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Sometimes Change Hurts: The Politics of Policy

Posted By Ben Miller, Tuesday, November 10, 2009
Updated: Wednesday, June 1, 2011

I was in Kansas City this past week for a conference, and realized a travesty was occurring on Saturday, which I had no control over: My hotel did not carry CSPAN.

For those of you non-policy wonks, CSPAN stands for Cable-Satellite Public Affairs Network. What was an out of town guy to do? The only thing that made sense to me was to begin walking and convince a bartender to change the channel from World Series of Poker to CSPAN. To make a laborious story short, I eventually ended up at a swanky seafood and steak house in the new Power and Light District in downtown Kansas City. The bartender graciously agreed to change the channel off the horse races to allow me a few minutes with the glorious debate unfolding before my eyes. They even turned up the sound for me so I could hear the constant objections and rude interruptions by some of our elected officials. I was in heaven. This was politics at its finest. Positioning, grandstanding and strategizing - all for a vote which would not come for many hours later. I could tell you more about my experience at this restaurant, including the cardiac nurse who served me my drink, the uninsured bartender who was confused on how healthcare was paid for, the hostess who told me the story of her being denied coverage, but I will reserve those stories for another day (you could also check out one of my favorite books on the topic: Cohn's Sick).

Policy, as one mentor described to me, is movement in a direction. What we saw on Saturday (if you were able to stay awake) was historical movement. This was the first step in a significant policy that could possible change healthcare for years to come. Was this bill perfect? Absolutely not. Was this bill a step in a direction? Absolutely! Speaker of the House Nancy Pelosi had to make concessions to allow this bill to come to the floor for a vote that would pass. Interestingly, the House has done their job so it is the Senate now standing in the way for healthcare reform to take place. In some ways, this was politics as usual, in other ways, the introduction and passage of the bill was not. Therefore, we have movement in a direction - we have the beginnings of a new health policy. (And how cool was it that Dingell sounded the initial gavel? If you don't know the historical significance of this, read here).

Change is usually not easy; however, we make changes daily whether or not we recognize them. Imagine doing something for so long that you don't know that what you are doing may have a different way to be done. Maybe it's pronouncing a word or singing lyrics incorrectly. To you, this is all you know ergo correct, but maybe it's not. Someone corrects your language or you hear someone singing the correct lyrics and boom, you are made aware of a discrepancy in what you have always known as accurate. Sadly, this has not been true for healthcare. The current healthcare system has been working ineffectively for years, and knowingly doing so, but despite being made aware of the inaccuracy of this approach, nothing has been done. While it may not hurt too much to change the way you say a word or sing a song accurately, it may hurt to change an entire system, which is responsible for taking care of what is often most precious to us, our health.

Tying this all together, there remains an opportunity to continue the inertia behind healthcare while still advocating for change. Collaborative care, as a field, is not directly addressed in the House bill. Does this mean that we cannot still push for policies on better care through integration and defragmentation? No, it means that we still have our work cut out for us. Stay involved in the national policy discussion, but act locally. Talk about this with your friends, family and colleagues. Inform the misinformed. Call and email your representatives to tell them what you think about healthcare. Use your voice. Change may be hard and occasionally hurt, but it begins with the recognition that there needs to be a change. There is no better place this is true than within healthcare.

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My Fantasy Football Healthcare Team

Posted By Jennifer Hodgson, Wednesday, October 14, 2009
Updated: Wednesday, June 1, 2011

Disclaimer- I am a Medical Family Therapist. My training is in systems theory and my lens is biopsychosocial-spiritual. My advanced degrees are in marriage and family therapy but my postdoctoral training is in medical family therapy.

Perhaps my husband's push to have me join his fantasy football league has impacted my use of metaphors these days. However, I offer up a challenge, that we create a fantasy healthcare team comprised of the "best" providers for the setting rather than what we believe are the "best" professions.

