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On Becoming Transformational: The State of Interprofessional Education and Its Future

Posted By Thomas Bishop, Jodi Polaha, Colleen Cordes, Thursday, March 24, 2016

A few weeks ago the ETSU Academic Health Sciences Department was holding its second full-day experience for students enrolled in the Interprofessional Education (IPE) Program. The day’s experiences centered on values and ethics in team based care, and the importance of considering social determinants of health. Student teams (nursing, medicine, pharmacy, psychology, public health and a range of allied health disciplines) worked with patient actors that presented with social problems that were intertwined with chronic medical conditions. These budding health professionals found themselves uncertain in determining their roles, how to work together, and in what they may have to offer.


The one thing that was clear to them, indeed it was the aim of the exercise, was that they needed each other to address the patient’s needs. The students saw the utility of the "pit crew” referenced by Atul Gawande1, and, we hope they started to see the value of team based care, which has been recognized for some time and has been shown to have a positive impact on range of measures including access to care, prevention, and movement toward health goals.2-4 While the Agency for Healthcare Research and Quality suggests that team training improves patient care and safety, 5providers continue to be largely trained in silos. IPE is trying to move the needle with training like this one, and move the new-in-training toward readiness for a team care environment.

IPE is a fast-growing area as academic health sciences training programs scramble to bring their students up to speed with the evolution of health care toward a team focus. It was in the 2000s that IPE represented a paradigm shift in health care with the Institute of Medicine’s report Crossing the Quality Chasm: A New Health Care System for the 21st Century calling for fundamental changes in addressing quality and service. The Interprofessional Education Collaborative (IPEC) was established in 2009 when six national education associations representing health professions formed a collaborative to promote and advance interprofessional learning experiences that would prepare health professionals for a new health system. The first Collaborating Across Borders conference was held at the University of Minnesota in 2007. The World Health Organization (WHO) Study Group on IPE and collaborative practice was formed with the report Framework for Action on Interprofessional Education and Collaborative Practice being published in 2010.6

The WHO defines IPE as when "two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.7 The WHO has identified a number of competencies that are widely accepted, but when examined more closely, are very broad and not operationalized. The members of our IPE initiative at ETSU reviewed a number of competencies addressed in the literature and pooled input from those doing team based care to formulate a list of competencies deemed important for the teaching rather than the practice of team based care (see Table 1). We have been working to identify specific, measureable behaviors for each of these competencies, and how they would be addressed in a curriculum. Most institutions who have been developing curriculum and IPE programs have moved from simply championing the benefits of team based practice to the identification of just how they may teach competencies and measure the impact of instruction through simulation and orchestrated exercises.

Table 1 Interprofessional Competencies

  • Communication
  • Teams and Teamwork
  • Roles and Responsibilities
  • Values and Ethics
  • Knowledge of Healthcare Policy Relating to Team Care
  • Learning Healthcare Systems

But where do we go from here? In reading the current literature on IPE and noting the aims of many presentations offered at national conferences addressing IPE, it seems that discussion is only beginning in how and in what way IPE is being translated to health care change and practice. A useful "tool” in examining this issue may be to consider three legs to IPE where instruction moves between being informational, formational, and transformational. The footers or building blocks to IPE are found at the informational level of instruction, instruction centers on concepts, ideas, and the identification of skills. It could be argued that most approaches to IPE are only at this informational level of instruction. A second leg, formational instruction, is where the focus centers on team member function, practice, and role-identity. Instruction moves beyond being about information and the learning of instruction, but to engagement and the practice of skills. To suggest that IPE instruction can and should be transformational, the third leg, is to capture the spirit of the WHO in championing team based care, where there is actual change in the "dance” of team members and a revolutionary change in health care. A true paradigm shift.

So, we are preparing future providers to change or influence the landscape of health care’s future. But we wonder if they will be ready for what they will find in the marketplace today. It is a difficult balance to be idealistic and innovative, while also training health care workers for actual positions. For this to work, the health care system needs to be willing for flexibility and open to change. We are beginning to see changes in payment incentives that encourage some movement toward team based care. Health care institutions are asking applicants about their experience and training in team based care. But once employed, how are current members of the healthcare workforce adequately prepared to operate in teams when their own educational experiences reflect historical educational silos? There is some talk of certifications and recognition for these experiences and there is a growing number of sites that offer training and tools for teaching and doing team based care, such as the Nexus Center for Interprofessional Education and Practice website (; however, utilization of these resources outside of educational institutions remains unclear.

In the same way that we have seen IPE evolve from a few championing the cause to the unifying of educators and providers behind a common goal (such as the formation of IPEC), we are now in need of organizations with similar passions to join forces in furthering research and a common set of principles in doing IPE. There are several organizations, such as the Collaborative Family Health Association, The Society of Teachers of Family Medicine, and certainly the Interprofessional Education Collaborative, as well as others, who have addressed aspects of IPE, though often indirectly under the auspices of "workforce development,” and not necessarily tied to articulated competencies. While many belong to a number of these organizations, there is a lack of shared vision and mission at the organizational level. This could be addressed by conferences occurring in tandem or perhaps having combined conferences from time to time where common efforts and collaboration could take place. The leadership of organizations could request that there be positions for representatives of other similar minded organizations so as to enhance common infrastructure for IPE. Perhaps there could be a national IPE commission that encompasses leadership representatives from the various organizations that are invested in IPE.

Just like that early day in February at our University, ETSU, as early health professionals were attempting to find their roles, work together, and determine what they may have to offer in regards to patient care, those with a passion for IPE could become more united in moving toward being transformative and in reaching a common ground. Perhaps then there would not only be pit crews for patients, but a common set of tools these mechanics can use. 



1. Gawande, A. (2011). Cowboys and pit crews. Harvard Medical School Commencement Address. Retrieved from

2. Grumbach, K. & Bodenheimer, T. (2004). Can health care teams improve primary care practice? Journal of the American Medical Association, 291(10), 1246-1251.

3. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

4. Leape, L. Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J., O’Leary, D., O’Neill, P., Pinakiewicz, D., & Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality and Safety in Health Care, 18(6), 424-428.

5. Agency for Healthcare Research and Quality. (2009). TeamSTEPPS™: national implementation (online). Retrieved from

6. Thompson, B., Kelman, G., Romanoff, B., Pieper, B., & Dacher, J. (2012). Interprofessional education and collaborative practice. Retrieved from

7. World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice (WHO/NRH/HPN/10.3). Retrieved from

Thomas W. Bishop, Psy.D.Assistant Professor of Family MedicineDirector of Behavioral MedicineEast Tennessee State University

Jodi Polaha, Ph.D. is a licensed clinical psychologist and Associate Professor in the Division of Primary Care Research, Department of Family Medicine, East Tennessee State University.  She has worked exclusively in integrated practice since 1998, and describes herself as a "pracademic,” engaging in a balance of clinical training, program development and research.  She has directed the integration of behavioral health into over 25 primary care clinics, has developed and implemented interprofessional training curricula across disciplines and learner-levels, and conducted funded research on integrated behavioral health in pediatric primary care.

Dr. Colleen Clemency Cordes is a licensed counseling psychologist, and the Director and Clinical Associate Professor in the Doctor of Behavioral Health Program at Arizona State University, the first graduate program dedicated to training the integrated behavioral health workforce. She has worked in primary care within multiple organizations, including Banner Good Samaritan Hospital in Phoenix, AZ, the VA Hospital in Long Beach, CA, the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA, and HonorHealth's Neighborhood Outreach and Access to Health (NOAH) clinics. She received a certificate in Primary Care Behavioral Health from the University of Massachusetts Medical Center, and is currently on the board of directors for the Collaborative Family Healthcare Association (CFHA).

