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FSH Poetry in the New Yorker

Posted By Administration, Thursday, January 22, 2015
  "Medicine and poetry have long been intertwined" - Alastair Gee, The New Yorker 


What is your favorite section of each new Families, Systems, & Health issue? Editor's comments? Media review? Original articles? Well, your favorite section may now be poetry.

Recently, Alastair Gee from The New Yorker highlighted the creative work of Adam Possner and Johanna Shapiro, co-editors of FSH. Brief history lesson: FSH was started by Don Bloch who also founded CFHA. Check here and here for more history. 

In the article, Gee shares one of Possner's more whimsical poems, entitled "Drug Holiday":

You work so hard,
with little thanks,
toiling nonstop
in the wet heat,
the airless dark

Gee also shares some insightful comments from Shapiro who believes patients are more akin to poems than essays. “You think a patient is going to be like a well-organized essay, but what you really get is a poem. You’re not sure what they mean, and they don’t tell you everything all at once, up front.”

The article is a nice hat tip to the editorial efforts of Possner and Shapiro who strive to balance the technical, data-driven journal articles of FSH with some art and creativity. Interested in submitting your own poetry? See the journal webpage for more information. 

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Top Ten Useful Measures, Assessments, and Tools for Collaborative Practices

Posted By Cheryl Holt, Thursday, January 15, 2015


In primary care, more than half of the office visits are for somatic complaints, which are often associated with depression and anxiety. These conditions often go undetected and can have a significant impact on health outcomes. As providers adopt a collaborative approach to care, many have incorporated the use of assessments for screening and early detection of symptoms of mental health and substance use conditions.

With an abundance of assessments, measures, and tools available for use, many collaborative care practices are challenged with determining which are most effective for use in the limited time available during a routine office visit. Screenings are important for all age groups. Below is a list of the top ten tools for use in practices. These ten were selected based on a number of factors, including reliability, validity, sensitivity, efficiency, and cost. In most cases, the tools are available for use at no cost. Most are also available in multiple languages as well.

1.       PHQ-9: The Patient Health Questionnaire (9) is widely used among primary care providers to identify depression. With only nine questions, this tool is easy to use and has been validated for early detection.

2.       AUDIT:  The Alcohol Use Disorders Identification Test is a 10-item questionnaire developed by the World Health Organization and is found to be very effective in primary care settings. 

3.       GAD-7: The seven-item General Anxiety Disorder screening identifies whether a more complete assessment is needed.

4.       DAST-10: The Drug Abuse Screen Test is a brief 10-item self-report tool that is effect for screening adults and adolescents for drug abuse.

5.       PC-PTSD: This four-item screen is effective for detecting post-traumatic stress disorder in primary care settings.

6.       Pediatric Symptoms Checklist: The 17-item version is easy to use in family practices for detecting developmental and behavioral problems.

7.       SBQ-R: The Suicide Behaviors Questionnaire is a four-question scale for assessing suicide-related thoughts and behaviors.

8.       Brief Pain Inventory: The tool is widely used in medical settings for assessing pain, and is available in 23 languages.

9.       Insomnia Severity Scale: This seven-question screening assessment is effective in identifying problems with sleeping.

10.   MDQ: The Mood Disorder Questionnaire (MDQ) is a 13-item questionnaire used to screen for bipolar disorder symptoms.

There are many excellent tools that did not make this list   


In order to limit the list to ten, there are many excellent tools that did not make this list. For example, some providers prefer the CAGE-AID to the AUDIT-7 for alcohol screening. In addition, many will find it very useful to have additional tools on hand to screen for additional conditions, such as:

·         Geriatric depression

·         Eating disorders

·         Postpartum depression

·         Intimate partner violence

·         ADHD

·         Autism

Integrating these tools into your electronic health record, including them in patient kiosks, and/or instructing support staff to make select tools available for completion while in the reception area are ways in which these tools have been included in practices. With routine use of many of these screening tools, collaborative care practices will efficiently and effectively detect signs and symptoms of behavioral health conditions. This enables earlier intervention, resulting in better health outcomes.

What is on your top ten list?

Cheryl Holt, MA, CEO of Behavioral Health Integration Consulting, LLC, is an advocate for the integration of behavioral and primary healthcare for whole-person health and assists organizations in adopting a whole-health focus. She is active in social media promoting integrated care, behavioral health policy, and global mental health. She blogs regularly via the Behavioral Health Integration blog and manages LinkedIn's Behavioral Health Integration group and the Behavioral Health Integration page on Facebook. You can follow her on Twitter: @cherylholt, @BHPCIntegration, and @WorldMentalHlth 


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Fresh Eye: Student Reflections on Their First CFHA Conference

Posted By Jodi Polaha, Friday, January 2, 2015

Every year I beg, borrow, and even kind of steal to get my newest students to CFHA’s conference. This year, CFHA scholarships and my Chair’s contributions, helped bring four East Tennessee State University doctoral students in clinical psychology to DC for their first-ever CFHA conference.  The effort has created momentum - ETSU staff, doctoral graduates, and current students numbered 17 this year! I was able to get a small space for a reunion, networking, and time to reflect on what we’d learned.  I am so excited that CFHA is taking hold as a tradition in our program.  

What is CFHA like for a first timer doctoral student, preparing to work in integrated practice? 

They have each prepared  a short reflection:


Kyle Suhr, M. S.

Through my doctoral coursework, I have learned about how to structure my practice to be effective in the primary care setting. My first CFHA conference taught me more about the latest research and practices related to adapting evidence-based treatments in primary care. Likewise, my coursework has helped me think about the administration of integrated care, and my peers and I had been working on an assignment to prepare a business model for integrated practice. The conference helped us with this assignment – providing a number of opportunities to learn about the intricacies of the business aspect of primary care. It was especially helpful to learn about billing and speak with professionals from other disciplines about integrating behavioral health into new locations. The conference was an excellent supplement to the strong training I am receiving in my current program and I think the cutting-edge information helped us earn an A on our class assignment!


Courtney Smith, M.S.

My first occasion to attend CFHA yielded three salient experiences. First, the atmosphere of this conference was palpably distinct from other national and local conferences I have attended. Specifically, there was a friendlier, more open feel. Similarly, the student to professional ratio allowed me the opportunity to connect with leaders in the field , and I felt like this was not just “possible,” but encouraged by way of casual before-and after-meeting activities. It seems very important to me to have this connection with leaders as a developing professional so that transitioning to a collaborative workforce is more fluid. The second experience I found meaningful was the pre-conference Writer’s Workshop.

