Posted By Joan Fleishman,
Tuesday, January 8, 2019
I decided to write a piece in response to the CFHA listserv discussion on detecting and addressing trauma in primary care.
As I watched the messages from my colleagues trickle in about how to address medical providers’ unease discussing trauma with their patients I paused and knew my contribution would be forthcoming. I have done a significant amount of work in my clinics to promote, train, and implement Trauma Informed Care (TIC) across our clinical system. The questions that were being asked on the listserv were real. They are the questions that my colleagues and I grapple with. How do we to address trauma in primary care? How do we prepare and support medical providers to do this work?
Why are we so uncomfortable with topics like trauma, with intimate partner violence, with suicidal ideation? The answer is complex and simple at the same time, these are not easy topics to talk about. Partially because they are sensitive, partially because they carry stigma, and partially because they are so prevalent that those having the conversations may be personally affected by them. Regardless of these factors, there is growing evidence for trauma informed care in medical settings. This work has been supported by agencies like SAMHSA, HRSA, and National Council for Behavioral Health.
I recently was asked to teach TIC to 3rd year medical students. In fact, one of our learning objectives was, “develop comfort in addressing a trauma disclosure with a patient.”
The first question I get in the class is should we be screening for trauma or PTSD. The listserv discussion included thoughts on universal screening for ACEs and PTSD in primary care patients. Although I think that screening is appropriate for some sub-populations served in a primary care setting, I have not yet seen robust evidence that this type of screening in a general primary care population leads to improved outcomes. As mentioned in the listserv discussion the USPSTF has not yet issued a guideline for screening for trauma or PTSD.
In the listserv discussion, there was a call for medical providers to provide validation, empathy, and sensitivity to patients with a history of trauma as an intervention that seems feasible and realistic for primary care providers to implement. It was pointed out that these should not just be applied to patients with a history of trauma or PTSD, but to all patients. I endorse this idea and will take it a step farther by suggesting that validation, empathy, and sensitivity should be applied in the context of trauma informed care and a universal precaution approach.
These three qualities (validation, empathy, and sensitivity) fit perfectly into the formal conception of trauma-informed care: fostering safety, autonomy, and trust in the patient-healthcare provider relationship. When operating with the universal precaution approach, direct screening is not necessary. We approach all patient care, every interaction, with the principles of trauma informed care including safety, trustworthiness & transparency, peer support, collaboration & mutuality, empowerment, voice, choice, and cultural, historical, and gender issues.
Being trauma-informed means that one can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization. It is important to remember that trauma-informed is different than trauma specific or trauma sensitive.
So, what did I teach my 3rd year med students? We discussed how to ask about trauma and how to respond to a trauma disclosure. I introduced the five points below. I hope these can help you in your practice. You may even want to share them with a colleague.
Use a Trauma Education Statement. It is important that we explain why you are asking about trauma in the context of their medical care and that we acknowledge the impact of trauma.
“We’ve learned a lot about how abuse, neglect, and chronic stress can lead to health issues like chronic pain...
“What we know about trauma is that people who have been exposed to abuse or have had bad things happen to them are more likely to have certain health problems like chronic pain…”
Inquire about the patient’s experience. I suggest to my students that the first time we bring trauma up we are simply planting a seed. I encourage them to lead with curiosity and compassion. I emphasize that it is important that we let our patients know it is not necessary to gather details for them to be able to help.
“I wonder if you have had some experiences like this in your past…”
“I don’t need to know the details of anything that may have happened to you. I wonder if you have experienced emotional, physical or sexual abuse in your past…”
Create safety. Once someone has shared about their experiences it is crucial that we validate their emotions and experiences. We also must act as a container and prevent activation and emotional dysregulation.
“You don’t have to share details with me. I want you to know that you can talk with me about these experiences and how they may be affecting you now.”
“I want to acknowledge that these are really hard things to talk about for most people because talking about them can bring up emotions or you might feel like you are reliving what happened to you.”
Addressing a disclosure. This is where my students felt the most unprepared. I encourage them to thank their patient for sharing their story. And I encourage them to connect how knowing the patient’s history can help them provide better care.
“Thank you for sharing your story with me because it really helps me understand the whole picture of your health and how you live your day to day.”
“Thank you for telling me this. Given what we know about certain health conditions and trauma, this will help your healthcare team provide better care.”
Preventing and reducing activation. If you begin to notice that your patient is fidgeting, playing with something in their hands, rocking in their chair, avoiding eye contactor seems “checked out” they may be activated or dissociated from retelling their experiences. I teach that in these moments it is ok to interrupt their story. Validate their experiences and emotions and explain that reliving emotions and telling the details of an experience is not necessary for you to help.
“I’m actually going to interrupt you because I can see that this is really distressing and hard to talk about and I don’t want you to have to feel the emotions that go with those experiences.”
“This sounds like this was a really significant event in your life. I want you to know that you don’t have to tell that story because you don’t have to relive the emotions that you experienced.”
If you have questions or if you wish to have further conversation about this topic, feel free to contact me at email@example.com.
Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.
This year is almost over, a signal it is time to highlight all the great blog posts published in 2018. We have terrific writers in the CFHA community who collectively represent unequaled experience and thinking in the field right now. Catherine Van Fossen et al wrote about a new tool that measures family functioning. They wrote “family functioning is not consistently measured in clinical health care settings or large-scale studies investigating child wellness. … we sought to identify a measure that enabled individuals to report their own functioning.” Barry Jacobs, a national expert on family caregiving, asks “So can families reduce healthcare costs? Probably, though we need many more robust studies with different populations to settle the question.”
One area we emphasize on the CFHA blog is research in integration. A constant challenge in disseminating integrated care is controlling the variability that naturally comes with the different clinic contexts and patient demographics across the country. The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) is a tool for measuring fidelity to the Primary Care Behavioral Health (PCBH) model. Greg Beehler reported that “the PPAQ-2 will [soon] be made available. … [it] has been expanded and re-validated to include new subscales to address essential components of collaborative care management. The PPAQ-2 will now be useful for both PCBH providers and care managers.”
