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Do some research and you’ll find…

Posted By Colleen Fogarty, Saturday, October 17, 2015

Hats off to the CFHA research and evaluation committee for developing a research and evaluation track for the 2015 CFHA Conference in Portland, Oregon. The session track consists of five workshops, the first two of which this blog post will review.

Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example


Session 1, presented by Jodi Polaha, J.D. Smith, and colleagues, “Unlocking Implementation in Primary healthcare: The Family Check Up as an example” provided excellent information for attendees on some crucial concepts in implementation science, using an illustrative case of implementing the Family Check Up in a primary care setting.

 

Implementation science, defined by the NIH, is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within real-world public health and clinical service systems.

 

This level of investigation is particularly crucial in our field, where we believe that integrated, family and patient-focused care matters, yet need to understand the barriers and facilitators of making and sustaining these actual changes in practice settings and take them to scale.

 

The EPIS model describes four phases in the implementation process:

 

E: Exploration

P: Preparation

I: Implementation

S: Sustainment

 

This group used the Family check up intervention, an evidence based model of family assessment and intervention, in a primary care setting to work with obese children and their families. J.D. Smith and his colleagues’ work have published using the model in other settings as well. To identify families for the intervention, they used the PSC-17 (Pediatric Symptom Checklist) as a screener.

 

While discussing the process outcomes of implementation, Jodi Polaha notes that these can reinforce behavior change at the system or team level. So, as the processes become established and more successful “on the ground” it feeds back to the ‘actors’, i.e. clinicians and staff, suggesting that the implementation efforts are ‘working.’ Thinking about this as system-level feedback for positive change represents an important parallel process to what patients, clients, and families may experience!

 

Jodi, who reflects that she is now a facile iMovie maker (as evidenced by the fantastic marketing video for the research track!), showed a video of physician and behavioral health consultants reflecting on the positive experiences of adopting the Family Check-Up using the PSC-17. Involving the whole team is key; providers are happy with the process and the intervention.

 

Stay tuned for more learning about implementation science and its role in evaluating collaborative and integrative healthcare settings!


Joe Grasso, Andrew Pomerantz

An Interactive, Case-Based introduction to quality improvement in Integrated care 


Andrew Pomerantz Joe Grasso, Ph.D. 

 

The second session on Friday, “An Interactive, Case-Based introduction to quality improvement in Integrated care” presented by Joe Grasso, PhD and Andrew Pomerantz, MD provided an excellent overview of the Quality Improvement process and a solid rationale for why this method is important to make change in integrated care practices.

 

For anyone who needs to learn or teach about Quality Improvement, check the definition and other resources in the Health Resources and Services Administration (HRSA) toolbox here.

 

Joe reminded us that QI is not research, mainly because it has a different purpose. Focused on local level questions and answers, the goal of QI is not to create generalizable knowledge, but to ask small questions and test small changes in series to result in sustained improvement in a system. Given that systems vary, seeking generalizability is not the point. Likewise, sampling is done within the defined local system, and the processes are the key element being studied.

                                

The process of change can be modeled on key elements of LEAN concepts that arose largely in manufacturing engineering. These are the 5S--Sort, straighten, shine/scrub standardize, sustain.  “Just like your kitchen” according to Andy Pomerantz! If only my kitchen could attain this bar! Plan, Do, Study, Act, or PDSA cycles focus on small, iterative tests of change around a carefully constructed objective.

 

To begin the PDSA process, the team must agree on one goal to start, and this should be in the “SMART goal” format: Specific, measurable, attainable, relevant, and time-based. Joe and Andy provided a structured small group activity for practice on this seemingly simple activity. The work in my small group demonstrated the difficulty of developing a SMART goal: we had lots of discussion about screening, identifying, referring, prescribing for depression. What were the important elements? Who should do what? Was the PHQ-9 the right tool? And on went the conversation. Eventually, the group achieved a SMART goal: in patients who screen 11 or more by the PHQ-9, the clinic would see an increase in the # of referrals by the primary care clinicians to the behavioral health clinicians by 15% in 3 months.

 

Large group reflection on this process revealed that other groups found this difficulty too. Joe pointed out that this realization mirrors life, and is one of the strengths of the short cycle test of change: PDSA cycles can identify other concerns or problems needing attention.

 

"Where are we going to find the time to do QI??" This question is heard across systems as we are called to improve our systems, maintain our physicians board certification, and reach PCMH or other national level certification. Joe Grasso says that stakeholder and administrator buy-in helps!

 

Both of these sessions “knocked it out of the park” in introducing conference attendees to important methods for evaluating and improving our work. I look forward to more sessions in this well-crafted track!


Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine.

Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example 

 

Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example 

 

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Live Blogging at 2015 CFHA Conference: Plenary Session 2

Posted By Colleen Fogarty, Stephanie Trudeau, Saturday, October 17, 2015

This is the second in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for one more.

The ACE Study: Linking Childhood Trauma to Long-Term Health and Social Consequences

CFHA 2015 Conference Plenary Session 2

Friday October 16, 2015 – 8:30 a.m. to 10:00 a.m


Vincent J. Felitti, MD, Co-Principal Investigator, Adverse Childhood Experiences (ACE) Study

 

Colleen Fogarty: Dr. Felitti is the past Chief of Preventive Medicine for Kaiser Permanente, and co-PI for the Adverse Childhood Experiences (ACE) Study. He begins by showing two pictures. There’s a question embedded in these two pictures: a newborn infant, and a 20 year old lying on the sidewalk; Dr. Felitti poses the question of how we can predict or create the outcome for the 20 year old depicted and he notes that in the 17 years since the first ACE publication, despite intense academic interest there has been essentially no clinical implementation of the findings.


He summarizes the findings that show ACE’s are common, powerfully predict health risks and social malfunction. “If we thought that smoke billowing out of the house was the cause of the problem, then fire departments would bring fans to blow the smoke away.”


Stephanie Trudeau: Dr. Felitti notes that the study began as a process of how to understand physical and mental traumas better. Studying findings show that the repressed role of ACE in adult wellbeing, disease and social function turns gold to lead. ACE indicators are common and disturbing and are mostly unrecognized. However, they are powerful predictors of adult social malfunction, health risks, biomedical disease and premature death. Integrating these finding into primary care medical practice appears to produce a significant reduction in health care costs.


Dr. Felitti presents a case study of what he calls the “Index Patient” whom he treated while working in a San Diego obesity clinic. He shows a photo at age 8, age 28 at 408lbs, and then age 29 at 132lbs. What is the core diagnosis? Which photo represents the patient’s problem??


