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Research Review: The Latest and Greatest

Posted By Matthew P. Martin, 11 hours ago

Welcome to the March 2019 research review, where I review some of the latest research findings and developments in the field of integrated behavioral health. Per usual, I include links to the articles in the headings and then snippets from the abstract below the heading.

As integration becomes more of the norm and less the exception, researchers are investigating model of integration in different arenas and for different populations. For example, two studies in this month’s review looked at integration of services for patients with debilitating conditions like co-morbid mental health and somatic disorder and dementia. I am also seeing more development and information on the practice of integration in community mental health settings, sometimes referred to as bi-directional integration. As is often the case, clinical practice outpaces research and evaluation as care delivery systems create and test new solutions for giving patients the care that they need. Researchers can learn a lot by joining with providers who are working at the leading edge of clinical practice.

 

One final highlight I leave you is the new ambitious framework for state-wide integration of Medi-Cal services in the great state of California. Although not a research study, I include it here because the plan includes major policy recommendations to reach state-wide integration by 2025, including the incorporation of value-based payments into the financing of behavioral health services. Although it remains to be seen whether it becomes adopted by decision-makers in the Golden State, the framework certainly offers much to consider.    

 

IMPLEMENTATION SCIENCE

Clinical Workflows and the Associated Tasks and Behaviors to Support Delivery of Integrated Behavioral Health and Primary Care

 

Integrating primary care and behavioral health is an important focus of health system transformation. Cross-case comparative analysis of 19 practices in the United States describing integrated care clinical workflows. Surveys, observation visits, and key informant interviews analyzed using immersion-crystallization. Staff performed tasks and behaviors-guided by protocols or scripts-to support 4 workflow phases: (1) identifying; (2) engaging/transitioning; (3) providing treatment; and (4) monitoring/adjusting care. Shared electronic health records and accessible staffing/scheduling facilitated workflows. Stakeholders should consider these workflow phases, address structural features, and utilize a developmental approach as they operationalize integrated care delivery.

 

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

 

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

 

Augmenting Mental Health in Primary Care: A One-Year Study of Deploying Smartphone Apps in a Multi-Site Primary Care / Behavioral Health Integration Program

 

The objectives of this study were to a) test the feasibility of using mental health applications to augment integrated primary care services; b) solicit feedback from patients and providers to guide implementation, and c) develop a mental health apps toolkit for system-wide dissemination. Our findings indicate mental health apps are applicable and relevant to patients within integrated primary care settings in safety-net health systems. Behavioral health providers perceive the clinical value of using these tools as part of patient care, but require training to increase their comfort-level and confidence applying these tools with patients. To increase provider and patient engagement, mobile apps must be accessible, simple, intuitive and directly relevant to patients’ treatment needs.

 

CLINICAL PRACTICE

Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review

 

Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.

 

Evolving Models of Integrated Behavioral Health and Primary Care

 

Using examples from the UK and USA, we describe recent advances to integrate behavioral and primary care for new target populations including people with serious mental illness, people at the extremes of life, and for people with substance use disorders. We summarize mechanisms to incentivize integration efforts and to stimulate new integration between health and social services in primary care. We then present an outline of recent enablers for integration, concentrating on changes to funding mechanisms, developments in quality outcome measurements to promote collaborative working, and pragmatic guidance aimed at primary care providers wishing to enhance provision of behavioral care.

 

A pilot study of an integrated mental health, social and medical model for diabetes care in an inner‐city setting: Three Dimensions for Diabetes (3DFD)

 

Using a non‐randomized control design, the 3DFD model was offered in two inner‐city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes.

3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [−14 mmol/mol (−1.3%) vs. −6 mmol/mol (−0.6%) respectively, P < 0.001], adjusted for confounding. Total follow‐up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost‐effectiveness ratio was £398 per mmol/mol unit decrease in HbA1c, indicating the 3DFD intervention was more effective and costed more than usual care.

 

Integrated care for adults with dementia and other cognitive disorders

 

The importance of better care integration is emphasized in many national dementia plans. The inherent complexity of organizing care for people with dementia provides both the justification for improving care integration and the challenges to achieving it. The prevention, detection, and early diagnosis of cognitive disorders mainly resides in primary care, but how this is best integrated within the range of disorders that primary care clinicians are expected to screen is unclear. Models of integrated community dementia assessment and management have varying degrees of involvement of primary and specialist care, but share an emphasis on improving care coordination, interdisciplinary teamwork, and personalized care. Integrated care strategies in acute care are still in early development, but have been a focus of investigation in the past decade. Integrated care outreach strategies to reduce transfers from long-term residential care to acute care have been consistently effective. Integrated long-term residential care includes considerations of end-of-life care. Future directions should include strategies for training and education, early detection in anticipation of disease modifying treatments, integration of technological developments into dementia care, integration of dementia care into general health and social care, and the encouragement of a dementia-friendly society.

 

POLICY

Advancing integrated care in England

Implementing integrated care models requires providers to develop new capabilities, which is challenging with resource constraints and often conflicting policy priorities. Given the current funding and legislative context for the NHS, we assessed effective and practical paths to accelerate the adoption of better integrated, higher-value care. We sought to identify feasible modifications in the NHS’ policies and feasible steps for NHS providers to take based on growing experiences in England and globally with integrated care.

 

Behavioral Health Integration in Medi-Cal: A Blueprint for California

 

This paper puts forth an ambitious framework to transform a fragmented system in California in which Medi-Cal enrollees with complex behavioral and physical health needs often fail to receive needed care that must be coordinated across multiple and disparate service delivery systems. This framework builds on areas of strength within the current structures while addressing the systemic barriers to improving care due to the current organization, financing, and administration of physical health care, mental health care, and SUD care in Medi-Cal.

 

WORKFORCE DEVELOPMENT

As a Pediatrician, I Don’t Know the Second, Third, or Fourth Thing to Do: A Qualitative Study of Pediatric Residents’ Training and Experiences in Behavioral Health

 

Despite a mandated 1-month rotation in developmental-behavioral pediatrics (DBP), pediatric residents report inadequate training in behavioral health care. As a first step in much needed curriculum development in this area, this study sought to assess learner experiences regarding the management of behavioral health problems during residency. Four focus groups were conducted for residents in years 1-3 of training in 2 residency programs in a northeastern state. Transcripts were analyzed and coded by researchers through qualitative classical content analysis. The exploratory analysis revealed 9 key themes: time requirements, rapport building, resources and referrals for behavioral health, psychiatric medications, diagnosis vs. treatment, working with families, the importance of behavioral health, fears of working with a pediatric population, and training issues. These qualitative data further identify gaps in the behavioral health training of pediatric residents and may inform future innovations in training curricula.

 

Ethical considerations for behavioral health professionals in primary care settings.