In addition to absorbing suggestions and tips from successful writers in the field of healthcare, we had the opportunity to have our own pieces of writing dissected and critiqued with feedback delivered in a kind and specific manner to foster improvement. As a student who finds writing challenging, this workshop armed me with tools to conquer writing, one draft at a time. The final experience I would like to mention was Richard G. Frank’s plenary speech on policy reform and its current status. While policy may not have been a reason I first wanted to become a psychologist, it is becoming a necessary part of my career path, as many policies will may enhance or diminish the types of mental health services I intend to deliver. The updates and forward progress on mental health parity was hopeful yet there is plenty of room healthcare providers to advocate for integrated care policies.


Laura DeLustro, M.S.

On my first occasion to attend the CFHA annual conference,  I had the opportunity to volunteer and present a poster. Being a volunteer meant plenty of time to meet with all the conference participants and a chance to get to know the amazing CFHA staff. The presentation that struck me the most was a plenary speech given by Marci Nielsen. She emphasized that we train doctors to be cowboys but ideally, they would be part of a pit crew. She referenced Atul  Gawande and her description of him motivated me to listen to an interview he did with NPR’s Diane Rehm in which he described his transition towards value-driven, quality of life medicine rather than an emphasis on a “quality death.”

For Dr. Gawande, his own father’s terminal illness convinced him that listening to a patient’s values and needs is more important than forcing a one-size fits all protocol onto each patient in an attempt to fulfill medicine’s agenda. All of us have at some point have had the failure of the current US health care system hit us on a personal level and it is encouraging that trail blazers like Dr. Gawande and Marci Nielsen are showing us a different way. The conference helped make the direction and pragmatics of the trail more salient for me, as though I was seeing how integrated care is becoming a reality. I loved the primary themes that emerged at the meeting; that CFHA is focused on creating a system in which a patient can express their values, be treated from a holistic perspective, and become an empowered participant in their own care.


Michael Lasher, M.S.

As a student attending the CFHA conference, it might sound strange to hear that my background is in prison-based treatment programs. What attracted me to a primary care psychology training program is the surprising divide often present between prison medical services (which is the de facto primary care in prisons) and psychological services. Where better to start thinking about how to address this problem than at the CFHA conference? Research presented at this year’s CFHA conference has many direct implications to integrated care in corrections. The prison population is more likely to use medical services for psychological needs than the general public, so utilizing some of the approaches to relationships and logistics discussed over the course of the conference is paramount.

On the other hand, corrections rarely benefits from generous funding, so many of the creative approaches to fiscal management, such as the CoACH tool that was shared with us on Friday morning, might be very appealing to administrators. Additionally, there are parallels that can be drawn between primary care and forensic research, such as the similarity in how risk assessment and resource allocation is conducted. During breakout sessions, many discussions about how to allocate services based on patient needs and health risks echo the Risk-Need-Responsivity model widely employed in forensic risk assessment. The important take-home for me is that the body of work presented at CFHA has relevance to a range of niche disciplines – like corrections - which have yet to embrace the benefits of an integrated care model.

Expanding our existing coursework, connecting our students to leaders in the field, creating and communicating aspirational goals, and providing new knowledge that is broadly usable.  Each of my students came away with something different but wildly positive reviews.  Now.  I’m signing off.  I’ve got to start digging around for some cash… for students wanting to travel to Portland!

Jodi Polaha, PhD, is an associate professor of psychology at East Tennessee State University.

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Collaborative Triumph Part 3

Posted By Tina Schermer Sellers, Lisa Zak-Hunter, Thursday, December 18, 2014


This is the last of a three part series on real stories from real people who have experienced collaborative triumph.

Story Fourth

Several years ago I remember being thrust into the center of a spiritual conflict brewing in the community around a patient of mine.  A patient I will call Betty was dying of metastatic breast cancer with metastisis to her brain.  She had a strong faith and believed if she doubted her healing, she would not be healed.  Because of this she would not allow anyone around her to discuss the possibility of her death.  The disease however, from all indications, was progressing and she was in the transitional care unit because she refused hospice. Her friends from church would come visit and they would talk about when she would get out – denying what they all feared.  This had been going on for a week.  Her oncologist who desperately wanted her to sign a DNR, came to me in a fit of panic, cornered me and said, “Tina, you have to do something!  She must sign that DNR! I refuse to code her!” Knowing I could not breech the subject without violating her mandate, I wracked my brain trying to think of what to do.  Finally I asked her husband, “Is there anyone she would tolerate the ‘both/and’ conversation of God-only-knows-when-and-if?”  He thought about it for a while and then said, “Our pastor.”  I said, “Great.” Let’s get him here tomorrow at 2.  I will call a meeting with the oncologist, you, me, and your pastor in your wife’s room.  The pastor will lead in the both/and conversation and we will take it from there.”  The next day, the pastor said the most beautiful thing to her about how we all need to be prepared because none of us knew the mind and heart of God. But someday, he would welcome us and say, “Well done, my good and faithful servant.” Was she ready whether that time was soon or far away?  

He honored how they all believed in God’s great power to heal and they trusted God’s wisdom.  She was riveted on her pastors eyes and he on hers.  After this, the oncologist who had been caring for her since her first dx 6 years prior, came alongside her bed and got nose to nose and in the most tender tone he spoke of how much he loved her and how he had loved caring for her.  He spoke of how he believed in God’s healing too, but if God was to call her home now, he did not want to have to code her.  How he thought it would break his heart. Tears ran down his cheeks as he spoke.  There was not a dry eye in the room. Her husband came in next and spoke of how much he loved her too.  Even in the anguish, there was a freedom in his love and tears that we all understood.  Unspoken that day, but held in the collective anxiety of our treatment team, was awareness that this dear man had lost his first wife to a tragic car accident twenty years prior and had watched her be coded.  He was scared to death to have that experience occur again. He too had been feeling caught between wanting to honor his wife's desire for absolute solidarity and his need to discuss what he most feared.

Even in the anguish, there was a freedom in his love and tears that we all understood 


This honoring of faith, meaning, complexity and connection was medicine at its finest and it showed the power and leverage of relationship to heal.  The pastor was the only one of us practitioners in the room who was versed in this kind of conversation and who had this leverage with the patient.  In fact for the oncologist and I, this conversation of faith, love and death was all rather taboo.  But we took the lead of the patient and what it meant to honor them all, and the complexity that was presented, and came up with a creative solution that walked us into that particular necessary taboo conversation.  That was one of the first of many conversations of faith, love, community and health to come in my career.  But preparation for this type of conversation was not in my training!

We can see the human drives of sexual bonding and spiritual understanding across history and culture. They both have innate power and defy being put in a box. They are unwieldy forces at times.  And yet both beg us as practitioners, to acknowledge their core place in the human experience and to find our own comfort in order to walk honorably with our patients on these poignant journeys.  


