Posted By Randall Reitz,
Monday, October 10, 2016
| Comments (2)
You're at this week's CFHA conference. You're glowing in the bucket list elation of a
just-finished speech from a professional hero. And then, a flock of
Questioners swoops to the microphone mid-way up the center aisle. Like the
cicada, this noisy species only makes a brief appearance and then disappears
for months or years. During their moment in the sun, they torment the speaker
and audience with randomness.
Vox populi, vox diaboli.
And yet, after
years of plenary sessions, this annual rite seems far less random. Over
time, the Questioners and their statements gain familiarity and order. If you
focus closely on the Questioners' gait, tone, dress, and breath, you can easily
discern their genus and species.
Here is a first
attempt at classifying the types of Questioners the astute observer might sight
at next month's CFHA conference in Charlotte:
Niche Gadfly — This Questioner attends every plenary with the fervent
expectation that all speakers explicitly frame their material around the
Questioner's particular pet cause. If not afforded satisfaction, the Gadfly will
counter with "I enjoyed your presentation, but you failed to address how
your material relates to _____". Common subspecies of the Gadfly include
Family Systems, RCT, Social Justice, ACEs/Trauma,and
the never abiding Pan-Umbrage.
Sycophant — While gushing is his sine qua non, always specify if of the Brown Nosing(secondary
gain)or Boot Licking (primary gain)genus.
Humble Braggart — Don't be fooled by this ostensibly lowly supplicant.
Hubris belies her genuflection. Typical humble brags include "It's been a
real struggle for me to grasp the full implications of your oeuvre, which I'm
painstakingly deconstructing as part of my Harvard fellowship" or
"Thank you for mentioning medical family therapy because I'm still licking
my wounds from when I was put in my place by Susan McDaniel over dinner at
Gramercy Tavern". Please specify Primarily
Humble or Primarily Braggart.
Political Hack — Cherry-picks statements from the speaker to make
overtly political commentary. While Blue Hacks typically
far out-number Red Hacks in the CFHA population, North
Carolina might provide a counter-veiling microcosm.
Idealist — Neophytes are classified as either Reverants
(i.e. "Would you please autograph my copy of your CV?") or Comeuppants (i.e.
"Never trust anyone over 40").
Intractable Dilemma — Easily
identifiable by its "Yes but! Yes but!" chirp, this species
presents an insolvably complex conundrum in hopes that stumping the
presenter will justify his case for martyred sainthood. The genus declares
itself according the urgency of the request, with varieties including: Here
and Now, Immediately After the Plenary,or Through Escalating
Long-Winders — All of this species have hypnotic powers, but not all
speak in soothing tones. Drones are typified by their
meandering fizzle while Warblers demonstrate characteristic
bursts of imploding and rallying, imploding and rallying.
Long-Worders — Two sub-species: Sesquipedalian (uses lots of big words, like "sine qua non” and
"sesquipedalian”) and Catachrestist
(uses lots of big words inaccurately, like "irregardless”).
Confessor — This tormented soul finds secular
Jesus amidst the cadence and crescendo of the keynote and approaches the pulpit
seeking the presenter's public forgiveness. Please stratify according to the
magnitude of the confessed sin: Myself, My Colleagues, My Privileged
Class, or Western Medicine.
So, there you have
the 24 known species and sub-species of Questioners. There are inevitably
more that have been observed in the wild, but not reported in the scientific
literature. If you're aware of any other species please describe them in
the comments section below.
AND, for your
conference-going pleasure, we have created Keynote Questioner Bingo
cards, see linked document below. Simply print out the card, randomly fill in the squares
with the species and sub-species, and bring the card to the major conference
sessions. Each time you sight a new breed of Questioner mark the
appropriate square until you have Bingo.
You might even be the first player to
achieve Black-out! Obviously, there is considerable overlap among the species
(notably Sycophants, Idealists, and Long-Winders).
As such, you will need to classify each Questioner within a single category for
purposes of the game.
|Randall Reitz is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO. He runs a pre-/post-doc fellowship for medical family therapists With CFHA he is a current board member and the previous executive director. His Questioner species is the unseemly product of a ménage à trois between a sycophant, a sesquipedalian, and a humble braggart.|
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Posted By Michael Hogan,
Tuesday, October 4, 2016
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Mike Hogan is the Saturday Plenary Speaker for the 2016 CFHA Conference in Charlotte, NC.
Increased deaths from suicide are
in the news. The Centers for Disease Control recently reported that the
increased suicide rate contributed to a rare rise in the overall death rate for
Americans in 2015. What can be done to stem this tide? And, while "upstream”
prevention efforts are needed, what should health care settings—especially
integrated primary care—be doing about suicide?
One would think that detecting
and caring for suicidal patients was not new. Unfortunately, this isn’t true.
Health and even mental health providers have not been tuned in to suicide care,
and the old but receding gap between health and behavioral health care makes
things worse. While care for common mental health problems like depression is
not adequate in traditional primary care settings, trying to detect and manage
suicidality is even tougher.
In multiple studies, up to 45 per cent of all
patients and a shocking 78 per cent of older people who die by suicide, saw a
medical doctor in the month before they died. But something was missing. In all
probability, they were not asked about self-harm or suicide. When it comes to
most of health care, a kind of "don’t ask, don’t tell” approach to suicide has
Suicidal people generally do not
want to die but can think of no other way to end their pain. They slip through
other cracks in health care as well. In a 2006 study in South Carolina, 10 per
cent of all suicide deaths were among people recently seen in emergency
departments. They may have been asked about self-harm, if suicidal impulses
brought them to the hospital.
But new and effective interventions (such as
developing a one page Safety Plan that provides practical alternatives that the
patient and family can take, or medical personnel making supportive follow-up
phone calls in the days and weeks following the visit) were probably not used.
Another surprising gap is the
poor training of most mental health professionals such as therapists,
psychologists and psychiatrists in treating suicidal patients. Good training in
caring for these patients should be expected, since suicidal patients are
usually sent for care to mental health settings. However, these skills are
rarely provided in the graduate training of licensed mental health
A few states, such as Washington and Kentucky, have recognized
this gap and passed laws to require continuing education in suicide care. But
the gap persists. It means that a referral to specialty mental health care,
long thought of as the best way to care for suicidal patients, may not be
It does not have to be this way. The
good news is that effective screening tools and treatments now exist. The bad
news is that since these tools are new, they not used yet in most health care
settings. We also have evidence that systematic suicide care can be effective.