We had a short series on quality improvement in health care by Alex Young and Kevin Raddean. Alex gave a brief description of QI while Kevin introduce readers to the fishbone diagram, (aka Ishakawa diagram). Finally, we published two reports on current finding in research: one in September and then one in November. Check out these reports for a quick guide to latest findings in integration.
Many CFHA members are heavily involved in training the next generation of workers in collaborative care, giving us a good reason to cover this subject on a regular basis. Each year we promote the STFM behavioral science fellowship, this year written by Max Zubatsky. Writing about supervision in integrated care, Kyler Shumway argues that “On the playing field of integrated care, supervisors have the opportunity to equally inspire and lead others.” Lastly, Katie Snow gives advice for new workers in the field of integration. She writes “For those who, like me, enter the integrated care world as a mental health provider not formally trained or experienced in PCBH or another model, working in a medical clinic feels like visiting a distant land with unfamiliar customs and language.” Her five tips will certainly help any new professional.
A regular topic on the blog is the PCBH model, a popular approach that is gaining in momentum but outpacing empirical research. Dennis Freeman answered questions about strategies for financing a PCBH-based service. He argues that “BHCs working in the PCBH model need to prove--with data--the presence of the behavioral health provider on the primary care team improves clinical outcomes, enhances practice efficiency and reduces total healthcare costs for the panel of patients cared for by the practice.” Ryan Landoll reports results of a quality improvement project undertaken by the USAF using PCBH within a stepped care framework. In one year, these sites doubled the number of behavioral health encounters, reached 150% more of the beneficiary population, and saved community mental health costs by over $100,000. These results far outpaced their peer institutions while maintaining high levels of patient satisfaction. We published other PCBH posts on patient outcomes and emergency room visits.
Next year the blog format will change significantly. We are moving to a columnist-model and are combining the CFHA and Families & Health blogs into one single blog featuring posts on innovations in team-based and family-centered collaborative care. Have a wonderful start to the New Year and stay tuned for more great writing in 2019.
Starting and sustaining a movement in healthcare is tough business, unless there is a plan and resources for dissemination. The movement to integrate behavioral health services into primary care began in diverse places, but now appears to have serious momentum. The challenges facing integration today are many and include the following big two: workforce development and variation. The first is a constant requirement for the health care ecosystem and a major determination for how fast a system can integrate. The second is a natural result of the germination of integration across many spots of land, some good and some poor. Variation is good for gene pools and music playlists, but not for disseminating best practice in primary care. Variation means everyone is NOT on the same page. It is a major impediment for research and dissemination. Closed systems seem to have the least amount of variation (see Kaiser, Cherokee, and the VA system) and often boast the most outcome data. The bad news is that many rural and remote clinics operate outside closed systems and lack access to info on best practices.
One possible solution for addressing these issues of variation, access, and even workforce development is Project ECHO (Extension for Community Healthcare Outcomes). Some of you are probably familiar with ECHO especially when it comes to liver disease management, HIV treatment, or psychiatry in primary care. ECHO is basically a marriage of professional education and care management that enhances primary care treatment. For those of you with behavioral health training backgrounds, it is very similar to group peer supervision (shout out to Dr. Springer, my favorite group supervisor). ECHO works to broadly share knowledge and build capacity among primary care workers, all in an effort to reduce disparities between urban centers and rural communities. For additional bonus points, ECHO also seems to reduce variation in practice and develop the workforce. The research is impressive. One recent article on ECHO for integrated primary care reports increased provider knowledge and self-efficacy and reduced feelings of isolation.
Short side story here: When I was a kid growing up in New York, my family did not have cable television. We had a big antenna on our roof and picked up major network channels and public television. I enjoyed the popular kid shows at the time, even though most of them were just 30-minute advertisements (GI Joe and Transformers, I’m looking at you). The only daytime option for television was the Public Broadcasting Station (PBS) channel. My three brothers, three sisters, and I (yes, big family) enjoyed watching classic PBS shows like Reading Rainbow, Sesame Street, and 3-2-1 Contact. I can sing the theme songs of most of these shows. These shows were ad-free, high quality, and funded by public and private payers. Project ECHO is like your local PBS channel, allowing everyone access to quality content.
Nothing compares to PBS. Those television programs have impacted millions of children in the US and continue to do so today. Beyond public education and public libraries, it is one of the most effective ways for sharing education with a wide audience. In healthcare, I believe that ECHO is one of the best strategies for making expert knowledge of integration as widely and freely accessible as possible. Imagine the small rural practice in Wyoming that wants to integrate, but has no access to an academic hub or enough funds for a consultant. That rural practice can join an ECHO group, connect with other similar clinics, and begin learning best practices immediately. All for free. The major challenge for most ECHO hubs (a hub is the collection of experts that work with the local sites, called spokes), just like PBS, is securing funding, often through sponsorship.
We have published previous blog posts on ECHO (here, here). I mention it again now because of recent developments by large organizations to develop ECHO hubs specifically for behavioral health integration. There are many hubs on opioid addiction and psychiatry, but none that focus specifically on integrating behavioral health providers into primary care. Some recent examples include ECHO Colorado and Arizona State University. The former is focused on patient treatment, the latter on practice transformation and management strategies. Despite the benefits of ECHO, there are challenges. I already mentioned funding, a common one because the founders of ECHO at the University of New Mexico require all hubs to make ECHO services free and accessible to primary care clinics. Another challenge is the struggle to measure practice transformation within spokes that participate in ECHO. Most studies that I see measure knowledge and self-efficacy. It’s difficult gaining access to multiple EMRs without major funding and expertise.