Tina Schermer Sellers, PhD is a recognized scholar in the integration of health into a multitude of areas represented in family and career life.  As a behavioral scientist, licensed family therapist and certified sex therapist, she specializes in helping to craft relationships and lives that flourish. Dr. Sellers draws from over 20 years’ experience as a teacher, professor, consultant, trainer and clinician.  Founder of the Northwest Institute on Intimacy, she also is a clinical professor at Seattle Pacific University in the School of Psychology, Family and Community and the University of Washington School of Medicine.  She lectures nationally and internationally on subjects of sexuality, spirituality, integrated health, family life and career.  She lives in Seattle, with her beloved, Gary, and together they have four children. 


Story Fifth

Anne was in her mid 50s when she was referred to me for care. To her long-time primary care physician (PCP), she was a very friendly and compliant patient. She had struggled with mild depression for years, which her PCP had managed with antidepressants. During one of her medical visits, her husband of almost 40 years, Mark, stressed his worry over her depressive symptoms. Historically, Mark was known to the clinic as ‘worrier’. The PCP was his physician as well and noted there was something different that day about Mark’s concern.

Throughout the time I worked with Anne, her PCP and I worked closely to update each other on psychotherapy progress and findings from medical tests and consults. In our primary care clinic, it is customary for behavioral health to send progress notes and speak to the PCP; we also share an EMR and patients are aware of this. Without this close collaboration, her PCP and I believe Anne’s concerns and crises would not have been handled in a timely and appropriate manner. Neither of us would have had the ‘full picture’. 


During therapy, Anne began describing a surprisingly deep, dark depression. This had been ongoing since her teens and she experienced daily suicidal ideation. She felt emotionally numb, disconnected. She insisted her life had been good, and felt guilty that her depressive symptoms were so severe and overwhelming. She felt guilty that she had not told her PCP that the antidepressants had not worked well for years. At first, she wanted to focus on ‘getting Mark off my back’. Mark was invited to session and I addressed his many questions about an accurate diagnosis, prognosis, treatment, and his role. He was clearly concerned and felt left out of this part of her life. Their dynamic followed a classic pursuer-distancer relationship; when depression was strong, she became quiet and reclusive, this terrified him and he repeatedly asked how to help. Anne became overwhelmed and withdrew further.

Anne did not want Mark to return for a while, so we regularly discussed different ways to address their dynamic and include him in treatment, while respecting her desires for privacy. She then very tearfully and hesitantly disclosed she had been abused in multiple ways in childhood. Mark was aware and supportive, but they did not discuss it. Over the next few months, Anne was further diagnosed with posttraumatic stress disorder (PTSD), and we agreed that a referral to psychiatry and a PTSD specialist could be helpful. Eventually she revisited this with Mark. To her surprise, he had not remembered and was overwhelmed. She brought him to our next session so we could address the impact her disclosure had on him and their relationship. 


Anne openly wept in gratitude over the degree of care we were providing 

Following this visit, Anne’s mood steadily improved. However, she developed new physical symptoms including GI problems, dizziness, and headaches that became increasingly debilitating and interfered with her functioning at work. Her depression worsened. Her PCP was concerned, since his work-up on her was negative. We called a team meeting including Anne, Mark, the PTSD specialist, her PCP, and me. At that meeting, Anne openly wept in gratitude over the degree of care we were providing, spoke frankly to Mark about ways he can continue to support her, described the current depth of her depression, and apologized to her PCP for not being more open about her well-being. Although we hypothesized her physical symptoms were more psychological in nature, her PCP scheduled further testing and consults to rule out anything organic. Her PTSD specialist and I agreed to continue with supportive care until she was more prepared to work through the abuse. Mark also voiced greater understanding after getting a ‘bigger picture’ of what was going on with her and identified specific ways he could support her. 



After that meeting, Anne quickly began coming out of her depressive episode. Her GI symptoms persisted for a while and eventually were more manageable. Her tests came back negative, and she continued to meet with her PCP on a regular basis for other health concerns. Throughout treatment, she gave high praise to us for collaborating so well together, felt well-supported and understood by all members of her care team and noted that Mark was more and more appropriate in helping her. She slowly became more open with him about her past and symptoms. He ‘backed off’, as she had originally requested since he felt more connected to her. Although this wasn’t traditional couple therapy, addressing their concerns in our visits and including Mark on the care team greatly improved Anne’s well-being, outcome, and their relationship. 



Lisa Zak-Hunter, PhD, LMFT is behavioral science faculty with the Via Christi Family Medicine Residency and Clinical Assistant Professor with the Department of Family and Community Medicine at University of Kansas School of Medicine-Wichita. She earned her PhD in Child and Family Development, specializing in Marriage and Family Therapy, from the University of Georgia. Her main clinical, teaching, and research interests lie in the realms of collaborative health care and increasing biopsychosocial understanding of mental and medical health conditions. She has a particular interest in adult eating disorders.

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Collaborative Triumph Part 2

Posted By Montefiore BHIP Team, Friday, December 12, 2014


This is the second of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week!

Story Third

Our pediatric practice, which is part of a large, urban medical center, recently experienced a collaborative care “triumph” that we truly believe would not have been possible without our model of integrated behavioral health. When Ms. Perez (all names have been changed to protect confidentiality), a 24-year-old Latina woman diagnosed with cerebral palsy and depression had her first child, Aiden, now age 3, she brought him to see Dr. Gee, who had also been her own pediatrician. Given Ms. Perez’s physical challenges, cognitive deficits, and psychosocial stressors, Dr. Gee referred the Perez family to the Healthy Steps program. Healthy Steps offers developmental and behavioral guidance and support to high risk families and children. Ms. Perez’s trust in Dr. Gee transferred to Dr. Stern, the Healthy Steps Specialist, who worked intensively to support Ms. Perez as she parented Aiden and then Aliyah, who was born approximately 16 months ago.  Dr. Stern identified Aiden’s delayed development early. He was diagnosed with persistent developmental disorder, and Ms. Perez obtained Early Intervention support for Aiden.  During Ms. Perez’s pregnancy with Aliyah, she became increasingly exhausted and overwhelmed, and struggled with her own mental health issues.  Dr. Stern referred Ms. Perez to Ms. Gordon, a Healthy Steps Specialist who focuses on providing individual psychotherapy to the mothers/caregivers of the children in the program. Ms. Perez began attending weekly therapy sessions with Ms. Gordon, in the pediatric practice, as she prepared for the arrival of her second child.


