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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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Collaboration is Personal Too: Speaking of Microblogging

Posted By Gonzalo Bacigalupe, Thursday, February 3, 2011
Updated: Friday, June 10, 2011

Microblogging, writing and immediate publishing of brief entries (i.e., 140 characters in Twitter), has been personally a compelling draw for several years. With almost 12,000 entries in my @bacigalupe account and about 2,000 in an academic project (@healthglobal), it is legitimate to ask the question of why a busy researcher and clinician would want to spend time almost everyday in such a medium. One way for me to describe its power is in its ability to continuously experiment collaboration in what seems a purely virtual environment; one in which the conversations are happening as if it were in real time. For me though, these conversations are an experiment with the artificial dichotomy of the real and virtual dissolving.

The ongoing sharing with about 6,000 individuals and institutions has been for the most part friendly, fun, intelligent, and thought-provoking: A true learning experience. I have met individuals from all over the world, old and young, unilingual and multilingual, the majority sharing some similar interests although from very different points of view. This social technology has brought together many streams of interests, personal, professional, and scholarly and often with gems (those #ff one would want everyone to follow) that seem to integrate them all. For the most part, these are people I had never met before but in planned, and at times surprising ways, found them next to me at a conference, a restaurant, or other venue.

What has been so rich is also the network of conversations that started in the public arena and have continued via direct email. In some cases, those conversations became the source of shared projects, i.e., a panel at the American Psychological Association. One of the richest aspects is the interdisciplinary nature of those participating. Folks I would have taken a defensive to, or even rejected their stance, if I had been exchanging ideas face-to-face have now become a way of expanding my view; of making collaboration possible across divides.

This exercise at collaborating in conversation, in what amounts to hundreds of conversations, has included discussions about politics and public policy, healthcare (a lot) and public health, education, ethics in research, psychology, and much more. One of the most fascinating weekly dialogues in which the medium has mirrored part of the content (a weekly discussion about healthcare and social media or #hcsm) was the initial stimulus to writing a scholarly paper on the subject of the potential role of social media in collaborative health care (soon to be published in Family, Systems, and Health).

During times of disasters, for example, the earthquakes in Haiti and my native Chile, these conversations took a different turn, they became a way of supporting those in the middle of the crisis and sharing useful and reliable resources with those trying to help the survivors in the field. And two upcoming papers (one in Family Process) explore how social technologies transform the immigrant family experience as geographical and time distances are reduced with the fast adoption of cell phones and cheap web-conferencing calls.

What happens with microblogging, similar to conversations with friends or good colleagues, is that the activity is truly participant-driven. Twitter exchanges are not about the technology we are using but about who is participating. Like conversations with friends or colleagues, in Twitter the best of a listening and transparent stance occurs if those who are in conversation (as Followers or as Following) are honest, interesting, and respectful. What distinguishes this virtual conversation from those around a real table is the possibility of having a much more diverse group of participants sharing their thoughts; the walls are much more permeable and barriers to entry are minimally guarded.

Like solid friendships, it takes time to "get Twitter.” It takes time and energy to foster good relationships via the web, like it does face-to-face. What is different though is the potential for a rich and continuous selective form of absorbing the wealth of information that comes to us or we directly seek. Like friendships, it may be that the group of followers and the ones you follow reflect a parochial reflection of my own interests, political leanings, and professional biases. That may be the case but despite these potential limitations, I am thankful for the ways in which microblogging has enriched my professional, scholarly, and personal life.

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Promoting Diversity in Membership: Growing the CFHA While Broadening its Constituency

Posted By Jennifer Hodgson, Thursday, January 27, 2011
Updated: Thursday, June 2, 2011

This blog is not filled with grandiose rhetoric. You will neither find state-of-the-art statistics nor endearing stories about collaborative successes. Rather this blog is designed to challenge the face of CFHA and establish tangible solutions to help us move forward. It is an exciting time to be a member of CFHA as our association is gaining national attention for our grassroots work. CFHA’s annual conferences and pre-conference summits have stimulated important discussions and actions at each sponsoring state’s policy, payment, and community levels.