Colleen: Dr. Felitti reflects on the Index Patient who lost so much weight in one year. Then he shows the re-gain curve the same patient experienced after the successful treatment intervention. He reflects on the patient’s disclosure of being sexually propositioned after her weight loss, and this contributing to her re-gain of weight. Further patient interviewing led her to disclose incest during her childhood. Many subsequent patients in the program disclosed child sexual trauma or other significant family or personal traumas. This collection of clinical disclosures, stories led Dr. Felitti and his collaborators to design and carry out the ACE study, which contained both retrospective and prospective design.


Dr. Felitti notes substantial difficulty in IRB approval, as the board was concerned that patients, upon being asked about difficulties in their childhood, would become suicidal. The IRB approved the study when they agreed to have a clinician carry a cell phone 24x7 for 3 years; they did this and received no calls during that time. In contrast, Dr. Felitti reports that the team received many notes of gratitude, summed up by a patient who wrote that, “I was afraid that I would die and no one would know what happened to me.”


Stephanie: ACE indicators/categories (with %) fall into three categories: Abuse, neglect, and household dysfunction. Abuse includes psychological abuse by parent (11%), physical abuse by parents (28%) and sexual abuse by anyone (28% or W, 16% for M). Neglect includes emotional (15%) and physical (10%). Household dysfunction: alcoholism or drug use in home (27%), loss of parent, death, divorce, mother abandonment (23%), depression or mental illness (17%), mother treated violently (13%), imprisoned household member (5%).

 

The ACE study questionnaire is 4 pages long, completed at home, and includes a face-to-face interview and a full medical assessment. ACE researchers used this style to ask the questions:  “I see on the questionnaire that … can you tell us how that has affected you later in life”.  This open approach turned out to be powerfully effective.


Study results show that 67% of participants experienced at least one category of ACE and that one ACE predicts an 87% chance of at least one other category of ACE being present. Women are 50% more likely than men to have a score over 5.


Colleen: Dr. Felitti shares comments via video of a man who had losses in his childhood and subsequently became a smoker, alcoholic, and user of drugs. The man says, “Twenty five years, [I had] poor childhood experiences with drugs, alcohol, cigarettes. I had no idea that the nicotine played such an important part in…keeping the door closed to the memories. I found that it blocked emotions and memories…” Dr. Felitti notes that addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.

 

In another video a morbidly obese woman shares her reaction to the recommendation of bariatric surgery. She reflects, “I cope with life with food…I feel like he’s taking away my safety [by suggesting bariatric surgery] I’m not ready yet to get the weight off and not be able to get it back. I can’t be safe then.”


Stephanie: The patient videos are very powerful! Dr. Felitti suggests clinicians with a focus on ACE can ask “How old were you when you first started putting on weight…why do you think that age and not another”?  What function does the “dysfunction” serve to our patients? Let’s ask! What is perceived as the problem is actually someone’s unconscious solution to problems we know nothing about. For example, what if depression is a normal response to abnormal life experiences?


Colleen: So, what can clinicians do? Gather a trauma informed history from patients and develop an approach to patient care using that information. Primary prevention is crucial; but we don’t yet know how to do this!


For more information about the ACE study, click here:

www.ACEconnection.com

http://www.acestudy.org/speakers/vincent_j_felitti_md


Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine. 

Stephanie Trudeau, MS, LAMFT, PhD student University of Minnesota. Behavioral Health Intern and Research Assistant in the Department of Family Medicine and Community Health at their Broadway Family Medicine Residency Clinic.

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Policy Summit at 2015 CFHA Conference

Posted By Matthew P. Martin, Friday, October 16, 2015

 

According to Senator Elizabeth Hayward, the process of health care change is "messy and organic”. And so agrees the rest of the expert panel at the 2015 CFHA Policy Summit in Portland, Oregon which included wonks from both the public and private sectors in Oregon and Colorado. This first-of-its-kind meeting covered current initiatives and barriers, stories of success, and future challenges. Robin Henderson and John Muench opened the summit and Deborah Cohen moderated the discussion among panel members who represent two states leading the health care transformation charge.


The expert panel included the following:


 

Janet Meyer, MHA

CEO, Health Share of Oregon 
 

Ron Stock, MD, MA

Director of Clinical Innovation, Oregon Health Authority 
 

Sean Kolmer, MPH

Principal, Health Management Associates 
 

Lynne Saxton      

Director, Oregon Health Authority 
 

Robin Henderson, PsyD

Chief Behavioral Health Officer and Vice President of Strategic Integration

St. Charles Health System 

Patrick Fox, MD

Chief Medical Officer

Colorado Department of Human Services 
 

Patrick Gordon, MPA

Associate Vice President

Rocky Mountain Health Plans 
 

Judy Zerzan, MD, MPH

Chief medical Officer/Director of Client & Clinical Care Office

Colorado Department of Health Care Policy and Financing 
 

Vatsala Pathy      

Director, State Innovation Model 

 

The format for the summit meeting was conversational and off-the-record. Panel members enjoyed a sense of safety in the intimate setting as they discussed mutual challenges with only a small sympathetic audience within earshot. According to one audience member, meetings between policy experts from different states rarely happen but they need to in order to push change farther. Two factors were clear at the onset of the meeting: 1) both Oregon and Colorado have had tumultuous histories with health care reform and 2) both states have taken advantage of recent crises to try new and bold initiatives.


For example, in 2010 Oregon faced huge financial problems in supporting state health services. In response, the state legislature approved (57 to 3) plans to create Coordinated Care Organizations (CCO) to "treat the whole person” and organize previously fragmented services for the Medicaid population. In Colorado, several factors lead to innovation including fallout from years of managed care, state fiscal issues, and the indomitable Colorado spirit of independence. State leaders began to invest in a new multi-payer system and integrated behavioral health services. Today, both states are finding success with their recent investments in groundbreaking policies strategies as well as facing ongoing, inherent challenges.


Some of those challenges include:


-          Working with federal, state, and local stakeholders: allowing for flexibility while striving for standardization in policies and protocols

-          Creating a clearinghouse for data management and sharing

-          Federal administrators have short tenures which disrupts momentum and working relationships

-          States are not collaborating enough to share successes and brainstorm new strategies

-          Fear and misconceptions of change and the health care industry prevent stakeholders from making progress

-          Moving customers from Medicaid to private insurance

 

Despite these challenges, both states have made remarkable progress. Colorado boasts one of the lowest uninsured rates in the country, has multiple integrated care clinics across the state, and utilizes an effective multi-payer model. Oregon has 16 CCOs across all parts of the state to cover over 2 million Medicaid recipients, is moving away from volume-based to outcome-based productivity models, and is working closely with counties across the state toward a global budget.

