The APM pilot is testing the idea that a per-member-per-month (PMPM) fee to care for a population can support comprehensive care. Integration of physical and behavioral health care is a great case for examining alternative payment methodologies, and it gives us a peek into what Oregon’s APM is (and isn’t) achieving.
Integration of behavioral health and primary care by health care systems is one of the most robust examples of patient-centered, comprehensive care that I have observed in this model. We know that emotional and behavioral issues commonly compound physical health risks and lead to worsening health outcomes. We also know that primary care is where most people struggling with these commonly co-occurring conditions are seen by health care professionals.
Our research team at Oregon Health & Science University have had the incredible opportunity to observe 25 practices across the nation, including six in Oregon that are working to deliver integrated, whole-person primary care. Integrated care is a practicing team of primary care and behavioral health clinicians, working together with patients and families, to address the spectrum of behavioral healthconcerns that present in primary care, including mental health disorders as well as psychosocial factors associated with physical health, at-risk behaviors, or health behavior change (e.g., smoking, diet). In some cases, a case management team also facilitates enabling services (such as transportation to appointments) or connects patients with community resources.
We have visited these practices through our work on three studies:
Advancing Care Together, a demonstration project in Colorado supported by The Colorado Health Foundation to advance integration in 11 practices;
a workforce competencies assessment supported by the Agency for Healthcare Research and Quality, CalMHSA, and Maine Health Access Foundation to study integrated care workforce in practices across the U.S.; and
TEAM-UP, a study funded by the National Institute of Mental Health to identify the health IT needs of integrated teams. Two practices participating in TEAM-UP are also participating in APM.
Through this work, we have learned that the transition to practice that delivers integrated care is an enormous undertaking. It involves structural, process, and cultural changes that are not for the faint of heart.
For some practices in Oregon, the APM pilot is allowing experimentation with embedding behavioral health professionals on their teams. In many of these clinics, physicians can now immediately refer patients to these behavioral health clinicians in a "warm handoff,” meaning the physician introduces the patient to the specialist in the clinic at the end of the visit.
Let’s look at an example. The primary care clinician determines that her patient is suffering from depression and this is impacting how the patient manages his diabetes. The clinician suggests that the patient meet another member of her team. The clinician invites the behavioral health clinician to join the visit, and the primary care clinician explains, with the patient’s help, what the patient is experiencing. The primary care clinician leaves the examination room, and the behavioral health clinician and patient begin addressing the patient’s depression right away. These introductions can help reduce the stigma of receiving mental health care and ensure access to the appropriate behavioral health care provider.
Warm handoffs don’t routinely happen in the typical primary care practice for a number of reasons. First, many primary practices cannot afford to employ a behavioral health clinician. Second, in those practices that do employ a behavioral health clinician, primary care clinicians often cannot find the behavioral health clinician because s/he is located on another floor or part of the building. This is a huge barrier, and renovating space to support integrated care costs money.
Third, behavioral health clinicians may be busy, particularly if a practice is employing a traditional model of 50-minute behavioral health therapy sessions for referred patients. In the traditional model, behavioral health clinicians focus on patients who need long-term therapy, who go through a formal intake. The clinician is paid for services rendered. If successful, a behavioral therapist will have a full schedule, making it prohibitively expensive to hire enough traditional behavioral health professionals to meet a clinic’s patient demand. This model leaves no room on their schedule for warm handoffs, particularly if these handoffs are not reimbursed. The result is that these professionals are inaccessible to the primary care team and their patients.
One of the clinics in the APM Pilot estimated that nearly half of the patients in its population has either depression or some other health issue with a behavioral health-related diagnosis. For many patients, long-term therapy and a 50-minute visit is not needed to help with their mild to moderate emotional or behavioral problem. In these cases, behavioral health clinicians can offer brief, problem-focused therapy. In this model, the behavioral health clinicians become familiar with the clinic’s panel of patients, and the team moves to a truly population-based approach. As of yet, however, this level of integration still remains the promise of a new care model rather than the current reality.
The Role Of Payment Reform
All of the practices we have visited are early adopters, and while money is not the motivating factor for these practices (how could it be?), financing must be addressed to sustain integration efforts. If the primary way a health provider is paid is through physician visits (which is how providers were paid under the Fee-for-Service model), then it’s extremely hard to finance an integrated health care model. The APM pilot is one step toward a payment system that better enables health systems to implement integrated care in a financially viable way.
While APM is not specifically funding primary care-behavioral health integration, it is freeing up practices to look more broadly at how they treat their patients.The practices in the APM pilot do not have requirements for how to they spend their PMPM fee. Therefore, instead of needing to generate a high number of physician-patient primary care visits, they now have the flexibility to spend some of their fees on behavioral and mental health services. As long as the net effect is budget-neutral, they can treat patients in new ways and with new combinations of providers.
Integrated care is comprehensive primary care. To make it common practice will require leadership to push further on paying for services that are central to comprehensive primary care, align payment across payers to reduce complexity, and support system-wide practice change.
Deborah Cohen, PhD, is an Associate Professor in the Department of Family Medicine at Oregon Health & Science University. She has been developing her skills in qualitative methods for more than 20 years, and has spent more than a decade studying primary care practices, with a focus on clinician-patient communication, practice change and improvement and health information technology use. Dr. Cohen has expertise in a range of qualitative methods and approaches, including interviewing, observation, and conversation analysis. In addition to her research, Dr. Cohen mentors and teaches on the topics of qualitative methods and practice change and improvement.
