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Integrated Care in Indigenous Populations

Posted By Melissa Lewis, Laurelle Myhra , Monday, September 12, 2016

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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News & Research Column

Posted By Matthew P. Martin, Thursday, August 4, 2016


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.


Texas 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.

Family-Oriented Program in England Partners Nurses with Patients

The Family 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

· Pharmacy: New push for more pharmacy collaborative care

· Patients with disabilities: Occupational therapists collaborating with other services

· Substance Use, Serious Mental Illness: call for more integrated services

· Women’s Health: International group calls for stronger integration of services to improve health outcomes among adolescent girls and young women

· Dental Care: Oral health screening for kids in Colorado medical office

Integrated 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.”

Mobile 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 province.

"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.


· Meta-analysis of 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 meetings: Researchers 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 treatment clinics.

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Integrated Primary Care: The (Somewhat Extended) Elevator Speech

Posted By Alexander Blount, Thursday, July 14, 2016

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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What if Prince had a Waivered Family Physician?

Posted By Matthew P. Martin, Friday, July 1, 2016

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?”

Prince: "No.”

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.”


Opioid Calamity

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.


Matt Martin, PhD, LMFT teaches behavioral medicine at the Duke/SR-AHEC Family Medicine Residency Program in Fayetteville, North Carolina. He is the CFHA blog editor.

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The Change Pace Paradox

Posted By Andy Valeras, Friday, June 10, 2016



  "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.


Change, however, does not always equate to progress. Why not?

The 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.


Adapted by Andrew S. Valeras from Senge2


When 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.


1. Wood, G. (2009). 

2. Senge, P. (2006). The Fifth Discipline. NY: Doubleday Publishers.

3. North Carolina House Bill 2. 


Andrew 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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News & Research Column

Posted By Matthew P. Martin, Wednesday, June 1, 2016

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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Integrated Care in India

Posted By Administration, Thursday, May 19, 2016


Health care systems across the globe are integrating mental health services into primary care. Click here for last week’s post on collaborative care in Israel.

Recently, Dr. Manjunatha from the National Institute of Mental Health and Neurosciences in Bangalore, India, wrote a report for the Lancet describing an ambitious program to integrate mental health services into primary care systems. The program, called the Manochaitanya Programme, provides mental health services every Tuesday in taluk hospitals, community health centres, and primary health centres in Karnataka. The services are also available during the rest of the week at all primary health clinics. Check out the rest of this fascinating program by clicking on the link above.


I reached out to Dr. Manjunatha, the lead author of the article, to ask a few more questions about the state of mental health care in India.

1. What is the state of the mental health care system in India overall?

Overall, mental health care system in India predominantly depends on public mental health care institutions of the country. In the last decade, general hospital psychiatry at medical schools have begun to take up the burden of mental health care in the country. Even psychiatrists in private practice are starting to take up the significant amount of mental health care burden. But, still in-patient care predominantly lies in public mental health care institutions.


2. How did the Manochaitanya Program get started? What is the overall purpose and structure of this program?

I am not sure how this Manochaitanya program started. But the state of Karnataka in India has always been innovative in the field of mental health. For example, the Bellary model, a community based experiment at Bellary district of Karnataka, in 1970s paved the way for National Mental Health Program (NMHP)/ District Mental Health Program (DMHP) of the country. Even the World Health Organization popularized this model in many countries throughout the world.

I believe the purpose of this program is to integrate mental health care at all public health care institutions of the state with the name of Mano-Chaitanya Clinic (MCC) on every Tuesdays. This MCC will provide mental health care at all primary health centres using respective public primary care physicians and at all taluk hospitals (taluk means administratively a sub-district in a district) by a qualified psychiatrist (either government or private) which includes academic as well as non-academic psychiatrists. Psychotropic medications are provided free of cost. First time, even professional organization such as Indian Psychiatric Society- Karnataka chapter has joined in this venture for successful implementation of this program.

3. How often do mental health and medical professionals collaborate with each other to help a patient?

The collaboration of psychiatrists and other mental health professionals to help a patient is mainly at mental health care institutions. Otherwise, it is often a rare scenario to see collaboration of mental health and medical professionals (I mean, non-psychiatric physicians) to help a patient in India especially in the area of medical comorbidities (Non-communicable diseases).


