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The Need for Collaborative Care

Posted By Golnoush Yektafar, Wednesday, November 21, 2012
Updated: Monday, December 10, 2012

As a new doctoral student in Marriage and Family Therapy with a concentration on Medical Family Therapy, I have been expanding my understanding of the social context of illness. I have read about the ways in which Western society has placed an important concern on the medicalization of an illness, emphasizes the biological aspects of the physical malady rather than considering the psychosocial-spiritual impacts of illness on the individual and family, and emphasizes the medical provider as the "expert.”

As I continue to learn from the literature about how social context of health impacts health and collaborative care overall, I am also better understanding my personal experiences and how they relate to these ideas.

From the time that I had the ability to comprehend what being "sick” entailed, I came up with a few observations. I often associated "sickness” with medications of sorts, visits to doctors, and feelings of fatigue and irritability. These were the things that I experienced growing up because my father was diabetic and had chronic cardiovascular disease. Ironically, looking at my father’s appearance, he was the epitome of health. A tall and slender man who enjoyed playing tennis and going for daily runs. To my father’s misfortune, the cause of his poor health was based on genetics. My paternal grandparents had both died from sudden heart attacks, and at the time of their death, their social context was a key contributing factor to their inability to gain access to the appropriate medical attention they needed. Living in Iran, a foreign country where the socioeconomic gap between the rich and poor is a problem that still exists today, it was apparent that the wealthy had more privilege in issues related to healthcare access and advanced technologies. Inevitably, these and other social factors prevented my grandparents and father from gaining knowledge on preventative measures when dealing with chronic illness.

Fast forward to three years ago when my father was admitted to the hospital by his primary care physician who after running numerous tests concluded that congestive heart failure (CHF) was the diagnosis. Since my father had a history of chronic cardiovascular illness and diabetes, the doctor informed my family and me that it would be best for him to remain in the hospital overnight. That evening, the cardiologist came in and poked and prodded my father. After asking a few questions, he concluded that the diagnosis of CHF was correct. As he was writing down notes he informed my family that he would be adding a new medication to my father’s existing medication regimen.

 I remember the nurse coming into the room late one night and simply handing my father a cup of water and a small plastic container with about ten different pills. This routine continued for another three days, however the morning of the fourth day was different. As I entered my father’s hospital room I was greeted by a primary physician, a cardiologist, and a nephrologist. They all looked concerned and began their interaction with my family by saying that my father may not be released as early as my family had hoped for. With a panicked look on his face and a trembling in his voice, the primary care physician said that according to recent lab results, my father’s kidneys appeared to not be functioning. A new diagnosis was blurted out; they said it was end-stage renal failure and an immediate procedure had to be done in order to insert a fistula so my father could begin hemodialysis. I remember having a million questions running through my mind, but I could not verbalize a single one. As I muttered out a quiet "Why?” the cardiologist said that the only answer he has is that one of the medications that my father was given to treat the CHF had an adverse effect on the kidneys. Since he was diabetic, he already had under functioning kidneys, but the medication had worsened the existing functioning capabilities of his organs. As the three physicians left the room all I kept thinking and questioning in my mind was how a doctor could not know what medication was contraindicated with another.

As I fast forward to one year after that incident, I have experienced my father not only go through the physical disadvantages that result from chronic illness, but psychological difficulties in dealing with the social context of his illness. The way society perceives him as "ill,” the way our family views him, his role in our family system shifting from breadwinner to someone who is unable to work, and a plethora of other setbacks that had contextual factors that were socially based.

Looking back on this experience as a doctoral student who is interested in medical family therapy, I can clearly see the need for collaborative care between physicians and all those involved with the patients. I have learned firsthand how important it is those nurses, physical therapists, family therapists, and anyone else who interacts with a patient work together in order to provide the patient with the best overall care. My hope is that one day, the social context of illness can be transformed in such a way that all medical professionals work collaboratively with other medical caregivers, patients, and family members in order to best treat the whole patient- mind, body, and soul.

Tags:  collaboration  family medicine  family therapy  Integrated Health 

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The Pros and Cons of Patient Portals: Can Integrated Electronic Health Records Help Empower Patients?

Posted By Peter Y. Fifield, Friday, February 3, 2012
Providers spend a significant amount of time with patients problem solving effective ways to manage chronic health issues. Through the use of Motivational Interviewing for example, providers focus on increasing patient self efficacy; "how do I guide this patient in owning their own health?".

With the rapid grown of Health Information Technology (HIT) I'm optimistic that HIT, specifically the use of patient portals, will provide more tools for not only improving patient satisfaction and reducing costs, but also in addressing another real issue in healthcare: Increasing patient autonomy.


