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PCBH Research Part 2: Discussion of a Recent Study Involving the PCBH Model and Larger Implications

Posted By Kyle Possemato, Monday, June 18, 2018

This piece is the second in a series of posts highlight research on the Primary Care Behavioral Health model. Click here for the first post.

           Research exploring the Primary Care Behavioral Health (PCBH) model has been increasing in the literature.  However, the body of work on this specific model of integrated care is still being built, and many unanswered questions remain.  There is consensus in the field that more study and research is needed to expand our understanding of the effectiveness, efficacy and systemic implications of PCBH work.  Gaining a more precise understanding of these issues will have policy implications on our health care system as well as on funding resources.  Research demonstrating effectiveness could assist in increasing implementation of this model of integrated care into the systems best suited for it, and expand funding resources to support the work.  Additionally, studies exploring the systemic implications for the PCBH model will increase our understanding of the complex, inter-related variables that impact access to behavioral health care and the effectiveness of this care.

 

            One recent study that has scratched the surface of the systemic implications of PCBH work was conducted in Madison, WI (Serrano et al, 2018).  This study utilized a data set that included primary care utilization data for an FQHC with 3 sites that utilized the PCBH model and for a primary care clinic that did not utilize PCBH.  Data was also collected on ED encounters for a subset of patients of the same four primary care clinic who were with a mental health diagnosis.  The study was pre-post in nature, exploring ED utilization before and after PCBH implementation at the FQHC clinics.  The primary care clinic (which did not utilize PCBH served as a control arm.  We found that one FQHC site did show a decrease (11.3%) in the ratio of ED visits to primary care encounters, and the other 2 FQHC sites did not.  We also discovered, not surprisingly, that research on health care systems is highly complicated, with many layers of intersecting variables that can make interpretation of data challenging.

 

            One specific challenge was finding a control site that controls for all relevant variables.  There are several reasons for this.  Finding similar clinics with and without PCBH, that have the same demographics, geographic area, same insurance mix in the same time-period would be extremely challenging if not impossible.  These are simply too many variables to control in a “real-world” situation, particularly considering health care disparities that exist both nationally and regionally.  The lack of adequate controls can make it difficult to interpret cause and effect in data sets.

 

            Ideally a controlled study could be conducted to help move the field forward and deepen our understanding of the model.  However, this would be extremely challenging to conduct.  For a formal randomized clinical trial, there would need separate clinics in the same geographic region with the same demographic mixes and insurance mixes in the same time period, one that has implemented PCBH and one that has not.  They would need to have similar services, provider types, access to care.  Of course, a formal randomized controlled trial, patients would need to be randomly assigned to treatment conditions (in this case clinics), taking away patient choice and likely not realistic.  Instead, it seems that more naturalistic studies will be more realistic, where clinics are compared but patients themselves are choosing the clinics.  It is recommended that as many factors as possible be controlled for in the analyses, including patient demographics, diagnoses, contextual factors, payor mix, geography and so on.  The more that is controlled for, the more specific the results can be, with less room for multiple interpretations.

  Kyle Possemato, Ph.D. is the Associate Director for Research at the VA Center for Integrated Healthcare 

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PCBH Research Part 1: A Pilot Study Across the U.S. Air Force

Posted By Ryan Landoll, Monday, June 11, 2018

The Department of Defense (DoD) was one of the original adopters of the Primary Care Behavioral Health (PCBH) model. Over 20 years ago, the United States Air Force (USAF) piloted its “Behavioral Health Optimization Program” or BHOP at a single Air Force Base. Since 1997, the program has expanded across 72 Air Force facilities and since 2013 has been incorporated into medical care across all DoD services. While there are many unique features of the Military Health System (MHS), its beneficiaries, which include not only Active Duty service members, but also retirees and their families, represent a diverse cross-section of America. DoD facilities are scattered throughout the United States, in populous cities and rural towns. As such, the USAF provides an ideal setting to study aspects of integrated care that apply across the diverse healthcare landscape.

 

A recent study published in Translational Behavioral Medicine describes the results of a quality improvement project undertaken by the USAF using PCBH within a stepped care framework. Three treatment facilities, chosen across the country to represent both rural and urban care facilities (ranging from 13,000 beneficiaries up to over 54,000), participated in this pilot. Without any additional resources (e.g., no hired staff), these clinics reallocated a behavioral health provider and behavioral health technician (equivalent to a medical assistant with exclusive behavioral health training) from specialty mental health to primary care. They also ran an aggressive marketing campaign to funnel new patients into primary care as opposed to specialty mental health. 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.

 

 Read the study here https://academic.oup.com/tbm/advance-article/doi/10.1093/tbm/iby046/4992907?guestAccessKey=9d8e2439-75a6-42b6-a336-466351261f2e to learn more about this innovation.

 

 

Ryan R. Landoll, Ph.D., ABPP, is the Assistant Dean for Preclinical Sciences at the Uniformed Services University. His research broadly focuses on two main topic areas: primary care behavioral health, and adolescent peer relationships (i.e., romantic relationships, friendships, and peer victimization, including cyber victimization) and internalizing disorders (i.e., social anxiety, depression). Dr. Landoll currently heads the Military and Sexual/Reproductive Health (MARSH) Research Program at the Uniformed Services University.


