & Berge, 2010; Mendenhall & Doherty, 2007; Mendenhall & Doherty, 2005; Mendenhall et al., in press; Mendenhall et al., 2010).

As we advance our efforts in collaborative and integrated care, it is important that we do not leave our patients and their families behind. Indeed, the greater vision of work done in this way is to create a model of healthcare, education, and outreach as work by and for its citizens, with all stakeholders – including patients and their families, physicians and other providers, researchers and administrators – working as active contributors.

At an early meeting in a project I am involved with that is focused on American Indian patients with diabetes, I shared how our group’s efforts were (are) advancing change in how health is embraced in the local community. One of the elders interrupted me and said, "This is for all of our people – here in Minnesota and across the country, and even the world.” As future efforts in this and related initiatives proceed, this vision of transforming health will serve as a sustainer of energy and commitment in the face of a formidable – but inspiring – mission.

References

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

Bradbury, H., Reason, P. (2003). Action research: An opportunity for revitalizing research purpose and practices. Qualitative Social Work 2: 155-175.

Doherty, W., Mendenhall, T., Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 489-402.

LaVeauz, D., Christopher, S. (2009). Contextualizing CBPR: Key principles of CBPR meet the Indigenous research context. Journal of Aboriginal and Indigenous Community Health 7: 1-25.

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

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

Mendenhall, T., Doherty, W. (2007). The ANGELS (A Neighbor Giving Encouragement, Love and Support): A collaborative project for teens with diabetes. In The Therapist's Notebook for Family Healthcare, eds. Deanna Linville and Katherine Hertlein, 56-70. New York: Apex Press.

Mendenhall, T., Doherty, W. (2005). Action research methods in family therapy. In Research Methods in Family Therapy (2nd edition), eds. Fred Piercy and Douglas Sprenkle, 100-117. NY: Guilford Publications.

Scharff, D., Mathews, K. (2008). Working with communities to translate research into practice. Journal of Public Health Management Practice 14: 94-98.

Strickland, C. (2006). Challenges in community-based participatory research implementation: Experiences in cancer prevention with Pacific Northwest American Indian tribes. Cancer Control 13: 230-236.

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"Family, Friends, and Faith"

Posted By Randall Reitz, Thursday, February 10, 2011
Updated: Tuesday, April 5, 2011

Nancy and Paul--Back in 1970, Paul and Nancy were a great young couple. Paul had just finished an accounting degree and an MBA at the University of Utah. Nancy taught piano and cut hair in their apartment living room while raising their 1 year old boy, Robert. Their second son, Randy, was born shortly after they moved from Salt Lake City to San Francisco to accept Paul’s first job as a CPA. Six months later Nancy was expecting again, but this child was born 3 months early and didn’t survive. Paul began to struggle with a skin condition on his right foot. The Doctor told him it was a fungus like athletes foot. In addition, within weeks Paul lost his job and the family returned to Salt Lake City to be closer to family.

After a few more months the skin problem was correctly diagnosed as a rare Ewing sarcoma that had already metastasized to his lungs. Paul continued to work as a CPA while participating in aggressive chemotherapy and radiation in the evenings. Paul was a private man, so Nancy was surprised when she attended one of his treatments and was informed that Paul only had a few weeks to live. Paul worked until 3 weeks before his death. Nancy was 26, Robert was 5, and Randy was 3.

The first few weeks were very hard on Nancy. She had seen Paul suffer horribly for 15 month and was glad that he was no longer in pain, but she didn’t have time to grieve. She couldn’t understand how God would leave her without a husband or her children without a dad. She distinctly remembers a conversation with herself: "Nancy, you have 2 choices, you can either stay angry and let it get you down and be bitter or you can rise above it and be a better, stronger person. There is no middle ground.” Through this time she got great support from her Mormon neighbors who were "tripping over each other” to help her out, including paying for the funeral expenses. Her parents and Paul’s parents played a central role in helping them get through, especially her father-in-law who built a beauty salon in her basement.

Nancy and Paul

Nancy and Paul, 3 weeks before he died
At the top of Brighton Ski Resort

Dave and Shawna--Dave and Shawna were a great young couple. They fell in love in middle school, dated through high school, and married in the first years that Dave studied at the University of Utah. During the lean college years they lived in a mortuary to save on rent, but still managed to grow their family with 2 boys—Todd and Brett. Their life changed 2 years after graduating. One evening Shawna went to bed feeling flu-like symptoms. She woke up during the night, went into the bathroom and passed out on the floor. Dave called 911 and started CPR. She was taken to the hospital by paramedics and was pronounced dead shortly thereafter. It was later concluded that she had died of congestive heart failure, probably caused by a virus. Dave was 26, Todd was 4, Brett was 1.

None of them got to say good-bye to Shawna and they didn’t have the opportunity to get their affairs in order. For Dave, the first days were a shocked blur, but he managed to stay focused through the funeral. Then as support waned, reality set in. He needed to learn how to take care of the house by himself, shop, raise the kids, and continue to pay the bills. He distinctly remembers putting the boys to bed one night and then collapsing on the floor crying under the weight of the demands on his body and the loss in his heart.

Fortunately they were able to get by because Dave had been the sole breadwinner and his in-laws took turns watching the kids during the week. Dave was sustained by his faith, which provided a larger perspective of the unexpected changes and gave purpose to his efforts.

Nancy and Dave--These deaths occurred 9 days apart. Three months later, Nancy and Dave were set up on a date by several mutual friends. After 4 months of courtship, Nancy and Dave married. Their shared history helped them to start out on equal ground in the relationship. The recent events were constantly on each others’ minds and they talked about it all the time. They found meaning in how their relationship offered a better future for their boys. Their shared faith helped them weather the hard times. Together, they had 3 more children: Heidi, Jyll, and Chad. When Chad was born, the oldest of their kids was 10. Nancy and Dave recently celebrated their 34th wedding anniversary. All their children are married and have their own children.

Randy and Randall--While all of my professional colleagues know me as Randall, people who knew me before grad school still call me Randy. Dave and Nancy are my parents and their children are my siblings. While I never met Shawna and have few memories of Paul, all 4 of my parents animate my life and guide my care. They urge me to invite my patients’ family members to appointments. Their friendships encourage me to inquire about my patients’ friendships and to encourage peer support programs in my clinic and community. Their faith inspires me to check-in on people’s spiritual activity and to encourage them to reconnect with their own faith traditions.

Similarly, while Randy is only physically present when I visit family in Salt Lake City or catch-up with high school friends on facebook, he still lives within me. Being raised in a home that was initially defined by morbidity and mortality had a deep impact on my decision to seek a career in medical settings. Having parents who had close involvement with medical professionals, committed friends, and an involved community led me to seek a clinical environment that extended well beyond the therapist’s office. Randy is aware that my parents didn’t seek assistance from counselors or psychologists during these hard times. Mental health services were not part of their lives—but talking with their church leaders and going to the doctor was. Their experience as they struggled with the loss of their loved ones and in bringing together 2 families is frequently on my mind when I see patients and train residents in whole-person care.

Randy and my parents hold me to this standard.

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

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