Working in healthcare has always been a strong passion of mine and is evident throughout my clinical, research, teaching, and program development interests. Ever since I chose my profession, I have felt more like a line backer than a mental health professional. Blocking aggressive maneuvers by other mental health professional groups to create space for my existence is a continuous battle. The culture of healthcare has bred this competitive state of being where we profess that we can do what another discipline does and even do it better. Our fragmented system has led us all to scramble for as much yardage as we can capture, building large pots of money to use when we need to lobby and secure our place in the industry. From lobbyists to insurance panels, money seems to determine what kinds of care people have access to and not necessarily the most well trained professional for their presenting concerns.

Many of my closest friends are from mental health professions that are not of my own. We all sit around confused as to why so many mental health professionals are intimidated by the presence of other disciplines. Sure we have crossover, but the added skills that we all bring are unique and necessary. Research has yet to catch up to this issue but that is another blog. Before we cast doubt on someone's credibility we need to make sure that we review the available literature on our own. For example, it makes me want to "call an audible" to hear that some people think my profession is an intervention that can be done by anyone with a mental health or medical degree. I hear this same thing about my colleagues in other mental health fields who specialize working in healthcare and medical settings. Anyone who knows what it is like to enter into a medical setting for the first time knows that you cannot do so without a clinical and/or research skill set and specialized training in healthcare practice.

Mental health professionals should not be judged by their license only, but by the skills and expertise they bring to the medical home. I want us to be about quality and not job security. We need each mental health discipline just like we need every medical specialization. Our consumers should have the right to choose which professional has the best training and skill set for their presenting concern. I believe this is called parity. Thoughts?

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Psychiatric Consultation

Posted By Peter Fifield, Monday, October 12, 2009
Updated: Wednesday, June 1, 2011

I have been fortunate enough to be part of the nascent stages of two integrated primary care programs. In both programs efforts to create a useful psychiatric consultation program were made. The goal: To provide psychiatric consultation to the primary care providers regarding the care of patients presenting with co-occurring medical and mental health issues. An expected result of this process was a reduced level of provider apprehension regarding the prescription of psychopharmaceuticals.

In our current practice, we meet one time a month for psychiatric consultation. The people at the table include a psychiatrist from a local community mental health facility, our primary care providers (PCP's) and behavioral health specialists. Typically the meetings combine an "In-Service” type educational component with actual patient case reviews. The hope is to gain insight into how certain psychopharmaceuticals can be used to affect the overall health management of these patients.

For the most part, this process has been quite successful. Anecdotally, in our facility, the nurse practitioners spend more clinical time addressing the psychosocial needs of our patients. Furthermore, they appear more likely to explore the world of psychopharmaceuticals. For them, the psychiatric consultation model is very appropriate.

For the doctors at our practice, however, this service appears not to be as useful. Their efforts are best spent trying to get their patients into psychiatry "where they need to be”. More often than not however, psychiatry is not a viable option. The reasons why vary but most of our patients simply cannot afford psychiatry. Exacerbating this fact, state mental health budgets are being trimmed and providers of mental health services expected to ration the care.

Although not explicitly stated in most articles, such budgetary cuts could result in an increase of patients presenting in the primary care setting with anxiety and depressive symptoms. PCP’s commonly address some mental health needs with medications. Often, certain psychotropic medications (i.e. fluoxitine, Wellbutrin, amytriptaline, hydroxyzine, Buspar etc.) are used as front line treatments of depression and anxiety in the primary care setting. Due to our clinic’s unique population, pain medications and benzodiazepines are typically steered away from due to their high propensity for habit formation. Mood stabilizers and typical and atypical antipsychotics are generally not resourced either. The concerns around these medications are warranted: These medications come with a significant increase in complexity for the provider and the patient. Among other things, frequent blood draws are required to monitor lipid and glucose levels, to assure therapeutic dosage and to prevent toxicity. This is not to mention the possible life threatening complications related to improper titration off of these medications; for example Steven Johnson’s Syndrome can be more severe and life threatening.

