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A Call to Engage Youth in Collaborative and Integrated Care: Part 2

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 30, 2011
Last week In my previous blog entry, I advanced a call to purposively engage youth in our efforts in collaborative and integrated care. As I have spoken-up regarding this topic across a variety of forums with colleagues, most have initially responded with a strong sense of enthusiasm, followed by a want for evidence that such efforts can be effective.

I have been involved in several community-based participatory research (CBPR) projects in health since beginning my current position at the University of Minnesota, and have seen time-and-again how professionals and patients learn new ways of working together that are different from conventional top-down/service-delivery models of care-provision (i.e., wherein professionals learn to function as citizens of the research process (vs. rigid leaders of it), and patients learn to not instinctively look to professionals for leadership or answers (and to instead work to tap resources within themselves and their communities that have heretofore not been tapped)). Generally this process evolves over several months as a new project begins and/or for new members to orient and function within CBPR-principles. However, I have noted that young persons appear to learn and adopt these principles very quickly (usually faster than adults), and they do extraordinary work.

The SANTA project (Students Against Nicotine & Tobacco Addiction), for example, is a health initiative that engages local medical and mental health providers in partnership with students, teachers, and administrators in a Job Corps training site/community to reduce on-campus smoking. The project has endeavored to better understand the causes of students’ smoking behaviors; change the campus environment in ways facilitative to stress-management and boredom-reduction; revise the manners in which smoking cessation and support services are conducted; and establish the project as a sustainable and stalwart presence on-campus. Every facet of SANTA’s efforts is owned-and-operated by its students, which is a driving force behind its sustainability and integration into campus culture. Since its establishment in 2005, campus-wide smoking (including new and established students) has decreased from almost 60% to 36%, and evaluations across several cohorts of students show that smoking rates decrease significantly with prolonged exposure to SANTA interventions (Mendenhall, Harper, Stephenson et al., 2011; Mendenhall, Whipple, Harper et al., 2008).

The ANGELS project (A Neighbor Giving Encouragement, Love & Support) is a health initiative through which adolescents and their parents who have lived experience with diabetes (called "support partners”) are connected with other families (called "members”) who are struggling with the illness. These efforts begin at the time of diagnosis, which occurs almost universally in the context of an emergency hospitalization. It is during this time that the initiative’s teens maintain that they want the ANGELS to connect with members, because the motivation to adopt healthy lifestyles is the highest at a time of crisis. Support partners and members meet in a variety of combinations (e.g., adolescents with adolescents, parents with parents, families with families), and they continue to meet off hospital grounds (or via telephone, e-mail, internet discussion boards) after initial hospitalization. Sometimes members simply need a pep talk; other times ongoing support is offered for several months (Mendenhall & Doherty, 2007; Mendenhall & Doherty, 2005).

Other arenas that I and my colleagues have worked in to engage youth in health care include physical activity, obesity, teen pregnancy, and interpersonal violence. Across all of these initiatives, our youth have risen to the challenge of taking an active part in their own health (Berge, Mendenhall & Doherty, 2009; Doherty, Mendenhall & Berge, 2010; Mendenhall, Berge, Harper et al., 2010; Mendenhall, Doherty, Baird et al., 2008; Doherty, Mendenhall, & Berge, 2010).

So why is it that teenagers appear to have less difficulty in learning how to work with providers in the PCMH and/or in CBPR? Is it because they have not yet been socialized into the conventionally passive patient-roles that are so consistent with conventional Western health care and/or "standard” education? Is it because they have not yet been socialized to presume that "real change” (however defined) takes a long time?

Honestly, I am not sure that it matters. What is important is that we not leave our youth on the sidelines as we advance our efforts in collaborative and integrative care. As we work to engage them, we will bestow in our youth the honor and confidence that they can take responsibility for their health and well-being. Their voice(s) and involvement represent an essential piece to a larger puzzle, and they are up for the task.

References:

Berge, J., Mendenhall, T., Doherty, W. (2009). Targeting health disparities though community-based participatory research. Family Relations, 58, 475-488.

Doherty, W., Mendenhall, T., Berge, J. (2010). The Families & Democracy and Citizen Health Care Project. Journal of Marital and Family Therapy, 36, 389-402.

Mendenhall, T., Berge, J., Harper, P., GreenCrow, B., LittleWalker, N., WhiteEagle, S., BrownOwl, S. (2010). The Family Education Diabetes Series (FEDS): Community-based participatory research with a Midwestern American Indian community. Nursing Inquiry, 17, 359-372.

Mendenhall, T., Doherty, W. (2007). The ANGELS (A Neighbor Giving Encouragement, Love and Support): A collaborative project for teens with diabetes. In D. Linville and K. Hertlein (Eds.), The Therapist’s Notebook for Family Healthcare (pp. 91-101). New York: Hayworth Press.

Mendenhall, T., Doherty, W. J. (2005). Action research methods in family therapy. In F.
Piercy, D. Sprenkle (Eds.), Research Methods in Family Therapy (2nd Edition) (pp. 100-118). New York: Guilford Press.

