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Resident Electives 0 J. McLean Hello, This is an inquiry directed to colleagues in residency settings.... We have a PGY3 resident that is interested in doing a two week elective with my behavioral health faculty colleague and myself.  He wants to further develop his primary care counseling skills and management of patients with behavioral health issues. Do any of you have residents work with you on encounters and patient visits?I am working on the structural pieces and am curious if any of you have residents as cotherapists? I want him to have a really good, practical experience and know that many of you may have done similar things. Any guidance appreciated. Best, Karla Hemesath, PhD, LMFT University of Iowa Carver College of Medicine Hey Karla! I work in a pediatric residency training clinic and work closely with the medical residents.  Being in the room with the resident is a really meaningful training experience and I have found it to be more effective than simply co-precepting with the medical attending.  Previously, we have just identified cases when they come up.  We are working to formalize the experience in our clinic during the residents "block month" where they are in clinic every day for a full month. Together, we set specific goals and target skills to focus on and do a mixture of co-precepting, education (readings, discussions), observations, and co-leading appointments.  We have found that setting realistic, pragmatic goals in the beginning of the experience is particularly important they often come into the experience with really eager expectations and sometimes an implicit assumption that they will master a whole field by seeing ONE, doing ONE, and teaching ONE.  We tend to lean heavier on cross cutting skills (e.g., MI, behavioral change principles, solution focused approaches) with the understanding that it's easier for them to find out WHAT to tell patient to do, much harder to coach them on HOW to do it. Happy to discuss more details if you would like. Cody Cody Hostutler, Ph.D. Pediatric Psychology  & Primary Care Red/Yellow Nationwide Children's Hospital Great question! Our family medicine residents have a two week behavioral medicine rotation with me their intern year. I created a "See One, Do One" checklist of some of the most common behavioral health concerns seen in primary care (including behavioral management of chronic conditions) where the intern is able to check off when they have seen and done various components of a BHC visit (brief eval, intervention) for different presenting concerns. The resident usually does straight shadowing the first day of the rotation. After that, they take a more active role in the visit. After receiving a handoff from another provider I turn to the resident and ask a variety of questions ("Based on the info we know, what are your differentials? What questions do you  need to ask to clarify the problem/diagnosis? What are some brief interventions you could use if that is the problem/diagnosis?). Following the visit we can review patient's readiness for change and how the resident's intervention aligned/didn't align with the patient's readiness for change and level of engagement. I'm using a couple of different evaluation measures to guide feedback to the resident as well. During their rotation they also visit a 12 step meeting and create a patient ed handout on a topic of their choice (they must make the handout interactive using their knowledge of motivational interviewing/behavior change). Hope this helps!   Danielle   Hey Karla, We (Central Washington Family Medicine) have four, one month rotations throughout the three years w/ Behavioral Medicine components.  During these rotations, we have a specific experiences: 1. BHCs observe residents during resident medical visits and provide feedback on patient centered communication 2. FM residents observe BHCs in their clinics.  This experience is progressive throughout the three years in that interns' expectation is to complete the Contextual Interview with new BHC appointments. R2 and R3 build on that experience and actually start providing psychoeducation and interventions with BHC.  It not uncommon for an R-3 resident to complete an entire BHC visit with the BHC obviously in the room. 3. Role-plays, which allows residents to practice the Contextual Interview, interventions, psycho-education and discuss philosophical concepts (e.g., what causes people to change, ACEs, etc.). 4. Coaching.  Residents are chosen weekly to be "coached" by one of our BHCs. This is different from the normal shadowing that they receive in that the BHC primes the resident to look at their schedule and identify two patients they would like to practice doing a BH intervention/technique. The BHC then shadows them doing so and provides prompt feedback. Let me know if you would want any specific information (e.g., curriculum, reading materials, evaluation materials, etc.)! David Bauman
by J. McLean
Monday, December 11, 2017