I recently had a conversation with our medical director regarding our involvement with the existing psychiatric consultation services. Although he was in favor of continuing the service, he stated "We are having a difficult enough time just treating patients with primary care issues like diabetes and hypertension…and I might add, we do a pretty good job. I have no interest in becoming a psychiatrist. That is not my specialty”. I’m sure his perspective is shared by many primary care providers—we are doing all we can here to manage the physical ailments of our primary care patients and we do not have the resources to treat their complex mental health related issues as well.

Our current intent is to continue with the psychiatric consultation services for it has proven to be insightful for all. Even though it has not completely ameliorated the anxieties around prescribing some types of medications, it has, in my opinion allowed our PCP’s to feel more comfortable addressing the patient’s mental health needs in general; including the use of select psychopharmaceuticals. After all that was the goal.

All in all this is a very successful program that I would encourage any integrated primary care practice to institute if resources allowed. In a perfect world, all patients could have their psychiatric needs met at a specialty mental health clinic. Another alternative could be to employ a psychiatrist or psych ARNP as part of the integrated team in a primary care setting. If both of these options are not accessible, psychiatric consultation could prove to be a viable alternative.

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Promoting Community Collaboration through the Creation of a White Paper

Posted By Randall Reitz, Friday, October 9, 2009
Updated: Thursday, May 26, 2011

Mesa County, Colorado is a unique healthcare community. We benefit from an investment of $1 million donated from the local physician's group with $1.5 million offered by the local health insurance company that self-started a regional health information organization (RHIO). This technical collaboration unites the health records of our entire community.

Similarly, the primary care physicians and mental health providers in our community have a long history of collaborating for quality patient outcomes. This is most striking in the collaboration between for-profit and non-profit offices. These efforts were originated and maintained through the coordination of the Integrated Care Council of Mesa County.

The Integrated Care Council's successes have gained some recognition on a state and national level, but they remain largely unknown among the inhabitants of our own community. This is to our detriment because it hampers our ability to grow our model. So, earlier this year the Council set a goal of publishing a white paper that would be endorsed by all the major healthcare players in our community. This was a daunting task because many of these stakeholders are competitors and some of them would be hearing of the council for the first time when we approached them for a signature.

Undaunted, we facilitated several brainstorming and writing sessions to craft the text of our document. Our aim was to convey the stats and stories of collaborative care in Mesa County, to celebrate success, to increase buy-in from the community, and to launch a next round of initiatives. From the outset, we set a goal of limiting the document to a one-pager (front and back) that could be easily distributed and digested.

Once we had edited it to the council's liking we began distributing it to community leaders. Everyone we spoke with signed the document and requested very few changes to the wording. This includes the heads of:

  • The largest for-profit primary care offices,
  • The local independent physicians association,
  • The safety-net clinics,
  • The community mental health center,
  • The largest for-profit behavioral health office,
  • The RHIO,
  • The predominant insurance company,
  • The predominant hospitals from the 2 largest cities,
  • The local NAMI affiliate, and
  • The largest human services non-profit.

The Council paid a nominal amount to have the content and digital signatures formatted by a graphic designer. Just this week, the dissemination-ready draft was given final approval by the signatories and the Council and this blog post is the official launch of our white paper. See the final document by clicking here.

Our next challenge is to capitalize on this momentum by going back to the signatories and partnering with them to advance the initiatives proposed in the white paper.

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Laughing and Learning in Spanish-Language Prenatal Group

Posted By Amy Davis, Thursday, October 8, 2009
Updated: Thursday, June 9, 2011

So, let me tell you about the very best part of my week.

The Marillac Clinic is a clinic for the uninsured in Mesa County with a satellite clinic in Palisade, Colorado. The Palisade site had it's origins as a clinic for migrant and seasonal farmworkers, but now serves the uninsured east valley community at large. The clinic is still a medical home to a largely monolingual, agricultural Spanish community. Included in this community are a group of pregnant women who do not have access to any public assistance for their prenatal care other than emergency Medicaid at the time of delivery.