It was clear that her daughter’s health was only the first of numerous stressors 

After Aliyah’s arrival, Ms. Perez’s levels of depression and anxiety escalated. Aliyah was born prematurely and Ms. Perez was terrified that she, too, would have developmental issues. Aliyah needed frequent pediatric visits for a variety of respiratory issues, including hospitalization for RSV (Respiratory Syncytial Virus). Dr. Gee saw both children for frequent pediatric appointments, and Dr. Stern continued to provide Ms. Perez with parenting guidance (e.g., promoting healthy sleep, managing challenging behaviors, managing her feelings of anxiety and depression so as to be present to parent). Ms. Scott, the practice’s clinical social worker, also assisted Ms. Perez with concrete services (e.g., housing issues, homemaker application). Ms. Gordon continued to see Ms. Perez in individual psychotherapy, but felt that Ms. Perez would greatly benefit from psychotropic medication. Ms. Perez, however, was very resistant and felt that she was not in need of “pills.” Still, her symptoms worsened. 



In mid-September, Ms. Perez presented to the clinic concerned about the health of Aliyah, who was congested and exhibiting increased respiratory effort. During check-in, a nurse who knows the mother very well noted that Ms. Perez was “not her usual bright self” and asked for assistance. Ms. Perez was introduced to Dr. Ray, the psychiatrist who had recently joined the Healthy Steps team. He also noticed that she was overwhelmed and tearful. He provided reassurance and support, highlighting the fact that despite her anxiety, she was making appropriate decisions caring for her sick child. The pediatrician recommended supportive care, Ms. Perez felt some relief, but it was clear that her daughter’s health was only the first of numerous stressors. Others included discord with her husband, avoidance of parents, and a sense of isolation. Dr. Stern joined the session with Dr. Ray, where Ms. Perez acknowledged passive suicidal ideation. Once safety was assessed, Dr. Stern highlighted the fact that the Healthy Steps team had been encouraging her to consider medication for some time. Given the acute nature of her distress, coupled with the fact that she had now established contact with a psychiatrist clearly trusted by the clinic team, she agreed to set up an appointment for a psychiatric evaluation the following week. At the end of the session, Aliyah’s condition worsened and could be quickly re-evaluated by the pediatrician and transferred seamlessly for inpatient admission.


Three days later, Ms. Perez returned to the clinic for both her psychiatric evaluation and her daughter’s post discharge follow up appointment. Due to our integrated services, the appointments could occur back to back. Ms. Perez expressed improved mood, but described multiple stressors leading to anxiety and depressed mood and agreed to a trial on an SSRI. Her time at the practice concluded with a brief meeting with Dr. Stern about sleep training and a meeting with Ms. Scott to construct a plan to allow her to access resources that could alleviate some financial stressors. Finally, Dr. Gee met with her and modeled ways to set limits with her child, as well as reinforced the importance of all of the plans created by the team.

Although it is too soon to know whether our efforts will benefit Ms. Perez and her children in the long term, it is clear that this family has been helped in a way that could only be achieved with collaborative care in an integrated setting.  She has improved communication with her parents and husband and as a result has mobilized familial support to help her overcome significant financial, housing, and emotional stressors.  She continues to take her medication and keep her appointments.  As a result Ms. Perez continues to report improved emotional stability.


The Pediatric Behavioral Health Integration Program (BHIP) integrates universal mental health screening, assessment, treatment, consultation, and referral as needed within all Montefiore Medical Group sites serving pediatric patients. All BHIP team members are housed at the site, share the same EMR, and provide these services. Depending on the size and needs of the site, BHIP team members may include Healthy Steps Specialists (LCSWs or early childhood psychologists), child and adolescent psychologists and/or child and adolescent psychiatrists.

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Collaborative Triumph Part 1

Posted By Julie Kaprelian, Linda Rio, Friday, December 5, 2014


This is the first of a three part series on real stories from real people who have experienced collaborative triumph. Check back for more next week


Approximately 2 ½ years ago, leaders in our field wrote brief anecdotes of their own collaborative care ‘follies’ in the main CFHA blog. These ‘aha’, ‘uh, oh’, ‘doh!’ or ‘SMH’ moments covered good learning points and insight. They normalized the experience of an accidental misstep or foot in the mouth in their efforts to provide solid collaborative healthcare. Veteran and novice collaborators alike took comfort (and perhaps a little chuckle) in knowing they weren’t alone, and took note of possible minefields to avoid!

In this series, we complement the problem based narrative with a strength based one and offer similar learning opportunities through collaborative triumphs! We focus on stories that emphasize ways to address family concerns in a collaborative setting and the importance of including family on the care team. Patient concerns do not occur in a vacuum; we are inherently social and relational creatures. Regardless of how well patients’ families are connected, involved, and aware of patient concerns, they impact patient well-being and vice versa. So, sit back, relax, and enjoy (and learn) as new and established professionals take you through stories of collaborative success. 

For a refresher on the Collaborative Follies blogs, click here, here, here, and here.


What else can I do for them?” is a common question that I hear again and again from pediatric residents in their weekly pediatric continuity (primary care) clinic.  It is inherent that they want to practice best medicine while meeting all of their patients’ need.  I have been providing integrated primary care services to the pediatric residents’ continuity clinic for several months and while implementing the service has been challenging, there have been important triumphs along the way – both for patient care and the department’s providers.

A week into summer vacation, 10 year-old Sara presented with her mom to see her pediatrician, a third year pediatric resident.  Mom had called the department for an appointment a few days earlier stating that there had been concerns raised by teachers about Sara’s back and the way she walked; Mom wondered if she injured it while playing softball but had not noticed anything unusual herself.  The resident obtained an account of the presenting complaint and completed a review of systems and physical exam – everything was within normal limits.  The resident thought it was peculiar that Mom reported that Sara ran around and played typically at home but that teachers went as far as asking Mom, “Does she have scoliosis?”  When the resident asked Sara about her “crouched walking” at school, Sara stated that she didn’t know why and immediately became tearful.

The resident briefed me on the situation and asked, “What else can I do for them?”  She knew a referral to Orthopedics was not indicated based on physical exam but also did not want to simply say, “Come back if the problem continues.” Integrated primary care allowed us the opportunity to discuss the patient’s presentation, consider additional relevant questions, complete a successful warm hand-off, and speak to the family together about the likelihood of anxiety playing a role as there was no organic cause.