 

In general, psychology training has been slow to adapt to a changing market and systems. Many of the most common dilemmas encountered in primary care are actually reflective of "cultural" and professional differences between medical and psychological service provision ethics and tradition. Therefore, the commentary we provide may not point the reader to one clear, irrefutable solution to a problem or dilemma; in fact, there are surely many more than we can outline here. However, we share a recommended framework for working through ethical dilemmas in integrated primary care (IPC). (PsycINFO Database Record (c) 2018 APA, all rights reserved)

 

Evidence Brief: Use of Patient Reported Outcome Measures for Measurement-Based Care in Mental Health Shared Decision-Making

 

An evidence brief on measurement based care (MBC) practices in mental health care, specifically in the context of using standardized patient-reported outcome measures in shared decision-making with individual Veterans. Findings from this evidence brief will be used to inform guidance for MBC within the VHA. This rapid review found no studies of the specific VA-recommended approach of using any of 4 recommended patient-reported outcome measures (PROMs) for implementing measurement-based care (MBC) in the context of shared decision-making in mental health. However, we identified other promising approaches to use of PROMs for MBC in mental health.

 

DISSEMINATION

Availability of Integrated Primary Care Services in Community Mental Health Care Settings

 

This study examined the availability of primary care and wellness services in community mental health centers (CMHCs) and outpatient mental health facilities (OMHFs). We used data from the 2016 National Mental Health Services Survey to examine the proportion of facilities that reported offering integrated primary care and wellness services (smoking and tobacco cessation counseling, diet and exercise counseling, and chronic disease and illness management). The study used logistic regression to model the odds that a facility offered integrated primary care as a function of facility characteristics. Across states, 23% of CMHCs and 19% of OMHFs offered integrated primary care. The odds of offering integrated primary care were significantly higher among facilities that reported more quality improvement practices, prohibited smoking, or offered wellness services. Less than one third offered smoking and tobacco cessation counseling or other wellness services. Integrated primary care remains uncommon in CMHCs and OMHFs and is more likely among facilities with certain characteristics.

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. Dr. Martin conducts research on integrated care measurement, medical workforce development, and population health strategies in primary care. He serves as the Director of the ASU Project ECHO hub for behavioral health didactic training and teleconsultation. 

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How Far Can Integration Go?

Posted By Joan Fleishman, Tuesday, March 19, 2019

 

I walk through an empty cobblestone plaza, once bustling with vendors,  the infectious smell of al pastor tacos, and fresh leather sandals. This plaza has been vacant since the period of time in the early 2000s when Tijuana became violent, even dangerous, and Americans didn’t visit.

I climb the snaking stairwells and tunnels leading me across the border, splashed with worn graffiti in two languages. It was as if these walls themselves were pleading for salvation and cursing the division of these two worlds. As I walk, I join the 90,000 people crossing this land border each day, making it one of the busiest in the world.

I don’t know what to expect from today. I’m joining Boarder Dreamers, a grassroots group of medical providers, to provide a mobile medical clinic to migrants at the shelters. Current US policies restrict access to asylum and slow migration, which leaves many people trapped in uncertainty in border towns like Tijuana.

***

First Stop: Enclave Carocol

We gather in the back of the soup kitchen turned clinic. We are a motley crew of medical providers and students, behavioral health providers, nurses, and legal advocates. Our mission today: Assess and address the biopsychosocial needs of migrants from Central and South America at the shelters and camps we will visit. They are awaiting their number to be called to begin the asylum process.

The clinic in Enclave is sparse. Light shines down from an exposed bulb hanging from the ceiling.  There are two corners of the large open room where colorful, old bed sheets are hung to create exam rooms. There is a 1970s exam table and shelves full of medical equipment. A bowl of shiny red apples and a 5-gallon water jug sit on a bare table. Hanging crookedly on the water jug a sign reads, “potable”.

We step back outside into the sun and brisk January air. We organize into small teams.  The behavioral health team, made up of myself, another psychologist, and two social workers, are going with the physician assistants and their students. They are equipped with a large duffle bag of medications and supplies. The students are in scrubs and around their necks hang polished stethoscopes. Their eyes are bright and wide.

***

 Second Stop: El Templo aka Little Haiti

Our Uber driver doesn’t actually take us to the Templo. The road is completely washed out and we walk the last ¼ mile on foot. The “road” looks more like a landfill, and what is later explained to us is that the residents throw their trash where the road used to be to help when the road washes out. Ah…yes, of course! Why didn’t I know that?! We walk up this “road”, flanked by horses, chickens, and the largest pigs I have ever seen (which is saying A LOT because I grew up on a farm).  There is wood smoke and Ranchera music in the air.  We are definitely in Mexico.

We see 63 patients at the Templo. Old and young. Haitians who left Haiti by boat after the earthquake and have spent the last few years living in Venezuela and Chile. They tell us they started their journey 5 weeks ago, on foot, to Tijuana. They have only been there a few days.

The medical providers treat scabies and lice, foot sores, and abscesses. They do pregnancy tests and hand out calamine lotion. But what is clear, is that they cannot treat everything our patients are struggling with. Hanging in the air, there is a weariness, an exhaustion, and a vigilance. We see it in their eyes. And we feel it in our hearts.

The statistics of immigration into North America are astonishing.  It is estimated that 500,000 people make the journey to Mexico every year. Many don’t make it. There is a high incidence of violence and sexual assault.  We listen as a mother and her 10-year-old son recount a night on their journey where they witnessed a horrifying event. The exposure to trauma is a given on this journey.

The behavioral health professionals gather. What can we do for these people, these families who have traveled so far, and have experienced unspeakable things? How can we help?  Their journey is not yet over. We ask ourselves, “What does mental health first aid in a migrant shelter look like?”

A few of us lead an art project for the children who are eager to use the colored pencils we brought and learn a few words in English. They are happy to draw and talk and laugh. They ask us questions and draw pictures of worlds in their imagination. We offer any child who wants to talk with one of us about their picture a few minutes of undivided attention.

The rest of us, with the help of our Haitian-Creole translator, facilitate a “charla” (a chat) for the men at the shelter. We discuss anxiety and depression. We normalize the anger and powerlessness.  We discuss the fear they have about the asylum process. For some they fear being separated from their wives and children. Those who don’t have a wife or children they fear they will not be granted a number, which would allow them to be called for a Credible Fear interview, the first step in seeking asylum in the US. The men agree, all they want is to work, to provide for their families, and keep their children safe. Lastly, we talk about resiliency, which of all the people I have met in my humanitarian work, these men truly embody.

***

 Third Stop: YMCA Youth Shelter

We arrive at the shelter housing unaccompanied minors. There are roughly 25 teens here. Some have been here for months. There is no formal asylum process for unaccompanied minors and they are often at the border for many months before they can cross. Today they are eager to be seen by the doctors.

I am setting up the table for the mental health consults and I start to realize that the way this clinic has been functioning behavioral health and physical health have been viewed as separate. We are asked to set up in separate spaces and do separate things. But I want to do something different. I suggest that the physician, who came with us to the youth shelter, and I see patients together. She is agreeable. So, as the nurse triages the patients, the physician and I set up three chairs in a triangle.

At first, it’s clunky. Who interviews the patient first? When does the physical exam happen? With our limited time and attention to urgent needs, what is most important to ask about or address? The teens have various physical complaints; stomach aches, tooth aches, swollen glands. A 15-year-old is 3 months pregnant. She has had no prenatal care, no prenatal vitamins. No one is sleeping well, a few are having panic attacks, one expresses passive suicidal ideation.