But those challenges are surmountable. Project ECHO is really a project of the willing. The people who stand to benefit the most from integrated care are those living in rural, remote, and underserved areas. Those clinics often lack access to expert knowledge. ECHO reduces this disparity just like Elmo from Sesame Street. But it requires self-motivated individuals who are willing to invest time and resources upfront before funding is later available. That is a tough pitch to make to your CEO. My advice is to just ask your CEO if he or she grew up watching PBS.
Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. He serves as the blog editor for CFHA.
Posted By Barry J. Jacobs,
Monday, December 3, 2018
During the 24 years I worked as a psychologist in family medicine, I heard many complaints about patients’ family members gumming up the healthcare system in various ways. For instance:
“My patient’s wife keeps asking me to do things I can’t do—like arrange for her husband to live elsewhere—and taking up my time with frequent phone calls,” vented one physician.
“I think the adult children are stealing and abusing my patient’s pain meds,” said another.
“The family members won’t decide about changing the patient’s code status,” said a third, “and are making our hospital team continue life supports we know won’t change the ultimate outcome.”
These were the gripes of frustrated clinicians. They were not daily reactions but occurred often enough to suggest a widespread professional leeriness towards families. At its most harsh, patients’ family relatives were viewed as nuisances or worse—unrealistic, demanding, self-serving and untrustworthy. They were occasionally condemned for upending plans, obstructing patient-provider relationships, and unfairly impugning doctors who didn’t agree with them. Many healthcare providers maintained cordial relations with family members but minimized deeper engagement as nearly antithetical to “patient-centered care.” If asked whether families help or hinder healthcare, these providers would probably contend that, on balance, they make professionals’ jobs more difficult and cost the system essential dollars through reduced efficiency.
That’s not the bet, though, currently being made by some of the nation’s biggest health insurance companies, including United Healthcare, Centene, AmeriHealth Caritas, and others, who have launched pilot caregiver support programs, especially for family members whose loved ones are receiving managed Long-Term Services and Supports. The insurers are looking at our rapidly aging society and the rocketing growth of home- and community-based services and believe that it is those sometimes-maligned family members whose valiant efforts can be the difference between chronically ill subscribers bouncing about ERs, hospitals and nursing homes and remaining safe and sound in their own homes. They believe that well-trained, devoted and hardy family caregivers, primed to partner with willing healthcare and social service providers, may be the key to holding down healthcare and long-term care costs.
On what grounds are the insurers basing their bets? Research—and perhaps a little wishful thinking. There is existing data to demonstrate that engaged family caregivers can help patients with dementia and other progressive conditions live as well as possible outside of institutions. But, historically, most family caregiver research has focused on the impact of caregiving on family members’ well-being and not on patients’ healthcare utilization. We need more research on which elements of family caregiver support yield the greatest decreases in patient utilization and costs.
It is worth reviewing what little we have in hand, however, because it is promising. Everyone points to the classic 2006 Neurology study by NYU epidemiologist Mary Mittelman and colleagues entitled “Improving Caregiver Well-Being Delays Nursing Home Placement of Patients With Alzheimer’s Disease” (https://www.ncbi.nlm.nih.gov/pubmed/17101889). It describes how a six-session individual and family counseling and support intervention, along with phone contact as needed, forestalled institutionalization of patients with dementia by 557 days on average—likely an over $150,000 savings per patient in today’s Medicaid costs. To many observers, it proved definitively that a proactive investment in family support could pay big dividends in the long run.
More recent studies on the impact of caregiver functioning on patient utilization lack the dramatic punch of Mittelman’s breakthrough work but are worth noting. In 2016, the National Bureau of Economic Research put out a White Paper, “What is the Marginal Benefit of Payment-Induced Family Care?”, which found that paying patients’ family members money to provide home-based care ultimately saved Medicaid significant sums. Patients tended to by family members had better health outcomes—including fewer bedsores, respiratory infections and urinary tract infections—and consequent lower healthcare utilization, compared to a control group with standard professional care, because their family caregivers effectively served as round-the-clock primary prevention and an early-warning system for acute medical problems.
And a 2016 study by Johns Hopkins epidemiologist David Roth and colleagues—“Medicare Claims Indicators of Healthcare Utilization Differences After Hospitalization for Ischemic Stroke: Race, Gender and Caregiving Effects” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518936/) –cites having a family caregiver as one factor leading to patients requiring fewer hospital days, ER admissions and primary care visits after they had been hospitalized for stroke.
So can families reduce healthcare costs? Probably, though we need many more robust studies with different populations to settle the question. I’m hoping that the insurers who are now rolling out enhanced family caregiver support programs around the country are rigorously evaluating whether these programs actually lower patient utilization and, if so, how.
The insurers’ programs would be greatly boosted if healthcare professionals also embraced family members as partners in care. Research alone won’t bring about that change in providers’ attitudes and behaviors—at least not in the short term. It will take transforming our patient-centric medical culture over the long haul through workforce development, perhaps by matching young learners during their graduate school programs with, say, the spouses of home-bound patients with dementia to show them who is really doing heroic work on the frontlines of healthcare. Only then will our professionals join our insurers in getting behind the nascent power of our families.
Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and Principal at Health Management Associates, a national healthcare consulting firm. He is the author of The Emotional Survival Guide for Caregivers (2006) and co-author of AARP Meditations for Caregivers (2016).
Welcome to the November Research Report. This is the post where I, your friendly neighborhood blog editor, save you time and keep you informed of the latest and greatest in integrated care research.
The studies you see below represent some of the best research coming out. I organized them into categories for easier reading and hope you find one that can make an immediate impact on your work. The categories are Implementation (evidence- and practice-based guidelines), Interventions (patient treatments), Informatics and Health Technology (innovative uses of EMR), Attitudes and Perceptions (what people think of integrated care), Workforce Development (preparing the next generation of providers), and Outcome Research (end results of care delivery research).
Each category includes an abstract from the article that seems most impactful and then links to other research articles. If you found a recent article that is not listed here and want to right that wrong, please contact me and I will make sure we highlight it in a future blog post.