4. What needs to happen for mental health treatment to become part of all regular and routine medical treatment?

This is exactly the vision of this innovative Manochaitanya program. The basic component of this program is mental health treatment should become part and parcel of all routine medical treatment at primary care institutions. I am in opinion that this is the first of kind public mental health program in the world with exclusive aim to integrate mental health in primary general practice. I hope this model will show significant success and pave the way for many countries in the world.


Dr. N. Manjunatha, MD, DPM, MBBS

Assistant Professor of Psychiatry, Department of Psychiatry

National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

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Collaborative Care in Israel

Posted By Administration, Thursday, May 12, 2016


Health care systems across the globe are integrating mental health services into primary care. Recently, Dr. Ohad Avny and colleagues from Clalilt Health Services and Talbieh Psychiatric Clinic affiliated with Hadassah-Hebrew University Medical School in Jerusalem, Israel, completed a literature review of collaborative care models in Israel and other countries.

In the article, the authors call for implementing more psychiatry liaison services in primary care to address the high rates of psychopathology. They also cite evidence that collaborative care models are effective and that primary care physicians are motivated to work within psychiatry liaison models. I reached out to Dr. Avny, the lead author of the article, to ask a few additional questions.


1. What is the state of the mental health care system in Israel overall?

Currently mental health care in Israel is going through an ongoing process of reform. All mental health care will eventually be managed by the 3 large HMO health care systems. Up to now, mental health care was financed directly by the state. The argument for this change is foremost financial and medical (growing gap between mental health care in the provinces in Israel as compared to the metropolis areas). As there is growing shortage of psychiatrists and financial strict management I have a sense mental health care is pending crisis. And so primary care physicians who are on the "front line" will share more of this burden.


2. What prompted you to do a literature review of collaborative care in Israel and other countries?

As a primary care physician I can relate to my own clinical experience in my clinic. I have been practicing in my HMO clinic for the last 16 years. I am leading my HMO clinic with six family physicians. Our patients are in the Geriatric "range" and as such need a multi-disciplinary approach.

We have in our district an ongoing psychiatric collaborative enterprise where we have a psychiatrist attending our clinic every two weeks. We refer patients and consult on phone. With time due to my personal interest and growing involvement in my patient's lives ( 16 years is a hell of a long time) I started dealing more and more with psychosocial aspects of my patient's illnesses and narrative . I found it challenging not to stigmatize patients with psychiatric diagnosis on the one hand and yet be able to diagnose and treat those who suffer from mental health diseases. Our collaborative model has empowered me as the main care giver in patients suffering from depression and anxiety disorders. And as I was a bit skeptical of my competency as a family practitioner, less experienced and trained than psychiatrists, I started looking for evidence supporting this model. To my joy my clinical "hunch” for treating my anxious and depressed patients was supported by RCT.

I was thrilled to see that family physicians who treat depression and anxiety of their patients with some collaborative backup model are no less successful and sometime are more successful than psychiatrists providing standard care.


3. How often do mental health and medical professionals in Israel collaborate with each other to help a patient?

In Jerusalem there are 20 large HMO clinic who have this psychiatric collaborative model. Yet it does not exist as an organizational project in other parts of Israel. There are some collaborative enterprises - but these are local initiatives. We have another long standing collaboration model with an endocrinologist who has been with us for the last 14 years. She consults with us once a month by reviewing patients cases without their presence. So you can imagine we have upgraded our knowledge and competency in diabetes management and more. In a sense, since both the psychiatrists and the endocrinologist have been with us for so many years they are actually part of our team and so these consults are enjoyable, fun, and informal which keeps us running together, fighting burnout. 


4. What needs to happen for mental health treatment to become part of all regular and routine medical treatment?

I would say:

1. Increased personal interest of primary care physicians to address psychiatric issues,

2. Available backup of a mental health provider - psychiatrist for stat consult and formal assessment if needed

4. Establish close collegial relationships with physicians in subspecialties who are in your collaboration team. Their motivation has to be "pumped" up since burden of care is also at times overwhelming for them.

5. Patience!! Patience!! Patience!!! And accept the fact that you will always be behind schedule.


Ohad Avny is a certified Israeli family physician. He attended a one year fellowship program in Geriatrics in Canada UFT at Bay Crest Center for Geriatric Care. He is involved in undergraduate medical training (medical humanities, and family clerkship) and post-graduate training in family residency. He has special interests in psychiatry, palliative care, and medical humanities. He is married with three children.

