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Retirement: It's Not Just the Money

Posted By Matthew P. Martin, Tuesday, November 11, 2014

  

Several years ago, a friend of mine went to see her primary care physician for her blood pressure. After reading her vital signs, the physician was concerned and began asking my friend about exercise and eating habits. “Yes, I exercise regularly and watch what I eat” my friend said. “Well, your blood pressure is much higher than usual. What else is going on in your life right now?” “Nothing much. My husband and I are planning a trip but that’s about it”.

The physician thought for a moment and then asked “Isn’t your retirement coming up?” That question shook my friend like a Polaroid picture. She suddenly realized how worried she was about retiring from a job that meant so much to her. “Yes, it is! And I am so scared to stop working.” She and the physician discussed some options for preparing for retirement and then ended the visit. My friend eventually retired not just once, but three times in total. She loved working so much it took several down shifts for her to become fully retired.

Retirement involves the loss of two characteristics: Income and status 

Retirement is a double-edged sword: it can be absolutely exciting or just plain terrifying for older adults. Most people think retirement, and all the devilish details that come with it, is all about money. People who think that way are either financial advisors or too young to vote. It’s more than just about the Benjamins. Retirement involves the loss of two very important work characteristics: income and status. Can both of these losses affect health? You bet. 

 

Now, please fasten your seatbelt. I am about to throw down some fast facts on retirement. 

Did you know?

The average American works 90,000 hours during a lifetime but spends 10 hours planning for retirement1

The over-85 age group is the fastest-growing segment of the population2

About 40% of Americans between 51-60 years of age have no pension income other than Social Security3

The median age of retirement is 60.6 years3

Those with poorer health retire earlier, especially African American men3

Unhealthy women tend to work longer because of inadequate income3

One out of four men aged 60-65 return to work after retiring3

Retirement is a relatively new concept. Before 1935, when Social Security was inaugurated, retirement was rarely considered by most Americans. In 1950, 45% of Americans 65 and older were working. Today, about 20% in that age group are working4. Even though retirement is more common today, it is NOT common for individuals and couples to be physically and mentally prepared for it. It’s even rarer for health professionals to inquire about a patient’s readiness for or adjustment to retirement. When is the last time a doctor asked you if you were emotionally prepared to give up your identity as a full-time worker for retirement?

 

 

Retirement is a many-splendored thing, fraught with opportunities and challenges. Some of the challenges include real health risks like increases in illness conditions (e.g., blood pressure, diabetes, and congestive heart failure), difficulty with activities of daily living, and a decline in mental health5. Some of these are attributed to the lifestyle changes that accompany swapping an office chair for a beach chair (i.e., decreased activity, fewer social interactions) and because many people retire DUE to health reasons. 

There are also several psychosocial challenges that come with getting off the work treadmill including identity change, questions of self-worth, limited social activity, asynchronous retirements in marriage, and more6. Here are some things you might hear an individual say:

“I was a supervisor for almost thirty years but now I’m fiddling around in the garage all day”

“My last job was creating new chemical solvents for Texaco Chemical. Retirement has left me without much purpose”

“I’ve enjoyed my retirement for the past two years by traveling and learning to paint. Now what do I do?”

“All of my friends are still working. Can I still spend time with them?”

Here are some things you might hear a spouse or partner say:

“She doesn’t have time to enjoy my retirement with me”

“I have things of my own to do but he just follows me around all day”

“I love having him home but now he tries to tell me how to do the laundry”

Delaying retirement age may lessen or postpone poor health outcomes 

Retirement is especially challenging when it’s unexpected due to health, family, or work pressures because then retirement becomes a necessity instead of a celebration. Moreover, retiring early is not always ideal. Delaying retirement age may lessen or postpone poor health outcomes, improve wellbeing, and reduce health care utilization7. Several protective factors can help individuals smooth the transition into those golden years including marriage, social support, physical activity, and part-time work7. 

 

 

Is money important for retirement? Without a doubt. AND (notice the absence of “but”) so is health including emotional and social wellbeing. Should a patient invest in a nest egg? Yes! Should she also mentally prepare for the huge changes in identity, status, and social activity? Absolutely. AND (I seem to have misplaced that word “but”) health professionals can play a big role.

Here are 7 things health professionals can do to support patients planning for or adjusting to retirement:

1.      Ask about retirement plans

What are your plans for retirement?

What have you and your family discussed or decided?

What concerns you about retirement?

What excites you about retirement?

2.      Ask about retirement adjustment

How are you adjusting to retirement?

What has gone well? What has not gone well?

How can I help you adjust even better?

3.      Collaborate with family friends, and other health professionals

4.      Conduct a thorough assessment of health risks, social support, and mental health

5.      Suggest a self-help book

What Color is Your Parachute?

How to Love Your Retirement

6.      Refer to financial advisor or life coach

7.      Watch out for unexpected retirements. These are the patients who may need the most attention. Love them, support them, and connect them with resources.

References

1.      Cavanaugh, J. (1997). Adult Development and Aging. Albany, NY: Brooks/Cole Publishing Company.

2.      The Center for Mature Consumer Studies. http://robinson.gsu.edu/magazine/aging.html

3.      Foos, P.W., & Clark, M.C. (2008). Human Aging. Boston, MA: Allyn and Bacon

4.      U.S. Department of Labor, Bureau of Labor Statistics

5.      Dave, D., Rashad, I., & Spasojevic, J. (2007). The effects of retirement on physical and mental health outcomes. Andrew Young School of Policy Studies: Research Paper Series, October(2007), 1-47.

6.      Cox, H., Parks, T., Hammonds, A., & Sekhon, G.(2001). Work/retirement choices and lifestyle patterns of older Americans. Journal of Applied Sociology, 18(1), 131-149.

7.      Dave, D., Rashad, I., & Spasojevic, J. (2007). The effects of retirement on physical and mental health outcomes. Andrew Young School of Policy Studies: Research Paper Series, October(2007), 1-47.

Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at matt.p.martin@gmail.com

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Finding a Rhythm Where There is None: Medical Family Therapy in a Pediatric Intensive Care Unit (PICU)

Posted By Alex Schmidt, Tuesday, October 28, 2014

Last year, I began working as a medical family therapy (MedFT) intern in a pediatric intensive care unit (PICU). During my master’s program, I worked as part of a collaborative treatment team in a clinic serving patients with neuromuscular disorders. I loved the steady, consistent pace of this bustling clinic and the team with whom I worked. Although many of my skills in designing behavioral health interventions transferred to this new setting in the PICU, I quickly realized there were significant differences between an outpatient adult neurology clinic and this pediatric intensive care setting.

 

 

In the PICU, there are more frequent changes of physicians and nurses as shifts rotate, no opening and closing hours, and an expansive variety of injuries and diseases being treated. In the past year, I have worked with patients and their families facing diabetes, cerebral palsy, hydrocephaly, seizure disorders, rare neuro-genetic disorders, leukemia, and accidental and non-accidental injuries including suicide attempts. This vast array of illnesses provides me the freedom to be curious and briefly research many different types of diseases. However, this has also presented a substantial challenge to my ability to accumulate a great deal of knowledge quickly. 