At the Henry Ford Health System in Detroit, the "Perfect Depression Care”
effort—a systematic quality improvement program within the behavioral health
division—reduced suicide deaths among people receiving care by over 75 per cent.
The new tools for suicide care
have been bundled together in an approach we call "Zero Suicide in Health
Care,” and implemented successfully in real world clinics and health systems. One
of the innovator organizations demonstrating that suicide safe care is feasible
in integrated primary care settings is the Institute for Family Health in New
York, where suicide care protocols have been successfully embedded in the
clinical workflow and EMR. The tools
involved in suicide safe care are demonstrated and available at www.zerosuicide.com.
The approach involves hard work,
but it is feasible. Over 200 health care organizations in the United States,
with others in the Netherlands and United Kingdom, are now putting it in place.
But this is only a beginning. Most health care today cannot be labelled as
"suicide safe,” and taking on the mission of suicide prevention is a new
challenge for health care organizations. It is especially difficult in health
care settings that have not integrated care for mind and body.
The Joint Commission
has issued a "Sentinel Event Alert” that puts health care organizations on
notice that detecting suicidality among patients should be expected. We hope
that these developments, and new leadership among health care professionals to
prevent suicide, can make a difference. Suicide is preventable—if we work at
|Michael Hogan, Ph.D., is a clinical professor in the psychiatry department at Case Western Reserve University School of Medicine in Cleveland.|
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Posted By Cathy Hudgins, Eric Christian,
Tuesday, September 27, 2016
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This post is by the 2016 CFHA Conference Co-Chairs.
Come See for Yourself!
A psychiatrist, a primary care doc, and a therapist walk
into a bar…So, you think I am joking, right? Actually, this type of meet-up is
not uncommon at CFHAs annual conference. Come to Charlotte, NC in October and
see for yourself!
One thing was clear during the initial planning meeting for
this year’s CFHA conference – we wanted the theme to be inclusive. It needed to
welcome all types of providers, practices, policy makers, and others who are
working together to make integrated care (IC) a standard of care. We may come
from different states, backgrounds, perspectives, and job roles, but we are
united and working toward the same goals. I can think of no other organization
like it for this reason.
There are always sessions that challenge the way I think about
some aspect of IC (over 80 to choose from!). Every year I walk away with new
tools and implementation strategies that put a new spin on the foundations
built by many of our CFHA members. This year you will have the opportunity to dive
deep into the IC models or learn more about how to negotiate health information
technology during the precons. You can choose from 2 Master Lectures: The Intersection
Between Physical and Mental Health Disorders in Older Adults or the Ethical
Challenges of Working with Diverse Couples in Primary Care.
We are also excited
to offer timely plenaries on the healthcare needs of LGBTQ and Ally community,
community-based solutions to the opioid epidemic, and provider strategies to
reduce suicides. All of these special events punctuate 6 specialized tracks to
choose from – topics that span from finance and cost control, training and
research, patient and family-centered approaches, team-based clinical skills
and innovations, workforce and inter-professional education, and population and
If all of that is enough, you also have the opportunity to
swap lessons learned and best practices with experts from across the nation --
the "rock stars” who share their expertise via publications, the listserv,
monthly webinars, and the special interest group teleconferences throughout the
year. Where else can you meet the people who authored your favorite IC books,
articles, and videos? These experts do not just present; they sit beside you
during the sessions and plenaries because they are there to learn about the
newest advances and successes from their peers and emerging IC talent.
To offer a broader view of the IC work in NC, we will have
the first CFHA state showcase. Working in North Carolina has opened my mind to
the creativity and effort that it takes to customize models that the IC
pioneers and early adopters developed, researched, and refined over the last 3
decades. NC has had a long history of public and philanthropic funding devoted
to developing IC in NC.
We will have the first CFHA state showcase
Charitable organizations, such as the Kate B. Reynolds
Charitable Trust, the Cone Health Foundation, and the Duke Endowment, continue
to support providers and organizations who are determined to keep their
patients from falling through the cracks of a fractured system. I encourage you
to stop by the NC Showcase to meet representatives of some of these projects
You will also meet members and staff of our NC Integrated
Care Steering Committee, State Departments, and countless IC task forces and
workgroups. They will gladly share first-hand stories about the energy and
movement going on behind the scenes – a story is full of herculean effort, deep
commitment, and dogged tenacity. Many hard-won victories and lessons learned
are shared at CFHA by people across the nation – it is truly an affirming,
I wouldn’t have the job that I have today at the Center of
Excellence for Integrated Care if I had not gone to a CFHA conference several
years ago. There have been so many CFHA members who have influenced my work and
career since then -- people who I am honored to call friends and colleagues;
people who I would have never met had I not discovered this organization.
I tell people that going to CFHA is better than any holiday for me (which I
really mean!), it is because I never know what magic will result each year. Now
it is my turn to give back as co-chair – and I can’t wait to see all of the
wonderful gifts that come from these 3+ exciting days of all things IC. I hope
you will join us in Charlotte to experience the magic as
we celebrate the many faces and places of Integrated Care!
|Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care. |
Paths to Integration and CFHA
It’s always intriguing to
hear personal accounts about how people became interested in their current profession
and what drives them to continue pushing the limits within their field. Some of
us who were trained in and began our careers in more traditional behavioral
health environments had an epiphany somewhere along the way when presented with
a new and exciting team-based integrated care (IC) delivery format, and decided
to pursue this new path.
This epiphany happened for me
in the ninth year of my career as a behaviorist. My work to this point was
fulfilling and I was able to advance into exciting positions within clinical
leadership. In 2004 North Carolina made sweeping changes in the care delivery
system away from state run community treatment to a privatized system, and after
a few years, the changeable environment became very complicated for many to
While managing an outpatient behavioral
health unit I began to notice how our nursing staff focused on a broader
comprehensive profile of the patient’s health beyond the presenting issue. My
curiosity grew deeper following a few encounters where physical illness was
exacerbating the patient’s behavioral health presentation, a factor which began
to broaden my perspective of which professionals should be a critical part of
the patient’s care team. How had I missed these important variables before?
presented with a unique opportunity to bring my behavioral skills to medical
settings, while simultaneously learning more about treating the whole person in
one setting, I chose this new path. IC provided me with an exciting new area of
learning and the opportunity to meet others who were inspired by the creativity
and targeted services that integrated settings offer to patients. Shortly
afterwards the path led to learning about the esteemed CFHA while assisting
with the conference in Asheville, NC in 2007.