Abstract: Behavioral health (BH) integration has been proposed as an important strategy to help primary care practices meet the needs of their patient population, but there is little research on the ways in which practices are integrating BH services. Methods: We conducted a qualitative analysis of BH integration at 30 US primary care practices that had been selected for the Learning from Effective Ambulatory Practices (LEAP) project following an interview-based assessment and rating process. Most LEAP practices looked to BH integration to help them provide timely BH care for all patients, share the work of providing BH-related care, meet the full spectrum of patient needs, and improve the capacity and functioning of care teams. Practices operationalized these goals in various ways, including universal BH screening and involving BH specialists in chronic illness care. As they worked toward their BH integration goals, LEAP practices faced common challenges related to staffing, health information technology, funding, and community resources.
Abstract: Pioneering strategies like WHO’s Integrated Management of Childhood Illness (IMCI) have resulted in substantial progress in addressing infant and child mortality. However, large inequalities exist in access to and the quality of care provided in different regions of the world. In many low-income and middle-income countries, childhood mortality remains a major concern, and the needs of children present a large burden upon primary care services. The capacity of services and quality of care offered require greater support to address these needs and extend integrated curative and preventive care, specifically, for the well child, the child with a long-term health need and the child older than 5 years, not currently included in IMCI. In response to these needs, we have developed an innovative method, based on experience with a similar approach in adults, that expands the scope and reach of integrated management and training programs for pediatric primary care. This paper describes the development and key features of the PACK Child clinical decision support tool for the care of children up to 13 years, and lessons learnt during its development.
Abstract: Integrating behavioral health into primary care can improve care quality; however, most electronic health records are not designed to meet the needs of integrated teams. We worked with practices and behavioral health (BH) clinicians to design a suite of electronic health record tools to address these needs (“BH e-Suite”). We conducted a convergent mixed-methods proof-of-concept study, implementing the BH e-Suite across 6 Oregon federally qualified community health centers (“intervention clinics”). Implementation improved process of care (PHQ-9 screening). During the course of the study, change in intermediate outcomes was not observed. Degree of BH e-Suite implementation varied: 2 clinics fully implemented, 2 partially implemented, and 2 practices did not implement at all. Initial practice conditions (eg, low resistance to change, higher capacity), process characteristics (eg, thoughtful planning), and individual characteristics (eg, high self-efficacy) were related to degree of implementation.
Abstract: Health care is increasingly delivered through team-based, collaborative strategies with interprofessional education as an important mechanism for building interprofessional practice competencies. This paper describes an Interprofessional Seminar on Integrated Primary Care (IS-IPC) designed to meet this educational need with interprofessional team-based learning as the foundation of an iterative process such that education and practice inform one another. The IS-IPC can be used to educate an interprofessional group of learners about key topics relevant to working together in integrated primary care. The IS-IPC describes steps in developing an interprofessional seminar, common challenges, and their solutions in creating interprofessional learning experiences, and eight foundational content modules containing an outline and curricular resources. The IS-IPC facilitates interprofessional educator partnerships at the local level and can be customized to fit the local environment, pedagogical philosophy, and learning objectives.
Abstract: Introduction: Behavioral health problems are pervasive in primary care and can impede efficient delivery of medical care.Primary care pediatricians PCPs address behavioral health issues during roughly 1 in 3 visits 1, and these visit require an average of twice as much time than those with only medical concerns 2. The present study examined how IBH impacted medical visit costs after its first year of implementation. All patients who presented for an initial behavioral health visit in Michigan Medicine’s first integrated pediatric primary care clinic between August 2013 and August 2014 were included in the sample N= 134. Patients in the sample averaged 3.11 primary care medical visits before initial IBH treatment and 2.96 visits afterward. The mean per patient cost of primary care medical treatment was $326 per patient in the year prior to initiating IBH treatment and $254 in the year following. Primary care medical visits were an average of $19.80 less expensive for patients after they initiated IBH services. This resulted in an average cost savings of $71.90 per patient based on the 134 patients who received services in the 1-year period.
1.Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis
2.A Scoping Review of Facilitators of Multi-Professional Collaboration in Primary Care
Interdisciplinary Perspectives on an Integrated Behavioral Health Model of Psychiatry in Pediatric Primary Care: A Community-Based Participatory Research Study
Abstract: Integrated behavioral health services have positive outcomes for patients and providers, but little is known about providers’ perspectives on implementing these services. This community-based participatory research collaboration with a Federally Qualified Health Center examined provider perspectives on implementing a collaborative psychiatry consultation program in pediatric primary care. We interviewed providers (N = 14) from psychiatry, social work, primary care, and psychology regarding their experiences implementing the program, and their recommendations for its sustainability. Providers described interdisciplinary integration arising from the program, with accompanying benefits (e.g., increased access to care for patients with complex diagnostic profiles, increased learning and role satisfaction among providers), and challenges (e.g., increased burden on primary care providers, potential patient discomfort with team-based care). Our results highlight the complexities of implementing collaborative psychiatry consultation in pediatric primary care, and suggest the importance of supporting primary care providers and patients within this context.
I vividly remember my first meeting with the OB-Gyn and maternal-fetal medicine providers in the early weeks of my role as a behavioral health consultant for a group of women’s health clinics. I wore my favorite shirt. I got up earlier than seemed reasonable (who knew how much doctors love 7 am meetings?). I brought handouts. I told them I was there to help them take care of their patients’ health problems that are impacted by stress or mental health challenges. The referrals started rolling in!
Just kidding. Deafening silence. I had a lot of time to make more handouts.
It turns out that this group of providers are very connected to their patients and, once I got to know them, I understood. They had cared for these women throughout pregnancies and delivered their children. For some, deftly slicing the abdomen and uterus open to do so before neatly stitching them back up; for countless others, theirs were the first hands to touch baby’s slick downy skin on its initial descent into the world.They had met some long term patients after a sudden pain led to an ER visit resulting in a gynecologic surgery that saved that woman’s life. They had seen others through crippling menstrual pain, loss, infertility, menopause, scary diagnoses and more. They weren’t going to suggest their patients talk with just any enthusiastic person in a nice shirt who showed up in the clinic. I had to earn their trust that I could add value to the care they provided.