Posted By Matt Martin, Cathy Hudgins, Barry J. Jacobs,
Wednesday, April 22, 2015
On April 7th, the Washington Post reported on a case involving Henry Rayhons, a former member of the Iowa House of Representatives, and criminal charges of third-degree sexual abuse. State prosecutors charged Mr. Rayhons for having sex with his wife, Donna Lou Rayhons, in August 2014 while she was incapacitated by dementia and living in a care facility. Jury deliberations began on Monday April 20th, 2015.
Henry and Donna Lou married after their longtime spouses had died. A few years into the marriage, Donna Lou was diagnosed with dementia. In May 2014, two of Donna Lou’s daughters met with care facility staff members to create a care plan for their mother. They, along with a doctor, decided that mom was no longer able to consent to sex. Henry was informed of this decision.
Donna Lou died in a nursing home in August 2014 after a four-year battle with Alzheimer’s. Henry was arrested and charged with sexual abuse a week later. According to law experts, this is the first case of its kind regarding capacity and dementia. At what point in dementia does a spouse or partner lose the right to say yes? Cathy Hudgins and Barry J. Jacobs provide commentary below. Click here for another viewpoint on this case.
CATHY HUDGINS: After reading this article and accompanying documents, I had more questions than I had answers. Early in my career as a Marriage and Family Therapist, I practiced at an adult day services center that served participants with various types of dementia and cognitive impairment. In working with these older adults and their families, I gained an appreciation for the extreme feelings of loss and confusion related to how to proceed with relationships and basic life issues. I worked with many family members and caregivers who had little guidance or experience prior to the onset of the disease. I remember giving these folks some room to learn and make small mistakes as they navigated the decline of their loved one. However, we taught our families that there were lines that no one would be allowed to cross, and those lines were drawn by the state’s definition of elder abuse.
Mrs. Rayhon’s disease progression was determined by the provider team, which included her family, at the facility through a validated screening tool and through the expertise of the providers and staff. As a way to educate and draw the line for Mr. Rayhon, it was conveyed overtly that she would no longer be able to consent to sex. From what Mr. Rahyon’s family wrote in rebuttal to his case, they believe (and I assume in concert with his belief and actions) that there should be no such restrictions to protect patients in a nursing home – even those that score a 0 on a dementia assessment. It is this kind of thinking that actually initiated protective services for vulnerable populations many years ago. The bottom line is that Mr. Rayhon knew that she could not consent, and he decided that his right to have sex with his wife trumped the law and the boundaries drawn for her based on an assessment of her capacity.
I do have several questions about this case, however. Does Mr. Rayhon have some type of cognitive decline or mental health problem that would make someone in his position as a law-maker disregard the law? While it does not sound like he had time with her prior to the sexual encounter to interpret her ability to consent at that time (I have seen several patients with dementia experience short windows of clarity), did he interpret something she did as consent?
Finally, I am not sure what Dr. Pearson meant by "at what point in dementia do you lose the right to say yes?” In my opinion, the ability to consent, if even possible at her stage of the disease, is transient, and the limitations associated with those moments of clarity are inconsistent at best. This fact is why the line must be drawn to protect vulnerable individuals, even from those who love them. There is no doubt that physical closeness can be curative and comforting. Nevertheless, there are other ways to satisfy this human need in lieu of an act that requires consent.
BARRY J. JACOBS: Some landmarks cases—whether legal or clinical—help us forge ahead into new territories of understanding and knowledge. Others, like signposts at the edge of frontiers, delineate the outer edge of the known world beyond which we are lost in cloudbanks and quicksand. The Rayhons case—about marriage, dementia and sexual consent—catapults us into a wilderness of clinical fuzziness, moral ambiguities, and legal murk.
We are all in agreement that sex should be consensual between intellectually capable adults. But determining exactly the point at which a person with a progressive dementia loses the capacity for informed sexual consent is not scientific at this point. It’s often clinical guesswork, based on wildly inappropriate measures (e.g., using memory test results to calculate degree of sexual understanding). The "line” that my colleague, Dr. Hudgins, refers to is not so clear; it is a legal construct, based on clinical impressions, extrapolations and opinions. This idea of a "line” is sometimes used to prevent people in nursing homes from engaging in sex, as if they lose that right once they enter the institution. The "line” was used in this case as a weapon by step-daughters in a power struggle with their step-father for control over their mother’s last months.
That is quite familiar in this family-and-illness drama (at least in the more detailed Bloomberg news story). Mr. Rayhons wanted to take care of his wife with dementia at home. Her daughters from her first marriage decided that he was in denial about her degree of impairment and, with the collusion of a family physician, placed her in a nursing home one day against Rayhons’ wishes while he was at a state legislative session 30 miles away. (As her husband, he should have had the legal right to make decisions about where she would reside. How did her daughters usurp that right?) After that, it appears that they sniped at one another and struggled over details of Mrs. Rayhons’ care at the nursing home. When the daughters took steps to protect their mother through limiting the privacy that their step-father would have with her, he responded by flouting the rules they set up. Seen from this perspective, his alleged act of having intercourse with his wife was, as much as anything else, a gesture of defiance toward his step-daughters.