Integrated Care provides
enhanced service delivery for patients, while at the same time does its part to
strengthen the broader continuum of services needed to manage the range of
healthcare needs in any one community. Along this continuum of services, in
North Carolina we are beginning to see expanding interest beyond traditional IC
to bi-directional integration, the use of peer support and community health
workers to engage patients, cross-training in behavioral health clinics on
common chronic illnesses such as diabetes, and greater strides in the use data
for decision-making and collaboration with each other across town.
In North Carolina we see expanding interest beyond traditional IC to bi-directional integration
As you well know, our current
healthcare environment is in great flux as we move away from fee-for-service
models towards accountable care. Many states, including NC, are somewhere in
the middle of this transition, but one thing is clear, integration will continue
to propagate and is gaining tremendous momentum as new clinicians discover it every
day. While providing technical assistance to IC sites I often meet clinicians
who are just learning about integration and are as excited as I am to envision
the possibilities it can provide. Do you remember when this happened for you?
year’s conference theme, Celebrating the Many Faces and Places of Integration, celebrates
the shift many have made towards IC and will inevitably increase the size and
breadth of the CFHA family. CFHA veterans are in a unique position to welcome
new conference attendees by sharing CFHA’s collegial environment which is focused
on supporting best practice approaches to integrated treatment.
As Co-Chair for
our conference this year, I’m excited to hear the stories of newcomers and how their
new path of exploration is inspiring them to stretch the constructs of care
provision while ultimately contributing to our collective movement to provide
whole person care. See you when our IC paths cross in Charlotte!
|Eric Christian, MAEd, LPC, NCC is a Licensed Professional Counselor and a
Nationally Certified Counselor who has been working in the field since 1998. He works as the Director
of Behavioral Health Integration for Community Care of Western North Carolina,
where he provides technical assistance and consultation to providers interested
in integration. |
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Posted By Jennifer Richman,
Monday, September 19, 2016
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We all know that primary care
doctors have to wear many "hats” in taking care of patients. Unfortunately, with the shortage of mental
health providers and the fact that those with mental illness are living longer
and more often than not, have multiple medical illnesses, it is often left to
the primary doctor to wear the psychiatrist "hat”.
As if the shortage of mental health providers
wasn’t difficult enough, there is little time or incentives to seek out more
education or to attend conferences, which often have high registration fees and
involve even higher travel expenses.
What if there was a free, biweekly
mentoring program that you could participate in from the comfort of your
office, which provides advice and education in treating those with mental health
issues as well as provides CME? What’s
the catch, right? There is no catch. The
ECHO© model was developed by the University of New Mexico to provide best-practice
specialty care and reduce health disparities through tele health.
In 2003, Dr. Sanjeev Arora, MD was a liver
doctor at the University of New Mexico, and was frustrated that many people in
the underserved areas were not able to receive treatment for Hepatitis C
because they could not travel to one of two specialized centers in New Mexico
and the primary care doctors didn’t feel comfortable prescribing medications
that often had serious side effects.
The solution came to him in the form of
technology. Weekly virtual clinics were
set up to engage primary care doctors in remote areas with specialists at the
academic medical center where they would present de-identified patient cases
and the specialist would provide recommendations. Over time, the hope was that primary care
doctors would learn how to treat these patients on their own, providing better
care for more specialized illnesses in rural areas.
The University of New Mexico studied the
providers who participated in the ECHO© program and discovered that
the viral load of patients who were taken care of by specialists at the
academic medical center were no different from those taken care of by PCPs
involved in the ECHO© program and a movement was born.
The solution came in the form of technology
With the help of the ground breaking
work from University of New Mexico, providers, both nationally and
internationally began to be trained in the ECHO© model and brought
it back to their institutions. There are
now multiple ECHO© models in every specialty you can think of all
over the world. Just over 2 years ago,
the University of Rochester became trained in this model and provided geriatric
mental healthcare mentoring to primary care offices as well as nursing
While the participating providers
found the model helpful and supportive, they felt that they needed more help in
learning how to treat the adult population with mental illness and the
University of Rochester Project ECHO© PSYCH was born.
does it work? The ECHO© Psych team, which consists of a moderator,
psychiatrist, Psych NP, psychiatric social worker, psychiatric pharmacist and a
psychologist sit around a table and listen to cases presented by the primary
care sites. The cases are de-identified
and only include the bare minimum information to generate a useful discussion.
Recommendations are made by the treatment team as well as those at other sites
who have recommendations based on their experience and the ideas are collated
and provided in written form. In
addition, there is an evidence-based didactic provided by one of the expert
panel which primary care sites can receive CME credit for. Clinics are
typically biweekly for 90 minutes.
goal is to not only help the primary care sites with the individual patients
they present in clinic but to educate them on strategies to treat mental health
issues common in primary care practices.
The other hope is that it creates a community of practice where all of
those involved in the program feel supported with difficult cases and where
sites often feel isolated. The team also
hopes to model how to provide team-based care even when there are
What is needed to participate? The beauty of the program is that most people
don’t need to buy any fancy equipment.
The application that our program uses can run on smart phones or any
computer and only requires a basic camera.
Although we encourage video participation, it is also possible to call
in through a phone without video capabilities.
Since ECHO Psych was launched in
March of 2016, we have had 12 clinics with over 60 attendees. Most attendees have returned for multiple
clinics. The average attendance per session has been 17 and these attendees
include multiple spoke sites with multiple providers often present at each site. ECHO Psych currently provides telementoring
for psychiatric issues to participants in over 13 counties in New York State,
spanning over 350 miles.
The goal is to educate them on strategies to treat mental health issues common in primary care practices
have presented 20 cases for recommendations, with a number of them presenting
for follow-up recommendations. Twelve
evidence-based didactics have been presented on topics ranging from evaluation
of post-partum depression to identification and behavioral treatment of OCD, to
lessons that have been learned from the STAR*D trial. An overwhelming number of participants have
graded the didactics as "very good” or "excellent”.