For those who, like me, enter the integrated care world as a mental health provider not formally trained or experienced in PCBH or another model, working in a medical clinic feels like visiting a distant land with unfamiliar customs and language.At first, the only thing that seemed certain were the skills I had honed over many years working in community mental health.Less certain was how to fit them into a brief model in a way that was valued by patients and providers. The good news is that providers did eventually start to trust me to help care for their patients. In fact, we have had to hire more help. Today I will share some of the tidbits that have helped sustain, grow and institutionalize behavioral health in my particular clinic setting. I hope some are useful and relevant for you. Over the next year my blog posts will focus on some of these topics in more detail and more, so stay tuned!
1.Integration is adaptation, teaching and learning:I learned everything I know about integrated care from colleagues working in primary care settings. Pretty early on, I realized that there were unique aspects to OB/Gyn care that didn’t fit with that model. I also realized that the providers mostly saw me as a co-located mental health provider and I would need to teach them about integrated care (which I was very much still learning). For one thing, I wasn’t working with 3 or 4 providers like my colleagues, it was closer to 25 in my physical location and 125 across the multiple locations for the company.And, instead of diabetes, tobacco use and obesity as the top 3 behavioral health referral problems I was seeing mostly perinatal mood disorders, pregnancy loss and menopause-related insomnia and mood issues.I was also heavily used for crisis situations, a challenge to the brief model. For example, when encountering a family that had just received news of an adverse fetal diagnosis or pregnancy loss, a 20 minute visit didn’t meet the need for connection, support and planning. In most cases, I found ways to adapt the model to work better for this population and setting.
I also had a lot to learn.I have already mentioned the level of care and concern for patients from this group of providers. This care came along with an expectation for patient hand-holding that was not comfortable for a social worker trained to highly value self-determination and self-efficacy, but I found some middle ground.And the acronyms! I had to start spelling out mine (no more CBT, DBT, MI etc.) and start learning theirs (SAB, LARC, IC, NSVD—OMG!). I used Google a lot.Most powerfully, I learned how important a warm handoff can be. Even if it meant leaving a scheduled visit, I learned to prioritize them. It quickly became clear that for many people, coming back for a scheduled appointment was not likely and I came to see that I could do more in a short period of time than I had expected. This comes with the added bonus of being known as the fastest run-walker in the clinic and some mad laptop slinging, type-walking skills.
2.Perfect your elevator pitch (and get used to saying it A LOT): You may be the only mental health provider in your clinic. You may also be the only mental health provider many patients ever speak with. So, by default, you will play ambassador and translator of the mental health and behavioral health worlds in your clinic.Don’t expect providers, staff or patients to immediately understand or remember what you do or how you fit into the big picture. Find a way to describe your role that makes sense to these varied groups and be diligent about communicating what you do. Here’s a typical spiel when I am introducing my role to a patient: “Hi, I’m Katie. I’m a member of the team here and a licensed mental health provider. My job here in the clinic is to learn about any problems that are getting in the way of feeling your best and work with you on some ideas that may help you feel better soon. I often see patients a handful of times, usually somewhere between one and five, to help out with this. I also provide help connecting to resources outside of this clinic, such as longer-term counseling, if you are interested.”
3.Focus on physical symptoms impacting functioning: It is a consistent challenge to deliver useful interventions to patients in a short time frame and, in some situations, it can feel like an impossible task.Most mental health issues have one, if not many, physical symptoms. When overwhelmed, remember to ask about basics such as sleep, energy level/fatigue, nutrition/weight gain, physical activity, rapid heartbeat/shortness of breath, pain, sexual health and the impact of any chronic health conditions.Or, ask some of the providers in your clinic about typical complaints they encounter.A focus on physical symptoms that are causing distress or contributing to or resulting from mental health symptoms will allow you to narrow your focus, provide meaningful brief interventions and help patients feel more hopeful about getting better. I was pleasantly surprised at how easily I could apply my clinical toolkit to these symptoms and have patients experience real results.
4.Save time with brief screening tools: Now that I use them all the time, I can’t believe I ever functioned without constant use of the PHQ-9, GAD-7, Edinburgh Postnatal Depression Scale (EPDS) and the Columbia Suicide Severity Rating Scale (CSSRS).Depending on the presenting issues, I often start with one or more of these to help quickly identify (and quantify) mental health symptoms. It really helps to know upfront if our visit is going to focus on safety due to suicidal ideation or if we will be able to move beyond that topic.Patients also benefit from a brief description of their score, scoring scales and information about how their symptoms relate to a particular mental health issue.
5.Stay updated on relevant community resources: Maybe you have someone else in your clinic who helps with this. More likely, you do not.Even if you don’t consider yourself an expert in this, take some time to get and stay updated on resources in your area that meet the needs of the specific population you serve. Providers and patients really value this expertise.I see a lot of women experiencing anxiety and depression in pregnancy and the post-partum period, so I am constantly on the hunt for affordable, accessible parenting supports, diaper banks and maternal-health aware mental health care.Most of the things that contribute to wellness take place outside of the clinic in the context of families and relationships. Your patient may be more likely to take your input on getting more physically active, starting some breathing exercises or shifting negative thought patterns if they see you as helpful in more concrete areas.
Let me know if you would like to hear more about these, or other topics, from the perspective of a newcomer to integration. Leave any questions or thoughts in the comments!
Katie Snow, LCSW is a Behavioral Health Consultant and Clinical Supervisor for Women’s Healthcare Associates, a group of OB/Gyn clinics in the Portland, Oregon metro area. Katie started out as a BHC in 2014, with 16 years of experience working in varied community mental health settings and 0 years’ experience working in integrated care.That number would have stayed at 0 without the incredible support of the LifeWorks Northwest Integrated Medical Services team and the genuine trust and support of the staff and providers of Women’s Healthcare Associates.
