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.
In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.
With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.
1.PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.
2.AUDIT: The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings.
3.GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.
4.DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.
5.PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.
7.SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.
8.Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.
9.Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.
10.MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.
There are many excellent tools that did not make this list
In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hand to screen for additional conditions, such as:
·Intimate partner violence
Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these tools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.
What is on your top ten list?
Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth
Every year I beg, borrow, and even kind of steal to get my newest students to CFHA’s conference. This year, CFHA scholarships and my Chair’s contributions, helped bring four East Tennessee State University doctoral students in clinical psychology to DC for their first-ever CFHA conference. The effort has created momentum - ETSU staff, doctoral graduates, and current students numbered 17 this year! I was able to get a small space for a reunion, networking, and time to reflect on what we’d learned. I am so excited that CFHA is taking hold as a tradition in our program.
What is CFHA like for a first timer doctoral student, preparing to work in integrated practice?
They have each prepared a short reflection:
Kyle Suhr, M. S.
Through my doctoral coursework, I have learned about how to structure my practice to be effective in the primary care setting. My first CFHA conference taught me more about the latest research and practices related to adapting evidence-based treatments in primary care. Likewise, my coursework has helped me think about the administration of integrated care, and my peers and I had been working on an assignment to prepare a business model for integrated practice. The conference helped us with this assignment – providing a number of opportunities to learn about the intricacies of the business aspect of primary care. It was especially helpful to learn about billing and speak with professionals from other disciplines about integrating behavioral health into new locations. The conference was an excellent supplement to the strong training I am receiving in my current program and I think the cutting-edge information helped us earn an A on our class assignment!
Courtney Smith, M.S.
My first occasion to attend CFHA yielded three salient experiences. First, the atmosphere of this conference was palpably distinct from other national and local conferences I have attended. Specifically, there was a friendlier, more open feel. Similarly, the student to professional ratio allowed me the opportunity to connect with leaders in the field , and I felt like this was not just “possible,” but encouraged by way of casual before-and after-meeting activities. It seems very important to me to have this connection with leaders as a developing professional so that transitioning to a collaborative workforce is more fluid. The second experience I found meaningful was the pre-conference Writer’s Workshop.
In addition to absorbing suggestions and tips from successful writers in the field of healthcare, we had the opportunity to have our own pieces of writing dissected and critiqued with feedback delivered in a kind and specific manner to foster improvement. As a student who finds writing challenging, this workshop armed me with tools to conquer writing, one draft at a time. The final experience I would like to mention was Richard G. Frank’s plenary speech on policy reform and its current status. While policy may not have been a reason I first wanted to become a psychologist, it is becoming a necessary part of my career path, as many policies will may enhance or diminish the types of mental health services I intend to deliver. The updates and forward progress on mental health parity was hopeful yet there is plenty of room healthcare providers to advocate for integrated care policies.
Laura DeLustro, M.S.
On my first occasion to attend the CFHA annual conference, I had the opportunity to volunteer and present a poster. Being a volunteer meant plenty of time to meet with all the conference participants and a chance to get to know the amazing CFHA staff. The presentation that struck me the most was a plenary speech given by Marci Nielsen. She emphasized that we train doctors to be cowboys but ideally, they would be part of a pit crew. She referenced Atul Gawande and her description of him motivated me to listen to an interview he did with NPR’s Diane Rehm in which he described his transition towards value-driven, quality of life medicine rather than an emphasis on a “quality death.”
For Dr. Gawande, his own father’s terminal illness convinced him that listening to a patient’s values and needs is more important than forcing a one-size fits all protocol onto each patient in an attempt to fulfill medicine’s agenda. All of us have at some point have had the failure of the current US health care system hit us on a personal level and it is encouraging that trail blazers like Dr. Gawande and Marci Nielsen are showing us a different way. The conference helped make the direction and pragmatics of the trail more salient for me, as though I was seeing how integrated care is becoming a reality. I loved the primary themes that emerged at the meeting; that CFHA is focused on creating a system in which a patient can express their values, be treated from a holistic perspective, and become an empowered participant in their own care.
Michael Lasher, M.S.
As a student attending the CFHA conference, it might sound strange to hear that my background is in prison-based treatment programs. What attracted me to a primary care psychology training program is the surprising divide often present between prison medical services (which is the de facto primary care in prisons) and psychological services. Where better to start thinking about how to address this problem than at the CFHA conference? Research presented at this year’s CFHA conference has many direct implications to integrated care in corrections. The prison population is more likely to use medical services for psychological needs than the general public, so utilizing some of the approaches to relationships and logistics discussed over the course of the conference is paramount.
