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:10.1037/0893-3188.8.131.524
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
Next year will be the 10th anniversary of CFHA blogging! During the past several years, nearly 600 posts have graced the digital face of our organization with many voices and viewpoints. The blogs have been a source of information and inspiration for our members as they work to advance the field of collaboration and integration in healthcare. It's been my pleasure to be the blog editor for several of those years.
The heart and soul of our organization is innovation. Changes help to generate that innovation and eventually blaze a trail toward better outcomes and opportunities. In that spirit, we have decided the following changes with the CFHA blogs:
There will no longer be multiple running blogs. We will combine the CFHA blog and the Families and Health blog into one single blog.
We will now use a columnist model to offer our audience consistent voices on topics important to the field. We will start with four columnists and plan to introduce them to you soon!
In considering and planning these changes, I worried about two things. First, will we lose the focus on families and relationships by combining the two blogs? I hope not. My plan is to continue telling the stories of families in healthcare and pushing for more family-centered care. I believe we can do that while also showing our solidarity through one single blog. Second, will other writers lose the opportunity to share their voice? The answer is no! We will hope other authors will contribute their pieces. We will not publish those pieces as often, but we still encourage our members to submit their work.
Please look out in the future for the first two columns this month and then two more next month. I'm excited to introduce you to our columnists and believe you will enjoy their wisdom, humor, and expertise. It is a terrific time to be in this field. New opportunities for growing and sharing our message continue to pop up all around us.
Matt Martin, PhD, LMFT is Clinical Assistant Professor at Arizona State University Doctor of Behavioral Health Program. He serves as blog editor for CFHA.
Posted By Randall Reitz,
Thursday, September 20, 2018
Policy change can be hard, slow, and seem daunting. This is especially true at the federal level, but many of the important changes happen at the more accessible state and local levels. For example, Pennsylvania leaders recently helped to change state Medicaid policy to allow licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) working as integrated clinicians in FQHCs to bill Medicaid. In this blog post, Cheri Rinehart, President & CEO of the Pennsylvania Association of Community Health Centers (PACHC), answers 5 questions about why and how this policy was changed.
1.What is the history of this issue in Pennsylvania that prompted you and your collaborators to take it on?
As the number of health centers working to integrate behavioral health (BH) increased because HRSA made this a priority, PACHC received growing feedback about the challenges the FQHCs faced in recruiting eligible providers. The need became even more evident and pressing when one of our partner organizations, the Health Federation of Philadelphia, negotiated managed care organization approval for a “warm handoff” initiative in health centers in Philadelphia. When discussion with the Department of Human Services (DHS) was initiated in the summer of 2012, our original goal was approval of licensed social workers (LSWs), LPCs and LMFTs as BH providers eligible to generate an FQHC reimbursable encounter. It became clear very quickly that if we adopted an all or nothing attitude, we would get nothing, because DHS felt strongly that LSWs should not be included because they do not exercise independent judgment. We agreed on that compromise and DHS agreed to pursue a state plan amendment to initiate the change to add LPCs and LMFTs. And then nothing happened. For a long time. And then, in response to one of our regular inquiries on status of the issue, DHS asked for validation of need. This was the pattern over many years: We would reach what looked like agreement and then a new question would be raised, requiring new data, analysis and time. Each time, after allowing ourselves to feel the disappointment, we regrouped, re-strategized and recommitted to the goal.
2.What was your overall strategy in framing and advancing the case?
It is important to share that our relationship with our partners at DHS was established long before we started this advocacy journey and has strengthened along the way. We both feel that our overarching goal is the same: improve access to quality, affordable health care, especially for the most vulnerable individuals and families. We recognize one another as important partners. Key officials from both organizations meet every month. Our initial discussions and exploration of DHS’ opinion on this issue were a more informal part of these regular meetings. Our first goal was to listen so that when we moved to the more formal step of submitting what we refer to as Recommendations for Consideration, the document would reflect and address issues and concerns that DHS had raised.
3. Who were the key collaborators and stakeholders and why was their involvement important?
The health centers across Pennsylvania were our key stakeholders and they served as collaborators on the initiative by regularly sharing with us their frustrations in trying to recruit a workforce adequate to meet the needs of the individuals and communities they serve. That meant that we could share with full honesty and integrity in our meetings that it was a rare week when we did not receive multiple calls and emails from health centers desperate to respond to the need and asking for an update on progress on the policy change to help them in doing so.