Historically, the Marillac Clinic has not provided prenatal care given the availability of such services in the private sector. However, changing funding streams created a need to provide these services, as many of these women did not participate in any prenatal care before presenting to the hospital at the time of delivery. In Colorado, 32.4 % of Hispanic women either present late for or have no prenatal care in comparison to 13.8% of white women.

Despite my perception that I should try to provide this service, I was thwarted by my knowledge that even when financial barriers are lessened or removed, disparities of utilization exist in access to prenatal care. I was also concerned about my abilities to efficiently provide care to this community of women when I only attend this clinic one day per week.

I decided to start a group prenatal visit for these women knowing that there are models and literature to support this. I easily convinced my behavioral health colleague at the clinic and our cultural diversity coordinator to join this endeavor. I have to admit we have been rather spontaneous about the project, but have been rewarded with unexpected enthusiasm and participation by our patients.

We usually cannot even get through introductions without the women laughing and "taking off" onto topics which interest them. The group has grown in number and the women bring their friends, mothers, and children. We had hoped during these group visits to provide education concurrently with their prenatal care, which I think has happened. However, more importantly what has happened is that these women have become less isolated, have shared their stories, their experiences, their sadness and their joy. They have shared with us their "creencias" and have taught us how best to help them with their health care.

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Development of Collaboration in a For-Profit Setting

Posted By Patrice Whistler, Thursday, October 8, 2009
Updated: Thursday, June 9, 2011

Primary Care Partners is a group practice in Grand Junction, CO with 21 Family Physicians and 14 Pediatricians. To better manage the behavioral needs of our patients we began collaborating at a distance with a local private counseling group, Behavioral Health and Wellness, about 12 years ago. Over time their staff and ours began to commute between offices and schedule joint patient appointments. Our partnership benefited from grant funding that promoted rapid diagnosis and treatment for ADHD. Through this project our pediatricians co-facilitated diagnostic sessions with their mental health staff.

Gauging our collaborative development using Doherty and McDaniels Five Level model, we started at a combination of Level 1, minimal collaboration, with referrals going to Behavioral Health and Wellness, along with some minimal direct communication (Level 2) before a referral visit was scheduled. This might have been a phone call or email, or faxed notes from the physician visit.

Two of us, myself as the pediatrician and one behavioral health and wellness counselor, started Level 3 (basic on- site collaboration) by traveling to and from each other's sites (7 blocks down a street), to have joint visits for certain complex patients or those who tried to "split" the physician and mental health counselor. This was time consuming and I often scheduled my visits to the mental health office on my days off; impractical but doable. In 2004 Primary Care Partners moved into a new building that allowed us to rent space to the mental health group. They now share a waiting room with our family physicians. Our proximity promotes daily shared patient care including joint visits, curbside consults, and availability for emergent evaluations in both offices. In this way we have fully implemented Level 3 (on-site collaboration) and sometimes level 4 (close collaboration in a partly integrated system)

This year we had a family physician and pediatrician complete Sandy Blount’s Primary Care Behavioral Health certificate program along with a psychologist and family therapist from the mental health office. We are also finalizing plans for a medical home that fully imbeds a few of their counselors into both our family physician and pediatrician exam room pods.

Recently we finalized a contract between the private behavioral health clinic and the state funded mental health center so that Behavioral Health and Wellness will be able to see Medicaid patients in the Pediatric office for up to 6 visits, for initial evaluation and stabilization. The requirements include a "warm" hand off by the physician, bringing the counselor into the room to meet the patient and family, and integrating the note from the counselor into our electronic health record that day.