 

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Taking the Hamster off the Wheel: How My BFEF Experience Helped Me Get My Feet Back on the Ground

Posted By Max Zubatsky, Monday, May 14, 2018

At the beginning of my year in the Behavioral Science/Family Systems’ Educator Fellowship (BFEF), I had  a gut feeling that I was “hitting the wall.”  The burnout week had arrived. This occurred both in my personal and professional life.  When I started my job 4 years ago, I hit the ground running and tried to offset my burnout by working even harder.  I quickly learned that this was not a successful coping skill.  As my second year of work progressed, I got back into my past hobbies of running and art. These were both therapeutic and a way to escape from being fully consumed by my job.  I still felt that as a new faculty member, I needed to keep reaching a higher bar to meet the constant expectations of the university.  I not only ramped up my workload, but my hobbies as well.  Now, my coping activities had turned into stressors themselves! I was doing too many things on hyper drive, while continuing to plan for upcoming things in my career. The hamster was pedaling so hard, that the wheel was now starting to break.   

During fellowship year, I decided to change my mindset around any potential onset of burnout.  I found the support of my small group and mentors was instrumental in that.  Here we all were just trying to do the best that we could and all having moments of insecurity.  We slowly could bolster each other up and help each other find small meaningful things in each work day.  I found myself trying to act quicker in the moment when any difficult work and personal issues arose.  Heck, if I emphasize these skills to my patients, then why was I not “practicing what I preached?” I often looked to comedy, inspirational quotes or human interest stories to put my life in context. 

I have to keep being mindful of my privilege as a white male professional.  Some of my hardest days would still be embraced by some of my patients and families that I treat in my practice and in the community.  These patients would be grateful for those days that challenged me but perhaps were just an everyday occurrence to others who did not have as much as I did.  It’s a constant reminder to myself of, “Max, these are issues that you are sweating way too much about.” Putting my life in perspective forces me to lessen my strict expectations that I often set for myself. Even if I can make 1-2 small breakthroughs during a tough week, these are moments that are meaningful and that I can pay forward to my students and residents.  The guidance from my mentors definitely made a difference in this new perspective towards my work.  Not looking over small breakthroughs or successes has now made me become more present-centered as a person and professional.  Whereas in the initial months of my job I was doing nothing but planning and coordinating future tasks, I now embrace more of the virtues that each day brings. 

I learned so much from my small group colleagues and mentors this year around momentum and self-motivation in our lives. A number of Ted Talks that we discussed as a group covered the need for self-balance and recognizing successes in life from different perspectives. Many in the group explained the ways that we can push through challenges or barriers at work, whether it be difficult leadership, team dynamics, resistant residents or overwhelming projects as a new faculty member. Before the fellowship experience, I was doing more self-guided learning and not enough team building, sharing, collaborating and group thinking.  Now, I make it a priority to run creative ideas past other faculty, create brainstorming sessions with residents and students, and facilitate reflection and observation activities with multiple learners. One thing that really stuck with me was that much of our expectations for our job and others at work can be largely determined by our own mindset. When I now face challenges or problems, I embrace them as an opportunity to learn more as both a person and professional. 

Little did I know that one of my most valuable fellowship lessons would be to slow down and take time to appreciation small things in life.  As early career faculty, we often think we need to speed up and do more in order to constantly make our mark.  My small group mentors continually reminded us that we need to set achievable work goals that are attainable and manageable. They encouraged us to be open to making mistakes and being vulnerable to learn from these teachable moments.  It’s important to grow from the challenges and the mistakes, but equally important to celebrate the successes, both large and small.  As Ralph Waldo Emerson puts it, “Bad times still have a scientific value. These are occasions a good learner would not miss.”  The hamster now gets on the wheel at his own pace, realizing that this journey is a marathon and not a sprint.

  Max Zubatsky, PhD, LMFT is Assistant Professor in the Medical Family Therapy Program at the St. Louis University School of Medicine.  

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The Pre-Rehab Checklist: How to Get the Most Out of Your Recovery

Posted By Caleb Anderson, Tuesday, May 1, 2018

In the United States right now, there are over 14,500 rehabilitation centers for people recovering from drugs and alcohol. These centers offer a range of treatment options, including detox and inpatient or outpatient rehab. With outpatient rehab, addiction specialists and nurse practitioners visit people in their homes, allowing them to continue with their normal routine outside of treatment. Usually, outpatient is recommended for patients with mild addictions. Inpatient programs, on the other hand, are designed to help people who suffer from severe addictions. These generally begin with some form of medically-managed detoxification – in layman’s terms, “withdrawal.”

 

Withdrawal syndrome is essentially your body restoring its chemical balance after the cessation or decrease of your regular intake of drugs or alcohol. The symptoms differ according to each substance, ranging from discomforting to excruciating, to possibly fatal. Alcohol withdrawal, for one, may begin 12 hours to a few days after you stop drinking. Mild symptoms include nausea, sweating, shaking, and high blood pressure. Intense trembling and hallucinations are just a few of the severe symptoms. Delirium tremens (“DTs”), meanwhile, comprise all the signs above, and cause seizures. If untreated, DTs can lead to death. Symptoms of withdrawal from illicit drugs are chillingly similar – drenching sweats, hallucinations, seizures, and death.

 

Keep in mind, those are the dire results if an especially bad withdrawal goes untreated by professionals. But with the stakes so high, it’s important for anyone with an addiction to go to rehab, and to be prepared before you check in. Following the steps below will assist you in focusing on your recovery.

 

Planning Your Absence

Before you sign into rehab, it’s important to determine your schedule. Some facilities offer programs that last just a few days – long enough for a patient to detox, but not fully recover. Thirty-day programs are usually considered “short-term”: sufficient for an addict to dry out and feel stable. The National Institute on Drug Abuse, however, recommends a 90-day timetable for individuals to combat their habit. That said, few people can clear their calendars for three months. So you’ll need to decide if rehab is worth quitting your job or significantly disrupting your employment.