Guidelines for BH Involvement in Chronic Pain 0 J. McLean Hey all,  I was hoping if you all could pass along any guidelines/best practices for BHCs to be involved in chronic pain workflows/policies in primary care, particularly CHCs. Specifically, we are looking for research/recommendations on how *often* BHCs should meet with individuals who are receiving long-term opioids. Appreciate any help! -- David Bauman, PsyD Behavioral Health Education Director   Hey David, In the Department of Defense, anyone on a pain agreement or sole provider program was required to see the BHC at least monthly. In some clinics we had the BHC appt before every medication refill so that meds could be adjusted regularly and so that the patients did not develop an expectation that meds alone will ever be the treatment plan. If the patients stopped coming to PCBH appointments, their medications we're not refilled...until they followed up with the BHC. All of these policies were included in the pain agreement and the patient signed it. We also had case management on board and family members involved when feasible. Like most sole provider programs we also had agreements (MOAs/MOUs) with local pharmacies that they would not refill these patients' pain medications at all or at least without calling us first to verify. I hope this helps. Best, Kent On Thu, Nov 16, 2017 at 11:42 AM, Greg Reicks wrote: This is a great topic and I would like to explore further.  We are trying to figure out how to use our BHCs in the most effective way with our chronic pain patients on opioids.  I had thought about Kent's program of requiring these patients to see BHC in order to get her medications refilled, but I'm wondering if that is the wrong message.  It seems that making this Requirement might lead to resentment which could  make the BHC/chronic pain patient interaction less effective.  I have heard of other clinics doing the same thing.  What kind of outcomes are they getting?  Reduction in opioids? Reduction in pain scores?  Increased functional scores?  Reduced disability? Our experience with many of these patients is that they are "stuck" on what has been called "pill Island" and cannot seem to - or are unwilling to- get on the bridge to get off the Island.  Many of these folks are not addicted per DSM criteria but certainly physically and psychologically dependent on these meds. I agree, Greg, and that is the question that I am having, as well.  In that, how do we use BHCs most effectively?  Truthfully, if we required all of our long-term chronic opioid patients to see a BHC each month, the BHCs would only see chronic pain patients. Furthermore, if we make universal guidelines, not only is there potential for the patient to become resentful but also the medical providers who may feel that they are losing their ability to care for the patient. I also struggle with the once per month idea due to it being fixed from the beginning. What if the patient is actually doing a lot better after a few visits with the BHC/PCP but is still on a small dose of pain medication? Does that patient still need to see the BHC every month? Lastly, and this goes to Greg's point, what is the outcome of having it be every month? Further, is there research/guidelines supporting this? I have reviewed some of the research and it seems that it is suggested that BH be involved but does not quantify how often that should take place... Really appreciate everyone who has commented and looking forward to other's thoughts! -David Greg and David, I appreciate your pause and I agree with you wholeheartedly. Forcing treatment is not helpful or sustainable. And, the military context/culture in which these programs exist may paint a certain picture that heightens your concern. Even if we put aside the fact that addiction and "pseudo addiction" play a substantial role here... Something I did not give ample attention to in my initial response is the idea that the programs must be communicated, marketed and run in a highly specific way. It is the key to the structure feeling forced versus supported. My concern, which I'm sure is shared by all of you, is that the message we send to patients by focusing primarily on providing medications is: "Medications are the solution to your pain (and the goal of pain management is to decrease pain)." Whereas, the goal of evidence-based pain management is to improve functioning while (hopefully) minimizing pain. The concept of improving functioning and quality of life needs to be loud and out front in these programs that require behavioral health consultation. Program design is one thing; implementation is a whole different animal. I am sure you have seen some of the same pain management practice trends I have seen in the private sector. In some cases the PCP literally refuses to see any patients who need or request opioids. Tl If the medical community (we) taught patients to use the opioids when we prescribed them, in my opinion, it's on us to re-educate them about what to do as we nation-wide tighten up and decrease opioid use. PCPs have no time for that facilitation and education. That's where we come in - although nurses have also been very helpful for this. Great conversation - let's keep the ideas flowing! Kent I provide BH services in a spinal and musculoskeletal institute, and all of  our patients are dealing with chronic pain. We using a screening tool at  intake to determine BH service necessity. If there is a positive screen, I  provide a Health and Behavior Assessment, which is a basic in-room check in. I administer the PHQ-9 and/or the GAD-7. We use those results to determine what services we offer. Some patients need therapy services, others care management, and others are receiving MH services from outside providers. I  also use a registry to track results and reassess as needed. It was important to me when creating this program that we provide patient centered care and not required care. There’s plenty of billing to be done just with patients who WANT services. Lindsay Scarpate, LMFT   Hello - The Substance Use Treatment Taskforce offered national practice guidelines. They were cited in a recent Open Minds post. Consistent with what I’ve been reading in this valuable thread, Recommendation #2 is for personalized  diagnosis, assessment and care planning.  