4. Why do you think you were successful?
Many factors contributed to our success, but the key to successful advocacy on any issue is clearly identifying and staying focused on the end goal so you don’t get distracted by the barriers you are sure to encounter on the advocacy pathway. Our end goal in this case was to expand the FQHC workforce to improve access to integrated BH services. While we identified early in the advocacy process what we thought the best solution was, if we had solely focused on that solution rather than the end goal, it would have gotten in the way of success. Success in advocacy requires development of relationships before you need them, being prepared for unexpected turns, extreme patience, a willingness to compromise, persistence, maintaining professionalism even when frustration levels rise, and seeking to understand as well as be understood. Several times over the years we thought we were close to the finish line and then were confronted with a new obstacle, but we never gave up and remained gently persistent, always including the issue on meeting agendas with DHS.
5. What lessons learned would you share with CFHA members seeking policy changes at a grassroots level?"
You know what you want and why, but success also requires understanding, framing and responding to the issue from the viewpoint of those responsible for making the change you are advocating. Because this issue for us was very FQHC-specific, we did not engage other advocacy partners, but that is not usually the case. Identifying and engaging the stakeholders who might support or oppose your proposal is an important early step in advocacy on any issue. Be prepared for success to take time and that you might have to change course multiple times. In a world that generally moves quickly it is hard for those awaiting the change to understand why it is taking so long, so it is important from the beginning to set an expectation of preparing for a marathon, not a sprint, and for progress at “the speed of government.” A single person in a key role can be a barrier—it does not feel fair, but it is often reality. Feedback from our members anxious for the policy change was not an annoyance—it was essential to keeping our commitment to success high. Never give up if it is truly something you believe is the right thing to do—reevaluate strategies and alternatives, but don’t relent. When we were feeling most weary from the journey it was hard to believe, but true, that success was just around the corner.
Cheri Rinehart, RN, BSN, NHA, is President & CEO of the Pennsylvania Association of Community Health Centers (PACHC), the state association representing the more than 300 Community Health Centers and like-mission providers throughout Pennsylvania. Ms. Rinehart is a registered nurse and licensed nursing home administrator. She has held various administrative positions, including vice president and director of nursing, in health care organizations. Her health policy expertise spans the health care continuum, from primary care to long term care and end of life care. Ms. Rinehart was one of 20 nurses selected nationwide in 2004 for a Robert Wood Johnson Executive Nurse Fellowship, is a graduate of Penn State’s RULE Leadership Program, and is a summa cum laude graduate of Bloomsburg University. She currently serves as Region 3 representative to the PCA Leadership Committee, serves on the national FQHC advisory boards of AmeriHealth Caritas and UnitedHealthcare, was named as a representative to the national Rural Primary Care Issue Group, and serves on the boards of several healthcare and other organizations. She has served on numerous state committees and task forces and is the recipient of awards for her work in rural and emergency health care.
There is so much good research coming out in the field of integrated care. Trying to keep up with all the new developments can feel like drinking from a fire hydrant. So, to save you time and keep you from overhydrating, your friendly neighborhood blog editor is here to separate the wheat from the chaff.
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), Specific Populations (integrated care for discrete patient groups), 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: This article describes how an innovative model of practice transformation, used by 4 integrated pediatric primary care practices over a 2 year grant period, promoted the practice of integrated primary care (IPC) behavioral health services. Practice transformation was possible through the implementation of an alternative billing strategy to enhance sustainability, effective utilization of clinical productivity to provide meaningful patient services, and the identification of strategies to further the practice of IPC. Specifically, we provide: (a) a description of the diversity of billing strategies typically used by pediatric practices utilizing integrated care and how those strategies are impacted by state health care policies; (b) a description of the grant, including the service delivery model, implementation phase, and data collection procedures; (c) results of implementation and billing/reimbursement data that were collected across the 4 practices; (d) an analysis of how billing strategies are critical in defining implementation strategies within pediatric integrated care; and (e) lessons learned about how billing strategies must be flexible and amenable to change over time to stay current with ever-changing health care policies and reimbursement models. (PsycINFO Database Record (c) 2018 APA, all rights reserved)
1.Cost-savings analysis of primary care behavioral health in a pediatric setting: Implications for provider agencies and training programs.