A family-oriented professional could have helped these warring parties find some compromises and accommodations before the story’s climax (so to speak). Unfortunately, the professionals seem to have banded together to demonize the husband. He may have acted rashly or even naively but I don’t believe he’s a demon. And I don’t think an Iowa jury will determine he’s a criminal—just a lost and angry man who wandered into the poorly charted landscape of dementia and the law.
Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at email@example.com
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.
Barry J. Jacobs, Psy.D. is the Director of the Behavioral Sciences for the Crozer-Keystone Family Medicine Residency and the lead faculty member for its super-utilizer program, the Crozer Connections the Health Team, and the Camden-Cooper-Crozer Hot-Spotting and Super-Utilizer Fellowship Program. He is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).
A colleague said he needed a slide on the history of integrated of behavioral health and could I give him a few high points. This is what I wrote.
The first integrated behavioral health program that I know about that was a large implementation and not just a couple of practitioners working together was the Gouverneur Health Program in New York in the 70’s. There is a chapter in my book about it, Integrated Primary Care: The Future of Medical and Mental Health Collaboration, Norton, 1998. There was a fully integrated program at the first HMO which was in New Haven that is described by Coleman, et al. In 1994 I published a paper in which the term "integrated primary care” was used for the first time.
1995 was a big year for integrated care. It was the publication of Katon, et al’s big JAMA article with the evidence for integrated care for depression and it was the first meeting of the Collaborative Family Healthcare Association, the first organization made up of physicians and behavioral health folks focused on collaborative care www.cfha.net. After that it was sort of a steady development for a while. The work in Seattle kept on, supported by RWJ and MacArthur, building to the IMPACT model and beyond. The Behavioral Health Consultant model also build out of the Northwest, from Kirk Strosahl and Patty Robinson’s work. You can see it almost formulated in Kirk’s chapter in my book.
Various pieces fell in place. The military picked up integration as did HRSA in the early 2000’s. Centers of excellence were built at Health Partners in Minneapolis by CJ Peek and at Sharp Health in San Diego. Lots of different reports fell into place. The next monumental moment was the passage of the ACA. That kicked integrated care into actuality all over the country. That was the start of the AHRQ Academy for the Integration of Behavioral Health and Primary Care. The BPHCI grant program of HRSA and SAMHSA juiced the mental health guild organization called NCCBH into creating the Center for Integrated Health Solutions which is trying to be sure that integration doesn’t marginalize the mental health centers by being a great source of information for the entire field.
Now we are at the point where the leaders are seeing the impetus behindthe movement begin to push it out in front of them. We find ourselves having to define what counts as integration so that the term doesn’t get applied to whatever people are doing that they want to be sure is in on the action. We see people placing mental health clinicians from mental health centers into primary care who don’t realize that what they have been trained in is specialty mental health care and what is needed is primary care behavioral health. That is why we started our training program to make sure folks can get the rigorous orientation they need to succeed. We have to keep reminding each other not to ask does integration work?, does the PCMH work?, can integration save money? We have to ask what form of integration works in what context? How are they doing the PCMH in what regulatory and payment environment so that it works? What sort of integration or camre management program targeted at which patients, accounted by looking at what parts of the system works financially?
Our current success and rapid development great, but it is a movement that is much bigger than all of the pioneers now. We have to keep reminding ourselves that integrated primary care, or integrated behavioral health, or whatever else we call it, is not important. Better care for patients is important. If we keep our eyes always on that, integration will evolve and be durable for a long time.
Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA. At UMass he has developed training programs in Primary Care Behavioral Health and Integrated Care Management that have already trained 2000 people for the workforce needs of the transformation of healthcare. His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’. He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.
In the small primary care office where I work as an embedded behavioral health specialist we are metrics savvy. We have graphs showing numbers of patients completing depression screenings, shared decision-making tools, and data to demonstrate the health care team effectiveness with reducing emergency room visits. With all of our analytics and quality improvement efforts, we don’t measure how the hospitality of the front desk staff positively impacts a patients’ sense of well-being and engagement. The relational skills of the front desk make a daily impact on all who observe and interact with them.
Observing the front desk staff interactions reminds me of Miles, a classmate of one of my sons, who decided that he wanted to make a difference by opening one of the high school front doors - every school day for four years. He arrived early and greeted each student by name as they journeyed through his open door into the school. Miles’ entryway was well traveled. Did his greeting make a difference in the learning of students, in the community health of the school, or in the decisions students made throughout their day? When I observed him holding the door open I smiled more, listened with increased attunement, and felt a little softer in spirit.
When patients check-out after an appointment, they have brief conversations of caring with the front desk staff. These meaningful conversations invite the patients to consider that they are more than their presenting problem or illness. "How is your grandson doing with his new job?” "Have you started planting your garden yet?” "Are you continuing to volunteer at Hospice?” The whole person is cared about. Greeting patients by name, welcoming with eye contact and an attentive smile may provide a needed healing balm and invitation to care for oneself.
Patients can consider that they are more than their presenting problem or illness
Front Desk Ladies at Foresight Family Physicians Clinic
The attentiveness of the front office staff gives a "we’re here to help” message to patients. Changes in spirit and self-care occur with experiences of kindness rather than criticism. Common feelings of vulnerability and fears coming into a doctor’s office may ease with consistent affirming interactions.