They have also resulted in an expansion of our membership base, hiring of staff, and increase in conference attendance. The key to success for any organization though is not accepting what it is but aiming for what it can become.Membership has always been the heartbeat to CFHA but until recently we have focused more on collaboration between the behavioral and medical specialties only. It is important and timely that we examine our diversity not only in discipline but also with regard to culture and geographic representation. We have been strong in the medical and behavioral health disciplines, particularly with family medicine physicians, marriage (couple) and family therapists, medical family therapists, and psychologists.

We have some representation from internal medicine, pediatrics, social work, counseling, pharmacy, psychiatric nursing, dental, nursing, and healthcare administration. However, many disciplines are missing from this list and are important to include and recruit to join CFHA. While some may be underrepresented (even those mentioned above), others are absent and need to be a part of our growing association. Which ones come to mind for you? How do you believe we can successfully invite them to become part of CFHA?

Diversity within CFHA does not just need to happen in discipline, but also in race, ethnic origin, and sex as well. While we are actively working on statistics regarding our current CFHA composition, attending the annual conferences gives a fairly accurate depiction of where we are not as strong. Again, it is critical that we work hard to grow the association so that it mirrors the populations we serve and represent. What ideas you do have? What are your thoughts about how we can grow and diversify our membership?

Lastly, we have a lot to learn from our international collaborators. Although we have drawn some presenters and attendees from other countries, this is one area of our outreach that is in need of additional focus. The challenge for many of our overseas colleagues is the expense of coming to the United States for a conference. Our limited budget precludes offering scholarships for international attendees. However, we need to think outside of the box for ways to engage groups who value collaboration as we do and who have learned how to study it, initiate it, and create policy for it. What international groups are you aware of that we need to begin to engage in active discussions?

In CFHA there is no need for guilds but there is a need for fair representation across all of the variables addressed above in this blog. I hope you will join me in celebrating our growth and accepting this challenge of diversifying our membership.

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The Relevancy of Relevance--Collaborative Care's Search for Maturity

Posted By Ben Miller, Thursday, January 20, 2011
Updated: Friday, May 27, 2011

In the spirit and tradition of Albert Camus, let us take a moment and dwell in the absurd. Now for you philosophy majors out there, I am not going to attempt to do justice to true absurdist philosophy, but rather take great liberties and address the field of collaborative care. Camus believed that life was absurd in that human’s constantly seek meaning from life, but have difficulty finding it. Collaborative care as a field continues to search for meaning. The ultimate question is where can the field find that meaning and is it possible to obtain this meaning?

It has been shown for some time that integrating mental health into the larger medical arena leads to better outcomes. While research of this type initially began in specialty medical settings, it has more recently expanded into the general healthcare arena, primary care. As where most people receive their healthcare, primary care identifies more mental health, treats more mental health, and arguably has the most to do with what happens "next” with mental health than the mental health system. Still, in the face of these facts, there remains difficulty integrating mental health providers into primary care to "streamline” and "defragment” how we as a healthcare system treat mental health. This fundamentally is a policy issue, and one that has not been tackled.

As I have recently charged the field to do more work in the policy domain for collaborative care (see upcoming Families, Systems & Health issue), I will not do so here; however, I want to make the point that much discussion and effort for collaborative care should continue to include policy whenever possible.

So conceptually, most agree that by integrating we are doing a great service to patients who would benefit from these services. We have some research, wonderful stories, and passionate leaders, but we do not have a firm standing in the healthcare system whereby our efforts are discussed as often as other "left out” aspects of healthcare such as prevention, quality measures and enhanced/modified payment schemes. So how relevant is collaborative care? How mature is the field? I will argue that there needs to be a tri-fold process that occurs to lead collaborative care down a road of increased relevancy and maturity especially as it relates to policy.

  1. Disruptive Innovation: Each new integration effort, started, studied and written up should do so under the auspices that the content can disrupt the status quo and attempt to address second order change. Papers simply rehashing what we know may not be that helpful for moving collaborative care forward; no more reviews of how great integration is – we have plenty of these. We need disruptive research and innovation that can move the "needle” for collaborative care.
  2. Policy Briefs: Sites interested and actively engaged in integration should become experts on how to write up one-page policy briefs. While stories have a powerful impact on policy, concise one page policy briefs that highlight an issue on integration with data (qualitative or quantitative) can be an even more powerful and persuasive argument for policy makers. One-page policy briefs, as difficult as they are to write, and write well, will be a distinguishing characteristic of a mature field where newly learned information begins to be included in the national dialogue on healthcare (for example of excellent one pagers see here). Additionally, policy briefs can accomplish the goal of getting the community talking about an issue germane to collaborative healthcare and bring the field more closely together.
  3. Seeing the Big Picture: Representing an ideal, a whole (field/movement), rather than a specific part (my model) means that rapid infusion of the collaborative care message into policy may be more likely as fewer barriers will be in place filtering the message. Policies advocating for comprehensive collaborative healthcare can be inclusive. Since there is much we still need to know about what strategies work for integration, it is premature to promote a "standard approach” to integration. However, by grounding our argument in the inseparability of mental from physical, we can discuss the cost of separating mental and physical, the problem with access to mental health, and providers desire to have onsite mental health, we can start to address the "big picture” not simply another workaround.