Abstract: The emerging era of integrated care represents a major opportunity for clinical psychology to migrate empirically supported treatments (ESTs) into the mainstream of public health. To succeed will require us to modify current ESTs to make them brief, cost‐effective, patient‐centered and acceptable to and easily learned by both the mental health and health‐care professionals that will deliver them. Changes to the recently modified standards for designating ESTs are proposed that will facilitate adoption of a population health model of treatment development and testing, designed to promote rapid dissemination of empirically supported interventions that are a “good fit” for integrated settings. Defining characteristics of the “new look” for ESTs are examined.
Abstract: Introduction. The purpose of this study was to pilot a brief measure of family functioning (Family Assessment Device–General Functioning [FAD_GF]) with caregivers of children aged 2 to 18 years, seen for routine pediatric primary care visits. Methods. This study evaluated the psychometric properties of the FAD_GF in a pediatric primary care sample of 400 families. Confirmatory factor analysis was used to validate the FAD_GF using R, and WLSMV was used to estimate missing variables. Results. The FAD_GF was found to be reliable with this sample, α = .90. The model fit was χ2(54) = 56.44, P = .38, with root mean square error of approximation = .01 and comparative fit index = .99. The 12 items were significantly predicted by family functioning, and family functioning explained more than 20% of the variance in the items, R2 > .25. Overall, 12.6% (n = 46) of families were identified as having clinically impaired family functioning. Discussion. The FAD_GF provides clinicians the ability to make evidence-informed decisions regarding referrals to family therapists.
To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review.
A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal (http://www.bireme.br website) through to June 2017. The articles included in the review were summarized through a narrative synthesis.
After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient’s adherence to treatment.
Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.
Abstract: In this chapter the authors will discuss an important aspect of the integration of behavioral health (specifically psychiatry) and primary care from a global perspective. The chapter examines this topic through the continuum of medical education, from medical student to psychiatry residency, and concludes with a discussion of post-residency continuing education opportunities. Current psychiatry residents share their experience in working in an integrated primary care clinic, highlighting the challenges and rewards. The need to fully integrate this concept into all aspects of medical training is the primary goal of the authors. This will require a change in culture from the existing specialty-driven approach to patient care. It will also help address the current crisis in limited access to mental health care around the world. There will never be an adequate number of psychiatrists given the current model of mental health-care delivery. This is not a new problem, but altering current training experiences has the potential to begin this necessary transition in mental health-care delivery. Achieving this goal will improve the overall quality of life for patients worldwide.
Abstract: Despite the compelling logic for integrating care for people with serious mental illness, there is also need for quantitative evidence of results. This retrospective analysis used 2013–2015 data from seven community mental health centers to measure clinical processes and health outcomes for patients receiving integrated primary care (n = 18,505), as well as hospital use for the 3943 patients with hospitalizations during the study period. Bivariate and regression analyses tested associations between integrated care and preventive screening rates, hemoglobin A1c levels, and hospital use. Screening rates for body-mass index, blood pressure, smoking, and hemoglobin A1c all increased very substantially during integrated care. More than half of patients with baseline hypertension had this controlled within 90 days of beginning integrated care. Among patients hospitalized at any point during the study period, the probability of hospitalization in the first year of integrated care decreased by 18 percentage points, after controlling for other factors such as patient severity, insurance status, and demographics (p < .001). The average length of stay was also 32% shorter compared to the year prior to integrated care (p < .001). Savings due to reduced hospitalization frequency alone exceeded $1000 per patient. Data limitations restricted this study to a pre−/post-study design. However, the magnitude and consistency of findings across different outcomes suggest that for people with serious mental illness, integrated care can make a significant difference in rates of preventive care, health, and cost-related outcomes.
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. Matt serves as the Director of the ASU Project ECHO hub for behavioral health integration. He is the CFHA blog editor.
Posted By Kevin Readdean,
Tuesday, August 21, 2018
A prescriber-patient miscommunication causes an adverse drug interaction, the nurse administers the wrong immunization to the patient, or the EMR system goes down five times a day. When adverse events like these occur, it might feel like it’s time for a fishing vacation, but what these events really call for is a root cause analysis (RCA). One simple and effective tool for RCA is the Fishbone Diagram. The Fishbone Diagram is a quality improvement tool used to guide a structured investigation of what went wrong and why, and it helps generate solutions to prevent an event from reoccurring. Think of the fishbone RCA process as casting a wide net and fishing for solutions to problems. While fishing is often a solitary, quiet activity, the Fishbone Diagram process is a group effort. So, share this overview of the Fishbone Diagram and the following case example with your quality improvement team as a way to gear up for your next RCA.