Patient portals become a window of opportunity for managing our own health. Metaphorically speaking it is like maintaining our car with the use of that dusty paperback in the glove compartment: The vehicle maintenance log. We resource the maintenance log to see what work has been done in the past and as importantly, what work needs to be done in the future. To compliment this log, we use the gauges on the instrument panel. We read the tachometer, the gas gauge, and the engine lights to understand what the vehicle needs. These data complete the feedback loop so we now know how to act: Get gas, inflate tires, flush your transmission.  You get the idea.

A patient portal could act in a similar way. Medications, appointment times and blood pressures could all be accessed via the encrypted portal and assist the patient in being a better manager of his or her own body. I can hear it now "there's an app for that"...imagine remote blood sugar sent from the glucose monitor to our medical record via the patient portal. Diet and exercise routines could be managed daily, calorie counts entered at each meal; all of this managed on your own medical portal (and possibly complimentary smart phone applications). Most important, it can all be updated and facilitated in real-time by patients or their HIT devices. There is a market here just waiting to explode.

With such potential, why is it then that so many providers have an issue with the use of patient portals? I heard one physician say: "not on my watch" and a BHC say: "I'm unsure of the benefits here" regarding initiating a patient portal access initiative at a local primary care clinic. In the spirit of investigating this enigma, I have listed a few key components of patient portals below that I think provide the most fodder for the cannon in terms of eliciting arguments from both camps. Just to clarify, in this blog I am referring to patient portal access to the patients own electronic medical record (EMR) not the "never-used" Electronic Health Record (EHR) that are typically little more than a hi-tech headache.

1. Patient portals can be thought of as a gateway to patient data, health record content, and web services associated with the hosting provider. Patients get secure, encrypted access via use of a patient ID and password; a similar process that allows clients access to other very sensitive information such as online banking. Unlike with online banking, medical information is often sensitive information and keeping unwanted eyes from seeing your portal could prove difficult. As this one article shows, the views on confidentiality are mixed.

2. Providers grant patients access via their username and password and through the patient portal, the patient may be able to perform the following tasks:
  • Check their appointment schedules and requests an appointment
  • View lab results and basic patient information such as BMI, BP, and weight
  • Examine medical and billing statements
  • Request prescription refills
  • Complete new patient intake forms and registration information
  • Complete ongoing assessment forms such as PHQ 9, GAD7, DUKE 17, etc.
  • Correspond with medical personal via encrypted email services
An interesting philosophical question here is that if the medical chart really belongs to the patient, why is it the provider that is granting access? Who is really driving the bus here? This may be a reflective residue of the slowly fading paternalistic role providers have played in the past. It could be argued that until the patriarchal paradigm is shifted to give power to the patient, they simply will not have it.

3. Through reviewing provider satisfaction research, one of the most often heard complaints is that the providers do not have enough time with patients. Period! In addition, providers spend significant time discussing symptoms and providing medical advice that they do not bill for. Simply stated, there are too many things to address aside from the Chief Complaint. Through the use of the portal providers and support staff can communicate back and forth with the patients and send messages such as appointment reminders, electronic statements, and lab results.

Historically, part of the provider-patient relationship included correspondence via phone. We could consider the patient portal a very high tech, and easy to facilitate version of that same information exchange, however; it would be more informative for the patient and much easier and less time-consuming for the provider.

4. The patient can complete much of the patient visit information and yearly paperwork prior to the visit. Existing patient intake and medical forms can be uploaded onto the website for the patient facilitating the process for not only the patient and provider, but for the support/office staff as well.

5. All of the interaction on the patient portal can be set to directly integrate into the chart. Although I disagree with this on a philosophical level [see above], pragmatically the medical practice is the ultimate authority regarding how much data is conveyed to the patient. Said otherwise, the patient does not have access to all of the doctor's records at any time. Patients only see what doctors want them to see and thus the physician note remains protected.

Portals could provide more patient access to a very valuable resource: Provider knowledge

Ideally, using a high quality patient portal allows the patient to upload their records to a central repository. The continuity of care between different doctors of different specialties, in different locations, becomes a reality for the self-efficacious consumer.

6. The portal is accessed through the practice’s web site. Educational material [including pdfs, photos videos etc] and links to other websites [i.e.patientslikeme.com, sermo.com, dailystrength.org] can be posted on the web site as well to provide adjunct services and supports. Many practices post educational information such as diabetes information, exercise options, support service information, times and dates of groups being held, diet/meal planning suggestions, and medication information, etc. on their practice web site as a service to their patients.

With the HITEC Act in place, it is reasonable to say that more and more providers will continue to venture into the world of high-tech charting. Patients could have far more access to their provider's vast knowledge by complementing the face-to-face visit with portal access and thus create a more interactive relationship with their medical record.