So you see, collaborative care has a way to go before we can increase our stage presence on the national healthcare stage. We can get there faster if we begin to consider how to mature our field by more comprehensively studying our disruptive integration efforts, writing up smart, concise policy briefs on said efforts, and recognize collaborative care’s role in the larger healthcare system.

Is it possible to find our "meaning” as a field or will we continue to search for meaning without ever finding it? Addressing policy head on is a proactive way to find our meaning for collaborative care. Because really, the last thing any of us want is for collaborative care to be a "stranger” in national healthcare debates.

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CFHA--A Foundation Perspective

Posted By Mary Jo Dike, Thursday, January 13, 2011
Updated: Friday, June 10, 2011

In 2008, I was tasked with taking over and breathing new life into the Foundation’s initiative on "Integrating Mental Health and Medical Services”. The initiative began several years earlier and was developed as a result of hearing Kentuckians tell us that we need increased access to health care for underserved and rural communities and that services should be delivered in a less fragmented way. I’m not a health care expert, "I have an MBA”, I thought. "How am I going to go about this?”

My first move was to ask a friend and colleague, Dr. Nancy G. Moore, Executive Director for Governance Affairs at APA. She said, "You need to talk to Ben Miller” – end of sentence. Ben who? Okay, so I email Ben Miller and two seconds later I had a response and thus, new life was breathed into the Foundation’s initiative.

Ben conferred with me on this initiative and spent time listening to the issues faced by Foundation grantees – The Foundation funded primary care and community mental health center demonstration sites in Kentucky working to integrate mental health and medical services. We learned that these sites shared many of the same challenges experienced by sites across the country. Ben started opening doors to resources, people and information; providing me and Foundation grantees with opportunities for training, technical assistance and guidance on tackling regulatory and policy barriers.

The biggest door he opened for me and the Foundation was to the Collaborative Family Health Care Association. Whew, that name is a mouthful. It’s almost as long as Foundation for a Healthy Kentucky. I was grateful to learn everyone calls it "CFHA”. I attended my first CFHA conference in 2008 in Colorado. It was instant – love at first site – everything I could ever want to know about integrating health care services was contained within this "small but mighty” organization.

I remember the first session I attended – it was a "Pre-Con” with Dr. Wayne Katon on "Evolving Models of Collaborative Care” – WOW, what a way to start a conference! My awareness and knowledge of the fundamentals, research and models of collaborative care went from zero to sixty in 3 days.

In the months following, I began funneling what I learned to our grantees and other key stakeholders in Kentucky. The Foundation began sponsoring tracks on integrated care at health care professional meetings in Kentucky; provided the Certificate Program in Primary Care Behavioral Health to Foundation grantees; and formed an Integrated Care Action Team (ICAT) to identify and seek to address regulatory and policy barriers to integrating services.

Because CFHA and its network of members had been such a tremendous resource for me, it was a no-brainer when I learned that hosting the 2010 CFHA Annual Conference in Louisville might be an option – I jumped on it and quickly identified Kentucky-based leadership to chair and serve on the planning committee. My colleagues (Drs. Baretta Casey and Sheila Schuster) were delighted when the Board voted to hold their conference in Louisville, and we immediately got to work as the 2010 Annual Conference Co-Chairs.

From the Foundation’s perspective this was a wonderful opportunity to bring the definitive organization for collaborative and integrated care to Kentucky. For Foundation grantees and others in Kentucky who are working on advancing these models of care, having local access to this conference was a tremendous technical assistance and networking opportunity.