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News & Research Column

Posted By Matthew P. Martin, Thursday, March 10, 2016

Welcome to the second 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 each month for additional reports.


Privacy Rules on Medical Records for Substance Use Treatment

The U.S. Department of Health and Human Services (HHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) are seeking to make it easier to access and share substance use treatment records.


The confidentiality rules for substance use records (42 CFR Part 2) were developed in the mid-1980s to give patients confidence to seek substance abuse treatment without fearing disclosure of the treatment. Under the current rules, identifiable information can be released only with the affected individual’s consent.

The rule differs markedly from the Health Insurance Portability and Accountability Act, which does not require patients' consent for a provider to disclose their records for treatment, payment or other healthcare operations.

According to the proposal, "Significant changes have occurred within the U.S. healthcare system that were not envisioned by the current regulations, including new models of integrated care that are built on a foundation of information sharing to support coordination of patient care, the development of an electronic infrastructure for managing and exchanging patient information, and a new focus on performance measurement within the healthcare systems.”


The modifications would allow the federal government, and subsequently the Centers for Medicare and Medicaid Services, to develop a new infrastructure for managing and exchanging patient information, with an increased focus on performance measurement and quality improvement. The modifications would also help to decrease stigma toward substance use treatment and make it easier to integrate behavioral health services.


Public comment on the proposed rule is open until April 11. Click here for an opinion article.


New Depression Screening Guidelines

The U.S. Preventive Services Task Force (USPSTF) recently published recommendations for depression and autism screening. For the general adult population, including pregnant and postpartum women, the USPSTF recommends screening for depression "with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up”.


For adolescents, 12 to 18 years of age, the USPSTF recommends screening for major depressive disorder with the same care systems mentioned for the adult population.


Finally, for autism spectrum screening in children aged 18 to 30 months, the USPSTF "concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for autism spectrum disorder (ASD) in young children for whom no concerns of ASD have been raised by their parents or a clinician”.


For a blog commentary, click here.


Call for Social Work to Move Toward Integrated Care

Educators at the Silver School of Social Work at New York University are encouraging their discipline to embrace and move toward integrated care. They argue that the Patient Protection and Affordable Care Act centers on the promotion of integrated health, thus creating a timely opportunity. The authors argue that traditional social work roles of care coordinator, case manager, and community organizer fit well within collaborative care and disease management models. They call for more leadership roles from social work in the growing integrated care field as well as a focus on workforce development for future social workers.



· New data suggests that depression management in primary care can help older adults with depression and diabetes. Researchers examined the mortality risk of 1,226 patients from multiple practices who received algorithm-based depression management for 98 months (2006-2008) from a depression care manager. They found that patients with depression and diabetes who received the intervention treatment were less likely to die post-2008. For heart disease, persons with major depression were at greater risk of death, whether in usual-care or intervention practices. The study is part of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial.

· Collaborative care has a modest benefit (effect size 0.3) over usual care, says data from the University of Manchester. Nineteen general practices in northwest England were randomized to collaborative care and twenty to usual care. Collaborative care included patient preference for behavioral activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Mental health professionals provided up to eight sessions of psychotherapy, with two sessions attended by a practice nurse. Patients in the intervention arm reported being better self managers, rated their care as more patient-centered, and were more satisfied with their care. Michael Sharpe wrote commentary on the study saying we know integrated care works but we still don’t know much about which interventions work best. He also believes there were several limitations to the study (e.g., care was not integrated with medical care, treatment was psychiatry-directed). He also believes we need more intensive treatment for co-morbid patients.

· Data from one study at the University of Southern California suggests that patients are generally accepting of automated remote monitoring of their depression. From 2010 to 2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)-a quasi-experimental comparative effectiveness research trial aimed at accelerating the adoption of collaborative depression care in a safety-net health care system-tested a fully automated telephonic assessment (ATA) depression monitoring system serving low-income patients with diabetes. They found that the vast majority of participants would participate in the future and found the technology useful and secure.


· Does integrated behavioral health services in primary care work for patients with serious mental illness? Researchers in one study compared minimally enhanced usual care with collaborative care for 404 patients with PTSD enrolled in Federally Qualified Health Centers. They found no difference in effectiveness between the two care models. In a similar study examining patients with bipolar disorder, researchers found that collaborative care was superior to usual care. James Phelps recently wrote a blog post on this topic for CFHA.


· Representatives from SAMHSA are calling for integrated care services to meet the mental health needs of children and adolescents. They state, "What may be needed is not a health home as currently conceptualized for adults, nor a traditional medical home, but a family- and child-centered coordinated care and support delivery system supported by health homes or other arrangements.”

· Qualitative data from 59 interviews suggests that collaborative care helps clinicians to see patients more holistically, gives patients space to talk about their mental health, and decreases stigma toward mental health care. Interestingly, patients also reported a desire to "discussing emotional health problems in a separate therapeutic space away from the” medical staff. Patients saw medical staff members as insiders who managed their medical care and behavioral health staff members as outsiders "which paradoxically granted patients freedom to talk emotionally about their life circumstances and medical conditions in ways that were not possible with” medical staff.

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Bucket Two: the Challenge of PTSD and Bipolarity in Primary Care

Posted By Jim Phelps, Friday, February 19, 2016

“The difficult we do immediately. The impossible takes a little longer.” 
(motto of the WWII Army Corp of Engineers)


Consider three primary care buckets, for simplicity:  in the first bucket, you’ll find patients with the many forms of depression and anxiety that can benefit significantly from the brief interventions commonly provided by Behavioral Health Consultants. 

In the third bucket, you’ll find those who clearly need specialty mental health services: psychosis, significant borderlinity, complex or treatment-resistant substance use, and complex medication regimens. Left over is a large group of patients our behavioral team has lumped in “Bucket Two”.  These are folks whose depression and anxiety is complex, or not responding to the interventions of Bucket One, but who are unable or not inclined to go see a mental health specialist. 

Bucket Two includes a mix of difficult-to-treat depression, anxiety, and bipolarity.  And, as CFHA providers well know, trauma histories in this group are extremely common. Patients in this bucket represent the majority of patients referred to our Primary Care Psychiatric Consultation (PCPC) program. Their diagnoses include substance use, GAD, borderlinity, ADHD – but most common of all are PTSD and bipolar disorders.  Unfortunately, these are difficult to treat in primary care: their complexity level is often very high (e.g. prior therapies, prior medications, co-morbid mental health conditions, and co-morbid general medical problems), potentially swamping busy behaviorist and primary care providers; and with their trauma histories, they often do not respond fully to brief interventions.

The Collaborative Care model for psychiatric consultation has demonstrated efficacy in patients with Major Depression, and is sometimes promoted over other models on this basis. But it has less evidence for efficacy for PTSD (e.g. the recent negative trial by Meredith et al, 2016) and bipolar disorders (e.g. Cerimele et al, 2014).  However, the news for Bucket Two is not all bad.  A recent randomized trial in the Netherlands showed that a collaborative care approach to bipolar disorders reduced the frequency and severity of depression symptoms relative to treatment-as-usual (van der Voort et al, 2016). And a Behavioral Integration program for small and solo primary care practices, being studied in a randomized trial (sponsored by a large insurance company!), utilizes an intervention designed to treat both unipolar and bipolar depression (Kilbourne et al, 2014).