 

All panel members agree that there is much more to be done. Ron Stock believes that states should be as transparent as possible when reporting outcomes of various quality metrics. He also notes that a more cohesive and comprehensive advocacy plan will carry the message of reform farther. Patrick Gordon reminded the audience that hospital systems need reform as well to completely move away from the fee-for-service model of yesteryear. Robin Henderson predicts that success with reforming the Medicaid systems will lead to future success in improving state employee health systems. Finally, Sean Kolmer believes that state governments can drive the conversation on integrated health care services and that state budget crises are real opportunities for designing innovative policies that take health care systems in new directions.


What does the policy summit mean for you? The takeaway messages seem to be, yes, change is messy AND stakeholders can have honest conversations about the barriers and challenges facing health care reform. Senator Hayward concludes that moving to new care systems is really hard for most people but that we can change our frame of reference from fear-based to what works. 


  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 matt.p.martin@gmail.com

 

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Live Blogging at 2015 CFHA Conference: Plenary Session 1

Posted By Jennifer Hodgson, Laura Sudano, Friday, October 16, 2015

This is the first in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for two more! 

Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehensive Population Based Care

CFHA 2015 Conference PLENARY SESSION 1

Thursday, October 15, 2015 - 6:00 p.m. to 8:00 p.m.

Moderator: Kristian Foden-Vencil, Reporter and Producer, Oregon Public Broadcasting

The CFHA opening plenary, “Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehension Population Based Care” was a powerful opener to the 2015 conference in Portland, OR. Each panelist described their perspectives on promising research, clinical innovation, and health policy change germane to the advancement of integrated behavioral health and primary care.


Panelist One: Maggie Bennington-Davis, MD, Chief Medical Officer, Health Share Oregon

Dr. Maggie Bennington-Davis 

 

Jennifer Hodgson: The plenary opened with a question posed by Kristian to Maggie Bennington-Davis. He asked whether or not the changes we are making to the healthcare system are working.  Dr. Bennington-Davis is a psychiatrist who has experience administrating services across the lifespan with a keen respect for cultural competence in the delivery of healthcare services. She is on faculty at the Sanctuary Institute and Oregon Health Sciences University and expressed great interest in how we can think differently about workforce redistribution and healthcare expenditures. She shared examples of Coordinated Care Organizations targeting energies and services to those who use healthcare the most. These programs were effective in reducing ER visits and connecting high utilizers with the primary care system; however, she wonders how we can prevent patients from becoming high utilizers. Her focus has shifted over the years to wrapping care around early life (i.e., children) and those most at risk, lowering cumulative disadvantages and eventually high utilizers.

Laura Sudano: According to Dr. Bennington-Davis, childhood events impact mental health conditions in later life which affects individuals as well as the healthcare system. So the question becomes what does it mean to be “Kindergarten ready”? How can we prevent unwanted and high risk pregnancies? Wrap around programs are a different level of integration and service.

Kristian: What kinds of wrap around services can you provide to head things off?

Maggie: The way that Health Share approaches this is to identify moms at great risk (e.g., substance use disorders). Interventions include parenting lessons, housing/food, safe environment, and staying with them for up to a year in order to provide skills for that child.

Kristian: How about the money?

Maggie: It is a $60,000 question or more! If that program prevents that one child to have months in a prenatal intensive program then you have paid for the program; however, it is tricky. Oregon needs to follow its own values and look for a way to transform health to make a difference in that way.

Jennifer: I just admired how she is thinking about prevention as a part of health and not exclusively treatment only after pathology has taken root. Her words illuminated an opportunity for healthcare providers to exercise being strength-based and channeling money toward prevention. I have been waiting my whole professional life to hear it spoken so eloquently! Music to my ears!

Laura: Barry Jacobs (audience member with a question) works in a super utilizer program and questions what you need to get the most bang for your buck. What are the resources you need to put in place for a program to be successful? He has witnessed the most need for housing. The other question is how to make changes sustainable and to help others take control of their own lives?

Maggie Bennington-Davis: Redistribution. Some services have fewer resources than traditionally and this is a hard question. At the ACO level, there is incentive money in Oregon transformation system to use it to explore to use it more upstream. In regards to housing, Maggie suggests that you need to work with social services to coordinate this.

Panelist Second: Jennifer E. Devoe, MD, DPhil, Associate Professor, Oregon Health & Science University, Department of Family Medicine; Chief Research Officer, OCHIN Community Health Information Network  Devoe-Jennifer-web 

 

Jennifer: Dr. Jennifer Devoe is a highly funded PCORI researcher and a recently elected member of the Oregon IOM and helps lead the innovative OCHIN. She said there is some thinking outside of the box with Medicare and sending insurers a bill for not offering preventative services. Dr. Devoe shared a story of a patient who was self-medicating, self-mutilating, had a trauma history and rendered Dr. Devoe feeling incredibly helpless against the issues that weighted her down. Her patient is now more stabilized and functional: She is now out of the ED, ICU, is not cutting or utilizing as much. Dr. Devoe credits that to the care of the biopsychosocial team. She stated that as a healthcare worker she knows now that she can provide better care alongside a biopsychosocial team and prefers it that way.

Laura: Dr. Devoe notes that her satisfaction improved because she was able to provide comprehensive care to her patient once a behavioral health provider was integrated into the clinic. How are we going to measure what we are doing in care? We saved on healthcare cost, but now they are incarcerated for the next 20 years. They dropped out of school but are on welfare. She notes, “Dare I say, but we might actually need to spend more money on certain healthcare services. On primary care.” We need to look at wrap around services to provide preventative care services. We’ve come along baby since 2003! But, we are revisiting history and we are learning how.

Jennifer: What Dr. Devoe described as being immeasurable, is how much better she feels as a provider. She stated “We have come a long way baby!” …but we need to think about how we are going to reimagine and rethink measurement. How are we going to measure what we are doing here? How can we invest on the front end and spend more money on certain healthcare services (e.g., primary care, behavioral care) and save people from unemployment, the prison and foster systems, etc which also results in great costs.  

I like her systemic perspective and agree completely that measuring gains cannot be exclusively done by examining the healthcare system’s bottom line.  We have got to think about the entire service system…there is no wrong door for patients to gain access to healthcare. Lastly, Dr. Devoe stated that the voice of the patient is critical.  The patient with their healthcare team should decide how the money is best spent. She wants to know when integrated behavioral health care will be the standard of practice! This blogger agrees!