 

Money is another consideration. Medicare covers certain aspects of rehab, and some nonprofit facilities offer low-cost admission, but most treatment centers are thousands of dollars a month. Outpatient stays can cost $3,000-$10,000 (90 days), while inpatient is $5,000-$20,000 (30 days). Per day, the price-tag of detox can run to $250-$500. Make sure that you – or someone you know and trust – can afford the treatment center before you sign up for it, and that your bills are covered in your absence. You’ll want the least amount of stress possible during your recovery, including financial stress, so that you stay at rehab can be an oasis of calm and self-reflection.

 

Finally, let your friends, loved ones, and coworkers know where you’re going, so that no one is worried about you. One of the most destructive features of addiction is that few addicts admit to themselves they have a problem. That’s why rehabilitation is a physical ordeal, but also requires tremendous honesty and self-confrontation. That you’re willing to ask for help is itself an accomplishment, which other people will recognize. Relieved that you’re addressing the core dysfunction in your life, they’ll probably send you letters or visit you or call, just at the time you need support the most.

 

Figuring Out Pet Care

One final call to make before leaving is what to do with your pets. If you’re living with or near family, a spouse, or roommates, they might be able to feed your dog or change your cat’s litter box. Expect to pay about $14-19 per hour for a pet sitter to look after even animals that require minimal care, like a turtle or a goldfish. And if you have a dog, you’re in luck. Nowadays the internet is rife with dog service apps that connect you with dog therapists, dog groomers, dog walkers, and more.

 

Usually, you’ll need to shell out $20-$25 to pay someone to walk your dog for 30 minutes. Twice a day, for the 30-90 days that you’re gone, that can add up, as can the many dog-boarding options out there. Kenneling your dog is usually priced at $25-$45 a night, while more “ritzy” dog hotels ask $50 per night. A pet sitter is about the same. The most reasonable choice is in-house boarding, where people who are usually dog-lovers themselves charge $15/night to hang out with your dog.

 

More and more, treatment centers are starting to let people check in with their dogs, since pets have been shown to provide a range of benefits to their owners. Some of these perks include assuaging your sense of loneliness, nudging you into a more active lifestyle, and even elevating your serotonin and dopamine levels. (Code for making you a lot happier.) Considering the joy and gentleness that pets introduces in our lives, it makes sense that rehabilitation centers allow them to join their owners to help allay a sense of fear and isolation.

 

Sometimes an addiction is so severe that you’re forced to face it, the same way you don’t have time to balance your checkbook before rushing to the ER. But for the best experience in rehabilitation, make sure that you’re truly ready for it. That means caring for your pets, arranging your finances, and letting your friends and family know where you are. That you have peace to face your addictions within a refuge from the volatility that drugs introduced into your life is vital to your stay, and to your long-term recovery.

  Caleb Anderson developed an opiate addiction after being in a car accident. He’s in recovery today and wants to inspire others to overcome their addictions. 

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Complex Patients: Positioning Teams for Best Outcomes

Posted By Matthew P. Martin, Monday, April 16, 2018

 

Patients living today with both complex medical and behavioral health problems are expected to die 25 years earlier than the general population.1 These patients have more medical problems than the general population and a disease burden that increases as behavioral health problems increase. Most patients with behavioral health problems are seen in non-psychiatric medical settings like primary care.2 Untreated behavioral health problems make it challenging for patients to improve their overall health.

Care management, a collaborative process of assisting and supporting patients, is a cost-effective approach for helping patients with complex health problems;3 however, most case management services focus solely on medical or behavioral health problems and do not always involve the primary care physician. The East Tennessee University Department of Family Medicine recently presented a regional conference on strategies for treating complex patients. Therese Narzikul, a gerontological nurse practitioner, was a co-presenter and helps answers some questions below about working with this patient population.


1. What are some of the challenges and barriers to treating complex patients?

Some of the challenges and barriers-or as I like to reframe these—the opportunities that we have in treating complex patients lie within the way the current system is designed. Structurally the system is set up for the average patient. The time allotted is generic and not geared for the complexity of the person. In fact the complexity/unique context of the person is rarely adequately explored or understood. We often do not ask the patient what matters to them and what are their life/health goals to ensure we create a plan that incorporates their perspective. The more complex a patient is-the more important the alignment and integration of the patients’ perspective with the plan.
The visit itself is problem-focused but often fails to appreciate the problem as an outcome of a complex system of interactions that are never fully explored or exposed—we treat the symptom. In science we break systems apart to make sense of them. With complex patients it is critical that we look at them as a whole in order to understand them. The dynamic nature of any complex system-biological/socio-cultural-makes their “problems” unpredictable and multidimensional. We have an opportunity to further develop care teams to explore and expose the relationships and connections and emerging outcomes for complex patients. This will provide the needed context to design interventions tailored for these dynamic, unpredictable and multi-dimensional complex patients and populations.

2. What are some prominent team-based practice models for assisting complex patients?

There are lots of super frameworks out there for assisting complex patients. The GRACE Model, Guided Care Model, The Transitional Care Model, etc…. The key to deploying any model is appreciating and designing it within the context of the organization and/or community as well as the population for which it is aimed to assist.
Taking time to understand the context provides key insights into model selection and implementation. In addition to the model selected and equally important is the underlying operating principles and appreciation of the role of shared vision, shared purpose, shared leadership, and shared understanding in enabling the team. In an environment that is focused on learning and improvement, the power of the individual and collective team perspectives can be shaped to design emerging solutions to the dynamic nature of complex patients and populations. Team members want to feel they are a part of things and want to have a hand in shaping the future. Leaders that create this environment for team-based practice models will be as successful as the teams.