Consider a review from Dr. Kilbourne’s group, on integrating bipolar disorder management in primary care (2012). In it she and her colleagues emphasize the unrecognized burden of bipolar disorder in primary care (“the de facto site of care for persons with bipolar disorder”) , noting:

Subthreshold bipolar diagnoses, such as bipolar disorder not otherwise specified and cyclothymia, are not only prevalent and clinically significant but also go largely untreated in primary care. In a nationally representative sample of U.S. adults diagnosed with depression, 40% of participants also had a history of subthreshold bipolar manic symptoms…  Notably, the role impairment associated with these subthreshold disorders is similar to that of bipolar I disorder and present with significant psychiatric comorbidity and symptom severity predisposing them to an increased risk for suicide and general medical conditions.

That’s Bucket Two – or rather, a portion of it.  As noted, the other common diagnosis in there is PTSD, which is similarly role-impairing and similarly likely to present with comorbidities, psychiatric and medical. 

Suffice to say that if your program is having difficulty managing the folks in Bucket Two, so are we: they need more than can be provided in Bucket One, the main territory of the primary care behaviorist, but either can’t or won’t access specialty mental health (in our case, access is a huge problem: our psychiatry residency program is just about the only place in a large catchment area that will take patients with Medicare, for example, so we have a chronic long wait list).  In a later post I will return to describe a program for the bipolar disorders in Bucket Two. Hopefully, between us all here in CFHA, the PTSD will take “just a little longer”. 


James Phelps, M.D., Staff Psychiatrist at Samaritan Mental Health, has specialized in bipolar spectrum variations for over 15 years.  He has authored multiple peer-reviewed articles on mood disorders, and serves as Bipolar section editor for Psychiatric Times.  His no-profit website,, focuses on complex bipolar variations; it has received over a million visitors.  He accepts no honoraria from pharmaceutical companies, but does receive royalties from McGraw-Hill and W.W. Norton for books on the bipolar spectrum. His new book from Norton, A Spectrum Approach to Mood Disorders, will be out in June 2016.

Dr. Phelps received his M.D. from Case Western Reserve University, and completed his residency in psychiatry and a fellowship in medical education at the University of New Mexico. Current grant funding focuses on primary care psychiatric consultation.

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100 Million Healthier Lives

Posted By Marianne McPherson, Wednesday, February 3, 2016

100 Million Healthier Lives is an unprecedented collaboration of change agents across sectors who are pursuing an unprecedented result: Mission: 100 million people living healthier lives by 2020. Our vision is to fundamentally transform the way the world thinks and acts to improve health, well-being and equity to get to breakthrough results. Together, we are systematically creating a community of solutions to the most intractable challenges that stand in the way of achieving health, wellbeing and equity across the globe. Our theory of change follows:

Unprecedented collaboration + innovative improvement + systems change to remove barriers = 100 million people living healthier lives by 2020. 


Our 700+ members have signed on because we believe the time is right for a major leap forward in the creation of health, wellbeing and equity. The rising tide of chronic disease, an aging population, structural inequity in health outcomes (despite advances in health care), and technology demand a fundamentally different approach, one which brings us together across sectors to address the physical, social and behavioral contributors to health together.

What’s more, all members of 100 Million Healthier Lives agree to adopt five following core principles in our work together. Several of those resonate strongly with the founding principles of CFHA of collaboration and family-centered care:

  1. Partner deeply and respectfully in the process of creating change with people, organizations, and communities.
  2. Promote equity, justice, strength, and wholeness in the process of creating health.
  3. Adopt a humble posture of learning and improvement that acknowledges the importance of both stories metrics that matter.
  4. Intentionally work to remove barriers in critical areas (e.g., payment reform, spread of good ideas) through intentional collaboration with traditional and nontraditional partners.
  5. Make the way we work an example of what’s possible.


We set an audacious goal of 100 million healthier lives precisely so that there was a goal so big that no one organization or community or stream of work could achieve it alone.


A key priority in the movement to is to shift culture and mindset to one of partnership, co-design, and wellbeing. Some examples:

·         Partnership means that, for example, we have shared leadership and decision making at every level of the initiative. We believe that everyone holds a unique and important piece of the puzzle in creating health. We are committed to seeing how those pieces fit in different combinations, letting go of the pieces we hold to combine them in innovative ways.

·         Co-design means that we are working with rather than for communities. We are working to create 1000 “communities of solution” around the world, believing that sustainable change for health, wellbeing, and equity, will come when communities, themselves are full partners in the work, when they set meaningful goals rather than having goals set for them. The 61 communities in the SCALE and Pathway to Pacesetter initiatives are working in multi-sector teams and using improvement science techniques to test and learn their way into their community’s health goals.

Wellbeing means that we define and measure health as broader than physical health to include physical, mental, social, and spiritual wellbeing. The importance of integrating mental health into primary care resonates deeply with our work and goals, including a stream of work aimed to “make mental health everybody’s job.”

We have organized work by focusing on the following “9 Whats and 9 Hows":

9 Whats

9 Hows

  1. Close equity gaps – this is “the “price of admission” in 100 Million Healthier Lives
  2. Help veterans to thrive
  3. Address and improve social determinants across the continuum
  4. Improve wellbeing of indigenous communities
  5. Help all kids have a great start to life
  6. Make mental health everybody’s job and take a prevention approach
  7. Engage people in their own health (nutrition, exercise, sleep, stress, food security)
  8. Improve employee health and wellbeing
  9. Create wellbeing in the elder years and end of life


  1. Shift culture and mindset to one of partnership, co-design, and wellbeing.
  2. Develop the health workforce
  3. Elevate peer to peer approaches
  4. Build improvement capability at the community level
  5. Use chronic diseases and risk factors to build the health continuum
  6. Improve high quality primary health care access for all
  7. Integrate data across siloes (health care, community, public health, social services)
  8. Create new financing strategies
  9. Transform health care to be great at health and great at care



The movement is more than words and ideas, it is coming to life around the world in everyday action. The story below is from the online community—anyone is free to join the community and share stories about a recent success partnering with high school youth in Algoma, Wisconsin, shared by Teal Vanlanen:

Through the recognition of our Live Algoma work, our local high school received a $5000.00 Hands-Only CPR kit from the American Heart Association and Bellin Health.  The students were tasked with "being creative" in using this kits - I think they went above and beyond creativity!


The students decided to partner with Live Algoma because "Live Algoma is by us and for us," they said.  As a result, we presented our Driver Diagram, our AIM, and how to complete a PDSA [improvement science tools]. The students were thrilled.  We told them to start small and SCALE up in the community.


For their first small scale test, the students wanted to train Hands Only CPR to members of our community at two local basketball games (basketball is a huge draw in our community). They were aiming for to train a minimum of 20 people per game; they trained 130! 


How are they planning on SCALING up in our community?  Wait until you hear this: next semester they are developing a class where they can go out to local businesses and train all of the employees on Hands Only CPR.  Then, they will meet with the local government, school administrators, and local business owners to share their data and convince them to make system and policy changes within their organizations to require all employees and students (grades 7-12) to be trained in Hands Only CPR each year.



Thank you for the opportunity to share our voices on your blog. We invite you to join with us via; you can join the movement, register for monthly momentum calls, visit our map of the movement, and share your stories. Thank you for all you do to improve health and wellbeing! 