I was thinking of offering a chronic pain management class for our long-term opioid patients who have refused evidence-based brief interventions. But, based on these guidelines I think I’ll stay away from mandates, at least until we have more research. I’d be happier if our clinic could get away from pain contracts altogether. Patty Rebeck, Ph.D., Licensed Clinical Psychologist Hello All, I appreciate Ms Scarpate's approach.  A pain patient with an organ/structural abnormality linked to their pain and with no evidence of depression, anxiety, ptsd or the prolonged impact of adverse childhood experience will have quite different needs than a patient whose pain seems disproportionate to their organ/structure issue and who suffers from one or more psychosocial stressors or mental health conditions.  A growing number of studies is showing the best outcomes are achieved when these contributing factors are addressed. Dave Clarke
by J. McLean
Monday, November 27, 2017
BHP to Medical Provider Staffing Ratios 0 J. McLean On Sep 27, 2017, at 5:56 PM, Alex Schmidt wrote:   Hi CFHA colleagues, Does anyone know of a recent reference that describes recommended staffing ratios of behavioral health providers to medical providers in     Sent: Wednesday, September 27, 2017 10:36 PM To: Subject: Re: [CFHA] BHP to Medical Provider Staffing Ratios   This message was sent by Patty Rebeck   Hello - The Missouri Department of Social Services (DSS) contracts with 35 major health service providers statewide to integrate behavioral health with primary care. This is for Missouri's Medicaid enrollees who have complex health conditions. DSS requires one full time behavioral health consultant for every 750 patients.   Patty Rebeck, Ph.D. Psychologist/BHC Swope Health Services Kansas City, Mo     On behalf of Heather Summers: Subject: [External]RE: [CFHA] BHP to Medical Provider Staffing Ratios   Can you provide a definition for Complex Health Conditions?   Heather Summers MS, RN Under Secretary of Operations, Hospital and Clinics The Chickasaw Nation     Hi Heather,   You can find a copy of the MO State Plan Amendment on the Medicaid.Gov website, on the Approved Health Home State Plan amendments.   here's the pdf for the MO Primary Care Health Homes     This document contains the list of chronic conditions that Missouri used to identify eligible participants for Health Home services.   I will be at the CFHA conference next month if anyone would like to discuss Missouri's integration efforts.   And to the original question in this thread, "Does anyone know of a recent reference that describes recommended staffing ratios of behavioral health providers to medical providers in a family practice? Or have a recommendation based upon their work in primary care?"   It usually depends on several factors. 1. the function/role of the embedded behavioral health provider, e.g. collocated Mental Health vs. PCBH 2. the patient volume of the family practice 3. type/needs of the patient population   We often talk in terms of a 3:1 FTE ratio (PCP to BHC) for the PCBH model, but again factors 2 & 3 might change that ratio. Basically the patient volume and population needs to support a BHC seeing 8-14 patients per day. I would also point you in the direction to the works of Robinson, Reiter, & Strosahl for more on BHC staffing. Staffing ratios can be found in the PCBH toolkit on the website   Dawn Prentice, LCSW Director of Integrated Care and Health Psychology St. Louis Behavioral Medicine Institute  
by J. McLean
Tuesday, October 17, 2017
PCBH and CoCM 0 J. McLean CBH and CoCM   Greetings all,   Regarding the new Psychiatric Collaborative Care Management Codes (specifically G0502, G0503, G0504) that took effect Jan. 1 of this year, which involves collaboration with a psychiatric consultant and behavioral health professional billed under treatment by the physician or APP; has anyone interpreted this as the medical provider (physician or APP) must actually deliver these services verses the behavioral health care manager/primary care behavioral health consultant? We are thinking that the intent was never for the medical provider to provide  these services but to oversee them... Thoughts? Sonny Pickowitz, MSW, LCSW Behavioral Health Coordinator Primary Care Behavioral Health Services  Hello- I have attached some guidance that my Health System received on the topic. We are working to operationalize these new codes in our primary care network-  not there yet!  Our hospital compliance department has interpreted the primary care provider involvement similarly to the existing CCM codes.  The work is done by a primary care team under the supervision of the PCP in consultation with a psychiatrist but the monthly charge is entered by the PCP. Hope this is helpful.  