3. What practice change targets can managers use to measure improvement in their practices?

It all backs up to what they want to accomplish? For whom? And Why? In healthcare practices we are trying to create value for our patients. Patients like practices value time, money and knowledge. They would like to get the best outcome without having to incur more time or money than necessary. The outcomes they want are to stay healthy, live with illness (if they have any) and get better (if they are sick). Change targets to measure improvements would be tied to the outcomes that help patients achieve these goals in the most efficient (least time, lowest cost) and effective (safe, equitable, patient-centered) manner. Do the patients at their practices get all the recommended care and services to keep them healthy...in the case of complex (more vulnerable patients): provide these to prevent their chronic conditions from worsening or an acute condition from impacting them more seriously? Etc…


4. What financial models or strategies help to maintain sustainability with treating this patient population?

Financial models and strategies need to be developed within the context of the organization, region and market. If an organization looks to design interventions where you get 3 for one and one of the 3 generates new revenue that is the best design. A design where all stakeholders win. The payer gets something they need, the provider gets something they need, the patient gets something they need, the community gets something they need, the care team members get something they need… For complex patient, an intervention that accurately assesses and addressed the patient complexity, incorporates the perspective of the patient and pertinent team, captures and communicates the risk/complexity to the payers (on an claim) and to other providers in the extended care teams (with EMR) and creates short-term (new revenue) and long-term value (triple aim impact) for the organization.

1. Parks, J., Svendsen, D., Singer, P., Foti, M. E., & Mauer, B. (2006). Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, 25(4).
2. Kessler R., Stafford D. (2008) Primary Care Is the De Facto Mental Health System. In: Kessler R., Stafford D. (eds) Collaborative Medicine Case Studies. Springer, New York, NY.
3. Smith, S. M., Wallace, E., O'Dowd, T., & Fortin, M. (2016). Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. The Cochrane Library.

 

Therese DeVries Narzikul is Vice President of Practice Design & Care Coordination at Jefferson Health where she is largely focused on designing care delivery to improve health, experience of care and health outcomes, with a special focus on vulnerable patients and populations.  As Gerontological Nurse Practitioner with an MBA, Therese provides expertise in the areas of care delivery system transformation, population health and risk management, care coordination across the continuum and performance improvement.

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Financing the Primary Care Behavioral Health Model: Q&A with Dennis Freeman

Posted By Matthew P. Martin, Monday, March 26, 2018

It's no secret that the US health care system is expensive and under significant change these days. One part of the system that is receiving a lot of attention in primary care. The evidence suggests that primary care is an excellent investment for payers who want better health outcomes; however, recent data shows that payers are actually DECREASING their investments in primary care.

In the midst of this confusion, innovators are pushing forward to test new clinical and financial models in primary care. One clinical model you may already know is the Primary Care Behavioral Health (PCBH) model, a team-based primary care approach to managing behavioral health problems and biopsychosocially-influenced health conditions. But does this clinical model actually fit with the movement toward value-based payment models? If so, how and what should proponents of PCBH know to push for payment reform? 

The authors of a new publication identify new financing strategies are emerging which will further support the viability of PCBH integration. I reached out to Dennis Freeman, lead author and CEO of Cherokee Health Systems, to ask a few questions about their article. See the exchange below:

  

1). What unfavorable reimbursement policies currently exist for PCBH or behavioral health integration broadly?

 

The most problematic policy barriers are created when behavioral health is “carved out” from the general medical benefit in health plans. Even when health plans claim to “carve in” behavioral health they often do not modify their internal administrative structure and continue to maintain separate, isolated staff with the responsibilities for network development, contracting and providing oversight of the behavioral health services benefit. Carving out behavioral health perpetuates bureaucratic silos. When behavioral health is carved out who has responsibility of paying for integrated care-- the behavioral health division who manages the behavioral health benefit or the medical division with the responsibility of overseeing primary care? Whether both or neither claim the territory it is double trouble for the integrated provider organization.

Coding of the service is another potential barrier. Behavioral health providers of more traditional specialty behavioral health care use commonly accepted psychiatric CPT codes accompanied by a psychiatric diagnosis in order to garner reimbursement for their services. Behavioral health consultants (BHCs) working in primary care have a broader scope of practice. The usual CPT codes utilized by specialty behavioral providers will fit some, but not all, of the services BHCs provide. For example, a BHC might focus on prevention, risk reduction or general health behaviors. The patient might not present with a psychiatric disorder but an intervention to promote health behaviors or cope with a chronic medical conditions is still indicated. There are CPT codes to cover these services, the Health and Behavior Assessment and Intervention CPT codes 96150 through 96155. Payers are often unaware of these codes and the provider must negotiate with the payer to assure these codes are in their contracts.

A third common barrier is a prohibition against billing two healthcare visits on the same day. Sharing care during the patient visit is core to the PCBH model. Expecting the patient to return on another day is inefficient for the providers of care and illogical from the patient’s perspective. Frequently, the patient does not return for a behavioral health visit scheduled on a different day.