In the early weeks on the job, I felt like I was trying to grasp onto a rhythm when the genre and pace of the music kept changing. At the same time, I was also very aware that I was the first MedFT intern to join this multidisciplinary PICU team. This meant that a significant part of my job has included educating medical providers about how I, as a medical family therapist, can improve patients’ experiences by helping meet essential needs of their families. As a supportive team member, I also serve as an outlet for the staff to process the social, emotional, and mental stresses inherent in this type of work.  

I was trying to grasp onto a rhythm when the genre and pace of the music kept changing 

By now, it seems cliché to say that working in a medical setting requires a great deal of flexibility. What may be cliché is also powerfully true, as I have seen in my experiences. There is simply no way to predict with certainty when a patient might develop an infection, when parents’ bosses may tire of being patient and demand a return to work, or, in the most devastating of cases, when a patient might die after an unexpected complication from treatment. As a MedFT intern, I have become accustomed to receiving calls for consults during weekends, holidays, and evenings since, not surprisingly, illness does not operate on a schedule. Whether you are a patient, a parent, or a provider in the PICU, you learn to expect the unexpected. 

 

 

I receive consults from charge nurses, hospitalists, and intensivists for a variety of reasons, including: patients with a history of treatment noncompliance, families experiencing significant emotional difficulties due to a devastating diagnosis, families struggling to elicit social support from others, and families appearing hesitant to answer questions from the medical providers. Whereas physicians carry a large case load of patients and are responsible for managing a great deal of information, I have the luxury of time and the training to sit a with a family in uncertainty for as long as they need – sometimes 15-20 minutes, and sometimes upwards of an hour in crisis situations. In sessions, I typically aim to meet several goals

·         Elicit the family’s illness story beyond simply tracking physical symptoms,

·         Assess for emotional, relational, spiritual, and physical needs that can be met during the family’s hospital stay,

·         Identify any barriers to meeting these needs and creating a plan of action, and

·         Identify the family’s level of satisfaction with and comfort with making requests for more information or additional support from the treatment team. 

In alignment with family-centered care principles, I overtly state to family members that I view them as essential partners in providing the highest standards of care for the patient. I make it known that, regardless of the circumstances, I value the wisdom and concern of family members. One of the first things I often say to parents and caregivers is, “I know most people here have probably asked you about how your child is doing, but my job is being aware of how this hospital stay is affecting your entire family. How are you doing?” Usually, this is met with a tired half-smile and “I’m doing ok, now that he’s doing better,” “I feel like I’m losing my mind,” or “You know, I haven’t even stopped to think of that.”

Working in an intensive care unit also requires intensive self-care 

 

This simple question reinforces for families that we, as a collaborative treatment team, realize that our patients’ lives do not exist in a vacuum only large enough for medical history. Rather, we recognize the importance of our patients’ relationships. Our team extends beyond those of us with clinical experiences in hospitals and degrees after our names to include those who love the patient most and know their innermost dreams and the sounds of their heartbeats.  

I have found it helpful to remind myself that working in the intensive care unit also requires intensive self-care. This work is adventuresome and thought-provoking and invigorating, but there are also days when it is draining. There are days when my heart aches for families who are in so much pain that I break into tears as soon as I get into my car. Caring so deeply for these patients and their families encourages me to care for my own spiritual, emotional, physical, and relational health so that I can continue to give my very best and deepest caring to those with whom I work.                                 

I have found that I am a better dancer when I don’t think too much about finding the rhythm in the music. By following my instincts and trusting in my training, my dance steps become more fluid, more like me, and more in sync with the music. Over time, I have found the same to be true of working as a MedFT in the PICU. By learning to let go of a need for a static job description, unambiguous answers, and a certain structure, I believe I have found my rhythm.

 

Alex Schmidt is a doctoral student in Marriage and Family Therapy at Texas Tech University. She currently works as a medical family therapy intern at Covenant Women and Children’s Hospital in Lubbock, TX, and she is a Licensed Marriage and Family Therapist-Associate (TX). Her clinical interests include working with patients in intensive care settings and patients with neuromuscular disorders. Her research interests include factors influencing the comfort of therapists in working with patients facing life threatening illnesses, the collaboration experiences of medical family therapists, and families’ experiences of raising an adolescent with diabetes.

 

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Finding Family at the 2014 CFHA Conference

Posted By Administration, Tuesday, October 14, 2014

The Families and Health Special Interest Group welcomes you to the 2014 annual conference of the Collaborative Family Healthcare Association! We have prepared this document of suggested concurrent education sessions for conference attendees who are interested in a special focus on families and health.

 

Period 1: Friday, October 17, 2014 10:30am – 12:00pm

 

A1a: The Case for Utilizing Psycho-educational Multiple Family Groups (MFGs) in Medical Settings: Our 25-Year Experience with the Ackerman Institute MFT Model (Peter Steinglass, MD & Talia Zaider, PhD)


Although MFGs have been enjoying increasing popularity in medical settings, they still remain very much underutilized. To take up this challenge, for the past 25 years we have been implementing a manualized version of an MFG in a wide variety of clinical settings, including community hospitals, a tertiary care cancer center, and out-patient settings. Join us for a whirlwind review of our MFG experiences, and a discussion of why this model can be so effective and has been so positively endorsed by participating families.”   Based on innovative models, this presentation will describe ways that providers can work with families living with diabetes across both community and tertiary care environments. Participants in this interactive session will be able to: 1) describe multiple ways that providers partner with families to better manage health, 2) identify how these collaborative efforts can lower diabetes-related health care costs, and 3) apply these skills in their own professional and community networks to target a broad range of chronic health conditions.” 

 

Period 2: Friday, October 17, 2014  1:30pm – 3:00pm

 

D2a: Integrated Treatment of Child Obesity and Overweight in the Primary Care Pediatric Setting (Timothy Marean, MD, & Jennifer Fontaine, PsyD)

 

“The Healthy Kids Program at Evans Army Community Hospital is a fully integrated, evidence-based, collaborative approach to treating childhood obesity and overweight that includes a pediatrician, a psychologist, the patient, family members, and a dietician. The team works together to identify, assess, educate, and motivate children and families to develop healthy lifestyle behaviors that lead to improved health outcomes, currently tracked and measured in our clinic through an ongoing performance improvement research project. The program combines current American Academy of Pediatrics (AAP) recommendations for medical treatment of obesity, as well as several evidence based behavioral interventions (including motivational interviewing), eventually leading to improved patient outcomes.”  

 

Period 3: Friday, October 17, 2014  3:30pm – 5:00pm

 

D3a: What Do I Do with this Family? Healthcare Innovations Using a Relational Lens (Tai Mendenhall, PhD & Jennifer Hodgson, PhD)

 

  This interactive workshop will offer a synthesis of contemporary advancements in healthcare using a relational lens through medical family therapy (MedFT) training, research, policy, and financial models. Presenters will highlight and draw from their recentlypublished text, Medical Family Therapy: Advanced Applications, wherein established and rising leaders across multiple disciplines have contributed cutting-edge knowledge about how to make the Triple Aim a reality in the ways that we prepare for, organize, practice, fund, and sustain care. From new trainees to seasoned practitioners, educators, administrators, and policy makers, participants will walk away with newfound energy and resources to take part in this exciting evolution. 