The last time I saw Sara it was a shared visit with her pediatrician 

Sara came to see me in pediatric primary care for four brief visits over a period of 3 months.  She identified that her first trigger was presenting a project to her class; from there her anxiety escalated at school.  I encouraged her to practice getting into that stance in the privacy of her own bedroom and then practice regaining a straight posture.  She practiced this regularly and at her next visit was able to show me this in the exam room; she established mastery and control.  She then was able to identify a few other academic stressors that triggered her anxiety; psychoeducation and establishing coping strategies helped to decrease these.  Parents remained closely involved and encouraged her to practice her new skills at home; this was critical as parents helped her maintain an awareness of any physical responses.  The last time I saw Sara it was a shared visit with her pediatrician. She excitedly shared that she had gone to 5th grade orientation the day before; she met her new teachers, saw her classroom, and talked with peers.  She approached the next school year with enthusiasm and the knowledge that she had the resources to manage her anxiety effectively.  Parents were grateful and pleased that they were able to return to Pediatrics for any additional questions or concerns. 


In the pediatric residents’ continuity clinic we reviewed this case and continue to regularly review the patient cases that warranted an integrated care visit to understand how this model and family involvement provides better patient care and provider satisfaction.  We use this time to ensure that residents and attendings recognize that the reasons to complete a warm hand-off to the behavioral health provider are endless.  There is no neat, comprehensive list titled “Patient presentations that warrant bringing a behavioral health provider into the exam room” – rather it becomes educating the pediatric residents early on in their training that it is alright when they do not have all of the answers and how to then effectively use the available resources in an integrated model.  The opportunity, as a team, to collaboratively work with the family on answering the question, “What else can WE do for them?” improves the outcomes for all involved.


Julie Kaprelian, PsyD is a licensed psychologist and currently completing a two year post-doctoral fellowship in Pediatric Psychology at Marshfield Clinic in Marshfield, Wisconsin. She provides consultative-liaison services and brief therapies to children, adolescents and families within the inpatient services at St. Joseph’s Children’s Hospital in the pediatric, pediatric intensive care, and neonatal intensive care units.  She has especially focused on program development while at Marshfield Clinic, specifically designing, implementing and assessing integrative pediatric primary care services within Marshfield Clinic Pediatric Residents’ Continuity Clinic and Department of Pediatrics.  She has presented preliminary findings of patient experience and satisfaction data at the Rural Behavioral Health Practice: Integrated Care in Rural Practice conference this past October, with plans to present final program data to Marshfield Clinic and involved organizations later this spring.  Her clinical and research interests include pediatric psychology, integrated primary care in rural settings, coping with chronic medical conditions, and program development. 



In my fourth private practice psychotherapy session with a 25 year old woman I knew that serious collaboration would not only be desirable but required. As this very thin, frail and ‘anorexic-appearing’ woman began to sob violently, she then became enraged as she talked about an altercation with a fellow-employee. Then she suddenly lost consciousness and collapsed into my arms as I caught her to prevent her from falling onto the floor of my office. I had many prior personal experiences with fainting/syncope episodes so I noticed the subtle signs just seconds before. I did not panic and assessed her basic vitals. I considered a 911 call but she regained consciousness and begged that sirens not be called. A friend was called and took her to urgent care, with a follow-up the following day with her PCP.

Over the course of her 24 month treatment I consulted (gaining appropriate consents) with her primary physician and due to my odd speciality with the hormonal-mental health connection I recommended an endocrine consult which he  agreed after her initial blood work showed my suspicions might be correct. Her endo and I spoke several times, especially since several trials were necessary to find the correct hormonal intervention. No signs of pituitary or adrenal disorders were found. This woman had severe menstrual irregularities and reported virtually no libido which was affecting her relationship with her long-term boyfriend. A host of additional issues were reported in her medical history. An eating disorder was ruled-out but only after I referred her to a nutritionist who specialized in working with eating disorders.

I met several times conjointly with this young woman and her boyfriend to assist in helping him understand that her lack of libido was medically/physiologically-based and not due to any deficit on his behalf. This was a difficult and sensitive issue for him to understand as well as for her to try to communicate to him. Other members of her family were also intermittently involved in family therapy sessions to help all better communicate and deal with the host of her perplexing behaviors that included depression, anxiety, low-energy, anger, and this woman’s general frustrations about her ill health. She was also sent home from work due to anger outbursts as well as tearful episodes that left her unable to function in spite of being well-educated and previously very competent. Her employer’s EAP case manager and I also spoke on several occasions due to fears about potential workplace violence (there was none).

I knew that serious collaboration would not only be desirable but required 


After 18 months of endocrine treatment menstrual balance was achieved and eventually also a return of sexual interest. Other health concerns were also finally resolved. She and her boyfriend got married. She maintained her job and eventually received a promotion. I don’t see her anymore but look forward to her occasional email updates.                                    

Mental and/or physical health issues do not just affect an individual. This young woman’s overall health concerns were intimately connected to her intimate/sexual relationship and her erratic and fluctuating moods certainly were a concern to her boyfriend as well as work relationships. Collaborating with all her physicians was essential to getting to core issues and helping promote an overall improved quality of life. 


Linda M. Rio, MA, MFT, is a Marriage and Family Therapist (MFT) in private practice in Southern California for over twenty-five years.  Her recent book, The Hormone Factor in Mental Health: Bridging the Mind-body Gap (2014) brings together contributors from around the world in the fields of endocrinology, medical research, psychiatry, nutrition, medical family therapy, and patient advocacy in addition to case studies and actual accounts from patients themselves. She has been an invited speaker at national, state, and local conferences, graduate and post-graduate educational institutions and others including: The American Association for Marriage and Family Therapy (AAMFT), The Collaborative Family Healthcare Association (CFHA), and The California Association of Marriage and Family Therapists (CAMFT). Linda is also one of the editors for, Pituitary Disorders: Diagnosis and Management ,(2013), which focuses on education for primary care physicians, nurses and others.

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Not All Models Are Created Equal: Which Tracks Are You On?

Posted By Matthew P. Martin, Thursday, November 6, 2014
Integrated primary care is growing in attention and presence. Recently, the Institute for Healthcare Improvement predicted that “in the not-too-distant future, “non-integrated” primary care practices … will become rare or even extinct”. Even more recently, the American Psychological Association devoted an entire special issue to integrating psychology into primary care. Working in the field of collaborative care is like riding a train: it has taken time to build momentum but once it reaches a top speed the train can become a juggernaut. Although the view ahead of us is exhilarating and breathtaking, it is helpful to notice what kind of tracks we are using for this train.


During my undergraduate training in psychology I enrolled in a class that required me to purchase a book entitled “What’s Behind the Research?” From this book I learned about the underlying (and sometimes hidden) philosophical assumptions of the behavioral sciences. For this blog post, I will borrow a page or two from that book to take a brief critical look at two models of integrated care. Understanding what railroad tracks we are using to move forward in this exciting field is important. This work involves helping human beings who are suffering. The way we view human suffering influences what kind of assessment and treatment we select and how we do collaborative care.