Laura: Dr. Devoe also believes we need to scale it, sustain it, and study the who, what, when, and where. We need systematic approaches to figure it out. The question becomes: Can technology help? Who needs the care? And who needs to provide it? Measuring needs to happen and how to do it is important. Where should care be delivered? What are the patients’ expectations? When should we refer? When will integrated care be standard practice?


Panelist Third: Somava Saha Stout, MD, MS; Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement; Lead Transformation Adviser at Cambridge Health Alliance (former Vice President).  

 

Jennifer: The third panelist, Dr. Somava Stout, is Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement and also the Lead Transformation Adviser at Cambridge Health Alliance. She recently received one of 10 inaugural Young Leader Awards nationally from Robert Wood Johnson Foundation for leadership and dedication to improving health and healthcare. She wants us to push integration models and find who is doing integration successfully and why. She described how Cambridge Health Alliance is a Safety Net System and they invested in behavioral and primary care.  She said they flipped their finance model from fee for service to a global payment one, now being able to cover 60% of patients. Subsequent to the change, providers reported that they enjoyed their jobs more and felt they could do things now to actually save patients’ lives.

Laura: Somava: She describes herself as a primary care clinician and is interested in how to change the system to provide comprehensive care. Why should there be a public health care system by 2020? It would improve experience for people and population health, and lower costs. It will be worth supporting for the Massachusetts. What would it be like to transform the system from the population up? In 2008, we need to flip it to fee for service to global patients. Sixty percent of patients were covered under the global payments, and the transformation was fulfilling. The satisfaction and joy of meaning and work went up for both physicians and mental health clinicians.

Jennifer: Dr. Stout argued further that everyone who touches the patient is a part of their outcome. She expressed that there is great joy and satisfaction for patients in knowing they can get help no matter where they lived.  She noted, “If you could know that you could lower absolute healthcare costs and improve outcomes on the mental health and medical side….that is the Holy Grail right?” She then said, “That is really only the beginning of the story.  We now need alternate payment models and have nothing to lose by trying. We have to move beyond screening for behavioral health issues only and then medicating poverty…the silent cause. I do not recommend medicating poverty. We need to do something about it. We need to be part of a system that takes care of patients holistically” Her solution-focused perspective was infectious and her belief that we can make a difference is exactly what we needed to hear at the start of the conference!

Laura: Somava notes that we need to include the social and behavioral determinants of health (SDOH). If there is no housing, then that doesn’t help anything. I (LS) think it is important to capture SDOH in primary care, and wonder how primary care clinics can capture this data in our electronic health records. Also, I wonder how people are teaching primary care providers SDOH.

Housing seems to be a theme between all presenters. Housing is an important aspect for individuals and we, healthcare providers, need to recognize this as an impact on patient’s health. Employees who can address SDOH have improved provider satisfaction across the board, i.e., staff, physicians, behavioral health, etc.

It costs 46,000/year a year to incarcerate one person. Dr. Stout notes that we should consider assessing SDOH and notes that patients are grateful for the questions. The challenge becomes how we ask the questions, when we ask the questions, and how we enter the data and track the outcomes.

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All But the Kitchen Sink?

Posted By Robyn L. Shepardson, Monday, October 5, 2015

 

Robyn L. Shepardson, PhD, is the 2014 CFHA Fellowship Award Recipient. Below is her reflection on her research project.

As a clinician working in the Primary Care Behavioral Health (PCBH) model in integrated primary care, I have a short amount of time to make a difference with my patients. I figure I have about a half-hour for each session if I’m lucky, or really more like 10-15 minutes after conducting a functional assessment or providing empathic listening when a patient really just needs to share his or her story. I never know if a patient will return for follow-up, as about 50% of patients attend only 1 PCBH session.

 

With so little time, and perhaps only one chance, to give my patients something (information, support, skills) they can use, I am eager to make a lasting impact. As a result, there are times I am guilty of throwing all but the kitchen sink at my patients and seeing what sticks. Based on the results of a new survey I conducted with PCBH providers, it seems I am not alone in this tendency to offer all but the kitchen sink...

 

At last year’s CFHA Conference, I received the 2014 Research Fellowship from the CFHA Research and Evaluation Committee. For the fellowship, I conducted a national survey of PCBH providers (N = 291) to identify the types of interventions used for anxiety in real-world clinical practice, as well as the types of comorbid symptoms/problems seen in patients referred for anxiety. I focused on anxiety because it is common and burdensome in primary care, but tends to receive less clinical and research attention compared to depression and PTSD.

 

I surveyed PCBH providers about their most recent session with a patient referred for anxiety. As anyone working in primary care knows, primary care patients are complex and often present with a multitude of both mental health symptoms and medical problems. In this case, 95% of patients had other behavioral health concerns (e.g., depression, insomnia) besides anxiety.

 

So, how did PCBH providers handle these complex patients? It appears they used a lot of tools from their clinical toolboxes – an average of 6.5 intervention techniques – despite sessions being less than 40 minutes on average. Clearly providers are drawing upon a variety of interventions to treat anxiety and/or comorbid symptoms. Of necessity, the time spent on any one intervention technique is likely very brief.

 

The high number of interventions used within a single session brought to mind the idea of "all but the kitchen sink.” Reflecting on my own clinical practice, I often use a combination of elements of various brief interventions, such as psycho-education, relaxation or mindfulness training, cognitive restructuring, and behavioral activation, as well as broader approaches/themes such as supportive therapy, stress management, problem solving, and increasing social support. I weave threads of these concepts into the discussion as appropriate, spending more or less time on a certain topic or skill depending on various patient factors.

 

Is this a good approach? How much is too much? Could we be overwhelming our patients with so many ideas that they don’t know where to start? How do we find the right amount of education to provide and the right amount of skills to teach? How do we strike a balance between providing support and helping patients develop specific action plans?


 

 

I tend to view my role as a PCBH provider as helping patients identify their options. I can provide information and describe skills likely to be helpful, and if time allows I include a brief demonstration of a relevant skill to illustrate how this might help. But in 30 minutes or less, there’s just no way I can learn everything I would need to know to make definitive recommendations on what would be best for them. It’s up to individual patients to decide what resonates and what they are ready and willing to try. We know "one size fits all” approaches will not work because every individual is so different and has unique challenges and psychosocial circumstances. So perhaps the "all but the kitchen sink” approach is not a bad idea after all, as it gives patients a menu of options from which to select what appeals most to them. PCBH providers and PCPs can then support patients in their efforts to make behavior changes and implement healthier coping skills. What do you think about the "all but the kitchen sink” approach we often take in PCBH?