 

G3a: Beyond the Exam Room: Leveraging Perinatal Data to Increase Father Involvement and Improve Maternal-Child Health Outcomes (Mark Thomas, PhD)

 

With the proliferation of electronic medical records (EMRs), providers have increased opportunities to leverage EMR data to improve health outcomes among the populations for whom they care. This presentation will describe the results of research that examined perinatal health data to identify predictors of low father involvement, which is often associated with poor maternal-child health outcomes. Participants will learn how the perinatal data contained in an EMR can be leveraged to proactively identify and intervene with at-risk populations.   

 

Period 4: Saturday, October 18, 2014 10:30am – 12:00pm

 

A4a: What’s Next? Advancing Healthcare from Provider-centered to Patient-centered to Family-centered. (Kaitlin Leckie, MS, Randall Reitz, PhD, Peter Fifield, MA, & Keith Dickerson, MD)

 

  With equal parts real-life application and hopeful idealism, this session presents the recent history and near future of healthcare's evolution. We outline the strengths and limitations of the paradigm shift toward patient-centeredness, and make the case that the full vision of "moving from fragmentation to integration" will only be achieved in a model that places family at its core. Direct application to care planning, care coordination, and health information technology provide take-home value. 
   

 

A4b: Putting Family at the Heart of the Collaborative Healthcare Team (Barry Jacobs, PsyD)

 

Family caregivers play essential roles as hands-on care providers, care coordinators and treatment effect observers for America's burgeoning numbers of chronically ill patients. Yet few collaborative care models embrace patients' family members as full-fledged team members. In this workshop, we will outline five ways for family members to be effectively integrated into healthcare and social service interventions from gaining recognition in the patient chart to granting access to professionals' treatment notes to practicing shared decision-making.   

 

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Doctors, Therapists, & Moms

Posted By Katharine Sileo, Tuesday, September 30, 2014

9-16% of new mothers experience some form of post-partum depression. As my friends started to have children I noticed how they were changing after childbirth. My first thought was that being a parent is hard and they’re just going through a transition period. However, I started to notice some friends were becoming extremely depressed, displaying OCD like symptoms or expressing hopelessness. I began to wonder why my friends were reacting to this life change so powerfully and why it was going unnoticed.

 

 

I started asking questions. The most informative and moving answer I received was “being a new mother is hard, but feeling like you should be happy, and not feeling happy, is even harder.” This conversation sparked my interest in post-partum depression and other perinatal mood disorders.

For many women, childbirth brings about feelings of extreme anxiety, depression and OCD tendencies. When mothers are experiencing these symptoms, they often feel lost and alone. When mothers struggle, the whole family struggles. Under these circumstances children are less likely to form secure attachments, marriages experience more difficulties and men begin to experience similar symptoms of depression and hopelessness.

As a clinician I am interested in the relationship between these symptoms, the tendency to ask for help, and the availability of that help. I explored the relationship between perinatal mood disorders, new mothers and their doctors. I was interested in whether or not the doctors identified their symptoms before they became harder to manage and if doctors were able to assist them in finding help. Beyond this, I was interested in whether or not the doctor and therapist were able to work collaboratively with the mother to discover the most beneficial treatment plan.  

Because of her perinatal mood disorder she experienced postpartum psychosis

To research this I met with a few mothers who experienced postpartum depression and listened to their personal stories. These women differed in many ways, from how many children they had to what post-partum symptoms they experienced. One of the women I had the pleasure of speaking with has four children under eight years old and is a full time working mom. She experienced post-partum depression after all of her children except the first. Her OBGYN suggested that she may be “having a hard time” and began prescribing anti-depressants, with no referral to a therapist. While this was a good catch on the part of the doctor, I wonder what would have happened if she was also referred to therapy. Her last episode of post-partum depression landed her in the UNC inpatient hospital. One of the other mothers that I spoke to reported that, with the help of anti-depressants, but no therapist, she lost custody of her daughter. Her perinatal mood disorder became so severe that she experienced postpartum psychosis and attempted suicide. While we cannot be sure, we can presume that with the help of therapy these women may have experienced different outcomes. I believe that this is evidence for greater collaborative between doctors and therapists. 

 

My goal in writing this blog post is to not only normalize the concept of postpartum depression and perinatal mood disorders but to inform mothers, fathers, doctors and therapists that there is a need for collaborative care in mental health. Providers can take the first step in officering collaborative care by encouraging their clients to sign releases allowing providers to share information. Ideally, collaborative care teams would consist of therapists, OBGYN’s and primary care doctors or pediatricians. They would collaborate on treatment plans, medication management and any changes that the client is experiencing.  Some barriers to collaborative care are the time that it takes for busy professionals to collaborate, as well as, the fact that many clients may refuse to sign releases allowing doctors to share information.

While there are many positive outcomes to be achieved if collaborative care became standard practice, we are far away from this being the standard. As the arena of mental health continues to gain recognition in the media and reduces its stigma, both patients and clients alike will feel more comfortable with collaborative care techniques.  It is becoming increasingly important to understand mental illness and figure out ways in which we can enhance awareness and help people have access to more resources; collaborative care is a promising first step. 

 

Katharine Sileo, MA, LMFTA is the co-owner of Mathews & Sileo Therapy Services in Cary, NC. Katharine completed her undergraduate degree in Psychology from North Carolina State University. She graduated at the top of her class from Pfeiffer University and received her Masters Degree in Marriage and Family Therapy. Katharine fell in love with Medical Family Therapy after interning at Duke Cancer Patient Support Program. www.raleighcarytherapy.com 

 

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The Dialectical Tension of Cultural Attunement in Collaborative Care

Posted By Katie Heiden-Rootes, Ariel Jones, Tuesday, September 16, 2014

It is highly likely that you took a “multicultural” course in graduate school. It is also likely that you heard terms like cultural “competence” that led you to believe that you were obtaining a level of professional competence for working with families who are different than you. However, it is also likely that you, like us, did not actually feel “competent” once you began working in the field. Perhaps you became painfully aware of your own lack of knowledge about different cultural groups, noticed inherent privilege you walked around with, or felt personal pain related to the oppression you’ve faced in life.

 

 

Falicov1 proposed a model called Multidimensional Ecological Comparative Approach (MECA) which seeks to embrace the dialectical tension of: 1) having knowledge about different culture groups and 2) acknowledging that we can’t know all of the different aspects of each culture given how different cultural identities interact to create unique ecological niches for families/individuals. Ecological niche refers to the particular location of a person’s cultural identity given their multitude of experiences – socioeconomic, race, religion, immigration status, education, marital status, children, etc. We need to hold in dialectical tension this knowing (e.g., many Latino immigrants adhere to traditional family values) and not-knowing (e.g., how individuals enact traditional family values when they are third generation Latino immigrants who are U.S. college graduates) in order to manifest a clinical and personal skill called cultural attunement. 