Care Management Model

One of the more prolific examples of this approach to integrated care is the IMPACT model, developed by psychiatrists from the University of Washington. IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) is an evidence-based collaborative care model that has an incredible amount of supporting literature. IMPACT is a stepped-care approach that includes a care manager (usually a nurse) and a supervising psychiatrist who collaborate with a primary care doctor to treat one or two conditions (usually depression).  Treatment typically includes psychoeducation (brochure, video), antidepressants, brief counseling and/or coaching, treatment monitoring, relapse prevention, and referral to specialty mental health as needed. This is class care management for chronic conditions. To learn more, click here.

Are depression measures and treatments adequate enough to address the suffering of primary care patients? The track record of the IMPACT model is extensive. According to the data, this model leads to a 50% reduction in depression symptoms at 12 months, works in various settings (e.g., inner-city, Veteran’s Affairs, HMO, fee-for-service) and with a variety of populations (e.g., older adults, adolescents, minority populations, co-morbid patients). Moreover, the average cost of the program per patient is usually less than $600! The strengths of this care management approach are obvious: amazing cost-effectiveness, effective symptom reduction, potential for implementing the model on large scales, and a perfect fit for experimental research. Despite the impressive résumé, there are several limitations to this approach that are a direct result of the philosophical underpinnings of the model. 


Care management approaches like IMPACT are a product of the disease model which assumes that disease is an abnormal, organic condition with symptoms that require medicine. Successful treatment includes symptom reduction or elimination. Providers using IMPACT track depression symptoms using a screening tool (usually the PHQ-9) and use treatment protocol to reduce those symptoms. If PHQ-9 scores go down, then treatment was a success. From this vantage point, depression is a discrete disease state that is qualitatively different from other mental illnesses like anxiety. Unfortunately, the biological etiology and pathway of most mental health disorders is largely unclear and rates of co-morbid mental illnesses (e.g., depression and anxiety together) are very high. This raises the question: are depression measures and treatments adequate enough to address the suffering of primary care patients?

On the upside, the disease model and experimental research approach is a match made in heaven. Clinical trials that use an intervention carefully designed to result in symptom reduction will probably produce outcomes of symptom reduction. That’s what they are supposed to do! But does symptom reduction equate to patient happiness or improved quality of life? Can a patient have a low PHQ-9 score and still be dissatisfied with her life? Treatment success then is evaluated using measures chosen by the researchers and not the patient. Isn’t this a little presumptuous?

Another drawback to the disease model and chronic care model overall is the narrow scope of treatment. Care management models are very good at targeting specific mental health conditions like depression. In fact, many care managers are referred to as depression care specialists. But what does a physician do when a patient experiences anxiety? Does the care team create another treatment algorithm for that new condition? Do you hire an “anxiety care specialist”? What if the problem is relationship-based or a result of community and environmental factors? In sum, the care management model is an approach rooted in the disease model that is great for experimental research and large-scale implementation but maybe not so great for comprehensive patient care.

Consultant Model                            

Another approach to integrated primary care is the consultant model which includes generalists (behavioral health consultants or BHCs who are licensed mental health providers) who provide treatment for a wide variety of concerns. BHC appointments are usually 15-30 minutes long and utilize brief interventions to reduce functional impairment. Like care managers, BHCs share an office with primary care physicians and work within the same clinic system. BHCs may see 10-15 patients a day with follow up appointments limited to 4 visits. The evidence base for the consultant model is not nearly as rigorous as the care management model. The major strength of this approach includes the wide scope of treating various conditions (e.g., depression, anxiety, insomnia, chronic pain, substance abuse, smoking cessation, anger).

Limitations include experimental research challenges, costs, and training. Since BHCs treat a wide array of problems and focus more on functional improvement than symptom reduction, it is very difficult to design randomized clinical trials for this model. The consultant model will never reach the same number of successful clinical trials as the care management model. It’s impossible because experimental research (which is reductionistic and mechanistic like the disease model) does not adequately capture what BHCs do.

I personally like the simplistic beauty of the care management model. You can train a large number of providers to treat a large number of patients using limited resources. This alone is a great improvement over the current system. I also like the breadth of the consultant model. You can treat mental illness as well as behavioral health problems (e.g., insomnia, substance use, poor concentration). Each integrated care approach has strengths and limitations but which one is the best for patients? I recommend using the pragmatic truth criterion to answer this question. According to this criterion, the “right” or “true” way is the one that facilitates a desired consequence. In other words, if a primary care clinic needs an integrated care model that can measure precise outcomes and treat a specific population of patients without increasing costs, then that clinic should use the care management model. If a clinic needs a model that can address a wide array of problems, then use the consultant model. 

What if you could combine both models? 


But what if there was a way to combine both to create a hybrid model that makes research and training a breeze and also meets the needs of a wide variety of patients? Let me know when you find it! In the meantime, let’s be mindful of the tracks carrying this train we call “collaborative care”. As the Cheshire cat told Alice, if you don’t care where you’re headed then it doesn’t matter which way you go. 

Matt Martin, PhD, LMFT, is Blog Editor for the Collaborative Family Healthcare Association. When he is not blogging or editing he teaches behavioral science to family medicine residents at the Duke/SR-AHEC residency program. Interested in writing for the blogs? Email Matt at

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Conference Wrap Up: What Happens in DC Doesn’t Have to Stay in DC

Posted By Matthew P. Martin, Friday, October 24, 2014

Sitting at my desk, surrounded by familiar objects in my office, I cannot believe that I was in DC last week for the 2014 CFHA Conference. It feels like I woke up from a dream Tuesday morning and found myself back in Kansas. But the conference materials and the poorly written notes in front of me attest to two things: yes, I was in DC and, yes, it was a great conference.



I drove to the conference on a Wednesday through heavy rain and wind and then left on a Monday with sunshine and a calm breeze. The symbolism is not lost on me. I came to the conference with wishes and concerns and left with a sense that we are headed in the right direction as an organization. How do we keep that optimism and energy going? How do we start to implement all those ideas that distilled upon us in DC like dew? 