We invite you to join the 100 Million Healthier Lives Community at our spring gathering in Orlando, Florida, from March 19-22 in conjunction with the Institute for Healthcare Improvement’s (IHI) 17th Annual Summit on Improving Patient Care in the Office Practice and the Community. IHI is honored to announce that Vice Admiral (VADM) Vivek H. Murthy, MD, MBA, the 19th Surgeon General of the United States, will deliver the closing keynote address. For more information, click here


Marianne McPherson, PhD, MS, is Director, 100 Million Healthier Lives Implementation at the Institute for Healthcare Improvement. Her responsibilities include developing and implementing new programs;  building external partnerships; and supporting a culture of unprecedented collaboration, innovative improvement and system transformation to support 100 million people worldwide leading healthier lives by 2020. Marianne received her MS in Public Health from Harvard School of Public Health, her MA in Women’s and Gender Studies from Brandeis University, and her PhD in Social Policy from the Heller School at Brandeis University. Connect with her directly at (email), (web), or @MariannePhD (Twitter).



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On Arriving and Departing

Posted By Jeffrey M. Ring, Wednesday, January 27, 2016

"The truth is of course is that there is no journey. We are arriving and departing all at the same time."  David Bowie


Just over a year ago I transitioned from my clinical and teaching practice at a family medicine residency to healthcare consulting.  This was no easy farewell.   I would be leaving a residency program where I served as psychologist/clinician, educator, mentor and colleague for 19 years.  I was leaving a place where I felt deeply imbedded in an integrated and beloved vulnerable safety net healthcare community in East Los Angeles.  The night before I was to announce my resignation, I made a pact with myself that I would do my best to be mindfully present for each and every farewell encounter over the weeks ahead.  My connections with others are important to me, and I felt a strong need to honor each relationship as well as I could in the face of this impending departure.  I bolstered myself for the emotional intensity to come and made a plan for how I would take care of myself. 

My bolstering and planning were imperfect at best. 

Over the course of the month, a patient would arrive for counseling, enter into the content of their exploration, and I would do my best to listen and assist.  About twenty minutes into the session, I would find a way to say something like, “I have something important to talk to you about our work together…”  At this point I would let them know of my tenure at the clinic drawing to a close. 

As clinician colleagues, you already can imagine the variety of reactions I received.  These ranged from tearful sadness, bitterness, and helplessness to tearful appreciation and celebration of our work together.  Blame, abandonment and unfairness surfaced often in our conversations as well.  I struggled with having shifted from a source of support to a source of consternation and loss.

The most painful aspect of these conversations was the unfinished work, the ongoing losses and health and trauma challenges, the poverty and immigration and deportation threats that impacted mind, body and spirit.  Some of these patients were relatively new to counseling, others had taken advantage of counseling off and on as needed over many years, returning to the safety and intimacy of my office as needed. 

This pattern of delivering news of my departure repeated itself hour after hour, day after day, for the entire month.  The clinical meetings were punctuated by colleagues and residents stopping by my office to also say farewell.  It was hard to catch my breath.  I did my best to stay present, but the pull to turn away, to close off and to escape the overwhelming emotions was deep and powerful.  This is not an unfamiliar response of medical caregivers in the face of strong emotionally laden patient encounters.

On the other hand, my announcement also invited a rich and unexpected opportunity (from patients and colleagues alike) for conversation about our relationship, our mutual impact, and reflection on life and change and the power of empathic human connection.  The immediacy and honesty of these conversations filled me with joy, appreciation and humility.  I celebrated the many gifts of profound human connection I had enjoyed in the context of that remarkable community.  In these moments, my breath returned deep and full. 

When the month of farewells drew to a close, I was depleted and spent.  It would take several weeks to find my way back to myself.  A year later, I now wonder how I might have managed the emotional intensity differently and more effectively.  My self-care model of recuperating wellbeing at the end of each day or two through movement, nature, family, and play now appears less than adequate.  I presume I would have fared better if my self-care strategy was woven into the fabric of my encounters throughout the day.

While the stressful situation I describe was unique to my career transition, the larger issue of workforce vitality in health care is pressing and relevant.  Health care delivery is an honorable profession marked by concern, altruism and sacrifice.  Yet worrying about and intervening with others can be uniquely depleting when practiced in the context of complex patients, uncertainty of decision making, onerous record keeping, and demanding time and productivity pressures.  With the arrival of the Affordable Care Act, and in the shadow of health disparities,  practitioners and health care systems are working furiously to meet the many pent-up medical needs of patients along with the onerous reporting/documentation requirements of practice.  Systematic attention to practitioner sustenance is an essential but missing link in the ongoing effectiveness of the U.S. health care system.    This is especially true for practitioners working with underserved and minority communities, and where social determinants weigh heavily on patient health. 

Our health system can ill afford practitioners who have lost their calling to care for others.  Burnout and cynicism are risk factors for poor quality care, medical errors, and low morale.  Moreover, practitioners under pressure are at increased risk for a whole host of medical and mental health conditions. Colleagues who leave their job due to burnout leave a wake of consequences ranging from lost continuity of patient care, to the costs of hiring and training.  A colleague who resigns due to stress (or in worst case scenario takes his or her own life) impacts the emotions, morale and workload of remaining colleagues.

What is a practitioner to do?  What are key elements of a practitioner wellbeing initiative or policy?  What are the costs and losses experienced in organizations that remain insufficiently attentive to the vitality of their practitioners?   What is the wellbeing imperative for healthcare organizations?  I propose enhanced attention to mindful practice, meaningful practice, collaborative practice, and sustaining practice.  



Mindful practice grows out of a tradition that speaks to fully immersing oneself in the moment at hand.  It is built on a foundation of observation of self and other.  It is bolstered by an awareness that stress lives in the transitions in life.  This includes big transitions as in a marriage, a new job or a death.  It also includes the small transitions from patient to patient, from home to work and back again, and from work in the clinic to rounds in the hospital.  Pathways to mindful practice can include focusing on the task or conversation at hand, minimizing internal thought distractions as possible.  Attention to breath can be a very powerful pathway to mindful presence.

Meaningful practice can grow only from the rich soil of reflection.  One must enter into a conversation with oneself and others about priorities, values, and calling, and the ways that these are vulnerable to erosion and change in the face of external demands that outpace internal resources.  Shared celebration of the successes and positive impact of one’s work on others is essential rocket fuel.  An enlightened healthcare organization is one that creates and welcomes opportunities for reflection on the meaning of one’s work, encouraging sharing of practical examples of positive impacts on others.  Humanities can provide a powerful on-ramp for just this type of reflection.  Consider the words by Rumi from the 13th Century:

Don’t turn your head.
Keep looking at the bandaged place.
That’s where
the Light enters you.

Collaborative practice facilitates an interpersonal approach to patient care.  This encompasses shared decision making models and optimally functioning health care teams.  Success in each of these arenas requires investment in learning innovative ways of communicating and of navigating conflict while enhancing nurturing.  Collaborative practice is built on a strong foundation of listening, caring and expressed empathy.  In the hectic pace of healthcare delivery, is there a place for appreciation and gratitude for patients, colleagues and for oneself?

Sustaining practice draws upon finding joy in one’s work and in one’s life.  It grows from the rich soil of social support and humility.  For me, mindful movement, immersion in nature and the richness of sharing time with family, friends and beloved colleagues are powerful sources of sustenance.  Enlightened leaders in healthcare are willing to take on the impressive task of considering the costs (financial and otherwise) and benefits of practitioner vitality initiatives that support a humane life balance.

So if life is in fact a series of constant and simultaneous arrivals and departures, it makes sense to do what one can to be there for all of them.  It makes sense to show up and to pay attention.  It lends an argument for enduring the painful farewells and for celebrating the precious reunions.  And it makes sense to share this wisdom with others who are arriving and departing all around us all of the time.