It becomes clear that most of what they are experiencing are reactions to stress, trauma, separation; the psychological toll of migration. We can only offer a kernel of what they truly need, but what we can offer is an opportunity to be heard, to be cared for, to have someone to talk to, tell their story to, and acknowledge their journey.

The sun is beginning to get lower in the sky and I know we need to speed things up. Instead of me seeing all the patients I suggest we try using a Warm Hand Off when the physician thinks the patient would benefit from talking to a behavioral health provider. This works well and is more efficient. She comes and gets one of us on the BH team, introduces us and explains why she thinks it would be a good idea if the patient chatted with us for a bit and then she moves on to her next patient.

In that moment, as we lose daylight and the chill returns to the air, the team gains something, a game changer. They discover how even in a mobile clinic in Tijuana, at a shelter for unaccompanied minors, integration of behavioral and physical health makes sense, saves time, and better meets the patients’ needs.

***

 As I walk back over the border on the worn sidewalks, through the metal detectors, and past the empty plaza, my teammates are a buzz with how we worked together today at the YMCA Youth Shelter and this new model of care. They are excited to try out integrating physical and behavioral health services at other shelters next weekend. They are eager to use Warm Hand Offs to introduce behavioral health to patients they know would benefit from talking with one of us.

Tonight I realize that integration has no borders.  The utility and value of an integrated model of healthcare is not confined inside the clinic walls, but can be deployed anywhere that multidisciplinary teams exist.

So, I really only have one question for you. Where will you take integration next?

Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.

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Integrated Behavioral Health in Ob/Gyn Clinics: Is there anyone else out there?

Posted By Katie Snow, Thursday, March 7, 2019

Join the CFHA Women’s Health Call

Thursday, March 14 at 1:00 pm PST/4 pm EST

One of the first things I noticed when starting out as a BHC in an obstetrics/gynecology clinic was that every template or model for integrated care focused on primary care as the setting for behavioral health integration.   Although much of that information is adaptable to ob/gyn care, the value of a community of behavioral health professionals working in ob/gyn has become apparent to me. The goals of this community would be to share ideas and to develop effective targeted interventions for issues that are unique to women’s healthcare.   

Please join the CFHA Women’s Health call on Thursday, March 14 at 1 pm PST/4 pm EST to discuss how we can pool our knowledge related to behavioral health care related to ob/gyn issues.  There are myriad opportunities for intervention. I will highlight a few here and encourage you to join in our conversation. https://www.cfha.net/events/EventDetails.aspx?id=1201796

 

Perinatal Mood Disorders: Intervention and Prevention

BHCs can play a role in identification and outreach to at-risk perinatal patients: deploying both brief interventions and skillful referrals with benefits to families, providers and payers. BHCs and medical providers frequently receive feedback from women indicating that they would have been unlikely to seek out care for a perinatal mood issue, even a severe one.  Patients tell us that they agreed to a warm handoff or behavioral health appointment out of trust for their ob/gyn provider, and because the care was quick, available onsite, and came with minimal barriers. As a result of earlier intervention, symptoms tend to resolve more quickly.

By sharing ideas and documenting results, we could increase the use of early intervention with potential for real impact with this population.

 

Miscarriage, pregnancy termination, stillbirth, neonatal death and infertility

Being in the right place at the right time is especially important in the many situations involving loss and grief in Ob/Gyn care.   There is a look of surprised relief in many patients’ eyes when I come in for a warm handoff after they have discussed or learned of adverse pregnancy findings or are in the throes of decision making with their medical provider.   BHCs provide space, time and expertise to process these experiences as they occur, in the initial period after a loss or while navigating the uncertainty of a high-risk pregnancy. We are able to provide a gentle touchpoint in the direction of self-care during the immediate crisis as well as monitoring for common complications of this type of grief such as insomnia, isolation, guilt, loss of self-efficacy, hypervigilance, suicidal ideation and ruminative self-doubt. Those with multiple losses or pre-existing mental health challenges may ultimately find a relationship with an ongoing mental health provider most beneficial but I rarely hear from a patient that they feel our time together was wasted.  

Exchanging information on this topic could offer us new ways to help our patients cope at this difficult time.

 

Perimenopause and menopause:

Symptoms of perimenopause and menopause such as weight gain, low libido, insomnia, vasomotor symptoms and depression may result in a referral to behavioral health. The factors contributing to these symptoms tend to be complex: many patients are in their most productive working years, are raising children or teenagers, caring for aging parents, adjusting to an empty nest, contemplating or experiencing divorce or recognizing that they are no longer willing to live within certain societal constraints that they had previously accepted.  Some women use alcohol or marijuana to cope, and need support to decrease or cease use. Some are ready to dive into an ongoing therapeutic relationship and just need help connecting to that care. Others have ventured far enough from their comfort zone just meeting with me in the clinic but are open to ideas about how to improve their quality of life and functioning. Because many patients have a good amount of insight by this point in their lives, they readily soak in some of the “nuggets” offered in brief visits and are often eager to take next steps on their own or with a limited number of follow up visits.

By pooling our knowledge and experience in this area, we can provide additional resources for this group of patients.

 

Pain—menstrual, sexual, chronic pelvic and more

Supporting patients related to their experiences with pain is, of course, a mainstay of integrated behavioral health practices.  When working specifically with female reproductive organ and pelvic pain, there are some additional factors to consider:

There exists a long history of dismissing women’s pain or attributing it to women being excessively dramatic. At the point I meet them, most patients feel that their concerns are being taken seriously by their gynecologist, though it may have taken months or years to be referred there. By some estimates, the average time from initial complaint to a diagnosis of endometriosis is 8 years.  I try to keep this in the forefront of my mind as I assess for and provide education about the role of trauma, depression and lifestyle factors that can contribute to a worsening experience of pain. My hope is to not dismiss or diminish concerns but rather shine a light on the constellation of interventions that tend to improve symptoms.

Many women also struggle with shame and internalization of distressing issues such as painful sexual activity and severe pelvic pain, particularly if a diagnosis has not yet been given to explain these symptoms.   In these situations, patients may feel understandably overwhelmed by too much direct questioning and require an especially sensitive approach – i.e. we need to slow down sometimes! Behavioral health can play a key role of support between or in conjunction with medical provider visits to learn coping strategies, obtain support or connect to ongoing mental health care as helping women address some long-avoided topics.  

What other ideas do you have about supporting women experiencing these challenges?

 

How can we improve the care we provide?

Women discuss a wide variety of issues with their ob/gyn. Many of these are ideal for a warm handoff to a BHC in order to continue the conversation and to provide support and intervention. There will never be a one-size fits all approach to any issue we see in behavioral health. However, for issues like diabetes, hypertension, tobacco use and even depression, we recognize the impact on well-being, can measure severity and evaluate progress, and have a toolbox of evidence-based interventions to use to help.  

The benefit of a community of practice focused on women’s health would be to push forward an evidence-based approach to the areas discussed above.

Join in to talk about needs you see or anticipate in your setting. All are welcome, even those just interested in learning more!