Posted By Catherine Van Fossen, Keeley J. Pratt, Robert Murray, Joey Skelton,
Thursday, November 1, 2018
Family functioning is one way to measure how a family meets its physical and psychological needs; in other words, it quantifies the family’s emotional environment1,2. Family functioning has been found to be associated with chronic physical and mental illness in children3–6; however, family functioning is not consistently measured in clinical health care settings or large scale studies investigating child wellness. While there are multiple measures available to assess family functioning, we sought to identify a measure that enabled individuals to report their own functioning and did not require lengthy assessment or responses.7
The purpose of this study was to pilot a brief measure of family functioning in pediatric primary care. We administered the General Functioning Subscale of the Family Assessment Device1,8, which consisted of 12 items to 400 families from two different pediatric primary care sites in Columbus, Ohio. One of the challenges we face as researchers and practitioners is to identify tools that will accurately and consistently measure a phenomenon of interest. In addition, we are also interested in measures that can accomplish these tasks without creating fatigue in our patients and participants. Patients are often inundated with assessment at appointments, increasing the likelihood of incomplete or inaccurate answers. Through piloting the General Functioning Subscale, we hoped to identify a brief measure, capable of assessing family functioning, or the overall family emotional climate, in pediatric settings. Further, we sought to understand the rate of families presenting to pediatric primary care with clinically significant levels of impairment in their family functioning.
To qualify for our study, participants needed to read and write in English, be patients at a pediatric primary care office, and have at least one child between the ages of 2-18. In addition to the General Functioning Subscale of the Family Assessment Device, participants completed a brief demographic questionnaire, which assessed caregiver age, race/ethnicity education, employment, marital status, and child age, race/ethnicity, education, health insurance, and health diagnosis, as well as family income and the number of people living in the household. Most caregivers in our sample were female (77.7%) with a mean age of 38.18 years (SD = 7.96; range = 21-69 years). The majority of caregivers identified as Caucasian (81.5%), followed by African American (13.7%), Asian (1.0%), Biracial or Multiracial (1.3%), and Other (2.5%); however, a small number of participants identified as Hispanic (3.3%). Children were on average approximately 8 years old (SD=4.53; range=2-18 years), with a near even split of male and female child participants (53.6%). Children in this sample were insured with private health insurance (72.8%), and the majority of families reported an income above $50,000 per year.
In order to evaluate the psychometric properties of the General Functioning Subscale of the Family Assessment Device, we evaluated its reliability and convergent validity. Reliability, when measured through internal consistency is a measure of whether each person answers the 12 items in a similar or predictable fashion. This measure was found to have high reliability (α = .90). The second thing we evaluated was the convergent validity of the questionnaire. In this study, we were specifically investigating whether all 12 items could fit together as one construct: family functioning. The model fit was χ2(54) = 56.44, P = .38, with root mean square error of approximation = .01 and comparative fit index =.99, which indicates good model fit, and a single factor of family functioning. After establishing that the General Functioning Subscale of the Family Assessment Device was acceptable for use in pediatric settings, we explored the rate of families who scored above the clinical cut-off for impaired family functioning. This means that families were indicating impairment at the same level of families who were presenting for family therapy. Approximately 13% of families seeking pediatric care had clinically significant impaired family functioning, or problematic family dynamics.
The General Functioning Subscale of the Family Assessment Device offers a promising way to quantify family dynamics in pediatric care settings. The brief questionnaire (12 items) can be administered to families and scored with minimal training. Physicians seeking to provide comprehensive care to families can utilize this tool to make data driven decisions about referrals to behavioral health providers. Finally, the rate of impaired family functioning practice in pediatric primary care emphasizes the need for high quality integrated care for children and their families.
1. Epstein NB, Baldwin LM, Bishop DS. THE McMASTER FAMILY ASSESSMENT DEVICE * Previous First Next. J Marital Fam Ther. 1983;9(2):171-180. doi:10.1111/j.1752-0606.1983.tb01497.x
2. Miller IW, Ryan CE, Keitner GI, Bishop DS, Epstein NB. The McMaster Approach to Families: theory, assessment, treatment and research. J Fam Ther. 2000;22(2):168-189. doi:10.1111/1467-6427.00145
3. Ferro MA, Boyle MH. The Impact of Chronic Physical Illness, Maternal Depressive Symptoms, Family Functioning, and Self-esteem on Symptoms of Anxiety and Depression in Children. J Abnorm Child Psychol. 2015;43(1):177-187. doi:10.1007/s10802-014-9893-6
4. Halliday JA, Palma CL, Mellor D, Green J, Renzaho AMN. The relationship between family functioning and child and adolescent overweight and obesity: A systematic review. Int J Obes. 2014. doi:10.1038/ijo.2013.213
5. Georgiades K, Boyle MH, Jenkins JM, Sanford M, Lipman E. A Multilevel Analysis of Whole Family Functioning Using the McMaster Family Assessment Device. J Fam Psychol. 2008;22(3):344-354. doi:10.1037/0893-3220.127.116.114
6. Herzer M, Ph D, Godiwala N, et al. Family functioning in the context od pediatric chronic conditions. J Dev Behav Pediatr. 2010;31(1):1-14. doi:10.1097/DBP.0b013e3181c7226b.Family
7. Hamilton E, Carr A. Systematic Review of Self-Report Family Assessment Measures. Fam Process. 2016;55(1):16-30. doi:10.1111/famp.12200
8. Byles J, Byrne C, BOYLE MH, Offord DR. Ontario Child Health Study: Reliability and validity of the General Functioning Scale of the McMaster Family Assessment Device. Fam Process. 1988;30(1):97-104. doi:10.1111/j.1545-5300.1988.00097.x
Catherine Van Fossen, M.S. is a doctoral student at the Ohio State University (OSU) in Human Development and Family Science and the Couple and Family Therapy Specialization in the Department of Human Sciences. Catherine has trained in both school and hospital settings to provide family therapy to diverse families. Catherine was awarded the American Association of Marriage and Family Therapy Minority Fellowship in 2016 and 2017. Catherine’s area of research is family based behavioral care interventions in pediatric primary care, with a focus on minority and underserved populations.