Well, let us first reflect. Here are some cool things that happened last week:

- CFHA leaders and advocates met with important people on Capitol Hill for a historic summit meeting to discuss the CFHA policy agenda

- CFHA celebrated its 20th anniversary by holding conference in the very same hotel as the first conference

- Parinda Khatri stepped down as CFHA president after a very successful year and passed the torch onto Rusty Kallenberg

- Four terrific plenary speeches were given:

Richard Frank, PhD spoke on the robust evidence behind integrated behavioral health care and the incredible need for delivery reform

William Beardslee, MD argued that family-centered care is key for mental health promotion and prevention but that we need more proper training and measurement

Marci Nielsen, PhD, MPH told us that we have too many people defending the status quo and that we must convince them with data and stories to make healthcare more patient-centered

Russell Glasgow, PhD and Deborah Cohen, PhD argued that program evaluation is vital for determining the reach, effectiveness, and implementation of an intervention

Our social media team interviewed a few die-hard CFHA conference attendees and asked them why they come to this conference. Here is the video:


Now that we are back in the swing of things, you may be wondering how to effectively implement all the great ideas you picked up in DC. Here are five ideas for doing just that:

1.      Dear Diary

Reflection is a great skill for developing self-awareness and for activating your parasympathetic nervous system. Make time to write down and organize your thoughts and impressions from the conference. Write a list of short- and long-term goals. Decide what changes are possible and meaningful for your organization.

2.      Thank You and Good Night

You probably met some great people at the conference. If you have contact information, reach out to that person to thank them for a conversation or presentation given. Talk about the ideas you got from the conference and what you plan to do. Networking is great for creating collaboration and energy.

3.      Blogs and Videos

Blog posts were written for each plenary speech and video recordings of the speeches should soon be made available. Make good use of these to remind yourself what you learned.

4.      Portland, Here I Come

Did you think of a great presentation idea for next year’s conference? Start now by fleshing out your idea and bouncing it off of other people. The submission deadline will be here before you know it.

5.      Through the Haze

Forgot what sessions you attended? Download the “Guidebook” app to review all the conference presentations including the names and affiliations of the presenters. Did you miss out on a particular presentation? Contact the presenters and ask them if they would be willing to send slides and handouts to you. 


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Live Blogging: Dr. Russel Glasgow and Dr. Deborah Cohen Plenary Speech

Posted By Administration, Sunday, October 19, 2014

This is the final in a series of live blogs posts for the 2014 CFHA Conference in Washington DC. Big thanks to all the writers!

Implementation, Evaluation, and Getting to the Triple Aim by Russel Glasgow, PhD, Deborah Cohen, PhD

October 18th 8-10 AM

 Colleen Fogarty and Stephanie Hern: Saturday blogging is more fun than cartoons any day 



Parinda announces those CFHA board members rotating off the board and encourages all members to participate in the election. She then passes the CFHA president baton off to Rusty Kallenberg, the new president. Rusty begins his presidential remarks noting the parallels between his career development and the organizational development of CFHA. When he was at George Washington, he often walked across the clinic to ask his behavioral health colleagues to help with patients. When he relocated to UCSD, he first met Todd Edwards and JoEllen Patterson, with whom he began to do collaborative care within the Family Medicine Department.

Rusty quotes Frank DeGruy, “Primary care fails without collaborative care.” CFHA is now at the developmental place of beginning “adult” activities. Rusty calls on us to grow the science and sustainability of collaborative care. “It’s a never ending job improving collaborative care.” “As a primary care physician who has taken 20 years to figure this out, we need to no have new physicians wait 20 years to figure this out. We need to teach them how to do this TODAY.”

Jennifer Hodgson introduces our plenary speakers, Drs. Russel Glasgow and Deborah Cohen.


Colleen Fogarty (CF): Drs. Glasgow and Cohen take separate podiums; noting that given the nature of CFHA, they wanted to integrate their presentations together.

How is implementation science relevant to primary care? Dr. Glasgow explains: Implementation science is designed to address the pragmatic challenges; much research isn’t really relevant to real world practice. Conducted under such controlled circumstances, it’s hard to generalize the findings to real world situations.

Russell quotes a valued collaborator, the ‘public health Larry Green’--“If we want more evidence based practice, we need more practice based evidence” (Larry W. Green, UCSF) He shows a schematic model of a contextual systems approach to implementation science, and cites several different models for implementation science. Notwithstanding critics’ concerns that implementation science contains “More frameworks and models than well-done empiric studies!” Dr. Glasgow notes that frameworks can be helpful in identifying what steps are required for success and can inform both planning and results.

Glasgow: Much of research isn't relevant to real world practice The RE-AIM model consists of 5 domains by which to consider an intervention:
- Reach
- Effectiveness
- Adoption
- Implementation
 - Maintenance



Stephanie Hern (SH): The goal is to try to convince implementation and evaluation science as key to getting to the triple aim. Implementation science is one of the future directions. Deborah will talk about evaluation and how to word evaluations and both of them will share about population health. We will see video of patient experience of the triple aim being attained within primary care settings.

The pragmatic challenge is that the key issue is that the majority of research is not really relevant to real world practice, it is concocted in ideal conditions, with selective populations, and hard to translate the results to real world care.  

Implementation science is a multi level research practice with a contextual systems approach. Critical elements of the intervention are present, but when we deliver a program it is embedded in many other things. Other important elements include the program delivery staff, the research evaluation team, the fit of the program, and the partnership among all players.

Models are theories and frameworks. They can be helpful to what we need to key on in order to be successful, for planning and understanding the results.  The RE-AIM model helps plan, evaluate and report studies. 


CF: Deborah Cohen reports on a demonstration project funded by the Colorado Health Foundation, Advancing Care Together (ACT). This study enrolled 11 practices, 9 primary care and 2 community health centers, who were experimenting with changing models of behavioral health in practice. As a demonstration project, these were not massively funded, but rather, received “a paltry amount of money to do something that can be sustained.” She asserts that “Little steps are monumental in a program’s ongoing development.”

SH: They knew costs would be lowered based on evidence from other programs. So these things were already proven for co-morbid conditions. With ACT, they wanted to know how to do it. How does published research inform how you work on the ground? They wanted to focus on implementation; but once its implemented, how are they doing?

CF: The team used the RE-AIM framework, recognizing that implementation of a new innovation occurs through rapid, short cycles of improvement. The team collected lots of data over 3 years, including using online diaries, telephone calls, and clinic visits where the team of 2-4 researchers looked at all aspects of a practice, including actual visits. 

SHSite visits were extensive and included all facets of operations of patients in and patients out.  They evaluated the reach, percent of target screened, target positive, and received services. Clinically relevant measure for the teams not only just an outcome. They would be able to take a look deeper at their numbers. What do we do with the data collected? Showed important steps in the change process. They reviewed every quarter with the data from each clinic. Utilized the data for learning moments and teachable moments.


CFDeb hands the microphone over to Russell with a “research fist bump.” Russell talks about the differences between individual level changes and system level changes, noting that the “Reach” of an intervention encompasses the participation rate among eligible individuals and the representativeness of those participants. The “adoption” of the intervention reflects the system level involvement including the participation rates among invited settings and staff and the representativeness of them. 