Although it is too early to have
data on ECHO Psych, we have qualitative data derived from 26 interviews from
the Geriatric Mental Health in Primary Care ECHO that ran previously. Most
found that the format was interactive and engaging, but also struggled with
finding time to attend as well as time to present cases.
Participants felt they expanded their
knowledge base in all areas including psychopharmacology, non-pharmacologic
treatment modalities and available social supports. Participants also felt they
there was large increase in their confidence in handling older adults with
mental health issues. Overall, Participants felt the ECHO model was highly
beneficial to their practice.
So you may be thinking, this sounds
great, how do I get involved in an ECHO program? More information about the University of
Rochester ECHO program can be found at www.urmc.rochester.edu/project-ECHO.Most programs are state
based, so it would be helpful to check the UNM ECHO© website at http://echo.unm.edu/ to determine what
programs are available in your state.
|Dr. Richman graduated with a BS from Cornell University and
received her medical degree from the University Of
Rochester School Of Medicine. She
completed her psychiatry residency at the University of Rochester School of
Medicine and Psychosomatic Fellowship training at Georgetown University. She is currently an Assistant Professor at
the University of Rochester and is medical director of ECHO© Psych
and Telepsychiatry. She also runs the
psychiatric consultation service at Strong Memorial Hospital and specializes in
perinatal psychiatry. |
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Posted By Melissa Lewis, Laurelle Myhra ,
Monday, September 12, 2016
| Comments (0)
Indigenous people of the United States and the world suffer from some of the worst health disparities. Disparities are linked to historical trauma, healthcare barriers, and epigenetic processes due to social, political, cultural and environmental violence. Indigenous health disparities are a result of historical oppression of these communities, as well as, the current inequities that exist in these settler-colonial states.
The systems of living that Indigenous people have continued to assert (e.g., Traditional ecological knowledge [TEK], Indigenous knowledge [IK], Indigenous economics, health knowledge, family and community systems) have been challenged or outright legally banned. These include the right to fish, hunt, forage, and use medicine, religious and cultural practices for health and well-being. In fact, until 1978, due to the American Indian Religious Freedom Act, many of these activities were illegal. Therefore, without the land, access to traditional food, and right to practice traditional cultural ways of being (including spiritual practices and medicine), health and wellbeing was compromised with increased incidences of cancer, heart disease, depression, and suicide. These diseases were uncommon before colonization and the subsequent disruption to Indigenous lifeways.
Indigenous communities continue to practice their traditions today, but with continued obstruction from state and federal government, as well as private citizens. For instance, treaty rights (which were granted by the United States government in exchange for land cessation-think of it as rent) allow fishing, hunting, foraging, and cultural/spiritual practices.
Despite this treaty obligation, Indigenous communities who practice these rights remain at risk for being (unlawfully) arrested, cited or jailed. Several northern Minnesota Ojibwe tribes- with leadership from Winona LaDuke, White Earth Ojibwe and executive director of Honor the Earth-are fighting for rights guaranteed by their 1855 Treaty to hunt, fish and gather, which are being threatened by the two major pipeline proposals, Sandpiper and Enbridge Energy’s Line 3 Replacement, which would impact wild rice waters and wildlife habitat and could adversely affect health for generations.
Further, the Dakota Access Pipeline has received approval by the United States Army Corps Engineers without the consultation of the original and current owners of the land, the Hunkpapa Lakota (and others) of the Standing Rock reservation, which, again, is a violation of treaty obligations. This pipeline threatens the health of the land and water-the very tools that these communities need to maintain their traditional ways of being. In other words, "If the land is sick, we are sick.”
While research with Native communities has historically been focused on problems, a shift has occurred and there is an increased amount of research on the resilience of Native people highlighting the importance of cultural practices for the health of Native people. For instance, Native people that identify strongly and positively with their identity and take part in traditional cultural activities are more likely to have improved academic performance, positive mental health for youth and adults, reduced substance use for and youth and adults, and improved physical health. Therefore, programs that facilitate cultural knowledge and pride may be able to redress the imbalance that so many Indigenous communities see by improving health and well-being outcomes.
In our own research we discovered that collaborative/integrated care appears to be an effective healthcare system for Native people. However, when Native culture was also integrated into care (see Figure 1 below), the positive effects appeared stronger. Integrated care at Native-serving sites resulted in a wide variety of health and well-being improvements including reduced depression, smoking, drinking, and criminal behavior; improved general health, employment status, and housing status; significant reduction in ED visits and hospitalizations; reduced turnover and increased employee satisfaction (see reference list).
Integrating behavioral healthcare into a medical setting resulted in discovering that Native-serving healthcare systems had a lack of mental health screening, lack of resources, and a high comorbidity of physical and behavioral health diagnoses. Healthcare systems integrated behavioral health care for a variety of reasons including:
1. High comorbidity of behavioral and physical health symptoms
2. Acculturation and general life stress related to a complex of physical and mental health problems are related to behavior-related mortality
3. High disease burden (both behavioral and physical) that requires quality, collaborative care
4. Patients with active mental health symptoms see medical provider but failed to be properly screened and treated
a. Untreated behavioral health symptoms can be ‘caught’ at medical sites due to comorbid physical complaints, i.e., medical visits
b. 60% of presenting problems in IHS primary clinic are attributable to mental health problems
5. More likely to seek mental health services from medical providers than behavioral health when compared to White population.
a. 96% feel comfortable talking to medical provider about their mental health
6. High turnover rates of physicians at IHS so rapport can not be built.
7. IC is validated by national health organizations for effective assessment and treatment of an array of health concerns.