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Caring for the underserved: Identifying the benefits for patients, families, and ourselves

Posted By Lauren DeCaporale-Ryan, Wednesday, April 20, 2016


About 90% of my clinical practice is focused on caring for the underserved:

The young,

The old,

Those suffering from chronic medical illness, now unemployed,

Those without a home to go to at the end of the day,

Those with a home but without any furniture or food,

Racially diverse individuals,


LGBT individuals often afraid to walk down the city streets that lead to our clinic,

& Medicare and Medicaid beneficiaries.


This list doesn’t even fully capture who might be labeled as "underserved,” but reflects many vulnerable populations that turn to primary care settings seeking behavioral health treatment. I work with patients in a family medicine practice that serves over 20,000 individuals annually, most of whom are from underserved backgrounds. These are families with low SES, who frequently have experienced poly-trauma, chronic loss, and environmental stressors. Often, they do not trust the medical system… and sometimes… when they first meet me, I’m sure they don’t trust me… The evaluation of the healthcare system as untrustworthy and unfair is not universally true, but it is also not unjustified. Bias and discrimination exist – just watch one political commentary these days and you’re bound to hear something about these very populations and assumptions about individuals from such backgrounds.

But what do I know about these things? I am privileged: my skin tone, my education, my SES, & my life experience make me different from every patient who walks through my door. There are other factors that distinguish us. And then there are commonalities: the most obvious for many is gender or age, but there are my own family experiences of aging and illness that provide me with a shared understanding. Some patients ask to explore our differences immediately. Others wait, reflecting as treatment ends that they weren’t "sure about” me but gave therapy a chance and that they are grateful that they did. Others explore the subject when someone throws privilege in their face: Questions are posed like, "can you believe this white lady,” "that doctor doesn’t care about me, he’s just in it for the money, right?” And suddenly, with these questions, we are processing that I too am a white woman and doctor. How am I the same as those who have acted from a space of privilege and how am I different?


Often, I cannot fathom what it is that these families have been through. Their narratives are burdened by unending stressors that often lead to pain and anger. They are estranged from family, have limited supports, and the practicalities of their stressors are real. So…what do I have to offer?


I have learned over time that I can very rarely fix the actual problems: the bed bugs, the lack of food, the violence in a neighborhood. I am aware that these factors will cause continued suffering, but there may not be the resources in my community to address the practical, environmental needs of each individual. What I can give instead is empathy, warmth, and compassion. I can provide a safe space that allows for processing an acute stressor or remote hurt that has only furthered an individual’s vulnerability. I can provide human contact that demonstrates that the patient is someone valued and that even when they feel no one else cares, their treatment team does. I can help them develop problem solving skills and work with their team to identify community resources (when they exist) that will help them overcome the limits that exist in their lives. I can simply be present, listen, and hear their stories. I can advocate for change with them. I can push myself to continuously learn about the value in what makes us each different. And I can educate others to have better knowledge, tolerance, and acceptance of differences.


I often end my days feeling drained, but then I remind myself of how fortunate I am and turn to gratitude. Of course, there is gratitude for my own upbringing and family, for the many gifts and opportunities I was granted… but it is more than that. I am grateful for patients’ wisdom and insight. As they battle obstacles in their everyday lives, I am motivated to make change in my own and hopeful that I can make even the slightest bit of difference in improving equality.


I leave work every day feeling lucky that families have had enough faith, hope, and trust to show up at my door and share their stories with me: that is privilege.

Lauren DeCaporale-Ryan, PhD is a Family Geropsychologist and Assistant Professor of Psychiatry, Medicine & Surgery at the University of Rochester Medical Center. In addition to clinical work, she provides coaching on patient-family centered communication skills and team-effectiveness to physicians and interprofessional teams in Internal Medicine and General Surgery. She is the Associate Track Director of the Primary Care Family Psychology Fellowship at URMC and serves as the Early Career Representative to CFHA’s Board of Directors. 