 

As our field works toward building a larger evidence base on effective brief interventions to inform clinical practice in integrated primary care, clinicians can play an active role in evaluating what works. Clinicians can use program evaluation and quality improvement methods to collect outcome data to monitor individual patients’ progress in treatment. For example, collecting data on the types of interventions we use as well as mental health symptoms and overall functioning would allow us to empirically answer the question of whether "all but the kitchen sink” is a helpful approach. It is not as hard as you might think and could help provide valuable evidence to help us answer this very important question.

 

One way you might help overcome any fears you might have about doing research is by learning essential basic research skills and how to conduct program evaluation and quality improvement. The new Research and Evaluation track at the 2015 CFHA Conference in Portland provides an opportunity to learn these skills. This track (5 talks) is designed to provide practical "how to” lessons on how to plan and conduct research, quality improvement, and program evaluation in real-world health care settings. Or if you have the skills, but just have not collected the data—help us answer this question in addition to the multitude of others that impact routine PCBH clinical practice.

 

If you are interested in hearing more of my results or sharing your take on using "all but the kitchen sink,” please join me at 10:30 am on October, 16th at the 2015 CFHA conference in Portland


 

Robyn L. Shepardson, Ph.D., recently completed a two-year postdoctoral research fellowship with the VA VISN 2 Center for Integrated Healthcare (CIH) and is now a clinical research psychologist at CIH. She earned her Ph.D. in clinical psychology from Syracuse University after completing a pre-doctoral internship in health psychology/behavioral medicine at the Brown Clinical Psychology Training Consortium in Providence, Rhode Island. Dr. Shepardson’s research interests include developing, testing, and implementing brief, evidence-based interventions for anxiety and depression in primary care patients. She is interested in increasing engagement in integrated behavioral health care by incorporating Veterans’ treatment preferences using novel resources, such as peer support and mobile technology, to reach more patients.

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Diving into a Behavioral Science Faculty Position

Posted By Emma Guerrero-Pavich, Wednesday, September 23, 2015

Emma Guerrero-Pavich, LCSW is a graduate of the Behavioral Science Family Systems Education Fellowship program. If you are interested in applying, please click here.

 

It all started when I got this amazing new job as a Behaviorist for a Medical Residency Program.  The first day on the job I felt like I knew nothing. How could this be? I came in with years of clinical experience, a seasoned faculty from a well-respected college yet here I was…lost.  I didn’t know what I was supposed to be doing with medical residents who seemed to look at me with faces that showed me that they had nothing to learn from me.  Perhaps it was my hallucination but it felt real to me.  They were doctors and I was a social worker.  I was told by my program director that my knowledge and experience mattered to the team and that what I brought to the faculty was invaluable. Yet I felt like I was in a tunnel, not sure what direction to go or where I was headed.

 

About 6 months into my job I was invited by my supervisor to attend the annual STFM Conference. He assured me that I would find it rewarding. I arrived to find many people who were very welcoming, and I felt hungry to be a part of this group but was too shy to reach out. I attended workshops which began to ignite my curiosity, I felt activated to try some of the things I was learning. I felt the fog begin to lift and I began to see the big picture but still I felt very green. I kept asking myself "What could I learn from this very uncomfortable situation?” Then the best thing happened. I met Julie Schirmer, a ball of energy and enthusiasm who was most welcoming and genuine. Julie began to talk about the Behavioral Science Family Systems Fellowship (BFEF). She invited me to apply for it.  I wondered if I might ask my program to let me apply. She encouraged it, but I was hesitant.  Then I told myself "Okay, Emma, just do it”.  I submitted my paperwork then asked my boss if I could do it then a few months down the road I got the word! I GOT IT!!! I was so amazed, excited and grateful.  Since that day, nothing has been the same. It was as though just being selected began to give me the confidence I had been lacking.

 

 I have learned so much this past year. I have met truly wonderful people who have opened their hearts to me fully. My small group is amazing; my group leaders are seasoned professionals in the field who are incredible women with smarts and hearts of gold.  Despite feeling initially terrified by the project we had to do, this group of people was inspirational and dedicated to my success.  They helped me see that I did indeed know what I was doing and had much to offer. At our final meeting at the STFM Annual Conference in 2015, I was fortunate to hear presentations from each participant in our class. We were all fabulous. We all grew, we all gave 100% and we all got the wings we needed to fly.

 

Without giving it all away, let me just say that if you are wondering whether you should apply for the STFM Fellowship or seek some other structured mentoring opportunity, I strongly encourage you to do it!  You will be so happy you did. I know people who did not initially get accepted.  They are now so excited about participating because they see firsthand the changes in those of us who have done it. If you feel like I felt, green, lost, unsure, and hungry…do it. This program is not only a confidence boost, it is a path to success. Once you finish this program you will be connected to a network of people who are generous with their ideas, who will help guide you and who will care about your success. You will have the knowledge, skill, and confidence to continue contributing to our field which is developing a solid presence in Family Medicine. Behavioral Medicine rocks and your presence in the field will be greatly appreciated.  Jump in, play hard, and make a big splash!


 

Emma is a Licensed Clinical Social Worker in the States of California and Hawaii. She graduated from University of California at Los Angeles with a Bachelor’s Degree in Sociology and a Masters Degree in Social Welfare. Emma serves as Social Work Faculty for the Behavioral Science Department with The White Memorial Medical Center Family Medicine Residency Program.  Emma was a participant in Class 5 of the Behavioral Science Family Systems Educator Fellowship.  She completed her Scholarly Project on Decreasing Social Barriers to Optimize the Learning Environment during Video Recorded Clinical Observations and presented it at the STFM Conference in April of 2015. 

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Broadening the Agenda

Posted By John Muench, Friday, September 11, 2015

 

This is the first of several blog posts preparing readers for the upcoming CFHA Annual Conference in Portland. Click here to register for the conference.


We Portlanders like to claim New York Times columnist Nicholas Kristoff as one of our own, despite the fact that he grew up outside our fair city, in Yamhill, Oregon, surrounded by farmland and lumber mills.  We’re proud that Kristoff takes on global social injustice issues such as human trafficking and poverty.  Occasionally he writes stories about his hometown. In a recent column ("U.S.A., Land of Limitations?” NYTimes 8/8/15) Kristoff related the story of a Yamhill friend, Rick Goff, who died in July of heart failure at age 65. 

 

Death of heart failure at 65. When I hear such stories a petty voice peeps up in the back of my mind trying to calm my own fear of approaching 65 by attributing Rick’s early mortality to behaviors and choices that would, of course, never affect you or I. Rick must have chosen to smoke, use drugs, be inactive, and/or not take those heart failure medications as prescribed, straightforward problems that perhaps we could have addressed with good patient education and motivational interviewing. 