As you can see from the 2010 Conference Report on the CFHA website, the conference was a tremendous success, 60 of the 355 registrants were Kentucky health professionals and students. CFHA membership increased from 3 to 25 active members from Kentucky. What is even more exciting, participants in the conference came from 37 states and 5 countries creating a dynamic learning and networking event.

By becoming involved in CFHA, the Foundation has facilitated linkages in Kentucky to a national network of learning, sharing and moving towards "a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities.”

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V-Forming Healthcare Through Collaboration

Posted By Ajantha "AJ"Jayabarathan, Wednesday, January 5, 2011
Updated: Thursday, June 2, 2011

2011 finds Healthcare in the throes of transformational change, locally and globally. In some Canadian provinces, such as Prince Edward Island, change has been as gradual as tectonic plates forming the earth’s crust but, Alberta, has known the volcanic eruption of change, destroying what was created before, while organizations and people struggle to survive the onslaught and the aftermath.

Remarkably, the issues plaguing the US, Canada and UK, have common themes, despite their differing approaches to healthcare and distinctly varied philosophies and values:

  • Emergency room overcrowding
  • Poor access to care
  • Disjointed silos of care
  • Escalating costs
  • Aging populations
  • Dissatisfaction with pharmacologically based algorithmic care
  • Separation of mind, body & spirit in the application of the medical model
  • Impact of ignoring social determinants of health
  • Caregiver & provider burnout
  • Challenges, risks & benefits linked with the use of the Internet and medical technology.

But 2011 finds me working as a doctor, healer, teacher and guide within a renewed context of self managed health and wellness. What transformed me and my practice in the last two decades?

The first influence was working collaboratively with patients, families and an inter-disciplinary mix of physician & non-physician providers. The second influence relates to the development of a robust electronic interface within my practice. Lastly, the freeing exchange of knowledge, enabled by the Internet, has broken down walls that once separated doctors, patients and other providers of care.

Many people working in interdisciplinary teams believe they are working collaboratively. I would like to challenge this view using the perspective gained from observing Canada Geese. "Lessons from Geese” has found worldwide circulation since it was written in 1972 by Dr. Robert McNeish, a biology teacher and student of nature from Baltimore. A combination of aerodynamic benefits and enhanced ability to communicate are thought to be reasons why geese fly in V-formation. They also fly is columns and clusters and V-formation flying occurs less than 25% of the time. Below are a few Facts, Lessons and Reflections comparing the collaborative nature of Geese to that of healthcare providers.

Fact: As each goose flaps its wings it creates an "uplift" for the birds that follow. By flying in a V-formation, the whole flock adds 72% greater flying range than if each bird flew alone.

Lesson: People who share a common direction and sense of community can get where they are going quicker and easier because they are traveling on the thrust of another.

Reflections: How often do you work as part of a team with others? Do you consider "patients” and "family members” as members of your team?

Fact:When a goose falls out of formation, it suddenly feels the drag and resistance of flying alone. It quickly moves back into formation to take advantage of the lifting power of the bird immediately in front of it.

Lesson: If we have as much sense as a goose we stay in formation with those headed where we want to go. We are willing to accept their help and give our help to others.

Reflections: Do you lift others with your energy? Do you allow yourself to be lifted by another’s energy?

Fact: When the lead goose tires, it rotates back into the formation and another goose flies to the point position.

Lesson: It pays to take turns doing the hard tasks and sharing leadership. As with geese, people are interdependent on each other's skills, capabilities, and unique arrangements of gifts, talents, and resources.

Reflections: Does your ego get in the way of recognizing what you need to learn from the experiences of others? Can you balance the needs of the flock and your personal ambitions?

Fact: The geese flying formation honk to encourage those up front to keep up their speed.

Lesson: We need to make sure our honking is encouraging. In groups where there is encouragement, the production is greater. The power of encouragement (to stand by one's heart or core values and encourage the heart and core of others) is the quality of honking we seek.

Reflection: Do you recognize when you seek to compete rather than collaborate? Are you secure enough, empowered enough, to give another what they need from you?

Fact: When a goose gets sick or wounded, two geese drop out of formation and follow it down to help and protect it. They stay with it until it dies or is able to fly again, then join another formation or catch up with the flock.

Lesson: If we emulated geese, we would stand by each other in difficult times as well as when we are strong.

Reflections: How much can you give up for another? Today? Tomorrow? In a lifetime? Is the path to your goal linear and rigid? How much change can you tolerate and how flexible are you?