Keeley J. Pratt, Ph.D. is an Associate Professor in Human Development and Family Science and the Couple and Family Therapy Specialization in the Department of Human Sciences and in the Department of Surgery at OSU. She completed her doctorate in Medical Family Therapy at East Carolina University, and a post-doctoral research fellowship at Research Triangle Institute International in an Obesity Signature Program. Dr. Pratt is an Associate Editor for Families, Systems, and Health. Her area of research is family-based pediatric and adult weight management and culturally tailoring weight management for racial/ethnic minority and underserved/insured families.
Robert Murray, MD attended Indiana University School of Medicine and did his residency training in pediatrics at DeVos Children’s Hospital, Spectrum Health, in Grand Rapids, Michigan. He was a professor in the Department of Pediatrics of the OSU School of Medicine and Nationwide Children’s Hospital He was the Director of the Borden Center for Nutrition and Wellness and served as the past President of the Ohio Chapter of the Academy of Pediatrics.
Joey Skelton, MD received his BS from Furman University, and MD from the University of Tennessee, Memphis College of Medicine. He did his training in Pediatrics at the Children’s Hospital of Wisconsin and the Medical College of Wisconsin, and completed a Masters in Health Sciences Research at Wake Forest University. He is an Associate Professor of Pediatrics at Wake Forest School of Medicine, and is Director of Brenner FIT, an interdisciplinary pediatric weight management program at Brenner Children’s Hospital. His area of research is family-based pediatric weight management and attrition from treatment.
The Plenary Session opened with the presentation of the 2018 Don Bloch award to John Rolland, a psychiatrist and creator of the Families, Systems, and Illness model. John is a Wingspread Conference legacy member and prolific writer on family-oriented approaches to healthcare. He and his lovely wife Froma Walsh are the co-founders and co-directors of the Chicago Center for Family Health over the past 27 years. It is hard to imagine of someone in the field that is more deserving of the award than Dr. John Rolland.
Regarding the first question, Professor Matthew recounted both historical and recent examples of injustice and racism including the original 13th amendment that was nearly ratified and the white supremacist rally in Charlottesville, Virginia. Dayna argued that we need just medicine because injustice happens when no one is looking and that injustice must be dismantled with persistence.
“Just medicine” includes an explicit recognition that there is a real race problem in the US and that many patients are treated differently in healthcare because of the color of their skin. The two major principles of this approach to healthcare are equality/equity (giving patients what they need when they need it as much as they need it to have an equal opportunity) and population-based care that emphasizes preventative care. “Just medicine” seeks to resolve significant disparities like infant mortality rates and pregnancy-related dates that unfairly impact black- and brown-skinned patients more than white patients. The 2003 report from the Institute of Medicine states that health disparities are found at virtually every step and process of healthcare.
We achieve “just medicine” by persistently identifying and addressing the mechanisms that produce attitudes, biases, and stereotypes in health disparities. A major driver of health disparities is institutional racism: the systemic, institutionalized, historic, and legally-enabled belief that one race is better than another. Dayna shared a troubling personal experience with a Lyft driver who initially refused to serve her and then offered to take her home. She felt scared and upset by the experience and later spoke with a Lyft emergency line representative with a deep southern Virginia accent. She anticipated an unempathetic response from the man but was surprised when he affirmed her fear and hurt. “I internalized racism and your patients internalize it as well. After I heard that man on emergency line say that I cried because I let go of all that hurt”.
Professor Matthew believes that we need to take real steps toward a healthcare system a “just medicine” reality by screening for and treating health problems impacted by racism. She argues that the literature is not clear about the harmful effects of implicit bias. See the following:
For those seeking to address their own individual bias, Dayna recommends a humble and mindful mindset. However, institutional racism demands a systemic and attentive reform effort including an emphasis on population-based healthcare. Disparities in education, housing, environment safety, and criminal justice are major, bi-directional drivers in health disparities. To achieve real equity in care, we must not only improve our one-on-one interactions with patients, but also join movements to dismantle the atmospheric and powerful forces of institutional racism. Professor Matthew believes that healthcare champions like the members of CFHA are in a prime position to be a part of the solution.
Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. He serves as the blog editor for CFHA.
The opening plenary session for the 2018 CFHA Annual Conference in Rochester, New York was led by internationally-renown expert on teamwork, Eduardo Salas from Rice University. His presentation was a fire hydrant of incredible information on the science of teamwork and included insightful advice on how to help a team of experts become an expert team.
Research on teamwork has grown exponentially since the late 1970s when researchers began studying teams in context, their natural environments. Scientific findings began emerging the next decade and since then has yielded important findings on what drives team effectiveness, a common language for directing teams, a plan for promoting teamwork in practice, and evidence that demonstrates teams are effective. For a concise review of current evidence, check out the special issue in American Psychologist journal that was co-edited by Dr. Salas and Dr. Susan McDaniel.
There is a compelling case, supported by multiple meta-analyses, for healthcare organizations to implement evidence-based strategies for designing and sustaining teams. One major meta-analysis of 130 studies demonstrated that better teamwork processes increases likelihood for success by 25%.
Dr. Salas shared several observations he has made over the many years in this field. First, it appears that collaboration expectations are rising and organizations are using teams more than ever; however, many teams perform sub-optimally draining energy and time from an organization. Second, achieving collaboration and teamwork is not a linear event; it is a complex phenomenon including multiple inputs, processes, and outputs. Dr. Salas has observed that the best teams include leadership exemplars and constructive conversations that allow teams to self-adjust and improve.