Seems like many are scrambling to implement these new codes. Darren Darren S. Boice, LCSW Director Ambulatory Behavioral Health Mission Health System   We are also trying to get them in rolled out in our health center and have not worked out a streamlined process for doing so. I agree that any and all input from trailblazers would be helpful! Thank you for this guidance. Tina Tina Runyan, PhD, ABPP University of Massachusetts Medical School Professor Dept of Family Medicine and Community Health   On Behalf Of Jeff Reiter  To my friend Rodger - I see that we agree on the goal of integration. But I feel like I lose you when you write about how to accomplish that goal. I’m not sure that I see the difference b/w Kathol vs CoCM (not that that makes Kathol wrong - just seemingly incongruent with the stated goal). I’m sure you’ll educate me on that! But if our goal is to support primary care, then why would we focus only on helping with certain populations? PCPs need help with all sorts of issues and problems throughout the day; not all are related to complicated patients. If, for example, a PCP is running behind schedule and enlists my help with completing the anticipatory guidance during a well-child check - so that the PCP can make up some time and therefore devote more time to a subsequent patient with a lot of needs - then I am helping improve primary care, as i think of it. But in the Kathol model you propose, such actions would likely fall outside of the scope of the BH provider, no? As you know, there are many factors and many different types of patients and problems that interrupt workflows and inhibit primary care from reaching its potential. Why would (truncated)  I don’t think you’re missing anything, Jeff.  I appreciate all the points made in the various posts on this topic but am concerned with the “either this or that” model approach.  Integrated care is not about a single model applied across all sites and populations.  It’s about doing what’s needed WHEN and WHERE it’s needed The VA, which has been recognized by bipartisan and nonpartisan groups as a leader in population based integrated care began implementation of a blended model of integration over 10 years ago.  This includes the core elements of CoCM and co-located collaborative care (embedded clinicians). The underlying principle is to "first, be of use" to the patients and primary care teams.  Thus, the actual structure and process may vary by facility as well as within teams, based on needs of patient, team and provider.  CoCM may support PCP treatment or it may support treatment by the embedded MH professionals on the team.   The model has various tweaks depending on local needs, but the core elements are required to be present.   Our group has developed and is in the process of implementing brief (4-6 30 minute appointments) interventions for problem solving, chronic pain, PTSD and insomnia. All are based on the longer traditional CBT approaches and serve either to take care of the problem within primary care or prepare more complex patients for more specialized care.  Support for chronic illness management is a staple in most as well.  National program evaluation has demonstrated a significant increase in identification of individuals in need of attention as well as increased engagement in treatment, either within primary care or when referred into specialty care . The real testament to the cost effectiveness of this blended model is that, since expiration of the special funding provided in 2006/7, dozens of sites have chosen to shift resources from specialized mental health clinics to integrated care, without new funding.  While the program has focused on uncomplicated conditions in primary care (the vast majority), some sites are now adding capability to manage more complex conditions (including opiate use disorder) within primary care. Andrew S. Pomerantz, M.D.  Well, this string represents why CFHA is one of the major (THE major, IMO) thought leaders in Integration. Love the robust exchange in this string! Q to Shanda: When was this tool kit dated?  Comment: IMO, what you have here is a process map or workflow for psychiatric consultation, one essential element of an overall toolkit. The visual map is really, really good and a great example of how to make this come to life within a provider org. Thanks for sharing!  We also have lots of research (peer & non-peer review) to date , so might be time to refresh the document & add updated refs. Just a suggestion. Thanks for providing the link to the Soldberg, et al 2015 pub. A great read! I would echo Andrew's comments as well. Having funded sites to do Collab  Care and sites using a blended approach over the past ten years, I can tell you (& have the specific site examples to point to), an overwhelming number of grant funded sites who started doing a form of integration versus TAU (I'm old school) continued to sustain integration programmatically once grant funding termed. How'd they sustain it? Some provider orgs (FQs, CHCs, MH clinics) sustained this through other grant funding; most through reallocating operational & programmatic funding & resources to continue integration work versus revert back to TAU. Means redefining current provider roles, deleting current vacant positions; rewriting current & new job descriptions with integration functions (& realloc these vacant salary dollars to fund positions). They chose to preserve what they considered core integration components like (not all inclusive) routinized assessments, team-based care, stepped care, care manager functions, workflows, evaluating outcomes, prescriber time & make them a part of "business as usual."  