 

Kristoff reminds us that it’s not so simple, that  "too often the best predictor of where we end up is where we start.”  He relates that Rick’s mother died when he was 5, that his father was alcoholic, and that Rick mainly raised himself and his three siblings.  Rick dropped out of school by grade ten, was divorced twice and raised two children on his own. Kristoff encourages us to look at these problems as neither simply biologic, nor social, nor psychological, but a complex stew of all three, because "the best metrics of child poverty aren’t monetary, but rather … how often a child is beaten, how often the home descends into alcohol-fueled fistfights, whether there is lead poisoning, whether ear infections go untreated.” We know now that such early family dysfunction translates directly into poor adult health.

 

Rick did, indeed, stop taking his medicines shortly before he died.  According to Kristoff, Rick felt the need to help a friend in a jam and didn’t have enough money left to buy his own medications that month.

 

 

 

I’ve grown tired of watching similar scenarios play out in the urban community health center where I’ve worked for many years.   Too often we see adults in our exam rooms whose real problems are lack of education, poverty, addiction, and homelessness that began with inadequate nurturing during their formative years, or as Kristoff would say "too little being read to and hugged.”  By the time they hit our exam rooms, these problems have grown far bigger than my PCP tools can handle and it often feels like trying to empty the ocean with a thimble.

 

We’re learning.  Broader team-based care, we know, can better address patient psychosocial issues. Over the past ten years we’ve welcomed case managers, social workers, and psychologists as partners into our medical homes; it feels like there has been progress.   But still, I meet "Ricks” whose problems seem so heavy that neither they themselves, nor I, nor a whole team of people can lift them by the longest of metaphoric bootstraps.  The hopelessness that arises is compounded when we think of the children at home, children who are highly likely be caught up in the same cycle of poverty and disempowerment.

 

This is why I’m excited about our upcoming CHFA conference. There is beginning to be a critical mass of researchers, healthcare providers and policymakers (including at least one influential newspaper columnist) who understand that exam room decisions and relationships are important, but so are the larger environments that affect patients once they go home from the clinic - environments that are physical AND psychological AND social.  There is a growing consensus that the triple aim can’t possibly be attained until we address this cycle of biopsychosocial illness begun in early childhood. And we’re nearing a critical mass that can translate this understanding into resources that will help us find and implement better, more comprehensive healthcare.

 

I can think of no better group to explore these issues than the CFHA membership that has pushed at the edges of biopsychosocial since George Engel coined the term in 1977.  We’ve seen enough to know that medications and counseling are necessary, but sometimes not sufficient to fix the problems that begin with adverse childhood experiences.  It’s up to us to explore the hard, complex questions, and to go home with new ideas to test.  I’m looking forward to our conversation in Portland in October.  A hearty welcome to all trailblazers.

 

John P. Muench, M.D., M.P.H. 

Although a native of West Michigan, Dr. Muench has worked at the OHSU Richmond Clinic since its opening in 1995.  He completed a National Research Service Award fellowship in 2001, receiving a Masters in Public Health Degree focusing on diabetes screening, and continues to study systems processes for screening in primary care.  Currently an associate professor at OHSU, he serves as the Director of Behavioral Medicine for the Department of Family Medicine, director of the SBIRT Oregon Primary Care Residency Initiative (focusing on alcohol and drug screening), and as the OHSU representative to the clinical oversight group at OCHIN, an electronic health record service shared collaboratively with other safety-net clinics.

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Happy Birthday CFHA Blog!!

Posted By Administration, Monday, August 24, 2015

 

The CFHA Blog turns six years old this month! As a token of respect and work-shyness, we are highlighting all the best posts from the last year.


Last summer, before the CFHA Annual Conference, Colleen Fogarty and Jeff Ring reflected on reflecting while Matt Martin opined the state of PCMH. Paul Simmons and Andrew Pomerantz goaded readers into attending their informative and highly entertaining CFHA presentation in Washington, DC while Don Bloch, the visionary behind CFHA, was honored in a reprint of an interview.


Lisa Zak-Hunter showcased three terrific collaborative triumphs here, here, and here. Cheryl Holt channeled David Letterman by listing the top ten useful measurements and tools for collaborative care and CFHA flexed some of its poetic muscle. The Super Utilizer movement got a bump from Barry Jacobs while Suzanne Bailey, Beth Schreiter, and Meghan Fondow gave us the skinny on effective supervision in primary care.


Wayne Katon, a pioneer in collaborative care, was fondly remembered in one post and Sandy Blount took us all to school for a history lesson on the integration of behavioral health into primary care. Cathy Hudgins and Barry Jacobs discussed the ethics of an intriguing and controversial case regarding caregiving, dementia, and sex while Juliette Cutts and Jackie Williams-Reade battled over the existential value of being an extrovert or an introvert in collaborative care. Finally, CFHA went across the nation to Colorado, Maine, North Carolina, and Oregon to discover the United States of Integrated Care.


Stay tuned for another year of excellent blog posts and be sure to check out Families & Health, a companion blog to CFHA blog.

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The State of Integration: How a Bill really does become a Law

Posted By Robin Henderson, Thursday, August 6, 2015

  

This is the fourth in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the thirdsecond and first posts.

 

I get it. I live in Nirvana. I get to live in one of the most beautiful places in Oregon that just happens to be one of the hottest tourist spots around. Skiing, biking, rafting, beaches, fantastic pinot noir and more craft beer per capita than any other state in America. Life is different in Oregon, especially in Bend. We have that "pioneeer spirit” that drives innovation, independence and even weirdness. Oregon is also home to the largest Medicaid experiment in the country—Coordinated Care Organizations (CCOs)—and at the heart of that experiment is a dedication to integrated care.

 

The CCO journey started in 2009 in Central Oregon and as luck would have it, that’s my backyard. Anyone who knows me quickly realizes that I have a tenacious spirit. Some would liken it to a honey badger with a beehive—I really don’t care how often I get stung as long as I get results. That tenacity paid off for our region with an early commitment to integrating behavioral health in primary care as part of our Medicaid innovation. It wasn’t a tough argument to make. At least 70% of all behavioral health visits were already happening in primary care, and when people were being referred to mental heath providers for follow up, only about 10% of them actually followed through. These statistics are common everywhere, so logical people reach the logical conclusion that you provide care where people present, right?

 

I was also naïve. I had the data, the providers, the evidence based practices—but what I didn’t have were regulations on my side. So, I did what most folks do at this point—I created a work around!