The current question driving research today in teamwork science is this: how do we turn a team of experts into an expert team? It appears that teams are not created equal and differentiate by the degree of coordination and task interdependence. In other words, “to what extent are team members reliant on one another and need to work together?” As you think about your own teams, you can begin to identify the ways in which team members complement one another and share a mutual goal for success.
If you are considering ways to improve your own teams, consider some of the following ideas:
·Team excel when there are clear roles, responsibilities, and reasons for existing
·A strong coach/leader can facilitate teamwork and exemplify the ability to self-correct
·Teams follow a cycle of pre-brief > performance > debrief
·Avoid “weaponizing” performance data to drive team success
·A pre-launch event is a great way to energize your team kick things off the right way
·Teach your teams how to huddle and debrief, a skill that does not come naturally
Dr. Salas believes that most problems in the US healthcare system are the result of poor or non-existing teamwork (e.g., medical errors; lack of care coordination and communication). If there is any industry that needs better teamwork, it is healthcare. Luckily, CFHA is in the business of helping teams thrive.
Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University. He serves as the blog editor for CFHA.
Posted By Jennifer Funderburk, Lauren DeCaporale-Ryan,
Thursday, October 11, 2018
Lauren and I both love CFHA, and attending the annual conference is one of our favorite things to do each year. We are so excited to welcome you to our city! We believe this conference will be one of the best, between the content highlighting CFHA’s history (due to it being our 20th conference) as well as presentations on interprofessional teams, issues across the lifespan, and opioids/substances use management. We know the conference programming will be engaging, enlightening, and thought-provoking and will help us all improve in our work within integrated care. For those who can’t attend, we hope you will be able to join in some of the action by checking out the mobile app (search for Attendeehub in app store) for content as well as CFHA’s Social Link, Facebook, and Twitter as attendees participate in the conference. You will find there are opportunities for you to experience it from afar as well.
Attending the conference provides the opportunity to add a little good food, drink, new/old friends, and fun into the mix. We wanted to tell you a little bit about our hometown and share some suggestions of things to do and places to eat. Rochester is a city of innovation—home to not only CFHA, but also many innovators within healthcare and other arenas, including social reform, music, science, and business (see sidebar). Accordingly, there are lots of opportunities to experience a piece of history if you are interested. A visit to Susan B. Anthony’s house (www.susanbanthony.org), Mt. Hope Cemetery with a guided tour (http://www.fomh.org/Events/SpecialTours/), or George Eastman’s house (www.eastman.org) will help you learn about some of these innovators in a fun, interactive way.
If you’re not into history, but like to enjoy good food, then listen up. Rochester has a wealth of good dining options. You can walk to several excellent restaurants from the hotel. For instance, Dinosaur BBQ is known for its amazing BBQ and cool atmosphere with bikers galore and a view of the Genesee River. We highly recommend the wings! Of course, all 600+ attendees will likely be searching for food at the same time, which may cause some congestion in these restaurants. Therefore, we have set up some easy ways to ensure you don’t have to wait too long. First, consider reserving a spot in a tour (see sidebar), as these allow you to experience Rochester, but also taste a variety of food and drink. Or if you’d rather, we have also set up reservations at some nearby restaurants for Friday night to give people a chance to meet other CFHA attendees and network while grabbing dinner quickly (https://www.signupgenius.com/go/10C0F49A4AC2DA2FF2-cfha).
Please remember that Rochester is a mid-sized city with relatively low levels of foot traffic. If you choose to walk to a restaurant, remember general good safety rules and always walk with someone else. If you need a ride, we have Uber, Lift, as well as several taxi companies that you will need to call or have the hotel contact – you won’t find taxis driving around to flag down. We have created a list of our favorite restaurants that are worth the trip if you decide you’d rather not walk, so check that out in the conference Mobile App.
There are several other attractions that we recommend you visit if you have time. For instance, The Strong, the national museum of play, is the world’s largest and most comprehensive collection of materials related to play (www.museumofplay.org). It is just as much fun for adults as it is for kids. Or catch a show at Geva, which is within walking distance of the hotel. During our conference, they are showing a romantic comedy about finding love called Fortune (Thu./Fri. at 7pm, Sat. at 7:30pm) as well as Thurgood, a show that follows the 58-year-career of Justice Thurgood Marshall, the first African American on the Supreme Court (Thu. at 7:30pm, Fri./Sat. at 8pm). Check out www.gevatheatre.org if you are interested in purchasing tickets. Or catch a film or live music at the Little (www.thelittle.org), an independent movie theater and café. On Oct. 19th they have musician John Ellison, writer of Some Kind of Wonderful. Or catch a film at the Eastman House (www.eastman.org); they have films each night of the conference starting at 7:30pm.
We hope this provides some good options for you as you visit our city and attend the annual conference. For those able to make it, we look forward to seeing you there! Otherwise, consider joining us in Denver in October 2019 for next year’s annual CFHA conference.
Some Examples of Rochester Innovators
oGeorge Engel, biopsychosocial model
oSusan McDaniel & Tom Campbell
oElizabeth Blackwell, first woman to receive a medical degree in US
oRochester Area Hospital Corporation and Hospital Experimental Payment Plan, innovative healthcare delivery
oFrederick Douglass (abolitionist)
oSusan B. Anthony (women’s rights)
oChuck Mangione (jazz),
oLou Gramm (from the band Foreigner),
oJeff Tzyik (conductor)
oFirst optics department
oHenry Ward (naturalist, geologist)
oGeorge Eastman (inventor, Kodak)
oWegmans (grocery store)
Jennifer Funderburk, PhD, and Lauren DeCaporale-Ryan, PhD, are conference chairs for the 2018 CFHA Annual Conference in Rochester, NY
P. O. Box 23980,
Rochester, New York
14692-3980 USA info@CFHA.net
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.