We begin this program in a few weeks. If a client needs more that 6 mental health visits, they will be referred over to the mental health center, hopefully to a select group of clinicians ready to take the referrals without waiting time. The exciting thing about this program is that we have Medicaid patients served DIRECTLY in our office, the same way private pay or CHP (Colorado Children's Health program) clients are served.

Our physicians have continued to develop this relationship because we have benefited by many positive outcomes:

1. A patient in crisis in our office has immediate intervention with the on-site mental health staff.

2.Accurate diagnosis and medication management is much easier when supported by a thorough work-up and on-going consultation by a mental health specialist.

3. Patient satisfaction increases with the integrated therapeutic relationship of physician and mental health providers.

4. Our mental health partners save us time through continually providing updated records.

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A Day in the Life of a Case Manager

Posted By Fran Parker, Wednesday, October 7, 2009
Updated: Thursday, June 9, 2011

Clinical case management is a core aspect of Marillac Clinic's Integrated Care model. It is provided by a full-time case manager, all of our counselors, and (to a lesser degree) by our medical and nursing providers. These services were recently described in the national periodical for case managers and in a description of Marillac Clinic's integrated care services that was presented to the Advancing Colorado's Mental Health Care initiative.

The following is a description of an actual day in the life of our full-time case manager, Sarah.

Sarah starts her Tuesday at 8:00 am at the weekly mental health providers' meeting. Her participation in the meeting is disrupted when the front desks calls her to help with a patient. Martha, a 58 year old homeless woman, has come to the Clinic, asking for an early medication refill.

By 10 am, Sarah has handled phone calls from two parents calling on behalf of adult children waiting for medications through the Medication Assistance Program (MAP). She's assisted two patients with the disability application process. The local mental health center has faxed a discharge plan for a patient who will be coming to Marillac for service, and she decides she needs to follow up for additional information.

Over the next hour and a half, Sarah gets two requests from women needing early medication refills because of travel plans. Lisa makes her request in person. Sarah is familiar with Lisa's case and provides a brief counseling intervention since her mental health provider is not available. The other early refill request is made over the phone. Sarah is familiar with Karen, who has "no-showed" for several medical appointments. The patient has been told repeatedly she needs to see a medical provider before her prescriptions will be refilled. Sarah tells both women she will need to check with the "medical team" and get back to them.

The Clinical Case Manager also answers disability related questions from another patient, reassures an asthmatic patient who calls concerned that her Advair will not arrive in time, and handles a phone call from a pharmacy provider confused about the pharmacy's new contract with Marillac Clinic. She briefs two of her colleagues, a physician assistant and a mental health provider, about a patient with auditory hallucinations. Sarah's scheduled the two providers for a joint appointment with this patient.

When a medical provider asks Sarah to "meet and greet" a patient just discharged from an inpatient substance abuse program, Sarah goes into the exam room, talks with him, and reinforces his relapse prevention plan. After 25 minutes, the two of them decide he currently has enough structure and support in an aftercare program. Sarah tells him to call her if he needs help.

At 11:40 am, Sarah finds the Medical Officer of the Day (MOD) and discusses the two early refill requests. The MOD approves Lisa's request. However, the MOD does not approve Karen's request. Instead, the MOD writes a prescription with instructions on how to taper down the patient's anti-anxiety medication. When Karen returns from her trip and keeps an appointment with a medical provider, her health status and medication needs can be reassessed.

Before she leaves for lunch, Sarah discusses financial assistance programs with a 29 year old patient who needs shoulder and eye surgery. After lunch, she fields another call from the pharmacy and faxes a voucher so the cost of medication for a homeless man will be billed to Marillac. She listens to voice mail message from a case manager at the local domestic violence shelter who's checking on the status of the agency's request for a psychiatric evaluation of an undocumented person.

There's also a message from a man who needs a psychiatric consultation about potential interactions between his psychiatric and other medications. Sarah has been working for three months to arrange a consultation with an out of town psychiatrist, due to the local shortage of psychiatrists. She makes several phone calls to arrange an appointment on a day the patient will have transportation.