Jeffrey M. Ring, Ph.D. is Principal at Health Management Associates where he works with health care organizations and medical education programs to provide innovative whole-person integrated behavioral health care to vulnerable and safety net populations.  As a certified leadership coach, Dr. Ring works with leaders and teams to strengthen effectiveness and efficiency.  Most recently, he is involved in projects aimed at improving practitioner and team wellbeing.  He is Clinical Professor of Family Medicine at the Keck School of Medicine at the University of Southern California, and is the first author of Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competency Training (Radcliffe Oxford, 2008).




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News & Research Column

Posted By Matthew P. Martin, Tuesday, January 26, 2016

Welcome to the first 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 each month for additional reports.


Reimbursement Codes

A new bill introduced by U.S. Senator Debbie Stabenow (D-MI), U.S. Senator Barbara Mikulski (D-MD) and Congresswoman Barbara Lee (D-CA) aims to help older individuals with mental illness by changing the way Medicare reimburses clinical services performed by social workers. According to Congresswoman Lee, a psychiatric social worker herself, “social workers are not adequately reimbursed for the vital services they provide”. The bill was introduced in the Senate on October 8th, 2015 and is now moving through the Committee on Finance.

The new bill, called Improving Access to Mental Health Act of 2015, would align Medicare payments for licensed clinical social workers (LCSW) with that of other non-physician providers like nurse practitioners and physician assistants. Specifically, this means that LCSW's would be allowed to deliver and bill for Health and Behavioral health services (codes 96150 - 96155) that are presently restricted to clinical psychologists only by Medicare. An LCSW would not need to use a mental health diagnosis but could instead use the medical provider’s diagnosis and focus on behavior change. This may especially help improve chronic disease management and expand behavioral health services to older patients.

ACO for SNFs has Positive Outcomes

Collaborative care works for Medicare beneficiaries in skilled nursing facilities (SNF), according to data from a joint venture by the Atlantic Accountable Care Organization (AACO) and Optimus Healthcare Partners. In 2014, ACOs in New Jersey started working with SNF leadership to improve collaboration and performance outcomes (e.g., length of stay, lowered hospital admissions). Within six months, there was significant improvement across all performance measures as well as a reduction in nursing home costs for sub-acute care patients. Sub-acute care is for patients who require more intensive skilled nursing care, but not hospital acute care.

How did they do it? The ACOs worked with administrators and leaders from each of the 61 participating SNFs to review facility performance and collaboratively revise or design new protocols and processes. Managers then worked with clinical staff to provide training and ongoing support to implement the new ideas which included great patient and family engagement. The success of the new network of SNFs is attracting other facilities in the state of New Jersey to join.

According to Poonam Alaigh, M.D., corporate consultant to the Atlantic ACO, “these results are proof that when you remove silos and work collaboratively across the health care continuum reduced costs are possible, while improving the quality of care.”

Global Payments for Behavioral Health Integration

A new report from the SHAPE pilot study in western Colorado suggests that global payments for primary care and integrated behavioral health services results in lower total cost per patient. "We are pleased, but not really surprised by these findings," says Patrick Gordon, MPA, associate vice president, Rocky Mountain Health Plans. According to Benjamin Miller, director of The Eugene S. Farley, Jr. Health Policy Center at the University of Colorado, "This is about changing the rules of the game to allow for seamless, unfettered access to behavioral health care in the setting where patients most often present with behavioral health issues."

Fixed-dollar payments for patient care, otherwise known as global payments, are nothing new to healthcare. The goal of global payments is to reduce costs while also not punishing providers for treating sicker patients. Instead, providers act as stewards over limited resources; they must deliver good outcomes while also eliminating waste. Historically, there has been less data for global payment systems compared to traditional payment systems like fee-for-service. The SHAPE study provides important analysis for determining the effectiveness of a fixed-dollar payment for integrated behavioral health services.

The SHAPE project is funded by the Colorado Health Foundation and supported by the Collaborative Family Healthcare Association (CFHA). Stay tuned for more information about this project in the future.


·         A case example from the University of Washington demonstrates the effectiveness of treating serious mental illness in a primary care setting using a collaborative care model. Primary care physicians consulted with on-site psychiatrists to successfully reduce symptoms and increase functioning for a 36-year-old patient. Click here for more information.

·         In the past, there has not been much research available on the effectiveness of integrated behavioral health services for pediatric populations. Now, a systematic meta-analysis from researchers at UCLA suggests a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models. Check out the additional commentary from David Kolko at the University of Pittsburgh. He considers this type of research a “national priority” and praises the researchers for their methodological rigor.

·         Several studies suggest that collaborative care is especially effective for chronic disease management. A recent systematic literature search from the Tilburg University in the Netherlands examines the relationship between context, mechanisms, and outcomes for thirty-two studies of integrated care and type 2 diabetes. The researchers concluded that most barriers to implementation are related to the organizational context level, including workflow changes, logistical barriers, and staff turnover or limited staff capacity. They also concluded that most facilitators for implementation occur at the social context level, which include involvement of staff in decision-making and planning, the ability to find committed staff and generate staff buy-in, and good leadership and intra- and inter-practice resource-sharing and cooperation.

·         Finally, researchers from the Mayo Clinic in Rochester, Minnesota conducted a retrospective cohort study of 7340 patients with depression to see if collaborative care management (CCM) was superior to usual care (UC). They compared the two treatments using (9-item Patient Health Questionnaire [PHQ-9] score <5) and persistent depressive symptoms (PDSs; PHQ-9 score =10) as end points. The results show that the median time to remission was 86 days for the CCM group versus 614 days for the UC group. Likewise, median duration of persistent depressive symptoms was 31 days for the CCM group versus 154 days for the UC group. The researchers conclude that patients enrolled in CCM have a faster rate of remission and a shorter duration of PDSs than patients choosing UC.

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Inside Medicine at Weill Cornell: Meeting in the Middle

Posted By Administrator, Thursday, December 10, 2015

This piece is a reprint of a post from Weill Cornell Medicine. Click here for the original post. Reprinted here with permission. 



She calls them her "miracle men and women," the Weill Cornell doctors who saved her from a stroke and figured out how to manage her recovery as she grappled with other, longstanding health issues. But Jennifer Harmon knew that her experience in the healthcare system had provided her with equally important wisdom — that of a patient — and she's now sharing it with the medical college's doctors in training.

Harmon, the subject of Episode 3 of the online video series Inside Medicine at Weill Cornell, was flattered when her internist, Associate Professor of Clinical Medicine Dr. Keith LaScalea, asked her to mentor students as part of theLongitudinal Educational Experience Advancing Patient Partnerships (LEAP) program. The program became a mandatory part of the medical school curriculum last fall in order to expose students to patient care over time, their psychosocial support, and to barriers to their health. "I consider it a huge compliment to be invited to join," says Harmon, a New York actress who has worked in theater for decades. "I was on board immediately. You need to develop every aspect of your humanity to be a good doctor.

"Being a patient, I was thrilled with the idea of a medical school going back and looking at what happens when a doctor and a patient go into a room together and the door is shut," says Harmon, 71, who has battled breast cancer, chronic swelling known as lymphedema, a hip replacement and immune suppression from a kidney transplant. "What is that relationship? What was the patient looking for, what was the doctor looking for? What does it mean to really listen to you, to really see you? Which I would think as a doctor, if I'm going to treat you, I need all the information I can get on every level."