 

Work arounds are great. They allow you to try out new practices, see if they work before you change the big things, and sneak your way about budgetary restraints to innovate. However, they are also dangerous. When we hired our first psychologist and placed him in a primary care clinic in rural Oregon, we had not defined how he would bill and be paid outside of a reliance on "Health and Behavior Codes” and the largesse of my employer, St Charles Health System. People were excited! Finally! They would have access to a psychologist in a community that had so few options for behavioral health; even Lucy van Pelt would have been an improvement! It was glorious….

 

 

Then, reality set in. Many payers rejected the H&B codes or set arbitrary limits on their use. Multiple co-pays ensued as folks struggled to figure out how to bill things. And then…the dreaded Regulatory Dragon reared its head and snarled fire, insisting that "mental health services could not be provided in primary care.” It all came down to ancient rules around who could bill for what services in what settings. In other words, it was all about the money.

 

For those of you who are unfamiliar with CCOs, I’ll give you a quick overview.  Prior to the Affordable Care Act implementation, as part of Oregon’s healthcare reform package, they proposed an experiment to remove many of the restrictions on how Medicaid funds can be accounted for and create CCOs, which managed a global budget for the provision of care to a given population. There are 16 CCOs in Oregon that have been operational since 2013. They have to meet their contractual obligations to a Transformation Plan that includes a plan for integrating care—physical, behavioral and dental—and they must show progress on Quality Incentive Metrics each year in order to receive their full allocation of funds. Most importantly, they must show a decrease in the amount of funds needed to treat the Medicaid population overall—and do this over time for years, with an overall reduction equal to the investment ($11 billion) when the project is over.  Suffice it to say, it’s complicated.

 

Most CCOs in Oregon didn’t have the built in expertise to immediately deal with behavioral health, much less integrated care. Integration was a great idea, but mental health and addiction services had always been the purview of the community mental health system. Their byzantine requirements to code and bill for mental health visits required a special "Certificate of Approval” even for licensed folks. Some CCOs found ways around these requirements, but many did not. That’s where Senate Bill 832 came in. If we changed the regulations, we could remove the barriers to providing integrated care. And so it began….

 

"School House Rocks” taught us that bills aspiring to be laws must pass through committees in a bicameral legislature then make their way up the long steps during lively debate to eventually become laws. If only it was that simple. The process for bills is far more complicated than that, starting long before the legislative session begins. I had the crazy idea that if we could define the practice of integrated primary care in statute, then we could promulgate rules to support that practice and begin to unwind decades of policy created to keep the provision of mental health services protected from the clawing hands of those who wanted their budget. Who could argue with that! Did I mention I was naïve?

 

Fortunately, I have friends. Some of my friends like C.J Peek and Ben Miller provided invaluable editorial guidance, grounded in the Agency for Health Research and Quality’s work on defining integrated care. Others are the great folks at CCO Oregon who sponsor the Integrated Behavioral Health Alliance of Oregon, a collection of the movers and shakers in Oregon’s integrated care programs, who served as the "think tank” behind what barriers needed to be removed to facilitate the sustainable practice of integrated care. While not formally able to sponsor the bill itself, their real world experience in a variety of CCO models was invaluable to creating model legislation.

 

 

 

I also have friends where it counts—in the Capitol itself. The path to making good legislation starts with the people who live in the building—Legislators, their staff, and the Lobby. Bills that become laws are part of the intricate dance between competing interests that often have little to do with the substance of a bill itself. In large part, that’s by design, creating a space where large interests don’t always get their way and small interests can find a path. The most import thing about the Capitol in any state is always to remember that your ethics define you. Always speak the truth, and if you make a mistake, own it and clean it up. Never surprise a Legislator unless you absolutely have to. Do favors for people whenever you can—and if you can’t do it, find someone who can (as long as it’s legal?) Be nice to staff—always—because they control your access to everything. And, don’t just come into the building for your own issues. Be there for those others care about—because you never know when you’ll need them.

 

The true tale of SB 832 is best told over a vodka martini, dirty and bruised, with blue cheese olives. Given that isn’t possible in a blog post, I’ll hit the highlights:

  • Run concept for bill past most influential Legislator you know who gets the issue and can move the bill. In my case, Senator Laurie Monnes-Anderson, Chair of Senate Healthcare. Get a note to draft a bill!
  • Work closely with Legislative Counsel on language for a concept that is difficult to explain and even more difficult to put into existing law. Negotiate on that language with a large group of your best friends for months.
  • Get your "final” Legislative Concept into your Chief Sponsor before the deadline so she doesn’t have to use a "priority bill” slot! Now, go find your friends and convince them to sign on as co-Sponsors. Remember to get plenty of R’s and D’s on both sides of the building! Trade favors with staffers to get sponsors for other bills—always good to build up goodwill!
  • Once your Legislative Concept comes out, be prepared for

o   Monday Morning Quarterbacks

o   Fear Mongers who are convinced you want their money

o   Supporters who run away at the first sign of controversy

o   Detractors who completely misread your concept and are convinced that PEOPLE WILL DIE IF YOU DO THIS

o   Closet Grammarians

  • Schedule your first hearing! Beg to be assigned to your Chief Sponsor’s committee, and scramble when you aren’t!

o   Bring those friends who helped you get here to tell the story

o   Be prepared to find out who really doesn’t like this idea and didn’t have the courage to tell you in advance

  • Get schooled in "back room politics”

o   Be persistent and flexible

o   Open your mind to new ideas, even if you don’t agree with them

o   Embrace sausage making!

o   Compromise is the art of the deal

  • WAIT
  • WAIT MORE
  • When your bill finally starts to move, stay close and shepard it so it doesn’t get lost in the bowels of parliamentary procedure and legislative process

o   Don’t be afraid to call those friends you’ve been helping along the way. You never know when they can help you unless you ask!

  • Don’t celebrate until the Governor signs your bill (don’t want to jinx it!)

 

At the end of the process, SB 832 did more than just define integrated care in Oregon. The new law also defines "Behavioral Health Homes” which will support the provision of primary care in community behavioral health centers, creating access for care to some of our most severely impacted people. There are now definitions for "Behavioral Health Clinicians” that include residents and interns, creating paths for them to be paid for their services and support workforce development. Most importantly, however, the new law promulgates rules that will define how person centered primary care homes implement integrated care in a standardized, evidence-based way, and create outcomes that will support sustainability.

 

It’s always better to slay the Regulatory Dragon than to find ways to bypass his kingdom. In my little corner of the world, that’s how my friends and I moved integrated care forward. Sure, there will be skirmishes and turf wars as we negotiate and implement these new rules, but we won the war and defined integrated care in statute.

 

Yup—I get it. I live in Nirvana—and its spelled OREGON.