The not-knowing stance can be likened to cultural humility, a popular concept in family medicine. Cultural attunement then is a personal and professional skill requiring the uncomfortable holding of two dialectical truths – knowing things and not knowing things about the cultural realities of the people we treat – and then enacting curiosity and empathy to understand the client/patient.

Two dialectical truths - knowing things and not knowing things 

In collaborative care, cultural attunement is vitally important for improving health disparities for people of color 2. The ecological niche inherently challenges stereotypes of different cultural groups through critical examination of the dynamic nature of cultural identities for a given individual – including the patient and other care team members (e.g., family therapists, physicians, social workers, etc.). The outcome of such examination could be improved interdisciplinary communication that manifests into better patient-centered care. To explore the various ways cultural attunement is imperative in collaborative care, the following case study is offered. As an intern, within Saint Louis University’s Medical Family Therapy program, I (Ariel) had the opportunity to work in a collaborative care setting with many such professionals.  

 

Case Example

A Latino family came into the clinic identifying a 36-year-old female, Maria, as the patient in need of care.  Maria (who spoke limited English) and one other female family member (acting as a translator) were brought back to an exam room while the rest of the family remained in the waiting room, per instruction of the clinic staff. Maria complained of leg cramps, which made walking difficult though was unsure of the cause of her pain. She went to a chiropractor however who did not help the pain.

Upon examination, the team of doctors and staff found no major issues with her leg. When explaining this to Maria, she became emotional and began sobbing loudly. Many members of the team were very unsure about what was happening since it was believed that good news was being delivered. As the medical family therapist, I (Ariel) was called into the room to meet with Maria due to her emotional response to the seemingly good news. During this time, I found out that there was extensive family in the waiting room, many of whom Maria had requested join her in the exam room to also meet with the doctors and staff. 

While I had some knowledge about Latino culture there were still many aspects of this family’s unique ecological niche that were unknown to me. I invited back the entire family and they shared that their father had passed away recently due to complications with his leg after receiving inadequate medical attention. The family feared that this same issue was occurring with Maria. Thus, they felt it was vital to have an opportunity to discuss these concerns with the doctors. It became clear that Maria’s sadness in response to “seemingly good news” was entirely reasonable given her and her family’s fear of receiving poor medical attention and suffering the loss of another beloved family member. I then met with the family and the medical staff to share this new information and the doctor returned to the room to explain the results of the testing with the entire family.

Many aspects of this family’s unique ecological niche were unknown to me

Analysis

This clinic serves many low-income and minority patients. Since I (Ariel) am a black woman, I am often seen as an expert on the lives and cultures of many of the clients that are seen in the clinic. And while I have some knowledge of these cultures, the uniqueness of every family, patient in a given ecological niche is generally unknown to me. At one point, the lead doctor made the final decision saying it was best to have one female family member come into the room to increase Maria’s comfort. And while there were several reasonable arguments for this decision, I saw the inherent gender and professional power imbalance. Given the existence of patriarchy in some Latino cultures it seemed to me that it would be most beneficial to have a male family member present to speak with the male doctor. 

In retrospect, the family’s disclosure to me of their father’s death and concerns about medical treatment likely occurred due to cultural attunement happening between us. Several contextual factors seemed to promote this: the removal of the male doctor, allowing the male family members to enter the room, and my own status as a person of color. Dialogically, I assumed both a knowing (inviting in the family) and a not-knowing position (being curious about the emotional response) enabling the family to tell their story and for me to hear it and respond. This is the essence of cultural attunement.

Conclusion

Cultural attunement in collaborative care requires holding difficult conversations about the nature of presumed “knowing”. 

When exploring cultural dynamics as part of a care team, it is important to note the implicit and explicit hierarchical differences between the care team members and between patients and providers. Explicit titles and job descriptions and implicit cultural norms and identities define our ecological niche making possible the interaction of a given cultural script (i.e., white, male medical doctors are given final authority on treatment because they appear to “know” more). The result is a genuine lack of cultural attunement between collaborative care team members and between patients and professionals. Creating cultural attunement in collaborative care settings will likely require reevaluating the way our medical community operates and holding difficult conversations about the nature of presumed “knowing”. 

 

Medical and mental health professionals are often presumed experts (“knowing”) in their chosen field. Likewise, people of color who are professionals are often presumed experts on all other people of color (“knowing”). Both presumptions of “knowing” can be highly detrimental to relationships because they overrule “not knowing” curiosities and shut down conversation that seeks to understand the ecological niche of both professional and patient. It is equally as important to create an environment where “not knowing” is valued, and where there is a safe space to ask culturally pertinent questions to both patients and team members (e.g., clarification about cultural language, possible gender or racial dynamics at play etc.) that would promote cultural attunement and, likely, improve patient outcomes.  

References       

1.      Falicov, C.J. (2014). Latino families in therapy (2nd ed). New York, NY: The Guiliford Press.

2.      Johnson, R. L., Saha, S., Arbelaez, J. J., Beach, M. C., & Cooper, L. A. (2004). Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of general internal medicine, 19(2), 101-110.

 

Katie M. Heiden-Rootes, MA, LMFT, PhD

Recent PhD graduate of Saint Louis University’s Medical Family Therapy program in St. Louis, MO. Clinically active at Ascend Family Institute in Rogers, Minnesota as a marriage and family therapist, supervisor, and Clinical Director. Also, teaching at St. Mary’s University of Minnesota in their COAMFTE accredited MFT Program. Research and clinical interests includes clinical effectiveness with racially and sexually diverse families; couples sexual and emotional health; and parent-child relationships in transracial adoption and foster care.

Ariel N. Hooker Jones, MSW, LCSW

Current doctoral student at Saint Louis University’s Medical Family Therapy Program in St. Louis, MO. Recent coordinator and family therapist at the Center for Counseling and Family Therapy at St. Louis University and recent medical family therapy intern at a community clinic providing free medical services for low-income patients in the metro St. Louis area. Research and clinical interests include counseling with minority and underrepresented families and couples; parent-child engagement and play therapy; and play as a protective factor within families exposed to violence.

 

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Engaging Family Members in Adult Integrated Care Settings

Posted By Irina Kolobova, Jennifer Hodgson, Tuesday, September 2, 2014
For football teams to score points, multiple members of the team, such as the quarterback and the skill players (i.e., wide receivers and running backs) must work together with the support and direction of the coaching team. Similarly, in integrated care settings, the patient (quarterback), family members (skill players) and the healthcare team (the coaching staff) need to work together to meet treatment goals (score points). It requires the collaboration of all of these parts of the system. Without the skill players, the quarterback and coaching staff can design plays but may struggle to execute them. Similarly, without family members’ engagement, patients and healthcare providers may struggle to successfully meet treatment goals.
 

 

Just like a football team, working together is a foundational aspect of integrated care. Family members are the wide receivers and running backs in treatment plans - their presence is not coincidental and their inclusion is critical. Just to give you an example of the magnitude of how many family members serve as caregivers, in 2009 alone there were 42.1 million family caregivers in the United States providing an estimated economic value of $450 billion in unpaid contributions1

What is concerning besides the amount of work caregivers do, is often the lack of preparedness providers have for interacting and intervening with them as a part of patient care.  However, family centered interventions have been shown to be superior to usual medical care for patients’ physical and mental health2,3. Cene et al provided one example of this when they reported that accompaniment of a family member to a routine medical visit was associated with better self-care in heart failure patients4. In this blog entry we will provide a few recommendations for how providers can engage family members in adult integrated care settings. 