While there were many positive outcomes, there were also a number of challenges to integrating care:
1. Provider anxiety around asking personal questions
2. Being able to address behavioral health symptoms in limited time frame
3. Behavioral health providers concerned that physicians had the appropriate skills to address depression symptoms
4. Adequate staff to support the follow-up appointments
5. Time Management (Case managers spent a lot of time calling and scheduling appointments)
6. Human resistance to change
7. Departmental turf wars
8. Reluctance of staff to take on additional work
9. Staff turnover
10. Lack of resources for providers
a. Which is related to lower performance of clinical quality
11. Lack of funding
a. IHS receives only half of the funding needed to care for the patients it serves
A model program for integrative care in an Indigenous community is the Nuka System of Care at the Southcentral Foundation in Anchorage, Alaska. Dr. Myhra and Dr. Lewis had an opportunity in 2012 to present our results and tour this system, and we were blown away! As you enter the primary care building the first thing you see on the outside is a traditional medicine garden. As you walk in past the stunning Alaskan Native art and photos of customer-owners (not patients) the first service you see is traditional healing. With several specialties inside, this large primary care center operates as a one-stop shop. In Family Medicine, all care providers (physicians, nurses, behavioral health coordinators, administration) sit in an open-air, team setting, which facilitates communication. Large patient rooms allow many family members to attend. Health outcomes include (Gottlieb, 2007):
- Evidenced-based generational change reducing family violence
- 50% drop in Urgent Care and ER utilization
- 53% drop in Hospital Admissions
- 65% drop in specialist utilization
- 20% drop in primary care utilization per patient
- 75-90%ile on most HEDIS outcomes and quality
- Childhood immunization rate of 93%
- Diabetes with 50% of HbA1c below 7%
- Employee Turnover rate less than 12% annualized
- Customer overall satisfaction 91%
This system of care provides a model for integrated care across the world and demonstrates that integration of behavioral health care into medicine should not be linear but be regional and community specific and address the culture and needs of the community.
Melissa Lewis, PhD, LMFT is an Assistant professor at the University of Missouri School of Medicine in the Department of Family & Community Medicine.
||Laurelle Myhra, PhD, LMFT is the Director of Health Services at Catholic Charities of St Paul and Minneapolis. Her clinical work and research has focused on families, resiliency, trauma, mental health, substance abuse and integrated care among American Indians. She received her doctorate in Family Social Science/Marriage and Family Therapy from the University of Minnesota.
Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: Considering the Role of Healthcare Systems in Health Disparities. Part I. Under review at Families, Systems, & Health.
Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: A Systematic Review of the Literature. Part II.
Integrated Care in Indigenous Communities
1. Abbott, P. J. (2011). Screening American Indian/Alaska Natives for alcohol abuse and dependence in medical settings. Current Drug Abuse Reviews, 4(4), 210-214.
2. Doorenbos, A. Z., Demiris, G., Towle, C., Kundu, A., Revels, L., Colven, R., . . . Buchwald, D. (2011). Developing the native people for cancer control telehealth network. Telemedicine and e-Health, 17(1), 30-34. doi:10.1089/tmj.2010.0101
3. Gottlieb, K. (2007). The family wellness warriors initiative. Alaska Medicine, 49(2), 49-54.
4. Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295. doi:10.1016/j.drugalcdep.2008.08.003
5. Parker, T., May, P. A., Maviglia, M. A., Petrakis, S., Sunde, S., & Gloyd, S. V. (1997). PRIME-MD: Its utility in detecting mental disorders in American Indians. International Journal of Psychiatry in Medicine, 27(2), 107-128. doi:10.2190/C6FD-7QWB-KNGR-M844
6. Sequist, T. D., Cullen, T., Bernard, K., Shaykevich, S., Orav, E. J., & Ayanian, J. Z. (2011). Trends in quality of care and barriers to improvement in the Indian health service. Journal of General Internal Medicine, 26(5), 480-486. doi:10.1007/s11606-010-1594-4
Indigenous Resilience and Culture
1. Whitbeck LB, Hoyt DR, Stubben JD, LaFromboise T. Traditional culture and academic success among American Indian children in the upper Midwest. Journal of American Indian Education. 2001;40(2):48-60.
2. Petrasek MacDonald J, Ford JD, Ross NA, Cunsolo Willox A. A review of protective factors and causal mechanisms that enhance the mental health of indigenous circumpolar youth. Int J Circumpolar Health. 2013;72(1):1-18. doi: 10.3402/ijch.v72i0.21775.
3. Garroutte EM, Goldberg J, Beals J, et al. Spirituality and attempted suicide among American Indians. Social Science and Medicine. 2003;56(7):1571-1579. doi: 10.1016/S0277-9536(02)00157-0.
4. Yu M, Stiffman AR. Culture and environment as predictors of alcohol abuse/dependence symptoms in American Indian youths. Addict Behav. 2007;32(10):2253-2259. doi: 10.1016/j.addbeh.2007.01.008.
5. Stone RAT, Whitbeck LB, Chen X, Johnson K, Olson DM. Traditional practices, traditional spirituality, and alcohol cessation among American Indians. J Stud Alcohol. 2006;67(2):236.
6. Wilson K, Rosenberg MW. Exploring the determinants of health for First Nations peoples in Canada: Can existing frameworks accommodate traditional activities? Soc Sci Med. 2002;55(11):2017-2031. doi: 10.1016/S0277-9536(01)00342-2.
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Posted By Matthew P. Martin,
Thursday, August 4, 2016
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Welcome to the fourth edition of the CFHA News and Research
Column, a new series of posts that highlight recent developments in the field
of collaborative and integrated care. Check back for additional reports.
Lawmakers Focus on Integrated Care
The state of
Texas is in a state of mental health crisis. Part of the problem is a shortage
of mental health professionals. The
Select Committee on Mental Healthwas specifically createdto
tackle the issue. In June, the committee — headed by Rep.Four Price,
R-Amarillo— met to discuss on how the state wants to take a holistic
approach regarding mental health treatment. The committee heard from experts on
insurance and criminal justice mental health professionals including Dr.
William Lawson at Dell Medical School. His goal is to get more minority mental
health providers into the underserved areas of Texas.He says integrated
care is key.
"We now know
that early intervention can actually change the trajectory of what happens with
folks who develop a mental disorder,” said Dr. Lawson.
Program in England Partners Nurses with Patients
Integrated Care program, at St. James’ Hospital in Leeds, England, empowers
parents to take control of their baby’s care by being given the skills to
become more involved and build confidence. Parents are coached by nurses on feeding
and changing as well as taking regular observations and giving medication. Rates
of breastfeeding at discharge from hospital have doubled to nearly 60 per cent
and the length of stay has been reduced by up to nine days in babies born up to
10 weeks early. Infections and complications also seem improved.