 

Join the CFHA Women’s Health call on Thursday, March 14 at 1 pm PST/4pm EST

Additional note:  I was thrilled to read the February 2019 US Preventive Services Task Force (USPSTF) findings regarding prevention of perinatal depression.  The USPSTF concludes with moderate certainty that counseling interventions to prevent perinatal depression have a moderate net benefit for persons at increased risk. They also highlight the potentially promising role of “embedded behavioral health specialists” in improving health system delivery of these interventions.  To read more: (https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-preventive-interventions )

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.

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Training the Ground Troops of Family-Engaged Care

Posted By Barry J. Jacobs, Wednesday, February 20, 2019

 Around the long mahogany board room table, the 40 middle-age nurse and social work care managers of this large Medicare ACO regarded me with a mixture of inquisitive and impassive looks. I was supposed to deliver the good news on how strategies for supporting family caregivers are becoming more sophisticated. I started off by asking how many of them had been caregivers in their own families. Everyone raised their hands. One woman shared her story of growing up with a grandmother who’d had a stroke. Another revealed she had a father with dementia.

They talked about how trying these personal experiences were. I then asked how many of them used formal, structured means of engaging and assessing the family members of the geriatric patients with whom they worked professionally. Not a hand went up.

 

Medical family therapists and physicians and nurses with family systems training--the heart and soul of CFHA--are not the frontline ground troops of family-engaged healthcare. Care managers are--or should be. Mostly seasoned female nurses with big overflowing hearts and steel-trap minds for details, they sit in back offices in primary care clinics, in healthcare insurer cube farms, and at hospital unit desks, making dozens of phone calls daily to smooth out care transitions, coordinate communication among disparate providers, and better address patients’ social determinants of health. They have learned ways of supporting patients who have housing, transportation and food insecurity challenges. But even though they work with the family members of those patients every day, they don’t know—and often don’t know they don’t know—about the latest methods for engaging families as partners in healthcare and social service delivery.

 

So, what are those methods? They loosely fit into three buckets:

 

Intentionally engage family caregivers: The care managers at the ACO training were quick to point out that they interacted with patients’ family members all the time. But they admitted that these relationships developed somewhat haphazardly. If the family members picked up the phone call for the patient when the nurse called or were present in the home when the nurse stopped by, then some conversation and coordination ensued. In many cases, though, this never happened and family members of great importance to a patient’s treatment course were never meaningfully engaged.

 

This wasn’t due to malicious disregard. Everyone pays lip service to the importance of family. But most of the care managers around the table never received training about intentionally engaging patients’ family members and still practice with the patient solely in their sights. In my opinion, this has only been reinforced in recent years by the increasing emphasis on “patient- or person-centered care.” “Family-centered care” is looked at askance as almost an antithetical heresy. That’s one reason I now push the term “person-centered, family-engaged care” to indicate that including families in our scope of practice won’t violate our duty to individual patients.

 

An intentional approach to engaging family caregivers requires reaching out to patients’ family members as a normative protocol at the outset of patients’ treatments. It is about acknowledging and valuing their potential contributions to patients’ well-being through the hands-on help and emotional support they give. For example, at Dignity Health System in Santa Barbara County, California, caregiver navigators show up at patients’ homes to meet family members—not patients—to establish relationships with them and give them educational materials and caregiver support gift baskets.   Those navigators may then arrange for community health workers to connect with the family members—not the patients--to better support their needs. For more about these kinds of family-facing strategies, see this May 2018 Washington Post article.

 

Assess family members formally: The care managers at the training also contended that they used their clinical instincts to gain a sense of how their patients’ families functioned and whether they could be relied upon to assist with patients’ care. But as far back as 2006, the California-based caregiver advocacy organization, Family Caregiver Alliance, devised a National Consensus Development Conference, spearheaded by trail-blazer Lynn Friss Feinberg, to create agreed-upon formal means of assessing family caregivers. That document calls for evaluating family caregivers’ backgrounds, beliefs, values, skills, resources, etc.

 

 In the years since then, healthcare has been exceedingly slow, however, to consider these standards, let along adopt them. It was only in 2019, in the fourth edition of its “Clinical Practice Guidelines for Quality Palliative Care,” that the National Coalition for Hospice and Palliative Care included recommendations for assessing and treating family members (guidelines 4.2.1-4.2.1 and 4.3 on pages 27-28). Few, if any, other national standards for family caregiver assessment exist in any other healthcare sector.

 

 In the training that I’ve done with thousands of mental and physical healthcare professionals over the last decade, I’ve expanded upon the Family Caregiver Alliance’s framework to a 7-point family caregiver assessment that includes family constellation, history, willingness to provide care, ability to provide care, willingness to receive help, meanings derived from caregiving, and stress-level. For more information, see this recent CFHA webinar.

 

 Provide family caregiver support that’s individually tailored and actually helpful: The care managers readily understood that family caregiving is stressful. They spoke of listening supportively to family caregivers’ concerns and referring them to social workers and/or caregiver support groups. These elements of their geriatric practices made me entirely grateful. I’ve learned through my clinical career, though, that not all help is helpful. Unless we really get to know people in the granularity of their life circumstances and idiosyncratic attitudes, we can’t fashion the right support at the right time--thus the need for diving deeply through family caregiver assessment. One-size-fits-all caregiver support groups rarely do. I’ve also learned that family caregivers are proud and are often loath to accept help. That’s what makes the relationship-building we should do with patients’ family members from the outset more essential. It is only when we take the time to establish ourselves as trustworthy guides that we have half a chance of convincing them to utilize the support services we can offer.

 

 After the training, the care managers’ director told me she found my presentation “eye-opening.” Her comment was flattering but also alarming. Little of what I presented should have been brand new to them—and yet the idea of approaching patients’ family members with intention and formal clinical approaches came as a revelation. Person-centered, family-engaged healthcare won’t make any advances unless the ground troops are on board. Those of us in collaborative family healthcare have a lot more to do to supply them with the orientation, tools, inspiration and will.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and Principal at Health Management Associates, a national healthcare consulting firm. He is the author of The Emotional Survival Guide for Caregivers (2006) and co-author of AARP Meditations for Caregivers (2016).

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What Is Your Philosophy of Screening? And Other Terrible Pick-Up Lines.

Posted By Matthew P. Martin, Wednesday, February 6, 2019

The title of this post is a terrible pick-up line, but it reflects my recent musings on how we identify patients in primary care who may benefit from behavioral health services. Health screening is standard practice in primary care. We screen for physical health, mental health, substance use, health behaviors, family functioning, social determinants of health, and more. We assume that the screening tools are accurate and use the data to inform our treatment decisions. We may even assume that patients do not completely understand their own health and that screening can be the first step toward an accurate diagnosis. Screening allows care delivery systems to process high numbers of patients, categorize patient health problems, calculate risk levels, and assign appropriate treatment.