1.  Shifting our View

Family members serve as an extension of the healthcare team 

Central to making integrated care more family-centered is the need to shift our view of the role of family members. It is time to shift our view from families as visitors to members of the care team. Family members are vital in supporting treatment goals, medication adherence, and lifestyle modifications1. Family members can also help patients remember care plans established during medical visits1.  In many ways, family members serve as an extension of the healthcare team. They continue to support the patient towards better health after the medical visit has ended. 

 

Having family members engaged in visits also leads to more information shared with the medical provider. Patients were more likely to discuss difficult topics and were more likely to understand the physician’s advice when a friend or family member accompanied them to their clinic visit5. Family members are also likely to disclose information to the provider that a patient may opt to omit. For this reason, we encourage providers to invite family members to be active participants early in the process. In practice, this can include greeting the family member(s) and patient together as a team, rather than greeting the patient and then the family member(s).  

2. Engaging Family Members on Site

While some patients will bring their accompanying family members with them in the room, others will be waiting in the lobby or in the car for their patient to come out. We have trained family members to do this and have set up our exam rooms to accommodate the bare essential number of people. By adding a second or third chair to the exam room it sends the message to the patient that bringing others with them is okay. Hanging photos in the office of families (diversity is important), regardless of your specialty, is equally important as it again sets the tone for inclusion and a welcoming family context. 

When entering the exam room, we recommend that the nurse or medical provider have the patient introduce those who are with them and ask if they want them to remain. If so, ask the family members what concerns them or impresses them most with their loved one’s health. Oftentimes family members, including children, are just waiting to be asked as they may not dare offer on their own out of respect for their loved one and the healthcare team. Finally, when setting the treatment plan make sure the patient AND family member understand the plan and what their role is in it. Make sure the family member is integrated to the best of their ability and that the patient and family members are clear on the treatment plan. 

3. Reaching out Beyond the Exam Room

Even when family members are not present for the visit, it is still possible to include them as active participants. With permission from the patient, it is recommended that a member of the healthcare team contact a patient-identified family member for their input regarding the biopsychosocial nature of the patient’s health and/or presenting issues.  This encounter gives healthcare team providers a chance to share with the family member the care plan so the family member can support the patient with this plan. If calling a family member is not feasible, another way to engage a family member is to ask the patient for the family member’s view point on the issue, the patient’s overall health, and the proposed care plan. Making space for the family member’s voice can be as important as having them present.

Making space for the family member’s voice can be as important as having them present. 

 

4. Caring for the Caregiver

As we think about the role of family members in integrated care settings, it is also important to consider how their role as a caregiver may impact their own health. Multiple researchers have reported that caregiving can negatively impact caregivers’ physical and mental health2,6,7.  As providers, it is important that we attend to the potential needs and health of the family members that are accompanying patients to their visits. This may be just as simple as asking the family member how they are doing. It is a simple gesture but is greatly appreciated by family members.  Just to see what this distribution looks like in your practice, try asking your patients how many people they are caregiving for in their lives emotionally, cognitively, physically, and/or financially. You will be amazed at how many of our own patients are doing what we do as providers all day long but without a healthcare team there to support them.

Making integrated care settings more family-centered requires intentionality in incorporating family members as active participants. As collaborative care becomes the new norm, it is time that we incorporate family members as a part of the collaborative care team. While the quarterback (the patient) is vital to the game, without the skill players (family members), the chances of coaching the team to a Superbowl win (overall improved health) is nearly impossible. 

References


References marked with an asterisk (*) are highly recommended

*1. Reinhard, S. C., Houser, A., & Choula, R. (2011). Valuing the invaluable: 2011 update: The growing contributions and costs of family caregiving. Retrieved from http://hjweinbergfoundation.net/ficsp/documents/10/Caregivers-Save-the-System-Money-With-Uncompensated-Care.pdf

*2. Hartmann, M., Bäzner, E., Wild, B., Eisler, I., & Herzog, W. (2010). Effects of interventions involving the family in the treatment of adult patients with chronic physical diseases: a meta-analysis. Psychotherapy and psychosomatics, 79(3), 136-148.

3. Martire, L. M., Lustig, A. P., Schulz, R., Miller, G. E., & Helgeson, V. S. (2004). Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health psychology, 23(6), 599-621. doi:10.1037/0278-6133.23.6.599

4. Cené, C. W., Haymore, L. B., Lin, F. C., Laux, J., Jones, C. D., Wu, J. R., ... & Corbie-Smith, G. (2014). Family member accompaniment to routine medical visits is associated with better self-care in heart failure patients. Chronic illness, 10, doi:10.1177/1742395314532142.

5. Rosland, A. M., Piette, J. D., Choi, H., & Heisler, M. (2011). Family and friend participation in primary care visits of patients with diabetes or heart failure: patient and physician determinants and experiences. Medical care, 49(1), 37-24.

6. National Alliance for Caregiving (NAC) & American Association of Retired Persons (AARP) (2004). Caregiving in the U.S. Retrieve from http://www.caregiving.org/data/04finalreport.pdf

7. Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. The Journal of the American Medical Association, 282(23), 2215-2219. doi:10.1001/jama.282.23.2215

 Irina Kolobova, MA is currently a doctoral student in the Medical Family Therapy Program at East Carolina University. Irina completed her master’s in Marriage, Couple and Family Therapy at Lewis & Clark Graduate School of Counseling and Education. Her current clinical and research interests include integrated care in rural settings and the psychosocial needs of Adolescent and Young Adult patients with cancer and their caregivers/support persons. Irina is particularly interested in program development and evaluation to better address healthcare disparities in primary care and oncology settings.
 
  Jennifer Hodgson is a Professor in the Departments of Child Development and Family Therapy and Family Medicine at East Carolina University (ECU). She has published and presented extensively in the areas of medical family therapy and integrated care, and has taught and trained in family medicine residency education since 1996. Her most recent accomplishment was a 2014 edited text entitled, "Medical Family Therapy" Advanced Applications" with co-editors Lamson, Mendenhall, and Crane. She helped to write and established the first doctoral program in Medical Family Therapy in the country and has initiated behavioral health integration in numerous primary, secondary, and tertiary care clinics. She is the past President of the Collaborative Family Healthcare Association, Past Chair of the Commission on Accreditation for Marriage and Family Therapy Education, and is outgoing Chair for the North Carolina Marriage and Family Therapy Licensure Board. Her academic leadership roles also include past program director for the ECU Marriage and Family Therapy master's program and founding program director for the Medical Family Therapy doctoral program.