Some consultation components of typical PCBH practice are not covered in a fee-for-service environment. BHC time spent in daily team huddles, hallway consultations, treatment team meetings, care coordination activities or similar activities that do not involve face-to-face time with the patient do not generally translate to an available CPT code. However, we have been able to make the case to payers these activities have value in and of themselves and contribute to the effectiveness and efficiency of care. Often we have been able to negotiate a secondary revenue stream to cover these non-revenue generating activities. 

 

2. What does the field of PCBH need to do to leverage itself as a valued component of the future value-based healthcare payment system? 

 

This is an easy question to answer though, quite possibly, not so easy to achieve. 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. These are team outcomes not individual behavioral health provider outcomes.

The BHC needs to know and understand the value-based opportunities available in the organization’s contracts and bring a measurement mentality to help track and improve the measures (utilization, HEDIS, cost measures) upon which value-based payments are made.

 

3. What can clinicians do to increase their knowledge of financing models and payment reform? 

 

It is important for clinicians to understand why there is such an emphasis on health care reform in our country. While improving the outcomes of health services and enhancing the overall health status of US population would be sufficient reasons, the major driver of health care reform in this country is cost. The US healthcare system is the most expensive of any nation on earth, more than 50% more expensive than the next most expensive national system. Our outcomes don’t justify the cost. US healthcare expenditures are a drag on our economy and we are at a competitive disadvantage with other nations as a result. That is the “why” of healthcare reform.

Understanding the big picture helps clinicians appreciate the economic forces impacting their work.  Employed clinicians should take the initiative to gain a basic understanding of the revenue sources and the financing mechanisms that support and sustain their organization. Understanding the financing helps the clinician gain an appreciation of the efforts and decisions administration is making to secure the future of the organization.

Is my wish that clinicians promptly forget all they know about the financing mechanisms when they enter the room with the patient. At Cherokee we don’t ever want the financing mechanisms or the payer source to impact the care a patient receives. We want the uninsured patient to receive the same level of excellent care as the patient with the most generous health plan. Frankly, clinicians have enough to be concerned about just focusing on delivering quality care.    

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Cultural Considerations for Behavioral Health Providers in Primary Care

Posted By Matthew P. Martin, Monday, March 12, 2018

Healthy People 2020 is a multi-year, multi-stakeholder effort by the US government to address social determinants of health and disparities. This vision for a healthier country includes specific actions that the United States must take to achieve better health by the year 2020.

Some of the goals include:

  • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
  • Achieve health equity, eliminate disparities, and improve the health of all groups.
  • Create social and physical environments that promote good health for all.
  • Promote quality of life, healthy development, and healthy behaviors across all life stages.

To address disparities in health and healthcare, behavioral health providers must apply their knowledge and skill in ways that meet the high demands for care. Specifically, they must apply a cultural lens to utilize knowledge about patients’ cultural background, values, and experiences when delivering services.

One recent article on this very topic appeared in the recent issue of Journal of Clinical Psychology in Medical Settings. I reached out to the authors Jessica Jackson and Adeya Richmond for answers to some questions and received the following responses. 

1. How can a culture-centered paradigm help address health equity? 

 

Patient engagement and subsequent compliance with treatment are one pathway to improving health equity. A culture-centered paradigm is a more comprehensive way of assessing patient needs and addressing barriers to care. In order for patients to make health decisions that are in their best interest they need the opportunity to receive and interpret basic health information in a way that resonates with their cultural frame of reference.  Patients are more likely to engage in and successfully complete treatment when they believe that the intervention aligns with their values and beliefs. Culturally sensitive providers who provide culturally competent care have the potential to increase patients treatment engagement.

 

2. What are the Five A’s Organizational Construct?

 

The Five A’s is an evidence-based assessment and intervention format for behavior change. (Hunter, Goodie, Oordt & Dobmeyer, 2009; Whitlock, Orleans, Pender, & Allan, 2002). It encompasses 5 phases that are patient-centered and collaborative: Assess, Advise, Agree, Assist & Arrange. This format equips providers with a tool to help thoroughly identify and address concerns that may be a barrier to optimal functioning and has been found to be especially effective in primary care settings.

 

3. What is the model of cultural competence you describe in your article and how can it help behavioral health providers?

 

The model of cultural competence described in our article is one put forth by Josepha Campinha-Bacote (2002): The Process of Cultural Competence in the Delivery of Healthcare Services. This model emphasizes cultural competence as a dynamic process that clinicians engage in as they work to understand and provide services within the cultural context of patients. This model encourages clinicians to develop (1) cultural awareness, (2) cultural knowledge, and (3) cultural skill which will influence their (4) cultural encounters and increase (5) cultural desire. This model can help behavioral health providers integrate their assessment of patient concerns with sociocultural factors that influence patient behaviors. Patients often understand and address their behavioral health and medical needs through the lens of their cultural beliefs (Andrulis & Brach, 2007) and providers need to be cognizant of how these beliefs are influencing behaviors and decision-making. Behavioral health providers who seek to understand these beliefs may be able to more accurately address patient needs and concerns.

 

4. How can behavioral health providers help other providers (physicians, nurses, and students) to develop a culture-centered paradigm?

 

Behavioral health providers often work in interdisciplinary settings and have the unique opportunity to help other providers understand how the cultures of multiple systems (medical culture, culture of the practice, the different personal cultures of the providers etc. interact and together and influence healthcare/behavioral health service delivery. Another way that behavioral health providers can help other providers develop a culture-centered paradigm is by assessing (formally or informally) the level of cultural sensitivity in the practice/clinic/classroom that they work in. This may include assessing for an understanding of the concerns of the specific community being served or ensuring that patients can receive health information in their native language or other community relevant concerns

 

  Matt Martin, PhD, LMFT is Clinical Assistant Professor at Arizona State University Doctor of Behavioral Health Program. He serves as CFHA blog editor. 