The fishbone diagram is often called the Ishikawa Diagram, as it was created by engineering professor, Kaoru Ishikawa, a leading authority in quality control in the 1960s. Ishikawa created the fishbone diagram process as a technique for visualizing causal connections. The diagram resembles a fish skeleton with the head representing the problematic outcome and each of the bones branching off the fish spine denoting the causal factors that contributed to the problem. Taken together, the fish skeleton presents a visual representation of the causes (fish bones) that led to the effect (fish head). See figure below.
The first step in the fishbone exercise is to articulate the process as a collective, open brainstorming session that invites input from all members of the team. The goal is to find and resolve weaknesses in the system, not blame any one individual or subgroup. The old adage, often attributed to Deming, ‘every system is perfectly designed to get the results it gets,’ is a great way to set up the fishbone analysis. This openness also can be achieved through the use of poster board, on which to draw the fishbone, and sticky-notes, to allow brainstorming to occur both verbally and in writing.
Once the fishbone process is explained and the fish skeleton graphic is displayed on poster board, the second step is to, as a group, describe the problem. Spend as much time as needed to develop consensus around a clear, concise, factual description of the issue. Write down the problem statement at the head of the fish (e.g., medication error – improper dosing).
The third step is to label each bone branching off the fish spine with the categories of causes which contributed to the problem. The standard fishbone causal categories are Machine, Materials, Methods, People, and Environment. However, in a healthcare context, these six P’s offer more useful categories: Polices, Procedures, Programs (EMR), Patients (clients), Providers (staff), and Place (environment).
In the fourth step of the process, the group brainstorms the sub-causes that contributed to the problem under each of the six categories. This can be done in groups of six, with a report back to the larger group, or can be done one category at a time by the entire group. Here again, the idea is to use brainstorming techniques to break down a multidimensional problem into its elemental, root causes. It is a time to methodically look back and analyze causes, not suggest solutions. This step is often aided by the use of the 5 whys technique. In this iterative approach, the facilitator asks a series of 5 ‘why’ questions, each one building upon the previous answer to drill down into the fundamental issue. For example, in the category of Programs (EMR) the 5 whys technique might look like this:
Q: Why did the EMR system go down? A: The server crashed.
Q: Why did the server crash? A: There was not enough space in virtual memory.
Q: Why was there not enough memory? A: Scanned images are taking up too much memory.
Q: Why are image files too large? A: They are set at maximum resolution
Q Why do they need to be set at maximum resolution? A: They don’t, they are legible at half the resolution.
Once all the potential root causes have been listed under each causal category, the final step is to have the team identify the themes that emerged in the process and begin to suggest solutions that can help prevent the problem from reoccurring. This could be any combination of changes to policy, procedures, modifications to the physical environment, training for providers, or different ways to engage with the patient’s family members. The fishbone process could also prompt the use of other quality improvement approaches such as a Plan, Do, Study, Act (PDSA) cycle to test out a potential solution. Alternatively, the process might create the need for further data collection, or a more in-depth quality improvement study, to validate subjective hypotheses that emerged during the fishbone process.
To summarize, the five main steps of the fishbone RCA process are: (1) establish an open brainstorming process about system level causes to an adverse event, (2) describe the problem, (3) categorize the potential causes, (4) pinpoint likely root causes in each category, and (5) identify solutions that will mitigate the root causes and prevent the problem from reoccurring.
I once had the opportunity to use the fishbone exercise with an integrated care team to address an issue where significant aspect of patient’s history was not fully shared across the team. The clinic received an ER report of an accidental prescription drug overdose. The report was reviewed in primary care and scanned to a patient’s EMR without being circulated to the specialty mental health providers involved in the patient’s treatment. The ER report was in the patient’s shared EMR for months, while treatment was ongoing, before it was discovered by a mental health provider. Fortunately, the lack of information access did not lead to an adverse outcome for the patient. Nevertheless, our quality improvement team felt the oversight needed to be addressed.
We employed the fishbone diagram process described above and came up with concrete resolutions to this communication issue. In brief, we changed our written policy and procedures on how external reports are processed upon receipt and instituted a new way to use the EMR to alert providers to newly scanned reports. While this was a positive resolution to the issue, we experienced additional secondary effects at the individual and team levels. The collective fishbone process served to strengthen a culture of whole health and interdisciplinary teamwork among the staff. For example, as a result of conducting the fishbone diagram exercise:
Individuals realized the importance of reviewing all aspects of the patient’s chart regularly.