Why is this important other than the front desk feel good take away? In my role as the behavioral health specialist I ask patients about what they value in life to highlight motivation for improving a specific aspect of health. Carrying the initial warm welcome, a patient may become more engaged when discussing health changes with a medical provider. If the initial interactions with the front desk staff were invalidating, the response with health care team members may lack some motivation. Courage and fortitude to move into new health behaviors are more likely to occur when we feel cared about and safe.
Measuring kindness is not a clinical data point. Warm and brief conversations encourages values of kindness and trust. When asked about their motivation for quality service, the reply from the front desk reflects that they know they make a difference in patients’ lives. With smiles they discuss observing serious faces relax, laughing with the lonely, being trusted with a reflection of the visit, and hearing that they are called by name. Sandi, Cassi and Jennipher positively impact patient’s health care experience. Where ever we serve in our office, we have the common goal of helping patients with their health.
Patient-centered hospitality by the front office staff offers a significant gateway to health engagement; "you matter” is the message; the patient response of "I value myself” can be the result.
Lisa Barnes, LCSW, has transitioned from an over twenty-five year Clinical Social Worker in private psychotherapy practice to Integrated Health Specialist at Foresight Family Physicians in Grand Junction, CO. This career change has been enabled through CFHA mentors, part-time hospital and physician office work experiences, and many webinars! Lisa’s mission is to promote health in a health care system.
With the increased awareness of the benefits of integrating behavioral health care within the primary care setting there is an ever increasing demand to ensure we have behavioral health providers that are trained not only to provide care within this setting, but also to thrive alongside their primary care colleagues and function well as part of an interdisciplinary team. Given the pace and intensity of the work in primary care, supervision is an essential tool to foster growth in trainees and to monitor progress. At Access Community Health Centers we strive to provide excellent patient care as well foster the professional development of future psychologists and social workers as Behavioral Health Consultants (BHCs) within the Primary Care Behavioral Health model.
We work with trainees according to their level of development, as we have taken on a broad spectrum of trainees from various training programs including practicum level students from clinical psychology, counseling psychology, rehabilitation psychology, MFT programs, and social work programs over the past 9 years. In addition, we have 2 post-doctoral fellowship positions annually for PhD/PsyD level trainees.
Training of Clinical Skills
In many ways, our style of supervision mirrors the medical preceptor model of supervision, with live, in the moment supervision occurring throughout the day. This enables supervisors to discuss each individual patient and their unique needs in real time. Live shadowing, where the supervisor is present for all or part of a visit, allows for more in depth and robust feedback. Although trainees often find shadowing to be anxiety provoking initially, it can also facilitate a more efficient visit as supervisors can speak to specific questions from the trainee regarding resources or options for care directly with the patient. Co-visits are be possible for particularly complex cases or issues a trainee may feel they have less knowledge or comfort in addressing. As we are keenly aware, providing care within the primary care setting requires a generalist mindset with the ability to show humility and openness for continual learning.
Our typical training scenario is as follows:
Trainees begin by shadowing a BHC, to observe the entire process from obtaining a warm-handoff, interacting with other providers, seeing the patient in the exam room to conduct the BHC visit, following up with the provider and documenting the visit.
Trainees shadow Primary Care Providers (PCP) to gain insight into the pace and breadth of the work in addition to the culture of primary care.
Once students are comfortable in the primary care setting and can effectively introduce BHC services, they begin to see patients on their own.
Supervisors continue to spend time with trainees in pre-visit planning, clarifying the consultation question, and helping trainees to organize their agenda for the visit once they begin the process of working more independently.
There is also much discussion on staying flexible to meet the needs of the patient in the room as well as addressing PCPs expectations for the visit.
Supervisors attempt to shadow as many consults as the schedule allows each day. However, if we are unable to shadow, then trainees will review their thoughts with their supervisor after the visit, focusing on patient functioning, plan of care (interventions), and process issues.
Since we utilize SOAP notes for documentation we typically have trainees present to us their overall assessment and plan to assist with case conceptualization and organization of their thoughts prior to seeking out the PCP to share their impressions. This builds trainee confidence and encourages succinct communication when interfacing with PCPs.
We coach trainees on focusing on one or two things to work on with patients during a visit which requires the trainee to assess and triage needs, prioritize options, and engage in shared decision making with the patient regarding areas of focus.
Training as Consultant
Supervision is always multifaceted while supporting the professional growth of trainees in various stages of development. Accordingly, this extends beyond the development of direct patient care skills. We strive to acculturate trainees to the primary care mentality of efficiency, compassion, and targeted interventions while also modeling self-care and seeking out support and feedback from other members of the healthcare team. Trainees and BHC staff use the same work areas as PCPs, sitting side by side with our primary care colleagues fostering a reciprocal learning environment. This allows students to gain appreciation for the variety of responsibilities handled by PCPs and other care team members.
Given that the PCP is our first customer, it is crucial to model and support professional development of the trainee as a consultant including the way a trainee presents him or herself to our primary care colleagues. Fostering self-awareness and professionalism while understanding the importance of balancing the relationship with the patient and the PCP is highly valuable and one way to encourage acculturation into primary care. Relationship building is the cornerstone of work as a BHC. Supervisors emphasize modeling collaborative and assertive communication with PCPs as an additional feature of the consultant role.