And as we know, buy-in from CEO/Exec Team/Clinical leadership is deal maker or deal breaker to successfully launching or sustaining any integration effort.  Lastly, I have heard directly from CEOs (a direct quote) "Rick, my staff would have my head on a platter if I told them we were going to go back to the old way of delivering care...we will figure it out..." And many of them have. There you go!  Thanks to everyone who contributed their thoughts/perspectives to this conversation and links to docs/resources. Look forward to seeing everyone in Houston for CFHA 2017!   Most sincerely, Rick   Rick,  Excellent input on integration and the recognition of "no turning back". In AZ, we're evolving and exploring new territory for the children's system with emphasis on family health. CFHA as a think tank is a constant value added, thanks to all our colleagues and affinity partners.  Things are moving fast, have a great week everyone!  Socorro Dominguez  Chief Operating Officer   All: I will just add to this outstanding conversation that it feels like our collective experience has been that:  1. the status quo is unacceptable (treatment as usual, which is really little to no care usually),  2. that flexibility targeted to supporting medical teams within the primary care setting (and increasingly outside of primary care) is key to better access to care, and 3. that roles for professionals within integrated care have taken on better definition over time (BHC, consulting psychiatry, care managers, peer support, PCP roles etc).  I for one don't really understand the gripe about PCBH given that there is really nothing better that has come along as far as a role for a mental health professional in the integrated care setting. Are we really going to go back to specialty mental health therapists in the primary care setting? PCBH, simply put, is the optimal role for a highly trained mental health professional in a primary care setting. If someone can point out an alternative role for mental health providers, I would love to be educated. It is not however the answer to all the needs in the population (e.g.. Barry's comment on high utilizers). I also feel strongly that the CoCM and SBIRT approaches make significant contributions to the monitoring and optimization of care for specific conditions. If a system is looking to improve depression outcomes for mild to moderate depression, particularly in a geriatric population, there is nobetter way we have thus far. CoCM also posits the best use of a psychiatrist in a primary care setting, which is a major contribution. As Shanda mentioned, our team at Access infused our PCBH approach with the best most sustainable version of CoCM that fit our setting and resources. And beyond this we still have the perspectives that must infuse our approaches to the varied issues within healthcare like the role of familial networks and systemic concerns like social determinants of health. Taken from this perspective, we stop talking about models battling one another and instead realize that we have come a long way towards a system that works better for the stated aims of improving access to quality care. Each of us will find our way towards operating to the top of our licenses while solving each of the pieces to the healthcare puzzle. To my mind this conversation exemplifies the progress we have made.   Neftali
by J. McLean
Monday, October 16, 2017
Highly thought provoking piece on CBT 0 J. McLean From: "Morgan T. Sammons, PhD, ABPP"   Subject: [HSP-Community] Highly thought provoking piece on CBT Date: September 25, 2017 at 10:34:20 AM PDT Colleagues, the September 21 issue of the Journal of the American Medical Association contains a short but thought provoking  article on the research database for CBT.  It is free full text.  Click on the following link or cut and paste the link into your browser for access. MTS   -----Original Message----- From: [] On Behalf Of Jeff 2 Sent: Monday, September 25, 2017 11:47 PM To: Subject: [Non-DoD Source] [CFHA] Fwd: [HSP-Community] Highly thought provoking  piece on CBT ---- Excellent article for anyone who thinks we should only be providing those manual-based CBT protocols that we all learned to worship in grad school (until realizing few people actually complete them in the real world) - thanks to Morgan Sammons for passing along on a different listserv. On a related note, I’m compiling studies on the long-term (in)effectiveness  (+ 2 years) of CBT. If anyone has come across such studies, I’d appreciate  you forwarding along a copy. Many thanks!! Jeff Begin forwarded message: On Sep 26, 2017, at 8:01 AM, Hunter, Christopher L CAPT USPHS DHA HEALTH: I agree with Dr. Reiter that this is a thought provoking commentary. The authors make valid scientific points related to weaknesses of CBT research,  the same criticisms would also apply to other psychotherapy research. I hope none of us would ever blindly apply a manualized treatment, but would  consider the unique factors of a given patient and apply the evidence-based/informed  components of a treatment/approach and use patient response to guide continuation/alteration of that treatment.  