Staff members were able to visualize how all different parts of the care team contributed to a single problematic outcome.
The interconnectedness of treatment planning was underscored.
We developed an appreciation of the EMR as an enabler of collaborative care.
The interdisciplinary team united around solving a system level issue.
These team level side-effects of the fishbone diagram root cause analysis process highlight the benefits of conducting this exercise with integrated care teams. Done well, this fishing expedition can, not only solve a problem, but also strengthen the provision of integrated, holistic care.
Adapted from University of North Carolina School of Medicine, Department of Pediatrics https://www.med.unc.edu/pediatrics/quality/files/qi-forms/editable-fishbone-diagram/view
Harel, Z., Silver, S. A., McQuillan, R. F., Weizman, A. V., Thomas, A., Chertow, G. M., … Bell, C. M. (2016). How to Diagnose Solutions to a Quality of Care Problem. Clinical Journal of the American Society of Nephrology : CJASN, 11(5), 901–907. http://doi.org/10.2215/CJN.11481015
Phillips, J., & Simmonds, L. (2013). Using fishbone analysis to investigate problems. Nursing times, 109(15), 18-20.
Kevin Readdean, MSEd, LMHC, is Associate Director of the integrated student health and counseling services at Rensselaer Polytechnic Institute. He is also a PhD student at Rutgers University studying the organization and delivery of integrated primary care behavioral health.
This post is a two-part series on quality improvement. Check back later this month for the second part.
Quality Improvement in Primary Care
The use of quality improvement is not a new concept to the medical field as quality improvement teams are often routine in health system settings. Primary care, however, appears to have a lack of generalizable studies that support quality improvement (QI) efforts (Balasubramanian et al., 2018). Despite this lack of QI research in primary care, a recent study proposes a different type of approach that builds on the existing interactions in primary care.
QI research efforts can be strengthened using a relational-based approach that is high quality and conforms to the time parameters of primary care interactions (Bitton, 2018). This approach would help to ensure that patients’ specific needs are identified and addressed in a collaborative but efficient manner. Through this interaction a more patient-centered approach could be possible in future patient encounters (Bitton, 2018). This relationship affords practitioners and patients a rapport that is positioned to improve quality from a patient-centered perspective. The use of a patient-centered approach hopes to encourage positive and effective change throughout the system in which primary care is based.
A Strategic Approach to Improvement
Approaches to quality improvement often use quantitative methods such as surveys or questionnaires to capture specific dimensions of improvement. These types of approaches can be helpful but often lead to a lack of voice from practitioners and patients. The current approach to patient-directed quality improvement could be guided by a mixed method approach using a sequential explanatory design or a concurrent triangulation design. This type of design would allow for quantitative data to be generalizable; while also supporting the development of meaning and voice from patients to identify what is working, and what improvements they would like to see for future visits. The qualitative component of this design could be comprised of brief semi-structured interviews using randomly assigned patients selected form the quantitative portion.
Brief Illustration of Intervention in Primary Care
In this patient-centered approach, every patient in a given time span could be given a brief survey about how they felt their visit went. This survey could be tailored to patients only receiving BHC services or every patient to encompass all services offered within the primary care setting. Once this quantitative process was completed and analyzed you could then randomly select from those who completed the survey. In this sample, you could invite them to think about a specific process in their experience. From this invitation you could ask them to focus on one of the many services offered in primary care such as nursing, BHC services, physician, or lab work and tailor your questions to that service.
After evaluating the responses to the qualitative portion of this design you could use both sets of data to develop an improvement strategy based on what is currently working for patients and what processes might need to be improved for a better patient experience. This experience has the potential to increase patient satisfaction with services and adherence to practitioner recommendations and interventions.
This emphasis on patient-centered improvement using a mixed method design is a slight shift from existing research. This shift in approach allows patients to be at the center of improvement with the hope that it improves the system and patient outcomes. This intervention would help to add patient voice to quality improvement strategies and expand the emphasis on quality improvement outside of the interprofessional system of primary care practitioners. Through this experience patients are afforded a form of systemic buy in, as their perspectives are being sought and used to improve the system that they belong to.
Alexander Young, M.A., LPC is a counseling doctoral candidate at Our Lady of the Lake University in San Antonio, Texas. He earned his master’s degree from the University of Texas at San Antonio in Counseling. He is currently completing his last practicum prior to internship at the Brady Green Clinic in San Antonio, Texas with Dr. Stacy Ogbeide.
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What We Do
CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.