Supervisors model collaborative and assertive communication with physicians
Similarly to focusing on one or two issues with patients, we as supervisors have found that trainees also benefit from focusing on only a few pieces of feedback at a time. It can easily be overwhelming for trainees to hear all the options of what “could have” been discussed in each visit or interaction with PCP, as it is easy to mistake options for errors. Helping students to learn that there are many ways to provide care and identify their own style is also important.
At Access, staff supervisors rotate between three clinics. While each trainee has a primary supervisor they also have the opportunity to work with several staff members and supervisors increasing their exposure to a variety of practice habits and clinical orientations. This experience fosters identity development and allows supervisors to share feedback and comments on areas of strength and areas for further development.
Overall, supervision in primary care works well when it reflects the pace and culture of the setting- immediate feedback, diversity in feedback across supervisors, and ongoing support throughout the workday. Attending to development of both roles, clinician and consultant will allow for the most growth for the trainee and assist in preparing a future workforce ready to take on the role of a BHC.
Elizabeth Zeidler Schreiter, Psy.D., is a licensed psychologist working at Access Community Health Centers (Access) in Madison, WI, providing primary care behavioral health services. In addition to direct patient care and supervision of trainees she serves as the liaison to the community and manages the consulting psychiatry service including training of psychiatry residents to practice within integrated care teams. She received her Psy.D. in Clinical Psychology from The School of Professional Psychology at Forest Institute with an emphasis in Integrated Health Care. In addition, she holds an appointment as a Clinical Assistant Professor with the UW Department of Family Medicine, where she assists with the training of family medicine residents. Dr. Zeidler Schreiter is passionate about working with the underserved and improving access to care via the primary care behavioral health model in addition to training new behavioral health consultants.
Meghan Fondow, Ph.D. is a licensed clinical psychologist working at Access Community Health Centers (Access) in Madison, WI, working as a behavioral health consultant (BHC) within the Primary Care Behavioral Health (PCBH) model. In addition to providing direct patient care, she is the Clinical Training Director, and tracks quality improvement data. She also holds an Adjunct Assistant Clinical Professor position through the University of Wisconsin-Madison Department of Family Medicine. Dr. Fondow received her PhD from The Ohio State University in Clinical Health Psychology. Dr. Fondow enjoys the variety and diversity of clinical work within the PCBH model in the context of an underserved population, working students and fellows with a variety of training backgrounds within the PCBH model, and practice based research.
Wayne Katon, vice chair of Psychiatry and Behavioral Sciences and a pioneer in collaborative mental health care, died March 1 from lymphoma. He was 64.
“Wayne was truly a great human being, a mensch, a dear friend, a generous mentor and a wonderful colleague to so many of us,” said Jürgen Unützer, UW professor and chair of Psychiatry and Behavioral Sciences in a letter to colleagues. For more than 35 years, Unützer said, Katon worked graciously and tirelessly to improve the lives of those living with mental and physical health problems.
“Along the way, he touched and inspired thousands of students, residents and faculty colleagues at UW and around the world,” Unützer said.
Recognizing that people with physical pain often suffer from depression, and that people who were depressed rarely received mental health care, Katon brought together the practices of psychiatry and primary care. He spent three decades testing and developing models of care to make mental health care more accessible.
That work led to the April 5, 1995, publication of his seminal paper in the Journal of the American Medical Association: "Collaborative Management to Achieve Treatment Guidelines Impact on Depression in Primary Care." Katon and colleagues showed that a collaborative intervention involving a psychiatrist working with primary-care physicians significantly improved patients' adherence to medication, depressive outcomes and satisfaction with care. More than 80 randomized controlled trials around the world have validated this approach since then.
He inspired thousands of students, residents and faculty colleagues
Dr. Katon was a plenary speaker at the first CFHA conference 20 years ago and at least two subsequent meetings. His research arguably forms the foundation for collaborative care. He will posthumously be awarded the 2015 Distinguished Service Award from the American Psychiatric Association for a lifetime of outstanding contributions to the field of psychiatry. The Wayne Katon Memorial Fund has been established to support the next generation of physician students in the Department of Psychiatry and Behavioral Sciences.
Posted By Suzanne Bailey,
Thursday, February 26, 2015
This is the first in a two-part series on supervision in integrated care. Check back in two weeks for the second part.
As the demand for behavioral health providers skilled in the provision of brief, targeted, and population-based assessment and intervention within primary care continues to grow, so does the need for a model of supervision that promotes the acquisition of clinical skills and professional development in this area. At Cherokee Health Systems, a comprehensive community care organization, we have a longstanding commitment to train psychologists and other healthcare providers for work in integrated primary care and have experience in a model of supervision to support this commitment.
I vividly remember my first day working in primary care as a BHC in training, now almost a decade ago. I saw nine patients that day, four of which were warm-handoffs, and all of whom had significant behavioral health and medical comorbidities. Having no experience with integrated care and limited exposure to co-located models I was immediately impressed with both the pace and pathology of primary care. I felt excited and overwhelmed as I began to hike a very steep learning curve.