Harmon brings memories of both positive and negative interactions with physicians to her work with students Peter Chamberlin '18, Christopher Reisig '17, Sam Woodworth '16, and Justin Granstein '15. (Newer students are paired with those farther along in their studies, providing a peer mentorship component.) While she once had to ask a doctor at another institution to talk with her from her hospital bedside, rather than from the door to the room, Harmon praises Dr. LaScalea and her neurologist, Assistant Professor of Neurology Dr. Halina White, for making eye contact with her while they take notes on their computers. They and her nephrologist, Associate Professor of Clinical Medicine and Medicine in Clinical Surgery Dr. David Serur, have additional qualities that make their relationships effective at promoting her wellbeing: compassion, empathy, and the ability to listen.

She views them — and ideally, all doctors — as her partners in care.

"The doctors at Weill Cornell can tell me their expertise," she says. "They are very good at imparting information to help me understand — they take the time to help me understand. Since the stroke, things are harder for me sometimes to grasp the first time around. They're willing to explain it again.

"But it's a partnership," she says. "I have to be on board with them. I have to take my medications. I have to do my exercises. I have to try and eat well. I have to get enough sleep. I have to not do so much in a day. That's what I mean about a partnership."


The approach is working. Though doctors are monitoring her blood pressure and she is due for a second hip replacement this fall, Harmon describes her health as "excellent." She'll return to the stage this summer in a production of "Outside Mullingar" at the Dorset Theatre Festival in Vermont.

Harmon is an effective patient mentor for several reasons, says Dr. LaScalea, who directs LEAP. She receives care from across the Weill Cornell-affiliated campus, is willing to allow students to be present at her appointments, and to share her experiences with them, he says. "She's the ideal LEAP teacher," Dr. LaScalea says. "She is very interested in giving back. She really cares about the next generation of doctors and how they're educated. She's kind and generous with her time. Unfortunately she has multiple diagnoses, but that is very educational for the students to see."

Harmon is equally impressed with her student mentees. And she's confident that their intelligence, curiosity and kindness will come through when they begin practicing medicine themselves.

"They're going to be studying anatomy and all that, but when they walk into a textbook they're looking at, it's an actual human being whose heart's in trouble, or kidney's shutting down, or they have cancer," she says. "That must be an amazing moment for them, and my hope is that the LEAP program will make that transition not quite so daunting.

"I'm a recipient of the medical field, and now I'm meeting the young men and women who've decided to take this on as a career. And I'm just — I'm in awe," she says. "They really make me stand in awe."

  Founded in 1898, and affiliated with what is now New York-Presbyterian Hospital since 1927, Weill Cornell Medical College is among the top-ranked clinical and medical research centers in the country. In addition to offering degrees in medicine, Weill Cornell also has PhD programs in bio-medical research and education at the Weill Cornell Graduate School of Medical Sciences, and with neighboring Sloan-Kettering Institute and The Rockefeller University, has established a joint MD-PhD program for students to intensify their pursuit of Weill Cornell's triple mission of education, research, and patient care. 

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Harnessing the Power of Collective Impact

Posted By Natalie Levkovich, Tuesday, November 17, 2015

This post is a reprint of the incoming CFHA President's message given at the 2015 Annual Conference in Portland, Oregon. Reprinted with permission.

I am so honored and excited (and a little intimidated) to be the incoming President of CFHA. First I would like to offer my thanks to our Executive Leadership Team.  The powerful thing these folks all have in common is an unassailable commitment to CFHA -- past, current and future. This is a commitment that I wholeheartedly share and that I will be proud to help harness and encourage as CFHA’s President.


In my day job I am CEO of an association, albeit one that is quite different from CFHA. That notwithstanding, I know first-hand some of the challenges of leading a member-driven organization, of being both strategic and responsive; inclusive and equitable; efficient and transparent in serving the needs of the membership while meeting the mission of adding value to the field -- AND while sustaining the organization itself. I will bring that perspective to my new role as your President.


There is another experience that I bring to CFHA and that is a deep and personal appreciation for its uniqueness. Over the 32 years of my career in public health and nonprofit leadership, I have been a member of a number of associations and served on a number of Boards. Each experience has had its value; however, none has matched the value I have derived from CFHA and from the friends and colleagues I have gained through CFHA.


I first heard about CFHA in about 2000 when I assisted in the management of an international healthcare development project in Kiev, Ukraine.  Through the project, we enlisted the involvement of Barry Jacobs, David Seaburn, and Suzanne Daub – all early members of CFHA and early adopters and ambassadors for collaborative care. With their help, we added the principles of Integrated Behavioral Health (IBH) into the overall scheme for community-oriented primary care that we were advocating and helping to develop in post-Soviet Ukraine.


Later, when we began to advance larger scale IBH closer to home in Philadelphia, I remembered how I first came to appreciate its principles and decided to attend my first CFHA conference in 2007 in Asheville, NC. What I discovered is what you, as members, know: this is an amazing association that convenes thought leaders and dedicated practitioners, educators, researchers and advocates who are extraordinarily generous, welcoming and accessible; who are focused on advancing the field, not their respective guilds; who are intellectually open and curious about a variety of evidence, models and approaches to whole-person, system-oriented healthcare; who are eager to share what they know and to learn from others; and who take it as their personal responsibility to nurture those newer to the field so that collaborative care can spread, strengthen and come to scale as the national standard of care. As a case in point, we now have a record number of participants in our formal Mentoring Program and scores more who have formed those connections informally. And, of our record number of new members one-third are early career professionals, which I consider to be a very powerful indicator of our vitality.


As a clear example of CFHA exceptionalism, we can look at a bit more of my own CFHA story. I am not a medical, mental health or any other kind of clinical professional; I am not a researcher or a university educator; I do not have a doctoral degree. Yet, here I am, talking to you today as CFHA’s incoming President. While I do believe I have a contribution to make, can you think of any other professional association that would embrace someone with my profile as its President? I can’t. The willingness to find a place for anyone who can contribute to the organization’s mission underscores the culture of inclusion, shared learning and movement building that characterizes CFHA. This is YOUR association and a place where YOUR talents and contributions will be recognized, encouraged and gratefully accepted.


So, what can you do to advance CFHA’s future and the future of IBH? Be a movement builder -- maintain your membership and encourage your colleagues of every stripe to join us. Get involved in a committee or SIG, share your experience through a blog or webinar, volunteer to be a mentor, encourage your team to attend the next conference, submit a manuscript to our journal Families, Systems & Health, include your CFHA affiliation in your bio and your introduction whenever you make public presentations, vote in Board elections and/or nominate yourself, share with us the advances occurring in your community or reach out to us if you have an idea for how CFHA can help you to advance collaborative care in your setting.


Given the direction in which health care reform is going with ever-increasing momentum – toward a more value oriented, population based, and integrated delivery system across all levels of care – CFHA has within its expertise and within its membership the capacity to disseminate the  “how to” strategies that accelerate the adoption of effective team-based care, patient and family inclusion and efficient integration of behavioral health in medical settings across the continuum. If you share those values, vision and sense of purpose with CFHA, add your voice and energy to our collective influence. As members of this association, you are CFHA and it is through you – each of you – that we can harness the power of collective impact.

Natalie Levkovich  Natalie Levkovich is CFHA President. She has served as the executive of the Health Federation of Philadelphia (HFP) for nearly three decades. HFP is the SE Pennsylvania network for community health centers that provides comprehensive primary care to nearly 300,000 low income and underserved individuals per year.  

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What You Should Know About Preventable Harm

Posted By Emily Newhook, Wednesday, November 4, 2015

This post is a reprint of a piece from MHA@GW, the online master of health administration from the Milken Institute School of Public Health at the George Washington University.