On the other hand, corrections rarely benefits from generous funding, so many of the creative approaches to fiscal management, such as the CoACH tool that was shared with us on Friday morning, might be very appealing to administrators. Additionally, there are parallels that can be drawn between primary care and forensic research, such as the similarity in how risk assessment and resource allocation is conducted. During breakout sessions, many discussions about how to allocate services based on patient needs and health risks echo the Risk-Need-Responsivity model widely employed in forensic risk assessment. The important take-home for me is that the body of work presented at CFHA has relevance to a range of niche disciplines – like corrections - which have yet to embrace the benefits of an integrated care model.
Expanding our existing coursework, connecting our students to leaders in the field, creating and communicating aspirational goals, and providing new knowledge that is broadly usable. Each of my students came away with something different but wildly positive reviews. Now. I’m signing off. I’ve got to start digging around for some cash… for students wanting to travel to Portland!
Jodi Polaha, PhD, is an associate professor of psychology at East Tennessee State University.
Posted By Tina Schermer Sellers, Lisa Zak-Hunter,
Thursday, December 18, 2014
This is the last of a three part series on real stories from real people who have experienced collaborative triumph.
Several years ago I remember being thrust into the center of a spiritual conflict brewing in the community around a patient of mine. A patient I will call Betty was dying of metastatic breast cancer with metastisis to her brain. She had a strong faith and believed if she doubted her healing, she would not be healed. Because of this she would not allow anyone around her to discuss the possibility of her death. The disease however, from all indications, was progressing and she was in the transitional care unit because she refused hospice. Her friends from church would come visit and they would talk about when she would get out – denying what they all feared. This had been going on for a week. Her oncologist who desperately wanted her to sign a DNR, came to me in a fit of panic, cornered me and said, “Tina, you have to do something! She must sign that DNR! I refuse to code her!” Knowing I could not breech the subject without violating her mandate, I wracked my brain trying to think of what to do. Finally I asked her husband, “Is there anyone she would tolerate the ‘both/and’ conversation of God-only-knows-when-and-if?” He thought about it for a while and then said, “Our pastor.” I said, “Great.” Let’s get him here tomorrow at 2. I will call a meeting with the oncologist, you, me, and your pastor in your wife’s room. The pastor will lead in the both/and conversation and we will take it from there.” The next day, the pastor said the most beautiful thing to her about how we all need to be prepared because none of us knew the mind and heart of God. But someday, he would welcome us and say, “Well done, my good and faithful servant.” Was she ready whether that time was soon or far away?
He honored how they all believed in God’s great power to heal and they trusted God’s wisdom. She was riveted on her pastors eyes and he on hers. After this, the oncologist who had been caring for her since her first dx 6 years prior, came alongside her bed and got nose to nose and in the most tender tone he spoke of how much he loved her and how he had loved caring for her. He spoke of how he believed in God’s healing too, but if God was to call her home now, he did not want to have to code her. How he thought it would break his heart. Tears ran down his cheeks as he spoke. There was not a dry eye in the room. Her husband came in next and spoke of how much he loved her too. Even in the anguish, there was a freedom in his love and tears that we all understood. Unspoken that day, but held in the collective anxiety of our treatment team, was awareness that this dear man had lost his first wife to a tragic car accident twenty years prior and had watched her be coded. He was scared to death to have that experience occur again. He too had been feeling caught between wanting to honor his wife's desire for absolute solidarity and his need to discuss what he most feared.
Even in the anguish, there was a freedom in his love and tears that we all understood
This honoring of faith, meaning, complexity and connection was medicine at its finest and it showed the power and leverage of relationship to heal. The pastor was the only one of us practitioners in the room who was versed in this kind of conversation and who had this leverage with the patient. In fact for the oncologist and I, this conversation of faith, love and death was all rather taboo. But we took the lead of the patient and what it meant to honor them all, and the complexity that was presented, and came up with a creative solution that walked us into that particular necessary taboo conversation. That was one of the first of many conversations of faith, love, community and health to come in my career. But preparation for this type of conversation was not in my training!
We can see the human drives of sexual bonding and spiritual understanding across history and culture. They both have innate power and defy being put in a box. They are unwieldy forces at times. And yet both beg us as practitioners, to acknowledge their core place in the human experience and to find our own comfort in order to walk honorably with our patients on these poignant journeys.
Tina Schermer Sellers, PhD is a recognized scholar in the integration of health into a multitude of areas represented in family and career life. As a behavioral scientist, licensed family therapist and certified sex therapist, she specializes in helping to craft relationships and lives that flourish. Dr. Sellers draws from over 20 years’ experience as a teacher, professor, consultant, trainer and clinician. Founder of the Northwest Institute on Intimacy, she also is a clinical professor at Seattle Pacific University in the School of Psychology, Family and Community and the University of Washington School of Medicine. She lectures nationally and internationally on subjects of sexuality, spirituality, integrated health, family life and career. She lives in Seattle, with her beloved, Gary, and together they have four children.