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Collaborative care and health disparities: A Case Example

Posted By Randi Dublin, Tuesday, April 5, 2016


A monolingual Spanish-speaking patient from Ecuador was injured on his job in the northeastern US. He was prescribed medicine for multiple physical injuries and had been previously diagnosed with depression prior to the incident. He carries shame about his history of depression and a suicide attempt before he was left unemployed, struggling financially as head of household, with physical injuries. Now the patient begins to experience mental health symptoms again; depressed mood, lethargy, low self-esteem. He begins to meet with me weekly in a pain management clinic for psychotherapy sessions. And he develops suicidal and homicidal ideation … voices telling him to hurt himself and a family member. My question to you is: how many barriers does this man face to obtaining appropriate and comprehensive, collaborative care to ease his suffering?


Let’s be sure to separate barriers to comprehensive, collaborative care that result from mental illness and barriers that result from health inequality. To address the first set of barriers, he carries shame that he is experiencing mental health symptoms which he perceives others aren’t experiencing, and self-stigma that he shouldn’t be feeling the way he is. But apart from these mental health roadblocks to comprehensive, collaborative care, this patient experiences barriers related to health inequality. He speaks a different language than I do and only with the help of a translator can we communicate effectively. He lacks funds to pay for medical services and can only see me because our visits are paid for by workers compensation. Furthermore, men from his country do not show "weakness” or a need for medical help, let alone mental health services, which are stigmatized. He doesn’t recognize that he is being denied certain medications by insurance because they are very expensive, not due to a personal flaw. The barriers posed by health inequality make it likely that this patient will not obtain comprehensive, collaborative care. A white male patient with adequate financial means may not face the same barriers.


This case example is not unique, unfortunately. Health outcomes often differ across groups, a term commonly referred to as health disparities. Factors such as poverty, economic barriers, limited access to healthcare, neighborhood problems and lack of education are just a few which lead to unequal health outcomes between groups. What about other reasons for different health outcomes? Do some individuals not seek effective healthcare because they turn to their own remedies or they don’t know what beneficial treatments might be out there? Or perhaps they don’t want someone in the Western medical establishment telling them how to get well? Or maybe the medical provider is of a different cultural background? Power dynamics between patient and provider plus history may make some groups not want to be "experimented upon.”


Recent accumulated evidence suggests that there is a longevity difference between the rich and poor in America, which is a continuing trend, attributed to economic and social inequality. When certain treatments are too expensive for some, they miss out on potentially life-saving solutions. The question ultimately is: can collaborative care, in its least restrictive definition (the integration of behavioral and physical health services and communication between care providers), help to reduce these health disparities and barriers to beneficial healthcare?


Although we lack sufficient research in this area, I propose that collaborative care can help to reduce health disparities. Collaborative care is geared towards focusing on the whole person, their biopsychosocial status, and not just on a mental health diagnosis or physical symptoms. A collaborative care team can first address whether certain biological factors predispose a patient to specific diseases or disorders. To address social factors which impact health such as poverty, unemployment, and access to healthy food, the treatment team can work together to assess nutritional needs, find financial benefit programs and unemployment resources. Collaborative care also brings the treatment to where the patient is physically located, which can ease financial burden for transportation costs. Behavioral health providers can assess for factors (i.e., depression, trauma) which may impede upon patient self-care or lead the patient to avoid health clinics for treatment. By focusing collaboratively on the whole patient, perhaps we can help reduce the health disparities that exist based upon someone’s race, education, and financial status.


We have an aging population to contend with for the next few decades. The Healthy People 2020 project is a national endeavor aimed at improving the health and longevity of Americans. Specifically, with regard to health disparities, this program aims to "achieve health equity, eliminate health disparities, and improve the health of all groups”. To meet this aim, we ultimately need to minimize barriers to healthcare for all people: economic, transportation, education, medical, and nutrition barriers. The list goes on. We need to work as a team to help the patient take care of their own health. Collaborative care is one way to break down these barriers. Let us, as the CFHA community, conduct more research to demonstrate how effective collaborative care can be in the fight to end health disparities and health inequality.

Randi Dublin, Ph.D. is a licensed clinical psychologist with particular interests in mental health advocacy and destigmatization, dissemination of evidence-based psychotherapy, integrated behavioral health & primary care, and promotion of psychological science in the community. She has worked across urban settings treating adults with psychological and health-behavior issues. Currently, she works with injured workers who are struggling with chronic pain, trauma, depression and other issues. She hopes health disparities will be addressed by collaborative care.

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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.