Anticipating the steep learning curve trainees new to primary care commonly experience, we utilize a developmental approach to supervision. Initially, trainees exhibit both high motivation and high anxiety and supervision must respond to the anxiety and dependence of trainees with support and prescriptive instruction. Early in training, strategic emphasis is placed on providing repeated opportunities for observation and practice in an effort to build a foundational understanding of the structure and operational aspects of primary care. Shadowing PCPs and BHCs allows trainees to develop a schema for work in primary care. Heavy emphasis on structured readings and didactic teaching assists trainees in developing primary care content knowledge (e.g., basic labs, common health conditions and comorbidities, behavioral medicine, etc.).
Mid-level trainees exhibit variable levels of confidence and rapidly growing competence. During this developmental period, trainees have established a foundation of clinical skills, an understanding of primary and population-based care, and are beginning to develop practice management abilities. We often tell our trainees, “You learn to do it, then you learn to do it well, and then you learn to do it quickly.” Mid-level trainees have “learned to do it well” and supervision works to refine their clinical and practice management skills such that they are able to match the pace of work flow in primary care. Advanced trainees exhibit increased autonomy, clinical skillset and practice management abilities, and exhibit the ability to think critically and “on their feet.” Supervision of advanced trainees encourages this autonomy and becomes increasingly collaborative and less directive, with increased emphasis on professional development.
Supervision doesn’t just happen in the sacred supervision hour
The structure and content of supervision in primary care mirrors the pace and structure of the primary care setting. With regard to the structure of primary care supervision a current intern explained, “Supervision doesn’t just happen in the sacred supervision hour.” Supervision in primary care is flexible, dynamic, and capitalizes on teachable moments. Real-time, on-the-fly consultations are a routine component of primary care and resemble precepting models of medical training. Examples of on-the-fly supervisory consultations include questions regarding diagnostic clarification, treatment planning, care coordination, appropriate triage, and practice management. The supervisor’s role is to listen to the trainee’s brief case presentation (30-60 seconds), ask clarifying questions, and offer prescriptive guidance.
The content of supervision in primary care is not strictly about the treatment of patients. Working in primary care adds layers of complexity to interprofessional practice, ethics, and practice management. Thus, supervision must balance strategic emphasis on patient care with more abstract issues related to professional development. “The sacred supervision hour” is didactic, directive, targeted, solution-focused, and fast paced. It is common for twenty to thirty patients to be discussed during a one hour supervision meeting. With each patient, the supervisor targets diagnostic clarification, the development of a unified primary care treatment plan, a defined target for treatment, the selection of best-practice interventions, and coordination of care with the primary care team. A current intern described, “A large portion of my supervision in primary care has been on how to translate my conceptualization, language, and training as a psychologist in training to serve the primary care team.”
Supervision in primary care requires supervisors to simultaneously play the roles of teacher, consultant, and counselor. It is complex, difficult, and immensely rewarding work. After all, the best way to promote integrated models of healthcare delivery is to train talented trainees who may spend their careers implementing the model and doing great work.
Suzanne Bailey, Psy.D. is a Licensed Clinical Psychologist and Behavioral Health Consultant at Cherokee Health Systems. She earned her doctorate in Clinical Psychology at Xavier University in Cincinnati, Ohio. As the lead Behavioral Health Consultant, Dr. Bailey practices in an integrated primary care clinic in Knoxville, TN. Dr. Bailey is a member of the training faculty of both Cherokee’s APA Accredited Predoctoral Psychology Internship Program and APPIC member Health Psychology Post-Doctoral Fellowship.
Posted By Audrey Martin,
Wednesday, February 11, 2015
In my work with patients who are frequently hospitalized, I am often reminded of the process of peeling layers off of an onion. Patients are intricate people, with layer upon layer of life experiences often unseen by the health care system. Just as it takes time and patience to get to the needed layer of an onion, engaging the complex physical and behavioral health needs of a patient requires time and a supportive atmosphere so the patient can feel comfortable letting our team into their lives and layers. The Care Connections Clinic of Lancaster General Health is an interdisciplinary team approach to caring for high utilizing patients, as a transitional high intensity intervention that includes temporary assumption of primary care services.
Patients are selected for participation in the Care Connections Program based on data analysis of hospital utilization records or by recommendations from the larger healthcare community for patients that meet utilization criteria. Our team is made up of patient care navigators (LPN, EMT, or Paramedic), nurses, social workers, behavioral health clinicians, administrative leadership, CRNP, and physicians. Through our team approach we seek to foster relationships of trust and security in which the patient can let go of layers of masked behaviors, emotions, maladaptive thought patterns, and hidden psychosocial stressors which often contribute to poor health outcomes and frequent hospital utilization. The Care Connections Clinic models and continues to improve the integration of behavioral health as an equal partner in the interdisciplinary high-risk team. The following case study illustrates how this integration impacts patient care and outcomes.
Mr. Worthington is a 40 year old Caucasian male, who joined the Care Connections program after the patient’s primary care physician noticed the patient had several hospital visits related to altered mental status and uncontrolled diabetes and sent a recommendation for the patient’s enrollment to the Care Connections team. The patient’s data related to hospitalizations was reviewed by the Care Connections team, and was found to meet criteria for the program.
His initial encounter with our team was scheduled urgently to address access to medications after hospital discharge because he didn’t have medical insurance. The patient came in with his wife. He was social and talkative, but had clearly impaired memory and cognitive function such that he could not give a reliable history. His wife was tearful and reported being completely overwhelmed caring for the patient with his cognitive impairment. The patient had brittle insulin-dependent diabetes and a history of long-standing prescription opiate use for chronic pain, but there was no clear etiology of his altered mental status.