Anne was in her mid 50s when she was referred to me for care. To her long-time primary care physician (PCP), she was a very friendly and compliant patient. She had struggled with mild depression for years, which her PCP had managed with antidepressants. During one of her medical visits, her husband of almost 40 years, Mark, stressed his worry over her depressive symptoms. Historically, Mark was known to the clinic as ‘worrier’. The PCP was his physician as well and noted there was something different that day about Mark’s concern.
Throughout the time I worked with Anne, her PCP and I worked closely to update each other on psychotherapy progress and findings from medical tests and consults. In our primary care clinic, it is customary for behavioral health to send progress notes and speak to the PCP; we also share an EMR and patients are aware of this. Without this close collaboration, her PCP and I believe Anne’s concerns and crises would not have been handled in a timely and appropriate manner. Neither of us would have had the ‘full picture’.
During therapy, Anne began describing a surprisingly deep, dark depression. This had been ongoing since her teens and she experienced daily suicidal ideation. She felt emotionally numb, disconnected. She insisted her life had been good, and felt guilty that her depressive symptoms were so severe and overwhelming. She felt guilty that she had not told her PCP that the antidepressants had not worked well for years. At first, she wanted to focus on ‘getting Mark off my back’. Mark was invited to session and I addressed his many questions about an accurate diagnosis, prognosis, treatment, and his role. He was clearly concerned and felt left out of this part of her life. Their dynamic followed a classic pursuer-distancer relationship; when depression was strong, she became quiet and reclusive, this terrified him and he repeatedly asked how to help. Anne became overwhelmed and withdrew further.
Anne did not want Mark to return for a while, so we regularly discussed different ways to address their dynamic and include him in treatment, while respecting her desires for privacy. She then very tearfully and hesitantly disclosed she had been abused in multiple ways in childhood. Mark was aware and supportive, but they did not discuss it. Over the next few months, Anne was further diagnosed with posttraumatic stress disorder (PTSD), and we agreed that a referral to psychiatry and a PTSD specialist could be helpful. Eventually she revisited this with Mark. To her surprise, he had not remembered and was overwhelmed. She brought him to our next session so we could address the impact her disclosure had on him and their relationship.
Anne openly wept in gratitude over the degree of care we were providing
Following this visit, Anne’s mood steadily improved. However, she developed new physical symptoms including GI problems, dizziness, and headaches that became increasingly debilitating and interfered with her functioning at work. Her depression worsened. Her PCP was concerned, since his work-up on her was negative. We called a team meeting including Anne, Mark, the PTSD specialist, her PCP, and me. At that meeting, Anne openly wept in gratitude over the degree of care we were providing, spoke frankly to Mark about ways he can continue to support her, described the current depth of her depression, and apologized to her PCP for not being more open about her well-being. Although we hypothesized her physical symptoms were more psychological in nature, her PCP scheduled further testing and consults to rule out anything organic. Her PTSD specialist and I agreed to continue with supportive care until she was more prepared to work through the abuse. Mark also voiced greater understanding after getting a ‘bigger picture’ of what was going on with her and identified specific ways he could support her.
After that meeting, Anne quickly began coming out of her depressive episode. Her GI symptoms persisted for a while and eventually were more manageable. Her tests came back negative, and she continued to meet with her PCP on a regular basis for other health concerns. Throughout treatment, she gave high praise to us for collaborating so well together, felt well-supported and understood by all members of her care team and noted that Mark was more and more appropriate in helping her. She slowly became more open with him about her past and symptoms. He ‘backed off’, as she had originally requested since he felt more connected to her. Although this wasn’t traditional couple therapy, addressing their concerns in our visits and including Mark on the care team greatly improved Anne’s well-being, outcome, and their relationship.
Lisa Zak-Hunter, PhD, LMFT is behavioral science faculty with the Via Christi Family Medicine Residency and Clinical Assistant Professor with the Department of Family and Community Medicine at University of Kansas School of Medicine-Wichita. She earned her PhD in Child and Family Development, specializing in Marriage and Family Therapy, from the University of Georgia. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.
Posted By Montefiore BHIP Team,
Friday, December 12, 2014
This is the second of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week!