 

Robin Henderson, PsyD, Chief Behavioral Health Officer and Vice President of Strategic Integration at St. Charles Health System, is responsible for the strategic direction, operations, and integration of behavioral health services across the health system and throughout primary care, and she oversees the development and implementation of the health system's strategic plan and system portfolio. She also manages the health system's advocacy efforts and its relationships with government programs and community partners, including their strategic partnership with the Institute for Healthcare Improvement. She retains an active Oregon license as a psychologist, and is past president of the Oregon Psychological Association. 

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What's Cooking in North Carolina

Posted By Christine Borst, Cathy Hudgins, Thursday, July 23, 2015

  

This is the third in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the second and first posts.

ChristineMost evenings, I have the opportunity to cook dinner for my family. To break up the monotony of this daily task, I try to find new recipes to add to the rotation. Every once in a while, I inevitably mess these new recipes up; I forget a step, I don’t mix things in the order I should have (I mean really, who has time to read all the way through a recipe?), or my two year old enthusiastically offers to help...in her own way.


After some reflection, I have decided that cooking and baking are a lot like implementing Integrated Care. You can have all of the "ingredients” (provider, support staff, behavioral health clinician, patients, families, etc), but without the proper knowledge of how and when to put everything together, you may fall short of achieving that pretty meal pictured in the cookbook (a fluid, functional, evidence-based integrated practice).


So, without further ado, allow us to share with you a little of what we have cooking down in North Carolina.


The Center of Excellence for Integrated Care (COE), a program of the North Carolina Foundation for Advanced Health Programs, is comprised of a team of Integrated Care (IC) experts who are committed to helping develop and advance sustainable IC systems across the state. We have built a multi-faceted, systematic training, assistance, and capacity-building program that provides practice transformation and education to contracted entities as well as IC projects funded by the Kate B. Reynolds Charitable Trust.

 


 

All of the sites engaged in COE technical assistance are varied in their model, including primary care, bidirectional, and school-based health centers. Most sites receiving COE services have significant financial barriers to making necessary changes to their care delivery systems. The majority of the participants are safety net providers that have a mission or legal obligation to provide health care and other related services to uninsured and underserved populations. The sites we help provide physical and behavioral health care, including substance abuse services, to low-income, uninsured, and diverse populations. Additionally, the COE also assists universities, private practices, and specialty care groups.

 

 

In addition to the TA services, the COE also works with a variety of organizations through its Community Capacity Building services, including community organizations and stakeholder groups, universities, government agencies, AHECs, and other state and national organizations. In this role, we help educate and address the policy and systems barriers that prevent successful IC development and delivery.

 

 

CathyDuring my short time in North Carolina, I have had the unique opportunity to work with and learn from the extraordinary experts that comprise my team and the COE and in the community of providers across the state. My current list of lessons learned boggles my mind – just reflecting on what we know now and what we began this journey with is overwhelming and embarrassing, to say the least. I realize that we are all working on helping practices, organizations, and providers transform their services by helping them change their minds about how that can be done. We often apply the Stages of Change, systems theory, and other clinical/theoretical concepts to our work with these practices (it helps us keep down our anxiety and blood pressure while maintaining a healthy empathy bubble). Ultimately, it is not our practice, and we can’t take responsibility for their system change.

 

Just a few federally funded programs that promote Integrated Care concepts and models in NC:

·         CHIPRA,

·         Project LAUNCH,

·         HRSA Grant awarded to UNC-Chapel Hill to increase the number of Psychiatric Nurse Practitioners,

·         2014 HRSA PCMH grant awarded to 18 community health centers,

·         SAMHSA/HRSA 2014 Workforce Training grant awarded to 4 universities

·         SBIRT

·         Other non-federal groups include the Kate B. Reynolds Charitable Trust, Duke Endowment

 

We present to a wide variety of groups, including the sites in which we are providing technical assistance. Recently, I have noticed how the focus of the questions and conversations has turned from "why” Integrated Care to "how.” The "why” has been so widely established across the state and many other parts of the country that we rarely have to pitch it prior to being asked to assist in practice transformation. We still encounter some hold-outs, but overall, if a provider or practice is ready to evolve to meet the changing definition of health, it usually is a soft-sell. To help illustrate more of the work we do, we put together our Top 10 Lessons Learned as Practice Transformationists (sort of sounds like we belong in a circus):


Top Ten Practice Transformation Lessons Learned


10. We do not take credit for the successes of our sites. If they fail at some aspect of IC, we look at our part of the issue, take responsibility for what was ours, and then we hand it back to them.


9. People can hear about Integrated Care all day long, but many do not understand the complexities until they try to do it.


8. Transforming a practice does not happen in a linear fashion -- it is often a one step forward, two steps back proposition.


7. Accepting where the practice and providers are when they begin to implement Integrated Care is key in helping them move toward a more successful, team-based approach -- even if they are still across town and just beginning to talk to each other!


6. Always include the patient and their families into the team-based approach.


5. Practices and systems will follow the physics of relationships -- they will try to suck us into their conflicts and systems’ roles, but we resist, resist, resist. We are very often thankful to both have backgrounds as licensed clinicians - it’s pretty amazing how helpful our multisystemic therapy training has been! We do not do drama!


4. Practices naturally want to jump right ahead to money, payment, and the bottom line. While these things are very important, it’s also important to learn how to integrate. HOWEVER: Even though the best approach to building effective, successful Integrated Care services should be based on the needs of the practice’s patients, we can’t ignore the currently billing and payment issues that are influencing reimbursement.


3. Integrated care is not the same as integrative care...and yes, it’s usually worth taking the time to educate the practices on the difference.


2. Providing assistance to sites attempting to integrate follows a parallel process -- so much so that we sometimes slip and call the practice our patient!


And, the #1 Lesson Learned (drum roll, please) is:


1. Integrated Care is not for everyone! 


 

Dr. Christine Borst is the associate director for the North Carolina Center of Excellence for Integrated Care, under the North Carolina Foundation for Advanced Health Programs. She has a master’s degree in Marriage and Family Therapy from Purdue University and a PhD in Medical Family Therapy from East Carolina University. Prior to joining the Center of Excellence team, Dr. Borst spent several years working in a rural community health center to set up and implement an integrated care model. Her research interests include brief behavioral interventions for use in medical settings, and identification of the needs of children and their families in rural integrated care. 

  Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs. Dr. Hudgins has experience in Integrated Care management and development, crisis assessment and intervention, community-based and college-based outpatient counseling, in-patient assessment and intervention, and community mental health consulting. She has practiced in community mental health agencies, hospital and healthcare settings, as well as in private practice. She has also held a variety of posts in higher education administration and student affairs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care.

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.