I see this as exchange of information via patient portal as a compliment to the face-to-face appointment; an extension of the office visit, if you would. Providers are the keepers of an infinite amount of medical knowledge and currently there are 2.7 physicians per 1000 people in the US. The informational bottlenecking lies in the finite space in time providers have to transfer that information to the patient. In a 15 minute visit we all know this is impossible. The patient portal could act as an expansion of this 15 minute window and would allow for more patient access to a very valuable resource: Provider knowledge.

Patient portals are obviously no panacea for the health care crisis. Ultimately nothing replaces patient accountability when it comes to overall health outcomes. However; the patient portal could function as an integral tool in increasing patients’ motivation for healthy living by giving patients access to their own information.

Inevitably technology will continue to play a role in patient care and most likely patient portals will be more widely used.

My question is, why not now? I'd be curious to hear other opinions out there regarding the pros and cons of using patient portals. Is there anyone out there in the CFHA audience already using them? How has it worked? What are your thoughts?


Pete Fifield is the Manager of Integration and  Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

Tags:  CFHA  health information technology  Integrated Health  patient portal 

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Eight Steps for Creating Successful Behavioral Health and Primary Care Partnerships

Posted By Cheryl Holt, Thursday, January 26, 2012
There are numerous initiatives underway that address the primary care needs of people with behavioral health disorders. It is heartwarming to see the silos begin to develop cracks, allowing the primary care folks and the behavioral health folks to engage in serious conversation about how they can work TOGETHER to serve this vulnerable population.

It isn’t easy for two disparate groups to work together. It takes considerable planning, patience, and commitment. Despite the fact that both primary care and behavioral health are healthcare fields, they have vast differences. Their cultures, funding streams, philosophies, and overall approaches to treatment vary greatly. Therefore, it is not an easy task for these two groups to collaborate together to serve individuals with behavioral health disorders….yet they are doing just that! The mission is far greater than are the differences! It is worthwhile to devote the necessary time, energy, resources, and focus to develop strategies for streamlining the integration process. Whether the services are provided in the primary care clinic or in the behavioral health clinic, working collaboratively provides enhanced results.

For a successful behavioral health – primary care partnership, these eight steps that were adapted from "Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, will provide the foundation for success:

· ESTABLISH THE MISSION OF THE PARTNERSHIP
It is vital for both organizations to sit down together and create a shared vision. This will likely require a merging of goals into a partnership mission statement. This mission statement must be communicated with everyone involved in the partnership. The success of the partnership will depend on frontline champions. They need to be identified and empowered from the onset. They will provide the energy to motivate other team members.

· IDENTIFY A COMMON LANGUAGE
Primary Care and Behavioral Health speak different languages; therefore, a common language must be identified. Clarity of communication enhances mutual understanding of cultures, roles, and expectations. While these differences might not seem important at the onset, it will become increasingly important as the partnership progresses. Most likely, each partner has a different language for many things. There are notable differences between contract deliverables, medical records, coding, management structure, procedures, and even the language used in describing the clients/patients/consumers/members/individuals served.

· MAINTAIN PACING, FLEXIBILITY, AND CAPACITY
It is very important to temper expectations within the partnership. Establishing regular meetings will help to promote ongoing communication. Mutual goals and disappointments should be continually communicated so that they can be addressed immediately. The partners must remain flexible in order to sustain a healthy partnership.

· DEVELOP SHARED SOLUTIONS
The decision makers must be open to new ideas and problem solving. Developing shared solutions maximizes organizational efficiency and capacity. Everyone must have skin in the game! Compromise is important for success.

· DETERMINE EXPECTATIONS
The project should first be piloted to allow for evaluation and for adjusting expectations to ensure that both partners are on the same page. Internal conflicts are inevitable and should be discussed openly. The partners must address differences of opinions on an ongoing basis. Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization.

· DELEGATE TRUST
Face-to-face meetings are essential for establishing and maintaining trust among partners. Be sure to focus on building trust at all levels. Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels.

· CREATE EMPOWERMENT
Success is dependent on the involvement of everyone. This requires empowering champions at all levels to move the mission forward. This empowerment develops buy-in among staff. Communicating with everyone and soliciting feedback ensures ongoing focus on the mission. Be sure to create a forum that allows both positive and negative feedback.

· MEASURE OUTCOMES
Establish the outcomes to be measured early in the project. Be prepared to modify outcomes as needed. Don’t overlook the benefits of partnership that include more efficient allocation of resources, less duplication of services, increased choice among clients, and the synergistic effect of the partnership resulting in enhancing the lives of those we serve.
Following these eight steps will assist in bridging the innate differences between behavioral health and primary care to ensure a successful partnership. Far too many promising partnerships have been derailed due to poor communication and lack of planning. Careful preparation at the onset will ensure a productive partnership that will ensure a focused mission aimed at addressing health disparities among people with behavioral health issues.