Our pediatric practice, which is part of a large, urban medical center, recently experienced a collaborative care “triumph” that we truly believe would not have been possible without our model of integrated behavioral health.When Ms. Perez (all names have been changed to protect confidentiality), a 24-year-old Latina woman diagnosed with cerebral palsy and depression had her first child, Aiden, now age 3, she brought him to see Dr. Gee, who had also been her own pediatrician. Given Ms. Perez’s physical challenges, cognitive deficits, and psychosocial stressors, Dr. Gee referred the Perez family to the Healthy Steps program. Healthy Steps offers developmental and behavioral guidance and support to high risk families and children. Ms. Perez’s trust in Dr. Gee transferred to Dr. Stern, the Healthy Steps Specialist, who worked intensively to support Ms. Perez as she parented Aiden and then Aliyah, who was born approximately 16 months ago. Dr. Stern identified Aiden’s delayed development early. He was diagnosed with persistent developmental disorder, and Ms. Perez obtained Early Intervention support for Aiden. During Ms. Perez’s pregnancy with Aliyah, she became increasingly exhausted and overwhelmed, and struggled with her own mental health issues. Dr. Stern referred Ms. Perez to Ms. Gordon, a Healthy Steps Specialist who focuses on providing individual psychotherapy to the mothers/caregivers of the children in the program. Ms. Perez began attending weekly therapy sessions with Ms. Gordon, in the pediatric practice, as she prepared for the arrival of her second child.
It was clear that her daughter’s health was only the first of numerous stressors
After Aliyah’s arrival, Ms. Perez’s levels of depression and anxiety escalated. Aliyah was born prematurely and Ms. Perez was terrified that she, too, would have developmental issues. Aliyah needed frequent pediatric visits for a variety of respiratory issues, including hospitalization for RSV (Respiratory Syncytial Virus). Dr. Gee saw both children for frequent pediatric appointments, and Dr. Stern continued to provide Ms. Perez with parenting guidance (e.g., promoting healthy sleep, managing challenging behaviors, managing her feelings of anxiety and depression so as to be present to parent). Ms. Scott, the practice’s clinical social worker, also assisted Ms. Perez with concrete services (e.g., housing issues, homemaker application). Ms. Gordon continued to see Ms. Perez in individual psychotherapy, but felt that Ms. Perez would greatly benefit from psychotropic medication. Ms. Perez, however, was very resistant and felt that she was not in need of “pills.” Still, her symptoms worsened.
In mid-September, Ms. Perez presented to the clinic concerned about the health of Aliyah, who was congested and exhibiting increased respiratory effort. During check-in, a nurse who knows the mother very well noted that Ms. Perez was “not her usual bright self” and asked for assistance. Ms. Perez was introduced to Dr. Ray, the psychiatrist who had recently joined the Healthy Steps team. He also noticed that she was overwhelmed and tearful. He provided reassurance and support, highlighting the fact that despite her anxiety, she was making appropriate decisions caring for her sick child. The pediatrician recommended supportive care, Ms. Perez felt some relief, but it was clear that her daughter’s health was only the first of numerous stressors. Others included discord with her husband, avoidance of parents, and a sense of isolation. Dr. Stern joined the session with Dr. Ray, where Ms. Perez acknowledged passive suicidal ideation. Once safety was assessed, Dr. Stern highlighted the fact that the Healthy Steps team had been encouraging her to consider medication for some time. Given the acute nature of her distress, coupled with the fact that she had now established contact with a psychiatrist clearly trusted by the clinic team, she agreed to set up an appointment for a psychiatric evaluation the following week. At the end of the session, Aliyah’s condition worsened and could be quickly re-evaluated by the pediatrician and transferred seamlessly for inpatient admission.
Three days later, Ms. Perez returned to the clinic for both her psychiatric evaluation and her daughter’s post discharge follow up appointment. Due to our integrated services, the appointments could occur back to back. Ms. Perez expressed improved mood, but described multiple stressors leading to anxiety and depressed mood and agreed to a trial on an SSRI. Her time at the practice concluded with a brief meeting with Dr. Stern about sleep training and a meeting with Ms. Scott to construct a plan to allow her to access resources that could alleviate some financial stressors. Finally, Dr. Gee met with her and modeled ways to set limits with her child, as well as reinforced the importance of all of the plans created by the team.
Although it is too soon to know whether our efforts will benefit Ms. Perez and her children in the long term, it is clear that this family has been helped in a way that could only be achieved with collaborative care in an integrated setting. She has improved communication with her parents and husband and as a result has mobilized familial support to help her overcome significant financial, housing, and emotional stressors. She continues to take her medication and keep her appointments. As a result Ms. Perez continues to report improved emotional stability.
The Pediatric Behavioral Health Integration Program (BHIP) integrates universal mental health screening, assessment, treatment, consultation, and referral as needed within all Montefiore Medical Group sites serving pediatric patients. All BHIP team members are housed at the site, share the same EMR, and provide these services. Depending on the size and needs of the site, BHIP team members may include Healthy Steps Specialists (LCSWs or early childhood psychologists), child and adolescent psychologists and/or child and adolescent psychiatrists.
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.