Screening is a ubiquitous practice in healthcare. I have worked in five different primary care systems and each one had a protocol for identifying patients with depression. Other industries use screening as well. Employers screen new employees for drug use and citizenship status; athletic teams screen players for physical prowess and potential ability; banks screen customers for credit worthiness. There seems to be this underlying belief that certain discrete points of data can predict something important about employees, athletes, customers, and patients. Although there is strong evidence that health screening works, it is certainly an imperfect science. For example, many patients with chronic pain symptoms will flag on the PHQ-9 (a depression screening measure) even if they don’t have depression symptoms. Most behavioral health measures rely on self-report and are at risk for false positives (and false negatives too!). Screening data should inform clinical intuition and experience; it is a starting point, not an end point.

It may help to take a step back and think about the functional purpose and rationale of screening. By taking a step back and choosing the target of your screening efforts, you can create a comprehensive strategy that meets multiple needs while efficiently using your resources. In my career, all of my clinical experience has involved universal screening. The purpose of universal screening is to identify as many candidates as possible; in other words, the wider your net, the more fish you catch. The rationale is that universal screening can identify anything on the spectrum: potential, developing, active, and even urgent health problems.  For example, SBIRT (screening, brief intervention, and referral to treatment) is an effective universal screening approach for identifying substance use and assumes that, because there are more risky substance users than those with full blown dependency, a greater number of problems exists with the former sub-population. Another example of universal screening is the recommendation from the United States Preventative Services Task Force for depression screening. They recommend all adults be screened, although they do not specify frequency. The collection of physical vitals data (blood pressure, heart rate, weight) is a universal screening approach too. Imagine seeing a medical provider and not having your blood pressure recorded.

Universal screening is pretty, well, universal in healthcare. There is another approach that has gained some recent attention that you may not know about. Although there is no official term for it, let’s call it focused case identification (FCI), a population health management strategy. This approach includes tools like patient registries, risk calculation, and non-clinical data. The purpose of FCI is to identify patients who would benefit most from a service based on an algorithm or risk score. The rationale is that, in a healthcare system of limited resources, our sickest patients are most likely to be high utilizers of care and have the worst outcomes.1,2 By determining risk level and focusing our resources on this segment of the patient population, we can get the biggest bang for our buck. There are four recommendations to follow when taking this approach: first, focus your case-finding efforts on patients with chronic medical conditions and high health care costs; second, deploy treatment resources in a fully integrated fashion; third, use only highly trained clinicians and evidence-based treatments; fourth, escalate care when appropriate using care management and coordination strategies.3 The assumption is that a focused case identification approach would reach the Triple Aim faster compared to universal screening.

So, what should your clinic do? Well, first let me say that I may be creating a false dichotomy here, a straw man so to speak. This comparison of two case identification approaches is just meant to highlight the strengths and limitations of each model. On the one hand, universal screening is a fairly straightforward and low technology-based strategy (you could do it all with paper surveys) that can create false positives and negatives. On the other hand, a FCI model can identify your sickest patients and efficiently use resources, but it requires significant expertise and sophisticated health information technology for maximum benefit (e.g., care management software, risk calculation tools). I can see hospitals using the FCI model because they have access to the knowledge and technology it requires, but a small clinic in rural New York? Not so much.

Here are some thoughts about moving forward. First, combine both case identification approaches into a comprehensive strategy. Clinics can’t focus on patients with chronic health problems and comorbidities unless they first screen for those issues. That usually requires a universal approach. Perhaps the solution is to only universally screen all patients with chronic health conditions like diabetes and congestive health failure, but not the entire patient panel. Second, clinics need access to knowledge and technology that make FIC possible. Payers, both private and public, can create knowledge networks that clinics can easily join to learn more. Some clinics may need practice facilitators to accelerate their transformation process. Finally, policymakers should create rules requiring EMR vendors to develop easy to use and affordable population health management tools, making FIC more likely to happen. So, perhaps instead of using “What is your philosophy of screening” as a pick-up line, maybe a better line is “What is your value-based case identification model?”

 

1. Cogan, S. (2014). What is population health management? Health Management Technology, 35(5), 18.

2. Zander, K. (2019). Population Health Management: Coming of Age. Professional case management, 24(1), 26-38.

3. Kathol, R. G., & Rollman, B. L. (2014). Value-based financially sustainable behavioral health components in patient-centered medical homes. The Annals of Family Medicine, 12(2), 172-175.

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. Dr. Martin conducts research on integrated care measurement, medical workforce development, and population health strategies in primary care. He serves as the Director of the ASU Project ECHO hub for behavioral health didactic training and teleconsultation

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The Unspoken Role of the Behavioral Health Consultant: 6 Tips for Navigating Colleague Mental Health Needs

Posted By Katie Snow, Wednesday, January 23, 2019

This post was inspired by a recent CFHA listserv discussion. If you are reading this and not a CFHA member, the listerv is one of the many amazing benefits of CFHA membership!

It usually looks something like this:

A face I know well pops into my office door—another staff member in the clinic where I spend my days as a behavioral health consultant. This face lacks the bright “just popping in to say hi” or frazzled “we need you right now a patient is in crisis” look.  It is more cautious, mingled with a sad or hopeful furrowed brow.

A voice soon follows, starting with an attempt at an upbeat, “can I ask you a question?” and a pause and then, in a softer, sometimes shakier voice, “it isn’t about work….”

The words that follow vary, but there are consistencies. They, or someone they love, are struggling with a mental health or substance use issue. They have tried to get help but have run into problems accessing or using that help.  I am the only person they know personally who has the “inside scoop” on the fractured, difficult to navigate mental health and addictions care in our community and they are desperate to access it.  They want the name of a good therapist.

The above scenario was one of the most surprising aspects of my new role when I began working as a behavioral health consultant.  I was accustomed to exclusively working with other mental health providers, not being the lone mental health provider in my workplace.  I was also used to an almost reverent relationship to the ethical guidelines ground into mental health professionals in graduate school and practicums: in particular, the expectation that we keep our personal lives very separate from work and that we do not engage in dual relationships.  This makes sense, particularly since we know how to access mental health care for ourselves and our families (not that we always do this, but that is a topic for another day).  I quickly learned that boundaries look very different in the medical setting. The medical staff and providers may agree with and support our boundaries once we make them clear, but dual relationships tend not to be front and center for them in the same way they are for mental health professionals.  

The request for referrals often came with additional information about personal or family problems. In my setting, where staff and providers are also patients in our clinic, sometimes these conversations occurred in the context of a scheduled behavioral health appointment because the staff member was referred to me by their provider (and, initially lacking other protocols or knowledge of how to handle this, I saw them).  In either scenario, I soon found myself to be the holder of a great deal of both information and concern about my co-workers.  I felt honored to be considered worthy of the trust implicit to their request, hopeful I could help, and overwhelmed at the prospect of managing all of these concerns in addition to my patient load.  If I am honest, I also felt a sense of loss.  We BHCs want and need collegial relationships as much as anyone.  It changes the power dynamic to see someone as a patient or know personal details of others’ lives without a friendship to contextualize that information.  It immediately requires a more mindful approach to that relationship.  It means we are working even when we are taking a break, needing to always hold this power in balance with the joking and fun-having that is a part of a healthy workplace.