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4 Things Your Supervisee Wants to Hear from You

Posted By Kyler Shumway, Tuesday, February 13, 2018

For the tiny town of Cottonwood, Idaho – population 900 people and 1800 cattle – sports were something to rally around. 

My senior year in high school, we made it to the football state championships.  When we took to the field for the championship game, it was breathtaking to see half the town in the stands, ringing cowbells and bellowing themselves hoarse.  We knew they were counting on our ragtag band of teenagers to make everyone proud and bring home the win. 

We were losing the game at halftime, physically and emotionally defeated.  I remember being on the verge of tears, outraged and fearful of the possibility of a loss – of the town’s loss.

I was dumbfounded when my coach entered the locker room with a grin on his face. 

“C’mon boys, smile!” he said. “You’ve worked hard to be here!  I am so proud of you… you’ve made us all feel like champions.”

Those words meant the world to me. 

I played harder than I had in my entire athletic career.  A simple shift in perspective and affirmation dramatically altered my drive. This was the power of leadership. 

On the playing field of integrated care, supervisors have the opportunity to equally inspire and lead others.  Many of us recognize the vitality of supervision the future of primary care behavioral health; yet, supervision was only just recently recognized as a core competency by the American Psychological Association. 

As a supervisee, I hope to share four of the most meaningful things I have been taught in my training. 

#1 – “Keep Your Chin Up”

Many supervisees (including myself) tend to be excellent self-critics.  Push yourself harder than any coach can, and no coach can push you hard enough.  Although this mentality promotes motivation and careful analysis, the focus remains on failure rather than victory. 

 

In my first year of clinical training, I remember discussing my work with a patient with whom I was “failing at therapy.”  We had completed around four sessions, with little to no progress towards our goal.  My supervisor wisely pointed out three things: 1) that I was still in training, 2) that the patient’s condition was stable and not worsening, and 3) that the pressure I placed on myself might actually interfere with the therapeutic relationship.  “Keep your chin up, you’ll get there” she said.  

 

The role of a supervisor incongruously straddles that of the coach, the administrator, and the therapist.  Although supervisees need direction and motivation to grow, sometimes encouragement can do wonders for the self-critic.  

#2 – “Thank You”

This one is more of a friendly reminder.

 

The importance of expressing appreciation is not unbeknownst to supervisors.  Yet, a simple thank you can go a long way. 

 

My colleagues and I were together at a group supervision meeting after a particularly heavy week.  As we began to discuss ongoing issues with client work and external stressors (classwork, life transitions, etc.), our supervisor caught us off guard. 

 

“Thank you all, so much, for your hard work and dedication despite these challenges.  Our clinic couldn’t do this without you.”

 

Instantly, I experienced a refueled sense of clinical purpose.  The work of a mental health professional is just as challenging as it is meaningful, yet we often lose sight of the meaning.  A well-placed “thank you” can affirm, motivate, and provide perspective to even the most burned out supervisee. 

#3 – “These are Skis”

A supervisor once shared a story about the first time they went skiing. 

 

“As the class began, the ski instructor held some of the equipment up and said ‘everyone: this is a ski.’  That’s when I knew I was in the right class.”

 

Many of the fundamental elements of behavioral health become second nature for supervisors.

As a supervisee, I have felt challenged to ride the fine line between competent and coachable.  Asking for direction, particularly when the direction seems fundamental, can feel threatening to a supervisee.  Some of the most helpful instruction I have received in supervision has focused on the fundamentals – how to document, how to introduce myself, how to use the phone system, which drinking fountain tastes best. 

 

The evaluator-evaluated dynamic of supervision does not always foster an environment where basic questions can also be safe questions.  Sometimes, being able to ask what a ski is can make a mountain’s difference in supervision. 

 

 #4 – “I am Human, Too”

The power differential in supervision is an unavoidable necessity.    

 

Every supervisor has a different style, yet the general structure is designed for supervisee training and oversight of patient care.  As such, the role of the supervisee can feel less-than-thou, or at least needing to prove oneself. 

 

One of my supervisors arrived late to our meeting looking a bit spread thin – coffee in one hand, a stack of referrals in the other.  Despite this, they arrived with their usual warm and welcoming smile.  So, I asked how they were doing. 

 

They chuckled, and said “Ah, I have no excuse.  I was up late watching Netflix and I slept through my alarm.  I am human, too!”

 

The pressure to be on top of one’s game, it seems, is mutual in supervision.  Just like the supervisee, the supervisor may also feel the weight of performance. 

 

Acknowledgement of the supervisor’s humanness greatly enhanced our working alliance.  I noticed myself being more willing to share my shortcomings, which then increased my supervisor’s capacity to provide feedback. 

 

We ended up losing that state championship game. 

 

My teammates and I scrapped and fought until the final whistle blew, but it just was not enough.  And while the sting of defeat still pangs me today, I will never forget the impact of my coach’s leadership. 

 

As supervisors and supervisees in the world of integrated care, we have the chance to provide that kind of leadership.  Your words matter.  We stand at the forefront of a monumental movement in healthcare, one that will be shaped by the standards we set as leaders and followers. 

 

Have you shared a similar moment as a supervisor or supervisee?  Share them with the CFHA community in the comments below!