He was social and talkative, but had clearly impaired memory and cognitive function
At his first visit in the office, the patient had a brief behavioral health evaluation by our Licensed Clinical Social Worker and was referred for neuropsychiatric testing. A few days later, the patient had a more extensive psychosocial intake evaluation with the same team member, which revealed inconsistency in the patient’s social history, raising concerns about possible psychiatric contributions to his overall clinical picture. A recommendation was made for psychiatric evaluation after the neuropsychiatric evaluation.
These consultant evaluations were delayed due to insurance access barriers and the patient had several more visits with our team focused primarily on other acute medical concerns such as dysphagia and weight loss and pain management. These issues seemed to stabilize and his cognitive function seemed to improve, but the patient became progressively more depressed. Behavioral health assessed the patient again and, at this follow-up visit, the patient’s spouse shared that he had a history of high risk behaviors such as overspending to the point of accruing overwhelming credit card debt, sleep disturbances, weight changes, and weeks at a time of “high moods” followed by weeks of “low moods.”
As the behavioral health provider and primary care doctor met to discuss findings, underlying bipolar disorder was strongly suspected and the patient was started on a mood stabilizing agent. The patient was monitored over the next few days, and it became apparent that he would require more intensive and immediate psychiatric monitoring for stabilization. With the team’s holistic medical and behavioral assessment, a case was made to the inpatient behavioral health team to admit the patient for stabilization. The Care Connections behavioral health provider was able to coordinate with the inpatient treatment team and participate in the patient’s family meeting on the inpatient unit. A clear plan for discharge was developed and the Care Connections team will continue to monitor the patient’s progress. Since receiving a clear explanation of the potential for a mood disorder, the patient and patient’s family now have a set of tools to help maintain overall behavioral wellness.
Today, the patient is stable enough to engage with our team in taking better care of his diabetes and addressing his chronic pain. It is not yet completely clear if his altered mental status is the result of multiple medical issues, mood disorder symptoms, or a combination of both. For our team, this case stands out as a victory for collaborative, interdisciplinary care. In particular, the integration of behavioral health into the care team helped us peel away some of the layers of medical and psychosocial complexity in a way that brought clarity and prioritization to the care plan and moved this patient forward quickly in the direction of true wellness.
The patient and family now have a set of tools
Here is what we’ve learned while developing an integrated behavioral health and physical health treatment team:- Normalizing Behavioral Health Treatment and Minimizing Stigma: The behavioral health provider is an equal voice on the treatment team of physicians, nurse practitioners, case managers, a social service liaison, and patient care navigators. The patients see the behavioral health provider, just like they would see any other member on the team. In doing so, the stigma often associated with behavioral health treatment is reduced and behavioral health concerns are treated collaboratively, similar to any other chronic disease.
-Interdisciplinary Learning: A great value of a full-integration behavioral health model is the collaborative learning implicit in the daily interaction of team members from different disciplines. The behavioral health provider will learn from the other team members about physical ailments and their management. Likewise, the medical team can learn from the behavioral health provider skills such as motivational interviewing techniques and trauma-informed care practices that enhance their effectiveness in patient interactions.
-A full view of the patient for promoting wellness : A team-based approach to patients that includes bio-psycho-social-spiritual assessments into the normal workflow of patient evaluation gives the care team a more comprehensive understanding of the patients’ life and situation. This deeper understanding can prioritize or target interventions or recommendations for maximum effectiveness.
-Flexibility in redefining workflow- The Care Connections program continues to evaluate and refine the process of screening and stratifying behavioral health needs into a standardized work flow. For example, not all patients may need an exhaustive behavioral health assessment done by a specialist on the team. We continue to work on developing front-line screening tools and criteria which trigger different levels of behavioral health intervention.
Overall, the Care Connections team has demonstrated the benefits of integrating behavioral health with physical health treatment for greater holistic care. The interdisciplinary team at Care Connections works in concert to promote a patient-centered, strength-based approach, encouraging greater patient security and enhanced engagement with the healthcare system. As the team takes time to meet the patient “where the patient is,” we begin to uncover layers of understanding previously hidden from the healthcare team. Our goal is to help patients find health and healing in the deepest layers of their lives and become advocates for health and wellness for themselves and others.
**Please note, names and identifying information for this case study have been altered to protect patient confidentiality.
Audrey Martin, LCSW is the licensed clinical counselor at Lancaster General Health’s Care Connections Clinic. Audrey provides patient assessments and individual/family counseling surrounding adjustment to illness and psychosocial barriers to health at the Care Connections Clinic. Audrey was involved in the initial pilot program for high utilizing patients at LGH for 2 years prior to the development of the Care Connections Clinic in 2013.
Posted By Barry Jacobs,
Thursday, January 29, 2015
Want to bend the cost curve in any community?
How do you start a revolution? Great press helps. In the Jan. 24, 2011 issue of The New Yorker magazine, famed physician-writer Atul Gawande published “The Hot Spotters” which profiled Jeffrey Brenner, MD, a family physician (and 2011 CFHA conference plenary speaker) who was dramatically lowering healthcare costs in the impoverished city of Camden, NJ through engaging “super-utilizers”—that city’s most frequent users of hospital and emergency room services. As depicted by Gawande, Brenner was a zealous and persistent reformer with a simple point: Five percent of patients nationally generate 50% of all healthcare costs; if you want to bend the cost curve in any community, decreasing the excessive utilization of the most psychosocially and medically complex patients is the best first step.