The Latin phrase “Primum non nocere” is familiar to all physicians: First, do no harm. Care providers do their best to avoid hurting people in the process of treating disease, but despite their best efforts, patients are sometimes harmed while undergoing medical care. Some harm is considered unavoidable, such as post-operative bleeding despite perfect surgical technique. Preventing other harm — harm due to mistakes — is a cornerstone in the movement to improve patient care and safety. This issue is serious. Up to1,000 patient deaths per day can be attributed to preventable medical errors. This means preventable harm is the third leading cause of death among Americans, behind only heart disease and cancer.

What Is Preventable Harm?

Lack of a clear, agreed-upon definition obfu¬scates a full understanding of the nature of preventable harm. Most working definitions include the idea that the harm is “identifiable” in that it can be attributed to medical care and “modifiable” in that it is possible to avoid. For the purpose of this article, we will be using TheInstitute for Healthcare Improvement definition of preventable medical harm as “Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.” Defining preventable harm is important because some studies suggest that up to half of the harm patients experience in hospitals is not preventable or not the result of an identifiable error. In addition, there is conflicting evidence regarding the prevalence of preventable harm.

Eliminating preventable harm is certainly a desirable goal, but, in practice, it may not actually be possible. The sad fact is, while harm may be “preventable,” a certain level of harm is considered inevitable because health professionals, like everyone, make mistakes. Hospital-acquired infections, misdiagnosis, wrong surgeries, medication errors, in-hospital falls and burns, some cases of deep vein thrombosis, surgical site infections and bedsores are common examples.

Most Common Types of Preventable Harm


Type of Harm Explanation Prevalence/Incidence
Hospital-Acquired Infections Hospital-acquired infections are caused by bacteria, viruses or fungal agents. Common types include blood stream infections, pneumonia, surgical infections, urinary infections and methicillin-resistant Staphylococcus aureus (MRSA). A Centers for Disease Control and Prevention survey found that, on any given day, an estimated 1 in 25 hospital patients are affected by a hospital-acquired infection.
Surgical Error - Wrong Site Surgery Wrong site surgeries include performing surgery on the wrong side or site of the body, performing the wrong surgical procedure and performing surgery on the wrong patient. An Agency for Healthcare Research and Quality study that analyzed information from nearly 3 million operations between 1985 and 2004 discovered a rate of 1 in 112,994 cases of wrong-site surgery.
Medication Errors Medication errors include prescribing errors, dispensing errors, medication administration errors and patient compliance errors. Somewhere between 3 and 6 percent of patients experience medication errors every year.
In-Hospital Injury Most in-hospital injuries are the result of falls. Rates of falls in U.S. hospitals range from 3.3 to 11.5 falls per 1,000 patient days. 

There are three types of medical misdiagnosis:

    • False positive: misdiagnosis of a disease that is not actually present.
    • False negative: failure to diagnose a disease that is present.
    • Equivocal results: inconclusive interpretation without a definite diagnosis.
No reliable data is available on misdiagnosis. Available studies vary widely in their conclusions. 
Deep Vein Thrombosis DVT is a blood clot that forms deep in the body, often in the lower leg or thigh. When a blood clot breaks off, it can travel through the blood stream and block blood flow in the lungs, heart or brain, resulting in an embolism. Risk for DVT is greater when in the hospital because major surgery and immobility can both cause DVT.  A Centers for Disease Control and Prevention study found the estimated annual hospitalization rate for DVT at 547,596 from 2007 to 2009. It is unknown how many of those cases were preventable. 


What Are the Costs?

The human toll of preventable harm is staggering. The most cited statistics come from a famous 1999 report by the Institute of Medicine (IOM) “To Err is Human.” This report, one of the first of its kind to bring hard science to the study of preventable harm, shocked readers by reporting 98,000 people die every year due to preventable adverse events. While many still quote this figure today, newer, similarly rigorous studies estimate the actual prevalence of preventable harm to be much higher — between 210,000 and 440,000 instances per year.

Besides the toll preventable harm takes on human life, ample evidence suggests medical errors cost health consumers billions of dollars each year. A 2012 study broke down these costs into additional medical bills ($17 billion), increased mortality rates ($1.4 billion) and lost productivity ($1.1 billion). If we include the indirect costs of preventable harm, the economic impact could easily reach $1 trillion annually. It should be noted that these cost analyses are based on the incident numbers provided by the IOM’s “To Err Is Human” study — if these calculations were redone using the higher numbers reported by more recent studies, the resulting costs would be up to 10 times higher.

Preventable harm also levies an emotional toll on everyone involved. Treating instances of preventable harm means doctors have patients under their care for a longer period of time, nurses have more patients, and resources get stretched — creating an environment that could produce more instances of harm and a loss of morale. Family, friends and caretakers are affected as they put extra time and effort into helping loved ones recover. Finally, patients take more time off from work, school and other activities they enjoy in order to fully regain health.

What Can Be Done to Prevent This from Happening?

In order to prevent harm, administrations, governing bodies and professional organizations do their best to develop evidence-based guidelines and best practices to raise the standard of care. When things go wrong, it is typically multifactorial and involves a systematic or human error (and sometimes both). Systematic safeguards are typically in place to prevent human error. So systematic failures, such as dysfunctional teams, lack of resources, bad communication, poor health administration, disregard for safeguards and checklists, or malfunctioning technology often predicate and facilitate human errors such as lack of knowledge or skill, caretaker fatigue and technical mistakes. Continuous monitoring of adverse events, along with working to update policies and safeguards, is the best defense against repeated adverse medical events.

As we develop new treatments and safeguards, what seems inevitable today can be preventable tomorrow. How do standards of care get developed and put into practice? Lets look at a common example: An elderly patient falls getting out of her hospital bed to go to the bathroom. The patient requires further care to set her arm and prevent infection, and she does not leave the hospital until several days past her original discharge date. After getting back home, friends and family must monitor her and assist her with every day tasks.

Back at the hospital, a team of health care providers and administrators investigate if an intervention on their part would have prevented the patient’s fall. Was the nursing staff spread too thin to respond to her call promptly? Should she have been fitted with a catheter or bedpan? Was the floor wet? Was she given non-slip socks? There are three possible outcomes to such an investigation: (1) they could find that the current standards of care would not have prevented the fall and modify them as a result; (2) they could find there were reasonable safeguards in place but they were not followed; (3) they could find there was no way to prevent the incident in the first place.

The hospital’s analysis finds that while all current safeguards were adhered to, no one discussed the high risk of falls with the patient, and the patient did not consider herself at a high risk for a fall. To prevent this from happening in the future, an additional safeguard was put in place where the nurse on duty communicates with the patient about the danger of hospital falls and encourages her not to leave her bed without assistance.

There are many resources available to those looking to reduce the number of adverse medical events. Many nonprofits, health organizations and governmental organizations work to provide both the public and the medical community with the latest and greatest in health care innovations. In addition, it is important that we educate the next generation of doctors, nurses and health administrators to understand the gravity of preventable adverse medical events and encourage innovation in finding solutions.

Additional Resources

National Patient Safety Foundation 

A 501(c)(3) nonprofit, the National Patient Safety Foundation (NPSF) has been a central voice for patient safety since 1997. NPSF organizes Patient Safety Awareness Week and offers resources for patients, families and health care professionals.


Synesis is a Georgia-based consulting company that works with hospitals to help them pursue “zero preventable harm.” Their clients include the Mayo Clinic, Inova Health System and the United States Department of Veterans Affairs.