 

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Family-Centered Care Needs Functional Support From the Health Care System

Posted By Leatrice Sherer, Tuesday, August 19, 2014
The physician’s request was compelling: “I have made an appointment for you with a 33 year old Hmong man and his wife. He has already had 2 heart attacks, from which he had to be resuscitated. His wife witnessed everything. He is being prescribed medications that could greatly prolong his life, but he is very depressed and noncompliant. He takes his meds some of the time, if his wife reminds him. He misses appointments. If he does not change soon, he will die soon, and I have told him that over and over again. I have told him to think about his 3 young kids, even if he doesn’t care about himself. You have to do something!”

At the time I received this request, I had worked full-time at this FQHC for 8 years. Despite having integrated records, and receiving occasional requests for crisis intervention, Behavioral Health Services was unfortunately still functioning pretty much as a co-located mental health service. Finally, after years of lobbying, I had been given the reluctant go-ahead from the Executive Director to embed within the clinic for one half-day per week for one-month, and “then we will see about continuing it”. The physician’s request came in the third week of the “let’s see” period. Frankly, it felt like a do-or-die situation for both the patient and me.

"If he does not change soon, he will die soon "

Being family-centered, the (also Hmong) physician had scheduled the appointment for both the man and his wife to see me, and both had come. Yet, when I entered the exam room, the man was alone. I immediately addressed bringing his wife in. He said she could come in later but first he wanted to speak with me alone. I “met him where he was” and began by speaking with him alone, actually for most of the session. He struck me as intelligent and insightful.

He had immigrated to the USA at 15 (just before his own father died of a stroke), so he did not get a decent formal education. He had only his physical body to rely on; he became an award-winning body builder, laborer and unlicensed auto mechanic. Following his heart attacks and surgeries, he lost his short-term memory and could no longer work as a mechanic. He had misunderstood post-surgery instructions to abstain from physical work as meaning “forever”, so he stopped all exercise. He had misunderstood instructions regarding his pacemaker and thought he had to stay away from electricity. That eliminated cooking, mowing, and fixing things. He now felt he could contribute nothing to his family. His wife periodically pointed that out and threatened to leave him.


Okay, I passed his test, but would I pass muster with his wife? 

Without his income, his wife was trying to start her own business. She needed the use of the one car and the one telephone they could afford. His days were spent sitting in her store front, watching the pre-school aged kids, relying on her to make his phone calls, remind him of things, and take him to appointments. He acknowledged his depression and hopelessness but said he wanted to live for his children’s sake. He also said that he had to depend on his wife for many things “no man should have to”, and between her alternately smothering him with advice and berating him about his irresponsibility, he felt like giving up altogether.

I asked his wife to join us, mostly to apologize for making her wait and to assure her that I would involve her soon. She immediately burst into hysterics, alternately crying and angrily “tattling on him”. He responded by acting alternately “stupid”, passive or rebellious. I immediately realized that this man had structured our initial interview correctly. First, in the absence of his wife, he showed me the man he could be, if treated respectfully. Second, with his wife present, he showed the relationship dysfunction that defeated both of them. Third, he was testing whether I would respond in a different way than his other providers. Okay, I passed his test, but would I pass muster with his wife? Structurally, I had to help her back away from either caretaking him or withdrawing from or carping at him. But I had to plan interventions that would earn her trust, help her understand that her over-reactive behavior was triggered by trauma, and help her manage the intensity of her anxiety and anger. 

 

At the time, this FQHC had a Hmong mental health case manager on staff, being paid by a grant. She and I discussed which cultural factors and family dynamics should inform our interventions. The case manager reminded me that because mistresses are common in the Hmong-American culture, she would have to start by allying with the wife to “gain permission” to take over some of the wife’s duties. I educated the case manager about the over-responsible/under-responsible dynamic and to be aware that the patient might try to get her “to do for him” instead of learning to “do for himself”. She did a good job; she helped him gain the knowledge and tools to gain access to the resources he needed to rehabilitate. The case manager frequently visited with the wife to maintain trust and to keep her anxiety level better managed. We both used some motivational interviewing to increase the patient’s commitment to self-care.

My job was two-fold:

• With the patient, addressing the many losses underlying his depression, affirming his effort and progress, and giving him “tips” about negotiating marital conflicts and strengthening his family relationships. (He and his wife could not manage to get into the clinic together for couples’ work).

• With the physician, making her aware that her style of interacting with the patient had become similar to that of the wife, with the same counter-productive results. She too had a high level of anxiety. As a first-generation Hmong professional, she was tremendously motivated to be a great doctor, and she was very committed to her community. The man’s frail health and noncompliance frightened her, and she made herself responsible to keep him alive. Once she understood, and I promised to keep her informed, her anxiety lessened and she was able to develop a more appropriate interactive style with the patient.

When I left the clinic 5 years later, this man was still alive and living with his wife and children. He was still not the most compliant patient in the world, but he was medically stable due to his greatly improved self-care. Looking back, I believe that no matter the type or number of behavioral interventions I could have used in this situation, none would have succeeded without the family-systems-informed context within which we worked, both within the patient’s family and within that health care delivery system. The principals would have continued to behave the same, and I would have become just another health care provider to avoid. I was fortunate to have had: 1) a case manager – who could work out in the community and whom I could supervise; 2) access to the primary care provider – who had learned to trust me; 3) the autonomy to develop a treatment plan that combined “behavioral” and “mental” health interventions; and 4) the availability of all the component services and an integrated communication tool, all centered in one place.

Unfortunately, when I left this clinic, the Hmong mental health case manager had been gone for 2 years; her grant had ended. A new CEO was more open to methods of integrated care, but “productivity” remained the bottom line. All health care providers were being hounded to see more patients for shorter periods, in part to pay for case management services. Locally, behavioral health providers in the FQHC consortium who had already gone to the half-hour appointment model were asking, “When do people find the time to chart? Talk? Think? Do teams?” 

No interventions would have succeeded without the family-systems-informed context within which we worked 

 

Nationally, some behavioral providers are suggesting that only “primary, behavioral care” should occur in the primary clinic and that “secondary, mental health care” should be referred out. Some behavioral providers – mindful of time pressures, privacy issues, and woefully inadequate EMR templates – are suggesting that we document only the minimum information necessary to get reimbursed by insurance. It is ironic that, while the philosophy of health care is moving more towards being more family-and-community centered, collaborative and integrated, financial and other factors are enticing providers to structure our health care environment in ways that can defeat the system-informed care that we know is best for patients and for us.

If we don’t make time to talk, and we don’t use chart notes as a way to inform and integrate all providers involved with the patient and family’s care, and we put up additional barriers by adding on outside providers, are we not in danger of colluding in the creation of a disengaged, poorly communicating, dysfunctional “family system” of health care delivery? Wherever our creativity and practicality lead us in designing new systems of health care, we need to remember that structure determines function. We need to design systems that facilitate both family-centered care and the collaborative, communicative work environment that allows the entire family of health care providers to do their best work. 