Mid-afternoon finds the Clinical Case Manager getting patient updates from several colleagues, a volunteer counselor and a staff mental health provider. She reviews the records on Larry, who has two prostheses. Larry can't afford the approximately $1,000/year cost of replacement parts. She calls the prosthetics provider about arranging a payment plan.

At 3:15 pm, a medical provider asks Sarah to meet with a woman who's grieving her mother's recent death. Sarah spends nearly an hour encouraging the woman to find some balance between meeting her father's needs and her own self care.

As the day draws near to an end, Sarah talks to a medical provider about potential resources for Leonor, a woman who has a very large kidney stone. Leonor's not a citizen so she isn't eligible for most assistance programs.

She responds to another call from the pharmacy and another patient who's seeking sample medications while waiting for MAP. After receiving a second phone call from a father about his daughter's medication, Sarah checks the Medication Outlet and finds the medication has arrived. She calls the father back with the good news.

Sarah ends her day noting that it has been kind of slow!

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Welcome to Grand Junction, CO

Posted By Steve Hurd, Tuesday, October 6, 2009
Updated: Thursday, June 9, 2011

Grand Junction's healthcare system has received considerable positive press of late. This attention grew on a national level from Atul Gawande's June 1, 2009 article in the New Yorkerand culminated in President Obama's August townhall meeting to discuss healthcare reform. The New Yorker article highlighted findings from The DartmouthAtlas that Mesa County, CO maintains nearly the lowest per capita Medicare cost in the U.S.

There are numerous drivers behind Mesa County's low healthcare costs, including:

    The effective cost controls of a long-standing local non-profit insurance plan;
    The efficiency of one of the nation's most successful regional health information organizations; and
    The presence of a non-profit hospital that sponsors a rural family medicine residency.

There is more to this story. Mesa County is also home to an enduring and expanding integrated care project. Marillac Clinic began providing behavioral health services in the primary care setting in 2000, when this concept was in a pilot stage.Over the past decade, the concept of integrating care for the mind and body has been widely embraced throughout the country.

Much of the work in building the Mesa County system has been carried out by the local Integrated Care Council. Council members represent the largest primary care offices, safety net clinics, public and private mental health offices, hospital services, healthcare payors, consumers, and families.

During this week, we will highlight successes of council members. On Wednesday Fran Parker, the coordinator of a 5-year integration grant, will present a day-in-the-life of a safety net clinic case manager. On Thursday 2 physicians will present integrated care initiatives. Amy Davis, a family physician, will present a prenatal group clinic for migrant families. Patrice Whistler, a pediatrician, will present the development of integration in the for-profit sector. And, on Friday, Randall Reitz, the current council president will describe how we have promoted integration through the creation of a community white paper.

Throughout this week, please take a moment to share some of your community's successes.

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What Potty Training Taught Me About Health Reform

Posted By Ben Miller, Wednesday, September 23, 2009
Updated: Wednesday, June 1, 2011

A.K.A.: "Don't Write Blog Posts Too Late At Night or This is What You Get"

Now that I have your attention, let me really get down to what I want to talk about: What potty training has taught me about health reform. You see, I have a 19 month old who is experiencing the rite that we mostly all have passed (hopefully), potty training. It occurred to me that there are many principles for health reform that also apply to potty training (and vice versa). So, without being too crude let me get started:

  1. Sometimes it is about patience: Patience is usually a great skill to have when entering into any type of new (and often significant) change. There are those who have committed serious amounts of time (read their life’s work) to seeing change in healthcare. While I cannot say that I have spent the majority of my life working on potty training, relative to how long my daughter has been alive, I would argue that it has been a significant amount of her life. Yet, we wait. There have been various aspects of healthcare that lead me to believe that yes, we are close to something big; however, just like potty training, when you think you have it, something inevitably happens that changes your opinion about the directions you are going. Take away: Deep breath, start again…
  2. Those most invested in success may not be who you think: This one is pretty obvious to me, but think about it from a child’s perspective: Why change when I have everything I need already in place? A diaper – check! A parent to change – check! There are those in the current healthcare system who are just this way. A public dependent on health coverage – check! Lots of sick people – check! Why change this? Well let’s begin with the fact that healthcare is a booming business. Even in our current economical situation, healthcare continues to prevail financially. Because many experts agree that payment reform is central to a redesigned and successful system, some may not want their bottom line affected. In addition, there are provider groups within healthcare that are afraid they will lose out because their specialized form of payment could be consolidated within a larger healthcare budget. These are all very real conversations that are happening now! Take away: Examining others motives in success (or failure) is not a bad thing to do.
  3. If at first you don’t succeed… Some failure with potty training is inevitable. I mean, come on, this is the first time the little one has had to demonstrate self-control (and in a major way). There will be small success and some setbacks, but all in all, it will be worth it if you can just stick it out. Healthcare? Well let’s just say that we have been trying to succeed at building a high-quality, cost conscious, efficient system for some time, but aren’t quite there. As a matter of fact, we have regressed in many ways. We pay more and get less for our healthcare than we have in the past, and there is little question that if we don’t change now, no one will be able to afford healthcare anyway! Take away: practice makes perfect (or at least better).
  4. Be prepared for false alarms: Baucus bill emerges; no one likes it. Having your child say the word "potty” meaning they are in the act of (verb) rather than describing the item they wish to use (noun). Take away: One can never really know if this is really "it” but we have to keep working like it is.
  5. Convenience vs. Inconvenience: Imagine this, you have the Cadillac plan for insurance – you are covered from head to toe, and pay relatively little for what you receive. Someone comes up to you and says, "Hey, we should change health insurance.” Your first response is not likely to be "OK that sounds great!” In the same vein, you are at home, and "potty” is mentioned – look how easy it is to access this wonderful and convenient service that doesn’t require you to do too much to accommodate. Now, same scenario – "potty” but you are now out on the road with no potty. Your first response is not likely to be "OK that sounds great!” Take away: Sometimes complex change requires us all to be a little inconvenienced for the sake of the greater good.

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Mental Health vs. Behavioral Health

Posted By Peter Fifield, Monday, September 21, 2009
Updated: Wednesday, June 1, 2011

In a past CBC blog there was a brief discussion around the difference between "Collaborate and Integrate”. Although to some it may only appear to be an issue of semantics, to others there is a need to create consistent definitions in our profession. A reliable discourse within our profession could facilitate the relay of ideas concerning policy, process and practice.

As the concepts of Integrated Care become more and more familiar within the medical landscape, there is a potential need for a universal discourse. On occasion I interact within our local and state-wide communities here in New Hampshire spreading the word of integrated medicine and collaborative care. Naturally, two phrases that are often used during conversations are "Integrated Care” and "Behavioral Health”. Shortly after these words leave my mouth, a look of inquisitiveness often arrives on the faces of anyone lending an ear.

Dr. Ben Miller asked an important question in a prior blog: "Where is Mental Health”? As I read the blog, I thought that before we can identify where "it” is we actually need to know what "it” is. I have a request of you all. Please post your opinion related to the difference between Mental Health and Behavioral Health. I have my own operational definition but quite often I find myself attempting to discern between them and I’m sure my resultant answer is rarely the same. Questions I find myself asking are: "Is it more than just a way to euphemize a service being sold to an unwitting patient?”, "Is there a core practical difference between the two or is it merely a philosophical difference?”, "Does behavioral health only occur in a medical setting and mental health in a specialty clinic?” and "Does anyone really care about the difference aside from the Medicaid/Medicare billing departments?”. I hope that there are some Behaviorists, Gestaltists and Psychoanalysts out there, from a range of professions, ready to respond to this topic.

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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.