Collaborative Care in Various Special Populations
New push for more pharmacy collaborative care
with disabilities: Occupational therapists collaborating with other
Use, Serious Mental Illness: call for more integrated services
Health: International group calls for stronger integration of services to
improve health outcomes among adolescent girls and young women
Care: Oral health screening for kids in Colorado medical office
Care is Not Sustainable
The latest NHS Financial
Temperature Check survey out of England of more than 200 finance directors shows
that just 16% were ‘very or quite confident’ that their organization could
deliver a sustainable integrated care service for the period up to March 2021. Paul
Briddock, director of policy at HFMA, said: "The scale of the NHS deficit
continues to reach unparalleled levels, and it is unlikely the provider
position will be in balance at the end of 2016-17, as originally planned.
"Our report confirms that while
finance directors are feeling the pressures of the current financial situation,
many also feel like short-term gains such as cash injections and non-recurrent
savings are merely storing up more problems for the future.”
Clinics Could Revolutionize Health Care
A senior Annapolis doctor says
that just four mobile clinics could revolutionize healthcare for rural Nova
Scotians — and they will come cheap.
Dr. Ken Buchholz, a former senior
physician advisor with the Department of Health, estimated that four
fully-equipped trailers plus their support vehicles would cost just over $1
million. This is the same average price tag as a single bricks-and-mortar
collaborative care clinic that the government plans to roll out across the
"Nova Scotia was once a leader in
the country with this mobile health model, but it fell victim to fiscal
restraint and a lack of vision by health department officials. Perhaps it is
time to revisit the notion of mobile healthcare, but this time with an open
mind and a more positive approach,” said Buchholz.
collaborative care for anxiety: Collaborative care seems to be a promising
strategy for improving primary care for anxiety disorders, in particular panic
disorder. However, the number of studies is still small and further research is
needed to evaluate the effectiveness in other anxiety disorders.
Checklist for family
developed the Family Meeting Behavioral Skills
Checklist (FMBSC) to measure advanced communication skills of fellows in family
meetings of critically-ill patients based on a literature review and consensus
of an interdisciplinary group of communications experts. The FMBSC demonstrated internally consistency and
structural validity in assessing advanced communication skills.
Collaborative care in
Nigeria: It is feasible to scale up mental health services in primary care
settings in Nigeria, using the WHO Mental Health Gap Action Programme
Intervention Guide and a well-supervised cascade-training model. This format of
training is pragmatic, cost-effective and holds promise, especially in settings
where there are few specialists.
Collaborative Care in
HCV Clinics: Depression collaborative care resulted in modest improvements in
HCV patient depression outcomes. Future research should investigate
intervention modifications to improve outcomes in specialty hepatitis C virus
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Posted By Alexander Blount,
Thursday, July 14, 2016
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This piece was originally published on April 18, 2013. Click here for original post.
One of the roles of leadership in a field is being comfortable speaking on behalf of the field. To do that, it helps to have a clear summary that is understandable to someone outside the field. One name for that summary is an "elevator speech. It is called that because it designates what a person could say to another person while making conversation riding together a few floors in an elevator.
I had an opportunity to try out my skills at the elevator speech for integrated primary care not long ago on an airplane. I was seated next to a gentleman for a couple of hours but we didn’t start to speak until the last 10 minutes of the flight. He was a guy who has to fly a fair amount because he has several small businesses. The businesses were quite varied. He was clearly a self-made guy who was doing OK but was not extremely successful, an entrepreneur on a comparatively small scale. He knew about doing everything his own way and he made his own decisions. It was not in an elevator, but we were changing elevation and the length was only slightly longer that a 15 floor ride in a high rise. This is not verbatim, but close, and the last line is a quote.
The conversation went something like this:
Bob: So, do you come to San Diego on business or pleasure?
Sandy: Business, I’m here for a conference on integrating mental health into primary care.
Bob: What’s the advantage of doing that?
Sandy: It’s the best way to improve the health of the people who come to Primary Care. Primary care is where people bring all the problems that they don’t know what to do about. A lot of times those problems, even the problems that are clearly physical, are related to the fact that they don’t take care of themselves. They are depressed or they are anxious, or they drink too much, or they don’t eat right, or don’t take their medicine, so they feel bad, so they hurt.
Sandy: When people are hurting it tends to make them more anxious or more depressed, or they drink more, or exercise less. If the doctor says he/she can take care of the part that hurts but they are going to send them to a mental health service or a substance abuse service for their anxiety, or depression, or drinking, a majority of the people don’t go. For them it doesn’t feel like two separate things. It feels like one thing. It’s only when you bring a person who can deal with anxiety and depression and alcohol use problems into the primary care and put them on a team with a doctor that the patient feels like he/she can get their whole situation cared for. It even costs less because if the person doesn’t get the whole situation dealt with effectively, they tend to go other places like emergency rooms to try and get enough care to relieve their various pains.
Bob:I’m trying to imagine what that would be like in the doctor’s office. How would it work?
Sandy: Well, if you came because you had a pain or because it was time for your physical, the doctor might talk to you about how your life was going or give you a screening test that would take about 5 minutes. The test would help pick up if you were having troubles with depression or anxiety or drinking. And if any of those seemed to be a part of the situation that you’re bringing, the doctor might call in a psychologist or a clinical social worker or some other person that they would probably call a behavioral specialist. The doc might introduce you to the behavioral specialist and go see another patient or two while the both of you talked.
Sandy: Just like primary care doctors take care of everyday kinds of problems after they make sure it’s nothing that’s going to kill you, behavioral specialist would probably do the same. He/she would ask you a couple of questions to be sure that you weren’t in a very serious or dangerous situation but then they would focus on getting you better as quickly as possible. They might work with you to find something that you like to do everyday, which actually has been shown to start improvement for people with depression, orthey might teach you some breathing exercises that actually make a difference with people with anxiety. When the doctor came back in the behavioral specialist might make a recommendation to the doctor about whether the doctor might consider prescribing you some medicine. You might come back to see the behavioral specialist a time or two to be sure that things are heading in the right direction. But in the long run you just go back to working with your doctor and the behavioral specialist would be somebody who would be available if you ever needed them again.
Bob:That sounds terrific, sign me up!
|Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.|
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Posted By Matthew P. Martin,
Friday, July 1, 2016
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This piece was originally posted on the STFM blog. Click here for the original posting. Reprinted here with permission.