Cheryl Holt, MA, NCP, BCCP currently serves as the Director of Training and Technical Assistance with SAMHSA-HRSA Center for Integrated Health Solutions for the National Council for Community Behavioral Healthcare. She is moderator of the Behavioral Health – Primary Care Integration Listserv, manages the Behavioral Health Integration blog, and is active in social media: Twitter, @cherylholt and @BHPCIntegration; and Facebook, Behavioral Health Integration


Blog Disclaimer: 

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

Tags:  family medicine  health policy  Integrated Health 

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The Lone Ranger Rides No More

Posted By Brian Bonnyman, Thursday, September 15, 2011
I finished my residency in family medicine in 1993, and returned to my hometown to start work in private practice. My office was located in an affluent suburb, and my patient population reflected that affluence. The patients were generally well-educated, insured, and motivated, and I thoroughly enjoyed caring for them. I had several excellent colleagues in my practice, but we generally worked as solo practitioners under the same roof, only consulting each other on occasional cases. I call this the Lone Ranger model of providing primary care, which is typical for most private practices, and represents the traditional and time-honored way of doing things.

After 15 years of work in this setting, I left that practice and started working across town, at a large urban community medicine clinic. The zip code of my office location changed by one digit, from 37922 to 37921, but those sites are worlds apart. Now my practice includes many homeless people, refugees, recent immigrants, and ex-convicts. The psychosocial disease burden in this population is astonishing, especially compared to my prior practice. As one person put it, the main problem for patients at our clinic is not medical in nature, but that their lives are broken. I have had to dramatically adjust my expectations for patient compliance and outcomes, and change the way I practice medicine. Among the many adaptations I have made in this transition, one of the most pleasant is working as a member of a team (rather than as a Lone Ranger), side-by-side with psychologists. In my old practice, if I thought a patient would benefit from therapy, I would have to give the patient a phone number of a good therapist. I call this referral method sending a message in a bottle, given the low likelihood that the patient would follow through on the recommendation.

If I successfully convince the patient of the benefit of seeing a mental health specialist (which is part of the art of medicine), I can now have a therapist see the patient in the very same exam room after me. I can get immediate feedback and additional history from the therapist. For mental health diagnoses, we collaborate on reaching an assessment, with appropriate treatment and follow-up plans. With this arrangement, we estimate that 80% of behavioral cases can be managed without further consultation. This is not too different than the 90% figure that I always heard represents the percentage of cases seen in primary care that can be managed without further consultation.

I see a significant improvement in the quality of care that I now provide, thanks to working in a team environment with behavioral health specialists. Now, if I have a patient that is non-compliant with diabetes, for example, I can enlist the help of the behavioralist to help treat a medical condition. Patients that are ready to address their substance abuse problems can enroll in a treatment program run by the psychologists. Likewise, I can get patients easy access to treatments that I have read for years are beneficial for a variety of difficult-to-treat conditions, but I could never offer my affluent, insured patients at my prior practice. Motivational interviewing for substance abuse and cognitive behavioral therapy for fibromyalgia are two examples.

Just having another person get additional historical information from the patient can improve quality of care, with little additional cost. Since about 80% of the data I need to arrive at a diagnosis comes from the patient’s history, every bit of information helps. For example, a psychosocial condition unrecognized by me, but detected by the psychologist, can be the key to getting the correct diagnosis of a challenging case. The patient with hypertensive crisis who admitted his cocaine use to the behavioralist (but not to me) comes to mind. Rather than work him up for some obscure cause of malignant hypertension, we could concentrate on his substance abuse. To paraphrase the old medical saw, I have learned that when I hear hoofbeats in the hall, it is more likely to be a horse with a behavioral problem, rather than a zebra!

As a clinician experienced in the ways of the Lone Ranger model, working in a team setting can be difficult in some ways. In a conservative field like medicine that has a history of less-than-nurturing educational methods, teaching an old dog (like me) new tricks can be hard. At times, the learning process can be a challenge to one’s ego, as when I find that my assessment of a psychiatric condition is off base. Recognizing that the correct diagnosis is in everyone’s best interest (especially the patient’s!), and seeing these moments as opportunities for learning help minimize potential embarrassment. Having supportive mental health colleagues is a big plus since their communication and collaboration skills are miles ahead of many of my MD friends, who aren’t used to working in teams. I now realize how much of my medical education revolved around intellectual one-upmanship, and appreciate the importance of creating a mutually supportive collegial environment in the office.

Overall, though, giving up the Lone Ranger role to work as part of a team makes sense, both for providers and for patients. Heck, even the Lone Ranger had a Tonto!


Brian Bonnyman works as a family physician with Cherokee Health Systems in Knoxville, Tennessee. He enjoys treating patients of different cultures, who cannot easily obtain care elsewhere. Habla un poquito de español, tambien.

Tags:  Cherokee Health  family medicine  Integrated Health  primary care 

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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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