Leatrice Mankin Sherer, PhD, LP, LMFT received her doctorate in Clinical-Child Psychology from the University of Massachusetts-Amherst and later pursued family therapy training.  She “lucked” into her first job, as a faculty member in a family medicine residency program. Although she was initially frightened that this unusual position would prevent her from getting a “real” psychology job in the future, it did not matter. She “lucked out” again; she had found her passion. Her career has been spent providing family-centered, integrated care, primarily within medical settings. She has served on the faculties of three family medicine residency programs, in SC, ME and MN. In the latter position, she established a medical family therapy internship program. She and the medical program director developed curricula to teach residents systemic thinking, to teach team-building skills using in situ learning opportunities (e.g., practice management committee), and to mobilize healthy aspects of the medical education system to help residents in difficulty. These curricula were presented through various STFM workshops and through consultations at several family medicine and other residency programs. She has also provided training to diverse medical and behavioral providers in medical and academic settings. Most recently, Dr. Sherer was the Director of Behavioral Services at an FQHC, where she provided patient care, physician consultation, and supervision of behavioral staff and medical family therapy interns.

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50 Shades of Family

Posted By Kaitlin Leckie, Tuesday, August 5, 2014
When I seek to justify the purposeful integration of the family in healthcare, the time I spent practicing analogies for the GRE, SAT and the other equally torturous standardized tests finally pays off. Ask me why family and other social relationships are essential to a patient’s care and—alas! My mad analogy skills finally have a chance to shine. For I will tell you, the patient is to the family as the organ is to the body.

After all, you can take the patient out of the family, but you can’t take the family out of the patient. In a recent presentation for healthcare providers on activating the family in support of the patient, I showed two lists:


Possible Family Roles



 

Possible Family Actions

 


Neither list is comprehensive, just compiled in a few minutes based on my experience with patients, but both made their point: whether or not the family is physically present in the exam room, the family is present in the exam room, for good or for bad. Whether or not a healthcare clinician chooses to acknowledge the family’s influence, a 10-60 minute visit with a healthcare provider cannot compare to years spent thriving or surviving with family.

Even when considering the power differential between patient and clinician and the authority the clinician status brings, the influence of the family on the patient cannot be denied and should be considered. From basic hygiene practices and beliefs about healthcare that are developed during childhood to stress surrounding current marital discord, the family’s impact on health is present and pervasive.


Although not everyone shares in my emphasis on the family, many do.


My belief in the importance of “family at the center of healthcare” is shared by other members of CFHA’s Families and Health Interest Group. We are guided by a shared vision of “improved healthcare through engaged families and collaborative relationships.” Our mission is “to promote a family-centered approach within CFHA and other healthcare organizations and to foster collaboration in scholarship, education/training, practice, and policy.”

While it is comforting to know that like-minded individuals exist who share in the “why” behind what I do as a medical family therapist, this knowledge is incomplete. What is needed next is more information about how we center healthcare on the family and what this looks like in the exam room.
 
Come Join CFHA’s Families and Health Interest Group 


What would a list of standardized approaches & treatments by healthcare providers to show their consideration of these roles look like? If we compiled the techniques used by clinicians when demonstrating family-focused healthcare, what actions would be listed?

We know a lot more about how we treat organs in the context of the body than about how we treat patients in the context of the family. Certainly, we’ve documented and tested physical treatments more extensively. The time has come to study our family-oriented/family-centered care to the same extent that Heimlich perfected his maneuver and dialysis was developed to replace the kidney.

We suspect integrated care is successful. Now let’s explore how we reach this success. We know the value of the family. Now let’s identify specific ways we include them. We will be better equipped to treat patients in the context of the family by systematically studying the tools and techniques that make up our treatments. Not by poking and prodding, but by sharing and observing our successes, failures, nightmares, and dreams. 

You are invited to start by sharing your views and vision in the following brief survey. Just 5-10 minutes of your time will contribute to a knowledge base that will help guide the Families and Health Interest Group (FHIG) in achieving our 2014 deliverables. The survey results will be shared at CFHA’s national conference (Session: What's Next? Advancing Healthcare from Provider-Centered to Patient-Centered to Family-Centered) and will be discussed during future FHIG meetings.  

Whether you are simply curious about the concept of family-centered healthcare or are as passionate as I am for the importance of the family in health, you are invited to join the Families and Health Interest Group, open to CFHA members. The easiest way to get involved is by connecting with us during our upcoming tele-meeting on Friday, August 8th, at 12pm (EST). Simply dial (530) 881-1212 and use meeting ID: 517-873-035. 

 

 

Kaitlin Leckie, MS, LMFTA (TX) is completing a Medical Family Therapy fellowship at St. Mary’s Family Medicine Residency in Grand Junction, Colorado. She is a doctoral candidate in Marriage and Family Therapy at Texas Tech University. She currently serves as the Chair-elect of CFHA’s Families and Health Interest Group. Her current research centers on the role of family and social support on patient health activation in high-risk patients, particularly in relation to their use of healthcare services. She is enthusiastic about teaching behavioral sciences and speaks movie quotations fluently.

 

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Social justice: Can collaborative care address the health disparities of society?

Posted By Ruth Nutting, Tuesday, July 22, 2014

 
It is my prediction that the majority, if not all, of you reading this have or are experiencing hierarchical, fragmented health care. Going to the doctor is like getting an appointment with a higher power. You wait for your appointment, perhaps months, in order to see your doctor for a coveted 10 minutes. During these coveted 10 minutes, you wait for the doctor’s decree…most often, a list of endless referrals. Then begins the journey, throughout the town or state, to these various providers; all the while, you are signing endless releases of health information, in hopes that communication will flow from provider to provider.

For some populations, the days of traveling to multiple appointments and hoping for communication to flow between various providers are long gone. As the collaborative model increases in health care, more and more patients, specifically patients from under-served populations, are experiencing collaborative care, often found in a Patient-Centered Medical Home (PCMH). Although various in nature, most collaborative models of care focus on the belief that family professionals (e.g. physicians, nursing staff, behavioral medicine specialists, social workers, etc.) need to deconstruct traditional patterns of hierarchy so that families are engaged as active, empowered participants in the services they receive.  

What can occur through collaborative care is mind-blowing. I say this from first-hand experience, not a as a patient but as a provider of behavioral medicine in a PCMH. At our clinic, we provide Shared Medical Appointments (SMA) to patients with Type II Diabetes. During these appointments, physicians, nursing staff, behavioral medicine specialists, pharmacists, and a diabetes educator collaborate in providing care to a group of 6-8 patients. The level of collaboration, which leads to resourcefulness and efficacy, is impacting, but what is most beautiful is the spirit and unity of the participating patients.

These patients come together, some for over a year and others for the very first time, and welcome one another with open arms. Together, they share personal highs and lows; they encourage one another to reach goals, whether it is lowering A1Cs, weight loss, or smoking cessation, and support one another in bettering their quality of life (e.g. getting involved in various volunteer services, scheduling group walks outside of the SMA). These patients are inspiring and what they offer one another cannot be offered by a provider.

I highlight this one initiative of collaborative care to demonstrate the possibilities and empowerment that collaborative care settings can offer. If these patients were seen by a typical primary care physician they would not experience biopsychosocial healing or the empowerment from others who face the same struggles. Instead, these patients would potentially feel isolated and discouraged, as they faced various appointments without a support system, and were responsible for continuous communication between providers.
Collaborative care models focus on deconstructing traditional patterns of hierarchy 

But what about patients who are not of an under-served population? These patients continue to receive the majority of their health-related care from primary-care physicians who do not practice collaboratively. As a result, these patients often receive fragmented care and most likely are not having their psychological, social, and spiritual needs attended to. Without these needs receiving attention patients are not being treated continuously or holistically and health disparities are likely to remain or increase.