A Prince in Crisis
On April 21, at 9:43 a.m., the Carver County Sheriff's Office received a 9-1-1 call requesting that paramedics be sent to Paisley Park. The caller initially told the dispatcher that an unidentified person at the home was unconscious, then moments later said he was dead, and finally identified the person as Prince. The caller was Andrew Kornfeld, son of Howard Kornfeld, a California addiction medicine specialist. Andrew had flown to Minneapolis with buprenorphine that morning to devise a treatment plan for opioid addiction. Emergency responders tried to revive the talented musician, but later pronounced him dead at 10:07 a.m.
On April 20th, the day before, Prince’s representatives contacted Dr. Howard Kornfeld, a California addiction medicine specialist, who agreed to see Prince later that week. Dr. Michael Schulenberg, a family physician in Minneapolis, saw Prince on April 7 and April 20 apparently for opioid withdrawal. However, Dr. Schulenberg is not a waivered physician and thus could not prescribe buprenorphine. If he had, perhaps Prince would now be recovering in a comfortable treatment center in California receiving state-of-the-art medical care. He would likely be receiving buprenorphine treatment to prevent opioid withdrawals. Recent autopsy results show that Prince died from an accidental overdose of Fentanyl.
Prince Rogers Nelson, a "master architect of funk, rock, R&B, and pop”, was 57 years old when he died and leaves behind a massive catalogue of music and a legacy of showmanship and flair. He was an extraordinary individual with immense talent and energy but all confined within the same physical limitations you and I have: a human body. Despite his magnificent gifts, Prince had a very real human problem: opioid dependence. Many people might wonder what might have happened if Prince could have attended that medical appointment on April 21st in Minneapolis or what might have happened if he could have met Dr. Kornfeld in California and started opioid treatment.
The Value of a Family Doc
Here’s another question, though: what if Prince had a waivered family physician who knew him and his body and could have started buprenorphine treatment months, even years, before April 21st, 2016? The conversation with his family physician might have gone something like this:
Doctor: "Mr. Nelson, it’s good to see you. I want to ask you a few questions about your health that I ask all patients during an annual visit. Is that OK with you?”
Prince: "Sure, that’d be fine.”
Doctor: "Mr. Nelson, do you use any tobacco products?”
Doctor: "How many times in the last 12 months have you had 5 or more drinks in one day?”
Prince: "I don’t drink alcohol, doctor.”
Doctor: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
Prince: "Well, doctor, I don’t do illegal drugs but I think I’m using my painkillers too much.”
Doctor: "OK. Let’s talk more about that. Perhaps I can help.”
The data is clear about two things when it comes to opioids: one, it’s a growing problem in virtually every state; and two, prevention and treatment work. While opioids have been used for decades to treat chronic pain, rates of prescription opioid abuse have increased in recent years. Get ready for some big numbers. Treatment admissions for primary abuse of prescription pain relievers surged from 18,300 in 1998 to 113,506 in 2008. The number of unintentional overdose deaths from prescription pain relievers has quadrupled in the U.S. since 1999. Even though hundreds of thousands of patients misuse prescription opioids, only 3 percent of primary care physicians offer them treatment.
Addiction to opioids can successfully be treated with medication-assisted treatment (MAT) which is a combination of medication (buprenorphine, methadone) and behavioral health services. Buprenorphine, a partial agonist, is prescribed in primary care settings to help suppress withdrawal symptoms, reduce cravings, and induce tolerance to protect against overdose. To prescribe buprenorphine you must meet certain requirements, complete eight hours of training, and then apply for a waiver. Having at least two waivered physicians to prescribe buprenorphine is becoming a recognized best practice for primary care clinics using MAT.
Barriers to Treatment
Here’s another gigantic number: almost 30 million persons have no access to a waivered primary care physician. What’s getting in the way? Some barriers include lack of physician training, stigma of addiction, bias against MAT, policy and regulatory issues, and financing. Education and training can easily help overcome the first three barriers; however, we need more institutions to support and offer buprenorphine training. Current state and federal policies cap the number of patients physicians can treat with buprenorphine, deny prescription rights to nurse practitioners and physician assistants, and make it difficult for providers to communicate about a patient’s care. The U.S. Department of Health and Human Services is reviewing several policies and considering changes which is very encouraging.
Opioid addiction is not going away any time soon. The next generation of family physicians will be at the front line of this battle and will need the knowledge and skills (and prescription rights!) to effectively help patients. They will need to know how to screen for opioid misuse and how to counsel their patients. As the STFM Addition Group, we recommend that future curriculum include, at a minimum, training in the following areas: SBIRT, Motivational Interviewing, and an introduction to addiction medicine and buprenorphine treatment. We encourage all family medicine training programs to review their substance use curriculum and consider requiring residents to become waivered.
In 1990 Prince wrote "Thieves in the Temple” a song about rejection and deception. "I feel like I’m looking for my soul, like a poor man looking for gold. There are thieves in the temple tonight”. We will never know how Prince might have responded to a waivered family physician’s invitation for opioid treatment. Undoubtedly he was struggling with real addiction and should have received help sooner. As the rest of the nation grapples with the epidemic of opioid addiction, buprenorphine treatment remains underused. Physicians can keep the "thieves” of misuse and addiction out of people’s lives using effective, state-of-the-art treatment.
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Posted By Andy Valeras,
Friday, June 10, 2016
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"Change has never happened
this fast before, and it will never be this slow again.”1
Graeme Wood wrote these words to describe the ways social media and technology have redefined
communication. The fact that you’re reading a blog right now is example of such
change. An increased velocity to change
seems to be the norm in the modern era. In fact, we have come to expect it of
our technology, and this expectation is extrapolated to the multitudes of evolutions
of thought, culture, and policy … and for our society as a whole.
however, does not always equate to progress. Why not?
accelerating pace of change, and change itself, is uncomfortable. Wood’s quote serves
as an emotional epithet for the shaky ground that is inherent to change. Discomfort with change, being on unsteady foundations
and uncertain futures, sometimes prompts instinctive reactions towards
homeostasis - seeking what is known and grounding. These reactions are pitfalls, however, when
they prevent perspective-sharing and dialogue.
Dialogue, as defined by Peter Senge2, is a willingness to
share and question one’s own worldview, while also being willing to hear and be
influenced by another’s worldview.
Engaging in dialogue serves the purpose of exploring and expanding one’s
"pool of meaning” through conversation and critical personal reflection.
Andrew S. Valeras from Senge2
changes are made without a willingness to engage in dialogue, a tension is created
between those who strive towards change and those who resist it. Those who do not need change are often in a position of privilege, and for those
individuals, change does not feel like progress, but like loss, particularly
when the change threatens the status quo of privilege and power.