  Kyler T. Shumway, MA, is a doctoral student in George Fox University's department of clinical psychology. Kyler graduated from Duke University in 2014 and began pursuing a career in Primary Care behavioral health. Kyler's upbringing in rural Idaho spurred a passion for bringing behavioral health services to marginalized and underserved communities. To learn more about Kyler, check out his website at kylershumway.com 

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The Warm Handoff: Turn up the research heat

Posted By Alan L. Schwartz, Tuesday, January 30, 2018

As I replay my experiences from the recent CFHA Conference in Houston, two primary themes emerged as key take-home messages.  The first, voiced by Executive Director Neftali Serrano in his eloquent plenary address, highlighted the central role of relationships and connections to the organization as exemplified by the mantra (paraphrasing) ‘don’t be afraid to gently accost people in the hallway for an introduction, question or conversation’.  The second message—crucial to the continued evolution of Integrated Care—was crystal clear:  as passionate advocates for Integrated Care, we as a community are tasked with providing the empirical evidence to support its continued development.  While the call was clearly heard at CFHA to unleash our members formidable research apparati and implementation science colleagues, we might be well served to not forget the humblest symbol of Integrated Care—the warm handoff (WHO). 

 

The WHO has long been a key element of Integrated Care and most notably of the Primary Care Behavioral Health (PCBH) Model.  Its simplicity and power in affording patients and providers instant access to behavioral health services is, as one primary care doctor expressed to me, “intoxicating”, particularly when compared to the Lord of the Rings-like travails required for a successful referral to outpatient treatment.  It is the rare provider that speaks ill of the WHO experience with the wealth of anecdotal evidence supporting its benefits.  It is typically a win all-around.  But do we have empirical evidence to support this important element of PCBH? 

 

Like the kids say, “Not so much.”

 

The concern about the empirical base for the WHO was raised in this very blog in a compelling post by Elizabeth Horevitz in 20111.  She noted at that time that “the warm hand-off has never been rigorously tested.  We have no proof of its effectiveness in enhancing follow-up to behavioral health treatment.”   She cited her own research which she later published2 suggesting that in her population of English speaking depressed Latinos, the WHO was associated with four times less likelihood of attending a follow-up session with the BHC.  The trust and rapport associated with the WHO3 was affected by factors including the patient’s primary language and the quality of the referral process and therapeutic relationship.  Clinicians responding to Horevitz’s post, themselves cited their own local data with either a small or no impact of the WHO on follow-up treatment.  

 

Since then, there have been few studies to further the research base of the WHO.  For one, Van Houten and Johnson4 reported an impressively high return rate—80%-- for the WHO as compared to 40% with less direct referrals, suggesting some impact on reinforcing patients’ connection with behavioral health services.  But aside from anecdotal reports, there is not much more in our literature.  Of course, as a part of collaborative care studies, the warm handoff is one of the elements that allows for facilitating the management of patients’ behavioral health concerns in primary care5.  

 

This came as a surprise to me as a psychologist who is relatively new to the integrated care world and someone who had transitioned from outpatient specialty care.  Everything about the WHO make sense, for the primary care providers, for the patients and for us.  While there are many variations on the WHO, the essence of the initial contact is the immediate connection between the provider, patient and behavioral health expert, connecting them as a treatment team at the most optimal moment to respond to their needs6 .  Considering that the term is borrowed from the customer service world, it is a fitting referent to the reaction often reflected in anecdotes of satisfied ‘customers’.  

 

But what should we expect of the WHO?  Certainly, the one-two punch of patient and provider satisfaction has helped many practices and organizations establish an initial foothold for the development of Integrated services.  In our organization, one internally grant-funded BHC position that introduced the WHO was the springboard for a systemwide transformation, based on compelling satisfaction data.  More than 90% of patents reported that they would not seek behavioral health care outside the practice as a result of this innovation. Beyond satisfaction, we also have seen the importance of using the WHO as a measure of utilization, engagement by Integrated Care teams.  Shelley Hosterman and Monika Parikh from Geisinger presented data in Houston on the functioning of their BHC team across multiple practices5.  They not only tracked the frequency of WHOs across clinicians and practices, but also the use of WHOs by hour during the day, day of the week and season of the year, allowing them to understand and adroitly address the changing demands. 

 

So, at this moment in our Integrated Care evolution, we have developed some important elements that have guided our work on the WHO.  We have established that our customers—patients and providers are incredibly satisfied with this humble tool.  Once introduced, it is hard to imagine one’s practice without it.  We have also seen, as exemplified by our colleagues at Geisinger, how data about the WHO can improve efficiency and the process of care.  Elizabeth Horevitz’s research challenges us to look beyond (or behind) the shiny headlines, as not everyone seems to respond in the same fashion to the WHO.  We are still looking for the answers to many questions.  For example, while we are aware of the broad outlines to the WHO how might variations in their implementation—time spent, level of therapeutic communication/intervention, quality of the working alliance—impact outcomes?  Is care improved with more or less education provided or more or less intervention provided? Do WHOs which lead to internal versus external follow-ups impact show rates or outcomes differentially? And what patient factors, aside from those discussed above contribute to a successful WHO and improved care? With these questions, among others, we have our work ahead of us.