My response to this situation has been multi-faceted. I certainly do not have all the answers, but I will share some advice and information on where I am currently landing:

1.     Seek Supervision: My supervisor had experience with this issue in a different group of clinics. It was applicable to my clinics and eventually helped me to formulate a practice standard for the team I supervise. In the interim, it gave me a place to process what I was experiencing and gain support and ideas.

2.     Talk to Human Resources: I recommend having a conversation with HR prior to encountering this situation if possible. Your clinic’s HR director probably has an opinion about the best steps to take when a colleague comes to you with a mental health or substance use problem.  Their stake in employee well-being is significant and they very likely have resources that you will find useful. They may also want you to direct employees with significant issues applicable to work performance directly to HR.

3.     Know employer-sponsored resources:  See item #2 above. HR will likely give you information on an Employee Assistance Program, possibly a physician/provider specific counseling resource and services covered by the employer-sponsored health insurance plan. Keep an easy to access, updated list of these resources as many employees are unaware of them. This list is always my go-to and can quickly reroute a conversation that would otherwise become much more in-depth.

4.     Refer internally but offsite if needed and possible:  For my team, it has made sense to create a practice standard that asks that employees seek behavioral health care from a BHC at another physical location within the company when referred. Again, this may not be relevant for all, depending on whether employees are also clinic patients. Because most of my colleagues are accessing healthcare within our clinic, it makes sense that behavioral health be available to them as a part of their care. In my group of clinics we have the luxury of being a group of 5 BHCs. We are spread across a large geographic area but it is possible to have a colleague simply access care from a BHC at another location.

5.     Except it isn’t always simple:  Even with all of the above options, sometimes people just need help right away or can’t get it any other way.  Maybe they work 8-5 Monday-Friday and there aren’t appointments available to them when they can attend. Or there is a 3 week wait for a new appointment and that is too long.  Sometimes resources are too far away to be realistic. Often the person assigns so much shame or stigma to accessing mental health/addictions care that they will not access them without support.  So, I try to be flexible within our practice standard, recognizing the key role behavioral health plays in filling gaps in mental health/addictions care.  At times, that has meant that I have been flexible and seen an employee for a few visits as a bridge, a warm-up to accessing care, or for stabilization.  At other times it has meant I have looked around for therapists meeting their needs for appointment time, insurance accepted and location and passed these referrals on to them.

6.     State your boundaries and check for understanding:  When I have ended up seeing a colleague for an appointment or having more extended conversations, I have gotten better at defining my role and boundaries upfront. I tell colleagues that taking someone on as a patient or having specific information about their situation can change our relationship and I try to provide some clarity about what this means. I am very, very clear about my mandated reporting responsibility.  I share my priority for finding them ongoing care. And then I listen.

 

Maybe it’s the new year, but while writing this post I spent a lot of time reflecting on our role as BHCs. It left me feeling more than a little bit grateful to the many folks out there who have and are contributing to the development of this field.  With all its complexity, integrated behavioral health truly has the potential to be one of the answers to the national conversation about how to increase access and decrease stigma surrounding access to mental health and addictions care.   Thanks to all of you for being a part of this movement. And Happy New Year!

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.

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Assume Trauma Until Proven Otherwise

Posted By Joan Fleishman, Tuesday, January 8, 2019

I decided to write a piece in response to the CFHA listserv discussion on detecting and addressing trauma in primary care.

As I watched the messages from my colleagues trickle in about how to address medical providers’ unease discussing trauma with their patients I paused and knew my contribution would be forthcoming.  I have done a significant amount of work in my clinics to promote, train, and implement Trauma Informed Care (TIC) across our clinical system. The questions that were being asked on the listserv were real. They are the questions that my colleagues and I grapple with. How do we to address trauma in primary care? How do we prepare and support medical providers to do this work?

Why are we so uncomfortable with topics like trauma, with intimate partner violence, with suicidal ideation? The answer is complex and simple at the same time, these are not easy topics to talk about.  Partially because they are sensitive, partially because they carry stigma, and partially because they are so prevalent that those having the conversations may be personally affected by them. Regardless of these factors, there is growing evidence for trauma informed care in medical settings. This work has been supported by agencies like SAMHSA, HRSA, and National Council for Behavioral Health.

I recently was asked to teach TIC to 3rd year medical students. In fact, one of our learning objectives was, “develop comfort in addressing a trauma disclosure with a patient.”

The first question I get in the class is should we be screening for trauma or PTSD. The listserv discussion included thoughts on universal screening for ACEs and PTSD in primary care patients. Although I think that screening is appropriate for some sub-populations served in a primary care setting, I have not yet seen robust evidence that this type of screening in a general primary care population leads to improved outcomes. As mentioned in the listserv discussion the USPSTF has not yet issued a guideline for screening for trauma or PTSD.

In the listserv discussion, there was a call for medical providers to provide validation, empathy, and sensitivity to patients with a history of trauma as an intervention that seems feasible and realistic for primary care providers to implement. It was pointed out that these should not just be applied to patients with a history of trauma or PTSD, but to all patients. I endorse this idea and will take it a step farther by suggesting that validation, empathy, and sensitivity should be applied in the context of trauma informed care and a universal precaution approach.

These three qualities (validation, empathy, and sensitivity) fit perfectly into the formal conception of trauma-informed care: fostering safety, autonomy, and trust in the patient-healthcare provider relationship. When operating with the universal precaution approach, direct screening is not necessary.  We approach all patient care, every interaction, with the principles of trauma informed care including safety, trustworthiness & transparency, peer support, collaboration & mutuality, empowerment, voice, choice, and cultural, historical, and gender issues.

Being trauma-informed means that one can screen for and identify trauma in a patient’s history, understand and respond to trauma, and avoid re-traumatization. SAMHSA refers to this paradigm as the four Rs: realization, recognition, response, and resistance to re-traumatization. It is important to remember that trauma-informed is different than trauma specific or trauma sensitive.

So, what did I teach my 3rd year med students? We discussed how to ask about trauma and how to respond to a trauma disclosure. I introduced the five points below. I hope these can help you in your practice. You may even want to share them with a colleague.

Use a Trauma Education Statement. It is important that we explain why you are asking about trauma in the context of their medical care and that we acknowledge the impact of trauma.

Examples:

“We’ve learned a lot about how abuse, neglect, and chronic stress can lead to health issues like chronic pain...

“What we know about trauma is that people who have been exposed to abuse or have had bad things happen to them are more likely to have certain health problems like chronic pain…”

Inquire about the patient’s experience. I suggest to my students that the first time we bring trauma up we are simply planting a seed. I encourage them to lead with curiosity and compassion. I emphasize that it is important that we let our patients know it is not necessary to gather details for them to be able to help.

Examples:

“I wonder if you have had some experiences like this in your past…”

“I don’t need to know the details of anything that may have happened to you. I wonder if you have experienced emotional, physical or sexual abuse in your past…”

Create safety. Once someone has shared about their experiences it is crucial that we validate their emotions and experiences. We also must act as a container and prevent activation and emotional dysregulation.

Examples:

“You don’t have to share details with me. I want you to know that you can talk with me about these experiences and how they may be affecting you now.”