Patient Safety Movement 

Founded by Joe Kiani, the Patient Safety Movement calls on hospitals, physicians and medical device companies to make pledges to reduce preventable harm. Massachusetts General Hospital, Baylor Scott and White Health Care System, and GE Healthcare are among the health care organizations that aspire to reach zero preventable harm deaths by 2020.

National Quality Forum 

The National Quality Forum (NQF) is a “not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care.” In 2012, NQF endorsed the implementation of 26 patient safety measures related to medical errors.

Patient Safety America 

Dr. John T. James, the former chief toxicologist for the National Aeronautics & Space Administration (NASA), created Patient Safety America. He started the organization after his son died in 2002 as a result of what he describes “as uninformed, careless and unethical care by cardiologists at a hospital in central Texas.” A National Hospitalized Patient Bill of Rights is among the organization’s policy goals.

Beth Israel Deaconess Medical Center 

Beth Israel Deaconess Medical Center is a model of hospital transparency. Its website provides up-to-date preventable harm statistics by injury type and detailed accounts of how it is working to address those issues.

Hospital Safety Score 

Founded by the Leapfrog Group, Hospital Safety Score assigns safety scores to nearly 2,500 hospitals around the country. The scores allow patients and families to understand how reliably a particular hospital delivers safe care from the correct use of antibiotics to the frequency of employee hand washing.

Partnerships for Patients 

Spearheaded by the Center for Medicare and Medicaid Services, the Partnerships for Patients is a collaborative effort between health providers and federal and state governments to make hospitals safer.

Gordon and Betty Moore Foundation 

Through its Patient Care Program, the Gordon and Betty Moore Foundation spent $49 million in 2013 on projects that “eliminate preventable harms and unnecessary heath care costs.” Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, and the University of California, San Francisco, were among its grant recipients.

IHI Global Trigger Tool 

The Global Trigger Tool allows researchers to comb for triggers or clues to “measure the overall level of harm within a health care organization.”


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Live Blogging At 2015 CFHA Conference: Plenary Session 3

Posted By Matt Martin, Barry J. Jacobs, Tuesday, October 20, 2015

This is the third in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check out the other posts here and here

"End of Life In Our Time"

CFHA 2015 Conference Plenary Session 2

Saturday October 17, 2015 – 12:00 p.m. to 1:00 p.m.

The Grand Junction Players

Randall Reitz
Amy Davis
Lucy Graham
Sabrina Mitchell
Stephen Mitchell
Paul Simmons



Summary: Matt Martin

The final plenary session opens with muted blue light and the voice of a woman piped from the speakers singing “You’re a sky full of stars”. Images of telescopic views of space and microscopic views of skin and flowers flash across dual projector screens. Various quotes from various thinkers like E.O. Wilson, Neil deGrasse Tyson, and Carl Sagan appear as the first presenter, Paul Simmons, reflects on our shared humanity including our molecular makeup, the intertwined relationship of life and death, and the gratitude for life we can feel in the face of unavoidable death.

The second presenter Sabrina Mitchell shares a personal story of visiting her father in the hospital in the midst of applying for medical school. She recalls seeing her father strapped to a hospital bed with a twisted gown and terse conversations with hospital personnel. Her father’s mental status deteriorates and she receives little compassion or understanding from the medical staff. No one outside her family acknowledges her suffering. What a poignant example of how medical professionals struggle to adequately witness death in a meaningful and supportive way.

Stephen Mitchell, the second presenter, shares the loss of his unborn son Bo which the medical community terms a “miscarriage”. How do you give birth to death? “I have never found the words to this abrupt ending.” He felt love for Bo and held all four inches, .7 ounces in his hands following the birth. He wonders aloud “Can I call this a death? Is there meaning and acknowledgement in the scientific realm? It feels like a death, still does.”

The fourth presenters, Amy Davis and Lucy Graham, walk onto the raised stage next. The first shares a story of treating a young Cora Indian with AIDS named Francisco. At first, he was engaged in treatment, dutifully attending all appointments. Later a case worker informed the presenter, a physician, that Francisco was deteriorating and that he was refusing treatment. During one home visit, she held his hand to understand his decision and asked what he was thinking. “The black gods have told me not to take anymore pills” he said through interpreters. He was choosing a preventable death, in other words a passive suicide. She wondered about his mental health and about his cultural and spiritual beliefs. What is my responsibility now, she wondered. The second presenter shares her reflection on this patient. She recalls how the patient changed her focus from problem-based to more of discovery. The first presenter returns and recalls consulting with the psychologist who encouraged her to be at peace with what Francisco was requesting. They tried to find family before he died but could not do so. He died two weeks after ending treatment.

Randall Reitz recalls early memories of his father including his death and funeral. The moral of my story is that death destroyed my family, death created my new family, and death forever affected my career. He shares the story of meeting his future stepdad who had lost his wife. Randall's mom and new stepdad married and raised a large family. This intimacy with illness and death focused his mind and prepared him for a career in health care.

Two presenters return to finish the presentation. The narratives they shared today have common themes: What is death? What role do others play in our deaths? What autonomy do we have? How do we reassert our humanity in the face of god-like technology? The 2015 CFHA Conference theme this year is a perfect match for a discussion on death. When a tree dies in the forest it dies a natural death, becoming part of the ecosystem. It continues to nourish the forest. When considering patients who recently have died, were they nourished in their last days? How did the forest sustain their needs? Some hospitals are using AND (Allow Natural Death) instead of DNR (Do Not Resuscitate) designations to allow patients respect of a natural death.

We need to come alive for the dying, focus our energy on allowing natural deaths. We can raise our voices to share stories of grief, anger, and hope of our patients and families. This is the greatest spiritual and moral imperative of our time. 

Reflection: Barry J. Jacobs

During the third plenary of the CFHA conference, in the middle of listening to Dr. Sabrina Mitchell’s searing story of her father’s death, I was struggling to choke back tears. I heard others around me sniffling in the dark. It wasn’t just the description of her dying father, strapped to a hospital bed and in agonized delirium, or of the treating nurse’s irritated callousness toward the visiting family members that so stirred the emotions. It was the spectacle of a fellow healthcare professional on stage, sharing raw, personal pain, but also implicitly revealing the rationale for many of our careers: We are wounded healers committed in our bones to relieving others’ suffering.


Dr. Mitchell’s story was one of several told by the Grand Junction Players (Amy Davis, Lucy Graham, Stephen Mitchell, Paul Simmons, and CFHA board member and the production’s organizer, Randall Reitz) during the plenary entitled “End of Life in Our Time.” Each player’s story—about our transience as beings, a fetal demise, cultural and spiritual reasons for a patient’s refusal of care, and the creation of a new family following the deaths of two young parents—evoked grief and made the point that we need to restore humanity to our healthcare system’s overly technological approaches to life and death. Their stories were various--a reminder of the respect we must have while listening for the particularity of every person’s story. The whole—illustrated with family photographs and enhanced by strummed music--was overwhelming.


I left the conference ballroom at the plenary’s end, sad and exhilarated and suffused with thoughts: I remembered my father, dead at age 52 of brain cancer when I was 15. I thought about how his death put me on the path to becoming a psychologist working in medical settings. I reflected on how he sits on my shoulder—sometimes heavily, sometimes lightly—during my days of trying to bear sure witness to patients’ lives. 


Matt Martin, PhD, LMFT, is director of behavioral science education at the Duke/SR-AHEC Family Medicine Residency Program in North Carolina. He is the current CFHA blog editor. Interested in writing? Send a message at

Barry J. Jacobs, Psy.D. is a clinical psychologist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent (2006, Guilford)

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