To further clarify, fragmented health care can often increase health disparities, as patients fall through “the gaps” of communication and care. Collaborative health care focuses on closing these gaps. Therefore, it is crucial that the collaborative model of health care be available to all populations in order for health disparities to decrease in the United States. It is my hope that with the increase of research highlighting the benefits of collaborative care more health-related institutions will incorporate this model so that all populations experience a decrease in health disparities and an increase in well-being.

Ruth Nutting is in the process of obtaining her PhD in Human Development with a concentration in Marriage and Family Therapy from Virginia Polytechnic Institute and State University. Currently she is interning as a Behavioral Medicine Specialist in the Internal Medicine Residency program at University of Nebraska Medical Center-Midtown Clinic. In this position she consults with providers and patients in regards to psycho-social concerns, provides ongoing psychotherapy to patients, supervises master’s MedFT interns, and participates in Shared Medical Appointment related research, among various other tasks. In 2012, she earned her MA in Applied Psychology with a concentration in Marriage and Family Therapy from Antioch University New England. Her research interests are related to the area of coping and resilience in relation to young adult couple systems in which one partner has a chronic illness.

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Community and health behavior: Who’s pushing people into the river?

Posted By Deepu George, Thursday, July 10, 2014
My dissertation study focused on understanding longitudinal community influences on health behavior, specifically physical activity (PA). As a clinician working in a primary care setting for the past year, I have begun to piece together the different implications of my study variables and the broader theoretical framework. The focus of my study was to understand environmental, social, and personal influences on PA. In order to go beyond individual factors influencing PA, I had to use a broader theoretical framework. The social organizational theory became the central lens through which I operationalized community influences on PA.

In a nutshell, the social organizational theory of community action and change helped me think about social structural and social processes that influence PA. There are real community antecedents that can influence behavior, particularly the physical and social infrastructure. I captured this by looking at neighborhood stability using census tracts contextual data from Add Health national data set. There are also important social organizational processes like informal networks and formal systems. Informal networks are friendship groups and relational settings that foster friendship, involvement, trust, and reciprocity within the community. Formal systems are agencies, organizations, and other structural groups that respond to different needs of the society. For more authoritative papers on the social organizational theory, check out this website.
 

Overall, results show that neighborhood stability during adolescent years is an important influence on PA over a period of time. Individual social participation through civic engagement and citizenship emerged as a strong influence on PA. Research on PA and its broader influences informs my work as a clinician in primary care setting in two ways.

Physical Activity and Therapy. Philosophers as early as Plato noted that PA is important for human development and growth: “In order for man to succeed in life, God provided him with two means, education and PA. Not separately, one for the soul and the other for the body, but for the two together. With these two means, man can attain perfection.”

Psychotherapy has developed mental and behavioral models to influence emotional and psychological changes. However, biological influences on emotional, psychological, and behavioral changes have largely been ignored in psychotherapy. PA is the ‘royal pathway’ to influence biology in psychotherapy. Including PA in therapy is helpful because of the following evidence:

• PA is intimately connected to workings of the human brain. In fact, regular PA can trigger similar mechanisms of psychiatric medications for anxiety and depression.

• PA has been found to help the following: academic performance, sexual satisfaction, increase concentration, decrease symptoms of depression, anxiety, and improve performance in learning, memory, and recovery from illnesses.

• More curiously, John Ratey and colleagues (results from their work documented in the book Spark), documented mechanisms through which PA improves memory, learning, anxiety and stress response. Their study showed regular PA alters seminal structural aspects of the brain to facilitate growth.

Therapists can find creative ways to incorporate PA as part of their therapy work with patients. Regular PA should be an important element in self-management long after therapy is terminated. Therefore, recommending and prescribing PA as part of therapeutic work is one way of influencing biology to better sustain changes made in therapy.


Physical Activity, Therapy, and Social Organizational Theory. In his essay entitled “A case for refocusing upstream: The political economy of illness”, John B. Mckinlay (2008) wrote an analogy using a river and drowning people to describe clinical medicine:

Sometimes it feels that I am standing by the shore of a swiftly flowing river when I hear the cry of a drowning man. So I jump into the river, pull him to shore, and begin artificial respiration. Just when he begins to breathe, there’s another cry for help. So, I jump into the river, reach him, pull him to shore, apply CPR. And then just as he begins to breathe, there’s another cry for help, and back in the river again and then another yell, and again and again. So, you know, I’m so busy jumping in rescuing them that I have no time to see who the hell is upstream pushing them all in. (p. 578).
 

Behavior changes like commitment to regular PA and other goals that emerge in therapy have both downstream and upstream factors. While psychological theories help address downstream factors, a lens like the social organization theory can help therapists consider upstream factors. In the present study, social participation and concentrated affluence were strongly associated with PA. Therefore, while behavioral health treatment is analagous to performing CPR (as in providing individual care through therapy), a broader perspective can help therapists and clients consider both upstream and downstream factors that are obstacles to behavioral improvement. In addition, therapists can incorporate individual theories of motivation and planned behavior change to help with PA. Using important reviews like Ratey and Hagerman’s work, therapists can better educate patients about how PA influences biology and brain functioning to help them work with depression and anxiety. To consider upstream or broader aspects of behavior change, therapists can use the social organizational model of community action and change. Understanding community antecedents – the physical and social infrastructure – of a patients’ social, environmental makeup can be instructive in planning various activities.

For example, in one of my recent clinical encounters, to help a patient manage her hypertension, it was important for us to figure out how, when, and where she would walk for exercise. As part of behavioral change work with her (downstream factors), we mapped out a schedule, identified barriers to walking, solutions to overcome present barriers, and made specific behavioral commitments. We further elucidated her motivations and reasons for her commitment to lifestyle changes (walking more regularly and eating a balanced diet). Then, we mapped out her neighborhood (upstream factors), location of the grocery store, took notice of nearby parks, school grounds. We utilized her own knowledge and used Google Maps to track details during her office visit. All of this was entered into her personalized plan for the appointment. As part of her plan, the patient was able to schedule two walks during the week to go to nearby grocery store as part of her walk schedule, especially to increase fruits and vegetables to her diet. Considering both individual level factors (commitment to behavioral change) and community antecedents (parks, school grounds, route to grocery shop) were important clues to change.
Understand the community antecedents – the physical and social infrastructure –  of a patient's environment

Deepu George, PhD, LMFTA, is the current Medical Family Therapy Resident at the Duke/SR-AHEC Family Medicine Residency Program in Fayetteville, NC. He is interested in social determinants of health, medical family therapy, community development and capacity building. With a Master’s Degree in Holistic Psychological Counseling from Bangalore, India, his aim is to continue his passion for applying systems lens in health care, family therapy, conflict resolution & peace-building, and community capacity work. He will soon graduate from the University of Georgia and has recently accepted a teaching position in McAllen, TX.

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Contact Us

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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.