“I want to acknowledge that these are really hard things to talk about for most people because talking about them can bring up emotions or you might feel like you are reliving what happened to you.”

Addressing a disclosure. This is where my students felt the most unprepared. I encourage them to thank their patient for sharing their story. And I encourage them to connect how knowing the patient’s history can help them provide better care.

Examples:

“Thank you for sharing your story with me because it really helps me understand the whole picture of your health and how you live your day to day.”

“Thank you for telling me this. Given what we know about certain health conditions and trauma, this will help your healthcare team provide better care.”

Preventing and reducing activation. If you begin to notice that your patient is fidgeting, playing with something in their hands, rocking in their chair, avoiding eye contact or seems “checked out” they may be activated or dissociated from retelling their experiences. I teach that in these moments it is ok to interrupt their story. Validate their experiences and emotions and explain that reliving emotions and telling the details of an experience is not necessary for you to help.

Examples:

“I’m actually going to interrupt you because I can see that this is really distressing and hard to talk about and I don’t want you to have to feel the emotions that go with those experiences.”

“This sounds like this was a really significant event in your life. I want you to know that you don’t have to tell that story because you don’t have to relive the emotions that you experienced.”

If you have questions or if you wish to have further conversation about this topic, feel free to contact me at fleishma@ohsu.edu.

Dr. Fleishman is the Behavioral Health Clinical and Research Director for OHSU’s Department of Family Medicine leading the expansion of the behavioral health services across 6 primary care clinics. She has worked closely with other clinical leaders on strategic planning, program development, clinician training, and workflow implementation. Dr. Fleishman has focused her work on practice transformation, population reach, alternative payment methodology, and team-based care. She is currently involved in several projects including a program evaluation of primary care-based Medication Assisted Treatment (MAT) Program, an implementation study of a screening approach to intimate partner violence in primary care, and implementing Trauma Informed Care standards in a Family Practice clinic.

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End of Year Review in Blogging

Posted By Matthew P. Martin, Friday, December 28, 2018

This year is almost over, a signal it is time to highlight all the great blog posts published in 2018. We have terrific writers in the CFHA community who collectively represent unequaled experience and thinking in the field right now. Catherine Van Fossen et al wrote about a new tool that measures family functioning. They wrote “family functioning is not consistently measured in clinical health care settings or large-scale studies investigating child wellness. … we sought to identify a measure that enabled individuals to report their own functioning.” Barry Jacobs, a national expert on family caregiving, asks “So can families reduce healthcare costs? Probably, though we need many more robust studies with different populations to settle the question.”

 

One area we emphasize on the CFHA blog is research in integration. A constant challenge in disseminating integrated care is controlling the variability that naturally comes with the different clinic contexts and patient demographics across the country. The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) is a tool for measuring fidelity to the Primary Care Behavioral Health (PCBH) model. Greg Beehler reported that “the PPAQ-2 will [soon] be made available. … [it] has been expanded and re-validated to include new subscales to address essential components of collaborative care management.  The PPAQ-2 will now be useful for both PCBH providers and care managers.”

 

We had a short series on quality improvement in health care by Alex Young and Kevin Raddean. Alex gave a brief description of QI while Kevin introduce readers to the fishbone diagram, (aka Ishakawa diagram). Finally, we published two reports on current finding in research: one in September and then one in November. Check out these reports for a quick guide to latest findings in integration.

 

Many CFHA members are heavily involved in training the next generation of workers in collaborative care, giving us a good reason to cover this subject on a regular basis. Each year we promote the STFM behavioral science fellowship, this year written by Max Zubatsky. Writing about supervision in integrated care, Kyler Shumway argues that “On the playing field of integrated care, supervisors have the opportunity to equally inspire and lead others.” Lastly, Katie Snow gives advice for new workers in the field of integration. She writes “For those who, like me, enter the integrated care world as a mental health provider not formally trained or experienced in PCBH or another model, working in a medical clinic feels like visiting a distant land with unfamiliar customs and language.” Her five tips will certainly help any new professional.

 

A regular topic on the blog is the PCBH model, a popular approach that is gaining in momentum but outpacing empirical research. Dennis Freeman answered questions about strategies for financing a PCBH-based service. He argues that “BHCs working in the PCBH model need to prove--with data--the presence of the behavioral health provider on the primary care team improves clinical outcomes, enhances practice efficiency and reduces total healthcare costs for the panel of patients cared for by the practice.” Ryan Landoll reports results of a quality improvement project undertaken by the USAF using PCBH within a stepped care framework. In one year, these sites doubled the number of behavioral health encounters, reached 150% more of the beneficiary population, and saved community mental health costs by over $100,000. These results far outpaced their peer institutions while maintaining high levels of patient satisfaction. We published other PCBH posts on patient outcomes and emergency room visits.

 

Next year the blog format will change significantly. We are moving to a columnist-model and are combining the CFHA and Families & Health blogs into one single blog featuring posts on innovations in team-based and family-centered collaborative care. Have a wonderful start to the New Year and stay tuned for more great writing in 2019. 

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What Big Bird Can Teach Us About Integration

Posted By Matthew P. Martin, Monday, December 17, 2018

Starting and sustaining a movement in healthcare is tough business, unless there is a plan and resources for dissemination. The movement to integrate behavioral health services into primary care began in diverse places, but now appears to have serious momentum. The challenges facing integration today are many and include the following big two: workforce development and variation. The first is a constant requirement for the health care ecosystem and a major determination for how fast a system can integrate. The second is a natural result of the germination of integration across many spots of land, some good and some poor. Variation is good for gene pools and music playlists, but not for disseminating best practice in primary care. Variation means everyone is NOT on the same page. It is a major impediment for research and dissemination. Closed systems seem to have the least amount of variation (see Kaiser, Cherokee, and the VA system) and often boast the most outcome data. The bad news is that many rural and remote clinics operate outside closed systems and lack access to info on best practices.

 

One possible solution for addressing these issues of variation, access, and even workforce development is Project ECHO (Extension for Community Healthcare Outcomes). Some of you are probably familiar with ECHO especially when it comes to liver disease management, HIV treatment, or psychiatry in primary care. ECHO is basically a marriage of professional education and care management that enhances primary care treatment. For those of you with behavioral health training backgrounds, it is very similar to group peer supervision (shout out to Dr. Springer, my favorite group supervisor). ECHO works to broadly share knowledge and build capacity among primary care workers, all in an effort to reduce disparities between urban centers and rural communities. For additional bonus points, ECHO also seems to reduce variation in practice and develop the workforce. The research is impressive. One recent article on ECHO for integrated primary care reports increased provider knowledge and self-efficacy and reduced feelings of isolation.

 

Short side story here: When I was a kid growing up in New York, my family did not have cable television. We had a big antenna on our roof and picked up major network channels and public television. I enjoyed the popular kid shows at the time, even though most of them were just 30-minute advertisements (GI Joe and Transformers, I’m looking at you). The only daytime option for television was the Public Broadcasting Station (PBS) channel.  My three brothers, three sisters, and I (yes, big family) enjoyed watching classic PBS shows like Reading Rainbow, Sesame Street, and 3-2-1 Contact. I can sing the theme songs of most of these shows. These shows were ad-free, high quality, and funded by public and private payers. Project ECHO is like your local PBS channel, allowing everyone access to quality content.