Not unlike your primary care provider would do. In their conclusion the authors comment: “CBT is probably the best empirically studied type of psychotherapy because  for other forms of psychotherapy, such as interpersonal therapy or psychodynamic  therapy, fewer high-quality studies are likely to exist. However, this assumption needs to be tested empirically because the risk of bias tool used  by Cuijpers et al has not yet been systematically applied to all studies of other psychotherapies while also controlling for researcher allegiance.” So the authors are not saying CBT is “bad” they are saying you can’t claim it as a “Gold Standard” given the  scientific research weaknesses in the studies and a lack of direct comparison to other treatment strategies. I encourage you to read the commentary yourself at: <> v/r Chris Christopher L. Hunter, Ph.D., ABPP CAPT, United States Public Health Service On Sep 26, 2017, at 8:24 AM, Mullin, Daniel: This conversation highlights a variety of interesting research methods and implementation issues. It is much easier to study manualized interventions than it is to study highly flexible, patient centered approaches. From the perspective of a researcher, determining whether or not a clinician has followed a CBT intervention for insomnia is far easier than determining if a clinician has used Motivational Interviewing for medication adherence.  Verifying treatment  fidelity of patient centered counseling requires complex and expensive methods that are challenging to organize and limited by tight research budgets. This is one of many reasons we end up with more publications that report on interventions that are relatively directive/driven by protocol. Unfortunately, this issue of treatment fidelity in counseling interventions is largely ignored within the larger world of healthcare research.  I have seen many studies published in traditional medical journals that report on outcomes of patient centered approaches without any mention of how they were assured that the intervention being studied was delivered as described.  This isn’t surprising.  When these journals publish studies of a new cholesterol lowering drug they don’t report the results of tests that verified that each pill contained the appropriate quantity of the active ingredients.  The authors and editors accept that if the pill bottle was labeled drug x than it contains drug x.  Likewise they seem to accept as fact that if a counselor says they delivered counseling intervention y, they  actually delivered y.  Those of us who counsel patients in the real world, or supervise or train clinicians to provide these interventions know that this assumption is risky.  There is surprising variability in fidelity to evidence based counseling approaches in studies and in the real world.  I am suggesting this variability is far greater with patient centered interventions.  The downstream effect of all of this is that when studies are pulled into meta-analysis the patient centered interventions often include  studies of the true intervention and other studies that claim to be the intervention but probably aren’t.  This should lead us all to be cautious about interpreting this literature.  Don’t accept what the abstract says without flipping to the methods section and checking for assurances of fidelity. I would propose that we need to consider these same issues when we are wearing our administrator or implementation hats.  Take SBIRT for example.  It is much easier to train a large group of people to do the Screening part of SBIRT with fidelity than it is to train a large group of people to do the Brief Intervention part with fidelity.  The essential steps of what makes Screening work can be broken down into concrete steps that will vary minimally between patients.  This standardization of Screening is desirable.  In contrast the Brief Intervention part requires much more patient centered flexibility.  Responding empathically to a patient with a substance use disorder and evoking their interests in addressing the problem requires the clinician to have generalized knowledge and the ability to flexibly apply skills.  The variability in the Brief Intervention is a feature, not a bug. It is likely that this personalization of the Brief Intervention is an essential active ingredient in SBIRTs effectiveness.  However, as with the research issues described above, adequately training clinicians to provide this flexible patient centered counseling costs money and time.  More time and money than simply training them to run a checklist. Daniel Mullin, PsyD ---------- Forwarded message --------- From: John Gardin   Date: Sun, Oct 1, 2017 at 5:50 PM Subject: Re: [Non-DoD Source] [CFHA] Fwd: [HSP-Community] Highly thought provoking piece on CBT To: <> I agree with you, Daniel.  In addition I have found after years of research into therapeutic approached to addiction in NIDA's Clinical Trials Network, that fidelity is, quite frankly, overrated.  While all studies in the CTN were and are controlled for fidelity, the implementation of the results in clinical practice is poor due to fidelity issues.  Be that as it may, no matter the actual intervention, I find consistency much more valuable and useful -  for my clinicians, our patients, and for me as an administrator. John G. Gardin II, Ph.D. Chief of Behavioral Medicine | SouthRiver CHC & ADAPT
by J. McLean
Friday, October 13, 2017

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