It is this
tension – for and against change – that seems to be driving the debate, not a
discussion, surrounding HB2, the North Carolina House Bill3 also
known as the "bathroom bill” and widely considered to be anti-LGBT. [To be
clear, I oppose HB2, as does CFHA, in that it goes against the fundamental
values of inclusion and integration of all forms of diversity, including gender
expression.] All of us are seeking ways to feel safe, not necessarily from each
other, but in a world that is changing too fast for some and not changing quickly
enough for others. HB2 serves as a symbol of control. It is the assertion of a
worldview, not to expand the pool of meaning, but in attempt to slow, halt and
even reverse the momentum of change. It is a policy that acts like a door,
separating not only individuals, but attempting to shut out progress.
How does CFHA remain relevant in such a rapidly
and gradually-changing and politically-charged environment?
CFHA can grow in an uncertain future by continuing
to demonstrate and model the tenets of an adaptive organization. We, as individuals
and as an organization, can seek to understand, to be part of, and to adapt to
the environment by how we thoughtfully choose to act, not react, upon it.
We can engage in dialogue with each other, and with those with opposing
worldviews. A call to revoke HB2 and to boycott North Carolina may lead to
change, but it will not be progress.
Progress can only come when those with privilege are not coerced to
change, but understand and aknowledge the
need for the change. CFHA, as a
collective voice of its members, is pushing ahead that work by obtaining,
sharing and advocating for the narratives of those without privilege, and the
impact an inequitable system has on people’s lives - on their health, their
families, at work, at school, on the bus, on the street.
The 2016 CFHA
Conference theme of "many faces and places of integration” embodies an
opportunity to bring people together and strive for dialogue. We can be part of the change, helping set the
incredible pace, rather than be overrun by it, by recognizing actions like HB2
for what they are. Remaining steadfast
to the mission of CFHA, while providing the secure space to regroup, allows
CFHA the momentum to push the next door down – and maybe the next door knocked
down will be a bathroom door in North Carolina. I hope to see you there.
P. (2006). The Fifth Discipline. NY: Doubleday Publishers.
Carolina House Bill 2. http://www.ncleg.net/Sessions/2015E2/Bills/House/PDF/H2v4.pdf
S. Valeras, DO, MPH is a faculty physician at NH Dartmouth Family Medicine
Residency. He received his undergraduate
degrees in Biology and Philosophy from Boston College, his Doctor of Osteopathy
from Midwestern University, and his Masters of Public Health at The Dartmouth
Institute. Dr. Valeras completed both
the NH Dartmouth Family Medicine
Residency and the Dartmouth Hitchcock Leadership Preventive Medicine Residency.
Dr. Valeras currently seeks to integrate
quality improvement and systems based thinking with the clinical practice and
education of family medicine providers in integrated teams. Dr. Valeras does this through the [Systems]
course, taught via 320 hours of longitudinal experiential learning, over three
years for primary care teams. Dr.
Valeras currently serves as a Board Member for CFHA.|
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Posted By Matthew P. Martin,
Wednesday, June 1, 2016
| Comments (0)
Welcome to the third edition of the CFHA News and Research Column, a new series of posts that highlight recent developments in the field of collaborative and integrated care. Check back in the future for additional reports.
European Countries Designing Large Collaborative Care System
Multiple chronic conditions make medical treatment more difficult for physicians. A new cloud infrastructure in Europe will span across 12 partners in seven countries to provide personalized treatment plans for each patient. Hospitals, general practitioners, and social care organizations across the system will be able to exchange information and coordinate care more effectively. The hope is that new models of patient-centered, integrated care will emerge to reduce admissions and costs. The project is funded by EU Horizon 2020 and supported by the Institute of Digital Healthcare, based at the University of Warwick.
The New Hampshire Integrated Care Medicaid Waiver
The Centers for Medicare and Medicaid Services recently approved New Hampshire’s Medicaid waiver for a "sustainable integrated care system”. This new system will serve all Medicaid beneficiaries and will progressively move payments to more outcome-based measures. The goal is to build capacity for transforming behavioral health care services in the state for Medcaid beneficiaries. Program evaluation will focus on the following five performance measures:
1. Quality of care delivered to individuals with co-occurring physical and behavioral health issues
2. Total cost of care for Medicaid beneficiaries with co-occurring physical and behavioral health issues
3. Rate of avoidable re-hospitalizations for individuals with co-occurring physical and behavioral health issues
4. Percentage of Medicaid beneficiaries waiting for inpatient psychiatric care
5. Average wait times for outpatient appointments at community mental health centers
Health is Primary Campaign Focuses on Integrated Care during Month of May
For the past several weeks, the Health is Primary campaign from Family Medicine for America’s Health focused its efforts in May on promoting mental health and its integration into primary care. As part of this effort, campaign workers released a mental health tear sheet that physicians can distribute to patients.
Benefits of Medicaid Expansion for Behavioral Health: DHHS Issues a Report
Under the direction of the U.S. Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation recently released a brief that analyzes national data on behavioral health including the impact of Medicaid expansion under the Affordable Care Act. Here are some key points:
· Many of those who could benefit from Medicaid expansion have behavioral health needs.
· In states that have not yet expanded, Medicaid expansion would provide considerable benefits for individuals with behavioral health needs and their communities.
· Access to appropriate treatment results in better health outcomes.
· States that choose to expand Medicaid may achieve significant improvement in their behavioral health programs without incurring new costs.
· Medicaid expansion also reduces costs that are incurred by state and local governments and state economies as a consequence of behavioral health problems.
· Across the globe:
o Call for major mental health reform in Australia
oCost-utility of collaborative care for major depressive disorder in primary care in Netherlands sample
oIntegrated care for homeless populations in Canada
oCall for mental health reform in Portugal including collaborative care
oCollaborative care is clinically and financially effective in England sample
· Patients prefer substance abuse treatment in primary care compared to specialty treatment centers according to a study at Johns Hopkins Bloomberg School of Public Health.
·Physicians in the Henry Ford System believe that integrated care is satisfying, improves patient care, is a needed service, and reduces personal stress level.
· Tele-health service based on non-clinically trained health advisers supporting patients in use of internet resources was effective compared to usual care in a randomized, controlled trial.
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