With its stories of patients with multiple illnesses and chaotic lives making significant turnarounds, the article was an electric spur to action. State and national legislators took notice. Funders stepped up with monies for existing initiatives. And health systems around the country—nervous about the coming shift in healthcare financing toward cost-containment--immediately began experimenting with super-utilizer pilots in their own backyards.
Now, 4 years later, we have an initial, detailed progress report by an early and ambitious group of Brenner-inspired programs. The Highmark Foundation-funded South Central Pennsylvania High Utilizer Learning Collaborative—consisting of the Crozer-Keystone Health System (where I help lead the super-utilizer team), Lancaster General Health, Neighborhood Health Centers of the Lehigh Valley, PinnacleHealth System, and WellSpan Health—has recently published “Working with the Super-Utilizer Population: The Experience and Recommendations of Five Pennsylvania Programs,” a white paper on their collective experiences.
Written primarily by Widener University healthcare business professor Caryl Carpenter, M.P.H, Ph.D., the 77-page document captures the struggles and triumphs, nuances and diversity of interprofessional team-based super-utilizer care. In essence, it describes how 5 geographically close but disparate health systems have taken Brenner’s original vision—using data to segment patient populations and then develop intensive intervention strategies—and creatively adapted it to their local conditions and cultures.
Three of the programs decreased hospital admissions for 138 patients by 34 percent--savings to payers of $1.1 million
Among the report’s highlights:
--How to define who is a super-utilizer (generally a patient with 2 or more hospital admissions in a 6-month period), including common social determinants of utilization;
--Tools for assessing super-utilizer patients’ psychological and social backgrounds and motivation for change;
--Different models of interprofessional team composition and functioning (including different approaches to whether the super-utilizer team provides primary care or only comprehensive care coordination);
--Similarities and contrasts between super-utilizer programs and Patient-Centered Medical Homes;
--Challenges of and strategies for engaging patients who are mistrustful of healthcare professionals or unwilling or unable to change their habits and circumstances;
--Strategies for partnering with other community-based healthcare and social service agencies to empower patients to take control of their own lives and health;
--Policy recommendations for state agencies and public and private payers;
The white paper also reports mostly impressive outcomes: Three of the programs (for whom data was available) decreased hospital admissions for 138 patients by 34 percent--savings to payers of $1.1 million. On the other hand, these same programs saw a slight rise in emergency room admissions for the same patients. And the rate of patients who dropped out of the programs because of lack of engagement or other factors was relatively high—over 30%.
What are at the heart of this document, however, are the same kinds of patient stories that Gawande documented. There is a short depiction of Bill, a homeless man in his 50s with cardiomyopathy and congestive heart failure, who had 25 inpatient and 6 ER admissions in a 6-month period. While in the PinnacleHealth program, his admissions decreased to 5 ER visits and 1 hospital admission during the next 5 months. There is the story of Robert, a 29-year-old man with Type 1 diabetes and chronic depression who had 12 inpatient and 15 ER admissions. Under the care of the Lancaster General Health program, his inpatient utilization decreased 50% and he had no further ER visits.
This white paper is a well-produced snapshot in time of an evolving approach to lowering healthcare costs. For as much of this territory as it describes in detailed narratives and charts, it also raises many key questions: How do we engage complex patients and empower them so that they eventually don’t need intensive team-based interventions? How do we make the transitions from PCMH to super-utilizer care (and back again once high utilization has decreased) as seamless as possible? How do we devise the most effective and sustainable teams? These questions will be answered by the calculated tinkering of these 5 programs and dozens of others around the country which regard reducing high utilization as an essential component of transforming American healthcare.
Barry J. Jacobs, Psy.D. is the Director of the Behavioral Sciences for the Crozer-Keystone Family Medicine Residency and the lead faculty member for its super-utilizer program, the Crozer Connections the Health Team, and the Camden-Cooper-Crozer Hot-Spotting and Super-Utilizer Fellowship Program. He is also the author of The Emotional Survival Guide forCaregivers (Guilford, 2006).
Posted By Administration,
Thursday, January 22, 2015
"Medicine and poetry have long been intertwined" - Alastair Gee, The New Yorker
What is your favorite section of each new Families, Systems, & Health issue? Editor's comments? Media review? Original articles? Well, your favorite section may now be poetry.
Recently, Alastair Gee from The New Yorker highlighted the creative work of Adam Possner and Johanna Shapiro, co-editors of FSH. Brief history lesson: FSH was started by Don Bloch who also founded CFHA. Check here and here for more history.
In the article, Gee shares one of Possner's more whimsical poems, entitled "Drug Holiday":
You work so hard,
with little thanks,
in the wet heat,
the airless dark
Gee also shares some insightful comments from Shapiro who believes patients are more akin to poems than essays. “You think a patient is going to be like a well-organized essay, but what you really get is a poem. You’re not sure what they mean, and they don’t tell you everything all at once, up front.”
The article is a nice hat tip to the editorial efforts of Possner and Shapiro who strive to balance the technical, data-driven journal articles of FSH with some art and creativity. Interested in submitting your own poetry? See the journal webpage for more information.
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