Fact: Geese fly south for the winter in the Northern Hemisphere.

Lesson: It is a reminder to take a break from the cold of winter and take a vacation to some place warm & sunny to rejuvenate ourselves.

Reflections: How well are you? How happy? How content? Are you alive? Are you engaged in your life? When did you last replenish your reservoir?

Fact: The larger flocks of geese usually inhabit areas where eating geese is more popular whereas when there are smaller flocks of geese flying, there is usually smaller demand for geese, to be consumed as food.

Lesson: Larger groups of humans may not always be as effective as smaller groups that can maneuver quickly in life and business without being eaten up by the competition.

Reflections: Is your "team” effective in affecting change that is meaningful? Is your team in "touch” with the real world? How responsive is your team?

These points of reflection are intended to evoke an inner dialogue about "collaborating” with others; physicians, non-physicians, patients, clients, families, caregivers, politicians, policy makers, administrators, students, and those in institutions that are linked with "health care”. As the winds of change blow and the currents of transformation threaten us, V-forming our disciplines through true collaboration appears to be the path of least resistance and best direction. Honk, if you agree!

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Two Steps Forward, One Step Back

Posted By Ben Miller, Tuesday, August 3, 2010
Updated: Thursday, June 2, 2011

In the current redesign of healthcare, there is precious little time for meetings to discuss what should be done next. The convening of various healthcare stakeholders to Baltimore, Maryland for the URAC/HAYES Paul Wellstone Mental Health Parity Stakeholders Conference was a unique opportunity for dialogue to occur around the future of mental health. This meeting was timely and precise in its attempt to examine the impact of mental health parity on current healthcare legislation, clinical practice, and payment strategies. There were three main points that emerged from the meeting that I will briefly address.

First, there appears to be growing sentiment that mental health parity is an important step for mental health treatment, but remains insufficient. Mental health parity law is in direct response to the fragmentation of the healthcare system. From an insurance perspective, parity brings mental health on an equal footing with medical benefits. This is a positive step for individuals in the community who need access to mental health services, but have previously been unable to access due to insurance barriers. However, it is important to note that just because insurance barriers have decreased does not mean more people will access mental health services. For example, we know that the majority of the public receives their mental health care in primary care, and that when referred to outpatient mental health, they often do not go. This may not change just because one has insurance to pay for services.

Second, within the redesign of primary care in the patient-centered medical home (PCMH), there is an increased opportunity to make the case that mental health and substance use must be included. While many know of the inseparability of mental health from primary care, this point still needs to be made every time the PCMH is discussed. The integration of mental health providers into the PCMH is one possibility for primary care’s redesign; however, mental health needs to constantly be at the table of discussions on the PCMH for this to happen. While this is just one future for mental health, acting now and acting fast is key to success as the fluidity of primary care’s redesign will not stay this way long.

Third, more research is needed to support the importance of mental health in the larger healthcare system. Without enhancing the evidentiary support for mental health and psychological treatment in medical settings, recommendations will be anecdotal and possibly ineffective. A golden opportunity could be missed. At a point in our nation’s history where we are looking to "bend the cost curve” and provide higher quality more effective and efficient care, our arguments should be grounded in science. There are many examples of this type of research happening now throughout the country. Mental health providers interested in the future of their field should consider using similar measures, tracking similar outcomes, and sharing this data so a stronger "business case” can be made for integration. Yes, there is a robust literature base on psychological treatments for medical conditions, but they have predominately been disease specific and limited in generalizability. We need more effectiveness trials that look at the heterogeneity seen in our healthcare settings.

There are rare opportunities in healthcare where systems can be profoundly impacted by their redesign. This may be one of those times. While mental health parity brought a group together in Baltimore, the passage of the bill itself was more confirmation of how far we still have to go. Dichotomizing mental health from physical health is a false separation. Two systems have developed from our inability to treat the whole person. Will healthcare providers of all ilks be able to rise to this momentous occasion and define itself in a new system? Will we be able to know what our future looks like and actively work towards this point? As I outlined above, there are many opportunities for mental health to become a major player in healthcare. Are we willing to take the risk? Are we willing to innovate? The choice is entirely up to us; but make no mistake, if we do not move, and move now, we will be left behind fighting for another version of parity in 10 years.

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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.