Frank deGruy: "Help Create the Collaborative Care Strategic Vision"

Frank,  thanks for posting the CFHA strategic plan in the blog.  I think this is a great opportunity to solicit public feedback and refine an action plan.

Regarding a one-page summary, the Integrated Care Council of Mesa County Colorado is finishing a community integration white paper that might serve as a model.  It is very local in its focus, but also impressive in the level of buy-in from all of our region's healthcare sectors.

It seems that our movement is now getting buy-in from all sectors for being a reasonable healthcare approach.  I would love to see if there is an opportunity to get the AAFP, NCCBH, AAMFT, APA, etc as signatories.  The downside is that we would be opening ourselves to their interests, the upside is we would be making our case from the mainstream rather than the fringe.  Ben Miller's board outreach with other organizations has hopefully made this a possibility.

From Frank:  This is a good suggestion, Randall, and it would be a good idea to use local examples to create a basis for the nation's plan. We don't know whether there will need to be many different solutions, or whether we can draft something that applies across settings. In any event, Mesa County is already in the nation's spotlight, and we would all learn something from what you have to say about this."

Posting the details of the action plan strikes me as inviting and stimulating ideas. From a national survey I recently completed with AAFP's national research network, I am in favor of boosting all efforts toward collaboration within the educational system of physicians. The study's findings suggest that family physicians are not completely familiar with the various psychotherapists who can assist their patients with mental or emotional issues. Becoming fully acquainted with the services of these mental health practioners may be one aspect to building collaborative care.

Teresa,  Did your research give any insight as to how best to reach family physicians?  My experience is that the window of opportunity is open during residency, but mostly closed thereafter.  I think a conference like CFHA is an ideal venue, but we don't seem to attract many family physicians.  The same is true of Sandy Blount's excellent training.  I'm sure a lot could be learned from drug reps, but...

Outside of the realm of MD's and DO's, one place to start may be in master's level social work, mental health and M&FT programs as well as at (as one women clarified at President Obama's speech at our local town meeting) the "core of medicine":  the nurse practitioner programs.  They seem like prime candidates due to the fact that their nursing philosophies seem somewhat in line to begin with.

The history of creating a conference that attracts a balance of physicians and behavioral health folks and others including nurses, is filled with great efforts but that end up in struggle. Probably the most successful meeting to my knowledge is the STFM Family in Family Medicine meeting. Note that the focus of that meeting was not behavioral health issues but a bigger, more encompasing topic-- the family.  The founders of CFHA, who were Family in Family Medicine devotees, included the term family but wanted an expanded focus away from the family doc and move to define primary care as a team effort. But in truth, we were all focused on behaviorral science.  My sense is that we hoped to include a balance of behavioral health and primary care practioners "and others".  Both the emphasis on the family  and the true participation of a diverse collection of disciplines has suffered.  Perhaps this is because there has been such a hard focus on integration of or collaboration with behavioral health.  "Let us in." "We are important."   Perhaps moving away from focus on behavioral health as the end and instead on the content of the medical home makes sense.  Rather than focus on integration of a specific role(behavioral health provider), how about functions to deal with the common and challenging aspects of primary care-- self management,  complexity, for example.  Just as primary care docs can not do it all, neither can behavioral health folks.  To get a broader representation the model that we emphasize may have to shift a bit to focus on creating a health care team that matches the complexity of the patients that it is attempting to care for and treat.

Larry,  A fascinating piece of hypothetical heresy from one of our true-believers.  I'm struggling to wrap my head around the full implications of what you just posited--both historically and moving forward. 

It seems that you suggest that CFHA struggles to involve more family physicians because, at its heart, our mission directly benefits mental health professions and clinicians (i.e. increased financial access, heightened status, expanded career horizon), but only influences family physicians based on their altruism and concern for patient care (and currently at the cost of their own financial gain and status).

It seems the alternative you suggest is to change our focus to more directly benefit family physicians by co-opting their burgeoning model (the medical home) as our area of focus.  In so doing, we would aim to reinforce the emphasis on effective family-based care and be less myopic about how this is accomplished.  Integration of behavioral health would be one tool among many (i.e. the chronic care model, care coordination, improved primary care billing, enhanced physician counseling skills).  Much of this effort would be focused solely on empowering physicians.

If I extrapolated your observation aptly, this would indeed be a shifted or expanded mission for CFHA, but it is perhaps our last, best hope of relevancy with mainstream family medicine.

Randall, the short quantitative portion of the survey revealed that these family physicians were more likely to refer to mental health professionals with whom they were acquainted. And yet, overall, the total number of patients with psychosocial issues referred for talk therapy hovers around 5% in America and around the globe. The majority of patients of primary care physicians are treated pharmacologically without the benefit of alliance of specialists who are expert with the other basics of the human species, such as emotions or relationships. Practice trends reveal that these psychosocial problems are mainly treated on the physical (medication) level but the roots of such problems are intertwined within the different aspects that make up a human. Thus antidepressants have become the number one drug ordered by US physicians with over 233 million prescriptions. Data shows that FPs see the complex needs of their patients and the current void in their mental health care. Again, I believe the best place to start is with those (teachers of family medicine) who are directly involved with influencing the future processes of collaboration of family physicians. If medical students and family residents are not made aware of the valuable assistance from the various psychotherapists, how can these future physicians be comfortable in referring their patients?   

I agree with Larry that focus needs to be in creating an effective medical home with the goal of improving the quality of care to patients and their families. More and more, in our pediatric sleep clinic we see three year old children on two or more psychotropic medications. What does the future look like for one of these children during the high school years? Do we simply keep adding more medications to produce the behavioral changes desired? Almost all of the founders of the various fields providing mental health care were physicians. Over these past fifty years, the gap between the worlds of medical and behavioral scientists has widened as each profession has confined their study to their separate specialties. Such narrowed focus has no doubt contributed to the great developments and significant discoveries made within these different worlds. 

But staying separate has limited the depth and quality of care given to patients and their families. Collaboration between medical and behavioral practioners must become the norm and those who teach these future professionals have a key part in reshaping the medical home. Indeed, a patient's complaints to his or her physician reflect great complexity of the systemic interplay of mental, physical, emotional, and relational components. Invariably, patients are the ones to suffer when healthcare providers limit the scope of care.