 

Nothing compares to PBS. Those television programs have impacted millions of children in the US and continue to do so today. Beyond public education and public libraries, it is one of the most effective ways for sharing education with a wide audience. In healthcare, I believe that ECHO is one of the best strategies for making expert knowledge of integration as widely and freely accessible as possible. Imagine the small rural practice in Wyoming that wants to integrate, but has no access to an academic hub or enough funds for a consultant. That rural practice can join an ECHO group, connect with other similar clinics, and begin learning best practices immediately. All for free. The major challenge for most ECHO hubs (a hub is the collection of experts that work with the local sites, called spokes), just like PBS, is securing funding, often through sponsorship.

 

We have published previous blog posts on ECHO (here, here). I mention it again now because of recent developments by large organizations to develop ECHO hubs specifically for behavioral health integration. There are many hubs on opioid addiction and psychiatry, but none that focus specifically on integrating behavioral health providers into primary care. Some recent examples include ECHO Colorado and Arizona State University. The former is focused on patient treatment, the latter on practice transformation and management strategies. Despite the benefits of ECHO, there are challenges. I already mentioned funding, a common one because the founders of ECHO at the University of New Mexico require all hubs to make ECHO services free and accessible to primary care clinics. Another challenge is the struggle to measure practice transformation within spokes that participate in ECHO. Most studies that I see measure knowledge and self-efficacy. It’s difficult gaining access to multiple EMRs without major funding and expertise.

 

But those challenges are surmountable. Project ECHO is really a project of the willing. The people who stand to benefit the most from integrated care are those living in rural, remote, and underserved areas. Those clinics often lack access to expert knowledge. ECHO reduces this disparity just like Elmo from Sesame Street. But it requires self-motivated individuals who are willing to invest time and resources upfront before funding is later available. That is a tough pitch to make to your CEO. My advice is to just ask your CEO if he or she grew up watching PBS.

Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. He serves as the blog editor for CFHA.

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Can Families Reduce Patients’ Healthcare Costs?

Posted By Barry J. Jacobs, Monday, December 3, 2018

During the 24 years I worked as a psychologist in family medicine, I heard many complaints about patients’ family members gumming up the healthcare system in various ways. For instance:

 

“My patient’s wife keeps asking me to do things I can’t do—like arrange for her husband to live elsewhere—and taking up my time with frequent phone calls,” vented one physician.

 

“I think the adult children are stealing and abusing my patient’s pain meds,” said another.

 

“The family members won’t decide about changing the patient’s code status,” said a third, “and are making our hospital team continue life supports we know won’t change the ultimate outcome.”

 

These were the gripes of frustrated clinicians. They were not daily reactions but occurred often enough to suggest a widespread professional leeriness towards families. At its most harsh, patients’ family relatives were viewed as nuisances or worse—unrealistic, demanding, self-serving and untrustworthy. They were occasionally condemned for upending plans, obstructing patient-provider relationships, and unfairly impugning doctors who didn’t agree with them. Many healthcare providers maintained cordial relations with family members but minimized deeper engagement as nearly antithetical to “patient-centered care.” If asked whether families help or hinder healthcare, these providers would probably contend that, on balance, they make professionals’ jobs more difficult and cost the system essential dollars through reduced efficiency.

            That’s not the bet, though, currently being made by some of the nation’s biggest health insurance companies, including United Healthcare, Centene, AmeriHealth Caritas, and others, who have launched pilot caregiver support programs, especially for family members whose loved ones are receiving managed Long-Term Services and Supports. The insurers are looking at our rapidly aging society and the rocketing growth of home- and community-based services and believe that it is those sometimes-maligned family members whose valiant efforts can be the difference between chronically ill subscribers bouncing about ERs, hospitals and nursing homes and remaining safe and sound in their own homes. They believe that well-trained, devoted and hardy family caregivers, primed to partner with willing healthcare and social service providers, may be the key to holding down healthcare and long-term care costs.

            On what grounds are the insurers basing their bets? Research—and perhaps a little wishful thinking. There is existing data to demonstrate that engaged family caregivers can help patients with dementia and other progressive conditions live as well as possible outside of institutions. But, historically, most family caregiver research has focused on the impact of caregiving on family members’ well-being and not on patients’ healthcare utilization. We need more research on which elements of family caregiver support yield the greatest decreases in patient utilization and costs.

            It is worth reviewing what little we have in hand, however, because it is promising. Everyone points to the classic 2006 Neurology study by NYU epidemiologist Mary Mittelman and colleagues entitled “Improving Caregiver Well-Being Delays Nursing Home Placement of Patients With Alzheimer’s Disease” (https://www.ncbi.nlm.nih.gov/pubmed/17101889). It describes how a six-session individual and family counseling and support intervention, along with phone contact as needed, forestalled institutionalization of patients with dementia by 557 days on average—likely an over $150,000 savings per patient in today’s Medicaid costs. To many observers, it proved definitively that a proactive investment in family support could pay big dividends in the long run.

            More recent studies on the impact of caregiver functioning on patient utilization lack the dramatic punch of Mittelman’s breakthrough work but are worth noting. In 2016, the National Bureau of Economic Research put out a White Paper, “What is the Marginal Benefit of Payment-Induced Family Care?”, which found that paying patients’ family members money to provide home-based care ultimately saved Medicaid significant sums. Patients tended to by family members had better health outcomes—including fewer bedsores, respiratory infections and urinary tract infections—and consequent lower healthcare utilization, compared to a control group with standard professional care, because their family caregivers effectively served as round-the-clock primary prevention and an early-warning system for acute medical problems.

            And a 2016 study by Johns Hopkins epidemiologist David Roth and colleagues—“Medicare Claims Indicators of Healthcare Utilization Differences After Hospitalization for Ischemic Stroke: Race, Gender and Caregiving Effects” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518936/) –cites having a family caregiver as one factor leading to patients requiring fewer hospital days, ER admissions and primary care visits after they had been hospitalized for stroke.

            So can families reduce healthcare costs? Probably, though we need many more robust studies with different populations to settle the question. I’m hoping that the insurers who are now rolling out enhanced family caregiver support programs around the country are rigorously evaluating whether these programs actually lower patient utilization and, if so, how.

            The insurers’ programs would be greatly boosted if healthcare professionals also embraced family members as partners in care. Research alone won’t bring about that change in providers’ attitudes and behaviors—at least not in the short term. It will take transforming our patient-centric medical culture over the long haul through workforce development, perhaps by matching young learners during their graduate school programs with, say, the spouses of home-bound patients with dementia to show them who is really doing heroic work on the frontlines of healthcare. Only then will our professionals join our insurers in getting behind the nascent power of our families.

 

Barry J. Jacobs, Psy.D. is a clinical psychologist, family therapist and Principal at Health Management Associates, a national healthcare consulting firm. He is the author of The Emotional Survival Guide for Caregivers (2006) and co-author of AARP Meditations for Caregivers (2016).

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