Mendenhall, T., Doherty, W., Baird, M., Berge, J. (2008). Citizen Health Care: Engaging patients, families and communities as co-producers of health. Minnesota Physician, 21(#12), pp. 1, 12-13.

Mendenhall, T., Harper, P., Stephenson, H., Haas, S. (2011). The SANTA Project (Students Against Nicotine and Tobacco Addiction): Using community-based participatory research to improve health in a high-risk young adult population. Action Research, 9, 199-213.

Mendenhall, T., Whipple, H., Harper, P., Haas, S. (2008). Students Against Nicotine and Tobacco Addiction (S.A.N.T.A.): Developing novel interventions in smoking cessation through community-based participatory research. Families, Systems & Health, 26, 225-231.



Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program, and holds an adjunct faculty position in the UMN's Department of Family Social Science. Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

Tags:  Behavioral Health  family therapy  medical 

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A Call to Engage Youth in Collaborative and Integrated Care: Part 1

Posted By Tai J. Mendenhall, Ph.D., LMFT, CFT, Thursday, June 23, 2011
The call for interdisciplinary collaboration in health care is a longstanding one, and our collective efforts to do this are evolving across medical- and mental health- training programs and care facilities today more than they ever have. Recent advancements in the Patient Centered Medical Home (PCMH) movement are arguably pushing team-based approaches in continuous and coordinated care toward the middle of the bell-curve, wherein someday soon our integrated models will represent the rule (not the exception) to how health care is done.

My experiences as a clinician and researcher in this exciting time in health care have exposed to me to a variety of definitions of what "integrated”, "collaborative”, or "medical home” sequences looks like, and efforts by the CFHA and others to standardize and clarify these characterizations are presently underway. However, while common themes throughout these descriptions encompass the collaboration between professionals who represent different disciplines (e.g., a family physician with a marriage and family therapist) and/or the collaboration between professionals and patients (i.e., encouraging and facilitating patients to take active roles in their own health), most hallway conversations, formal presentations, research studies, professional literature, and clinical work that I have taken part in (or am aware of) around the PCMH frame patients as adults.

I believe that it is important to extend our call to engage "patients” in collaborative and integrated care to purposively include children and adolescents. I support this call on two primary grounds:

• First, many of the most prevalent and difficult presentations in health care today (defined as those that are the most common, most expensive, and/or most connected to co-morbidities and death) begin early in life. Diabetes, for example, is highly correlated with cardiovascular diseases (which represent the #1 cause of death in the United States), kidney disease, reduced or lost vision, amputations, and depression – and is directly connected to the rising epidemics of childhood obesity and sedentary lifestyles of America’s youth. Smoking is similarly correlated with cardiovascular diseases (as well as asthma, diabetic retinopathy, optic neuritis, influenza and pneumonia) – and most smokers (up to 90% of them) begin as teenagers or young adults. Put simply, then, it is easier to prepare than it is to repair. By engaging patients in health-related activities early in life, it is more likely that they will avoid experiencing commonplace troubles later on down the road.

• Second, the advancements of the PCMH and parallel efforts in community-based participatory research (CPBR) bring with them a sharing of responsibility between providers and patients. While providers maintain responsibility for learning and appropriately using knowledge in the prescribing of medications or performing medical procedures, for example, patients maintain responsibility for managing their diets, physical activity and other health-related behaviors. This is important to note because it transcends conventional provider/consumer models in which passive patients are rendered care (i.e., "fixed”) by all-knowing/all-powerful providers. And just as adult patients must assume responsibility for their own health within the PCMH, so to should children and adolescents. As we encourage and facilitate our youth to do this, a new generation of active (not passive) patients is born.


As I have advanced the call for active engagement of youth in health care across a variety of formal and informal meetings with colleagues, almost everyone has agreed that the idea carries a great deal of face-validity. They add that, too, that oftentimes kids (read: teenagers) will listen to each other more than they will to an adult, and that facilitating care sequences and/or supportive interventions that allows for this may offer a great deal.

But it’s when my colleagues ask about evidence of such efforts being effective that I really light up. Beyond the (admittedly limited) articles that any of us could find through a literature review regarding youth-engagement in health, I have been involved in several such projects since beginning my current position at the University of Minnesota. In my next blog entry, I will highlight some of these projects – and the extraordinary work our youth can do as we facilitate their active participation in care.

*This is the first of a two part blog on engaging youth in collaborative and integrative care.




Tai Mendenhall is an Assistant Professor at the University of Minnesota (UMN) in the Department of Family Medicine and Community Health, the Associate Director of the UMN’s Citizen Professional Center, and the co-Director of mental health teams within the UMN’s Academic Health Center / Office of Emergency Response’s Medical Reserve Corps (MRC). He is the Coordinator of Behavioral Medicine education at the UMN / St. John's Family Medicine Residency Program, and holds an adjunct faculty position in the UMN's Department of Family Social Science.  Dr. Mendenhall’s principal investigative interests center on the use and application of community-based participatory research (CBPR) methods targeting chronic illnesses in minority- and under-served patient and family populations.

Tags:  Behavioral Health  community health  family medicine  Integrated Health  medical  Youth 

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