Alan L. Schwartz, PsyD

 Behavioral Health Consultant/Psychologist

Family Medicine Center-Foulk Road

Christiana Care Health System

Wilmington, DE

References

1Horevitz, E.  (2011, December 22). Integrate this: Evidence-based practice in integrated primary care. Retrieved from http://www.cfhs.net/blogspot/689173/136267/integrate-This-Evidence-Based-Practice-In-Integrated-Primary-Care 

2Horevitz, E., Organista, K.C., Arean, P.A. (2015).  Depression treatment uptake in integrated primary care: How a “warm handoff” and other factors affect decision making by Latinos.  Psychiatric Services, 66(8), 824-830.

3Integrated Behavioral Health Partners. (n.d.). Accessing the behavioral health counselor.  Retrieved From http://www.ibhpartners.org/get-started/procedures/accessing-the-behavioral-health-counselor/

4Van Houten, P. and Johnson, M. (n.d.) Integrating behavioral health in primary care settings.   

5Serrano, N. and Monden, K. (2011).  The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ, 100(3), 113-118.

6Strosahl, K. (2001).  The integration of primary care and behavioral health: Type II changes in the era of managed care. In N. A. Cummings, W. O'Donohue, S. C. Hayes, & V. Follette (Eds.), Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice (pp. 45-69).

7Hosterman, S.J. and Parinkh, M. (2017, October). It’s all in the handshake:  Patterns and outcomes from warm handoffs in integrated pediatric clinics. Presentation at the 19th Annual CFHA Conference, Houston, TX.  

 

COMMENT 1

I’m so glad Dr. Schwartz has taken the time to reinvigorate the conversation about the efficacy of the warm handoff, and the need, in general, to expand our evidence base for such IBH-specific practices. Since I published my study, I’ve been asked to give many presentations about the effectiveness of the WHO as a patient engagement strategy to various health care organizations, and the response from practitioners has been extremely interesting. Specifically, in spite of mounting evidence showing that the WHO may not be an effective patient engagement strategy for Latinos (and may have the opposite of its intended effect among English-speaking Latinos), I inevitably get multiple comments from IBH practitioners about how wonderful it is, and how it just feels like the right thing to do.

 

However, we have yet to establish which components are effective for which intended outcome (is the goal provider satisfaction? Patient satisfaction? Engagement? Clinical intervention?). Like any clinical activity, a warm handoff is both an art & a science, and if we are to devote significant clinical time to it, it is imperative that we move beyond doing things that “seem” like the right thing to do when the published data shows them to be ineffective at best, and detrimental at worst. 

 

Until we understand the effective components better (who, what, when, where, why?), I am using the evidence we do have to inform my practice. For example, at my clinic, we save the warm handoff for crisis intervention, rather than prioritize it as an engagement strategy. When my clinicians have no-shows, we happily fill the slots with warm handoffs for purposes of initial assessment/intervention, but I have asked that our PCP colleagues not interrupt an active session simply as a means of patient engagement, given the lack of evidence to support such a practice.

 

For purposes of patient engagement, perhaps a better use of time would be to use the warm handoff address specific patient barriers to care—time, money, transportation, stigma… I urge all of us to move in the direction of implementing practices backed by effectiveness research. And, for those of us in the practice world, we can start by making use of our QI departments to help with the initial steps of testing some simple changes on-the-ground in a rigorous way to point us in new and improved directions. 

Elizabeth Horevitz, LCSW, PhD

 Director of Behavioral Health

Marin Community Clinics

UC Berkeley, School of Social Welfare

 

COMMENT 2

Thank you to Dr. Schwartz for his timely commentary highlighting the limited empirical evidence on outcomes from WHO activity.  It is crucial that CFHA members continue to lay down the “research gauntlet” in this way so we can continue to partner in advancing the evidence for integrated care models and key components.  The 2017 CFHA presentation was our Geisinger team’s first attempt to examine WHO data in a systematic way. I was surprised that even this first, very simple review of the data carried some clear operational and clinical implications for our team.  We consider WHO activity an important and powerful part of the model.  Although we believe this is the case and “feel” this is an important part of our model, our group has yet to generate evidence to support this assumption.  Our group has several projects in progress designed to answer some core questions posed by Dr. Schwartz.  Specifically, we are conducting a study of three years of clinical data that will examine access and utilization variables across integrated care clinics and the traditional outpatient therapy clinic within our system.  That study will examine influence of clinic type (integrated or traditional), wait time, WHO, and distance to services on outcome of first schedule visit.  We look forward to sharing those results with the broader community and to watching how other programs and investigators approach this research challenge.  Generating empirical evidence for WHO outcomes will be an important piece of the puzzle in our case for value-based payment models.  We are anxious to see how the story emerges from our data.

Shelley J Hosterman, PhD

Psychologist

Geisinger Bloomsburg

 

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Health care records on your iPhone?

Posted By Matthew P. Martin, Friday, January 26, 2018

Yup, Apple is making the foray into health care.

One of the biggest companies on the planet wants to give you access to your medical records using the popular iPhone. This feature will be available once the iOS 11.3 update rolls out later this year. 

Check out the article link above for details on how it works (basically using a phone app that links with care systems that have opted into an agreement to share records; patients have to opt in as well).

The implications for this development are enormous. Patient portals via web browser have been around for several years but many of these portals are limited in stability and scope. Moreover, clinical researchers have been challenged for years in gathering more patient-reported data to evaluate health interventions. A new phone app like this one may be the break they need.

Maybe the biggest implication is that electronic health records may now finally be streamlined into an easily accessible platform for both patients and physicians. Imagine interacting with patients more often outside of a medical or behavioral health visit. Imagine collecting additional health outcome data from them or family members. 

The rollout for this new app is quite small but hopefully will gain momentum in the near future. Stay tuned listeners ...

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