Russell points out that denominators are crucial—reach and adoption are often confused; they ARE similar principles, but operate at different levels. If you don’t know the EXACT denominator, it’s okay to estimate!

SH: Deborah talks more about the ACT program. It included brief counseling in PC, referral to traditional long term therapy, warm hand offs, and joint PC and CH counseling joint visits. They looked at whether screening was done. Some clinics had 80-90% screening while others did discretionary screening. Why does this happen? It depends on how much you want to know about the patient population and what capacity you have to meet those needs. Not screening makes it impossible to fully know the needs of your pt population. Knowing the needs of your pop is a stimulator for practice. Not screening is a little like sticking you head in the sand. 


CFRussell takes the microphone and switches to talking about the patient experience. Effectiveness (individual level) represents the effect on primary outcome and the impact on quality of life. Maintainance represents the long term effects of the intervention at the level of the setting, e.g. the clinic or health system. Evaluators look at the sustained delivery and modification of the intervention.

SH:  Rusell talks about the lessons learned on those two dimensions (sustained delivery and intervention modification). Back to the systems perspective: there are always consequences, some positive and some negative unintended consequences. Some programs with greatest effect have the lowest reach. And vise versa. Second level maintenance is seldom sustained but almost never is a program continued the same way. 

CF: They show a powerful video of a patient health story, given by Patrick, who gave permission to share the video. Patrick talks about the impact of sustaining an injury that left him partially paralyzed and the family disruption, isolation, and ensuing alcohol abuse. He credits his physician with helping him find the motivation and resources for change, and the success of a behavioral health intervention when he reached a plateau in his change process.

SH: Patrick - Where do I find the courage to go further? My doctor could have said your great. But he said, okay if you want the courage I believe it is in your behavior. Coaching from his doctor opened the issues of where Patrick had plateaued and felt that could go up.

CFIn closing, Dr. Glasgow quotes a colleague saying, “All models are wrong” and noting the value of the RE-AIM model to inform our evaluation of integration innovations.

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Live Blogging: Dr. Marci Nielsen Plenary Session

Posted By Administration, Saturday, October 18, 2014

This is the fourth in a series of live blog posts for the 2014 CFHA Conference in Washington DC. Check back for one more!

Transforming Primary Care Practices in Pursuit of the Triple Aim: How Great Leadership Can Make or Break the Deal by Marci Nielsen, PhD, MPH

October 17th 12-1:30 PM

Jennifer Hodgson and Barry Jacobs: This isn't their first rodeo 





Barry Jacobs (BJ): Sprightly, buoyant Dr. Marci Nielsen, CEO of the Patient-Centered Primary Care Collaborative, opened her talk by stating that the American public doesn’t know the term “Patient Centered Medical Home” nor “Triple Aim”. It is our responsibility, she said, to help people understand these ideas and to bring their voices into the national discussion. It all comes down to influencing people who are voters and who are concerned that healthcare costs too much. We have to make the case that healthcare transformation is good for them.

Jennifer Hodgson (JH): Dr. Nielsen opening up her plenary to talk about the importance of leadership in enacting the Triple Aim. She advocates for Health System Transformation using the Triple Aim as the roadmap. She said our job is to translate what we do to the public so they can be brought in as real stakeholders. Healthcare Transformation is about “people.” She stated that the Affordable Care Act has been a great platform for payment and delivery reform but we have consumers that have no idea what their role is in all of this. Our job is to make sure that we are doing this as a part of our work.


BJ: She commended New Yorker writer Atul Gawande, MD for his skill conveying these complex healthcare concepts and through stories. She cited a Gawande speech that stated we train doctors to be “cowboys” and that we ought instead to be training healthcare professionals to be “pit crews,” valuing humility, discipline and teamwork.

JH: Dr. Nielsen pointed out that Atul Gawanda, MD, delivers this to the public via his incredible stories. She stated that we train our physicians to be “cowboys” and independent. She said Dr. Gawanda thinks we should train physicians to be members of pit crews instead. However, this requires changes in our values where we become more humble and allow the leaders to be those that can address the patient’s need at that time.


BJ: She said there are yet gaps in evidence about whether PCMHs work. She also said we need primary care in addition to super-utilizer care, as well as partnering with everyone else in the healthcare system and community. The US is one of the few countries that seems to believe that health and healthcare are the same thing. A lot of this comes down to politics. Many politicians think that the free market can fix all of our problems; many people in government believe that it is all up to government programs. She says that it needs to be all stakeholders pulling together. We have too many people defending the status quo. We have to convince them with data, stories and changing our values to make healthcare more patient-centered.

JHBelieves that we need both super utilizer and Patient Centered Medical Home data. She reminded us that primary care is only 5% of our expenditures. PCMHs need to be partners though with everyone in the healthcare system (e.g., community centers, schools, employers, faith-based organizations, and public health).


BJDr. Nielsen pointed out that employers are frustrated not just with personal health costs but also the impacts of behavioral health and other problems on worker productivity. But a recent Health Affairs article stated that only 14% of ACOs currently have perfectly integrated behavioral health. 43% have some behavioral health integration. She says that that’s our opportunity—to help those ACOs integrate more fully and benefit in terms of return on investment.

JHDr. Nielsen shared that there are more healthcare expenditures per person requires industry and government solutions. If half of all healthcare expenditure dollars in the US are linked to private and the other half gov’t, we need alignment of both camps to develop solutions. Noted we have to change the way we fund healthcare….we are fragmented and siloed….overused and misused. It is very frightening for the “haves” to have the “have nots” be a part of the solution. We need to convince them (the “haves”) that there is room for everyone at the table. The key is to focus on “the patient.”

Employers are focusing on productivity (absenteeism and presenteeism) …we need to focus on patients’ quality of life.  The top 5 conditions employers spend their money on are related to behavior health issues. Stated 14% of ACOs have integrated behavioral health but 43% total have started. 


BJShe argued that primary care is still incredibly undervalued. And that primary care must include behavioral health. Reported outcomes for policy-makers have to include costs. Presentations to patients and families have to focus on improved quality.

We are moving, she said, from a volume-based reimbursement to a value-based reimbursement system. We need to push this with policy-makers with data and stories. PCMHs and ACOS have to join forces. We have to partner with people we’ve never partnered with before. Public health and behavioral health have seats at the table now that they never had before. 

JHBarbara Starfield’s research tells us primary care is effective but Dr. Nielsen believes primary care is still undervalued as evidenced by only 4-5% of healthcare expenses being in primary care services. Job of Patient-Centered Primary Care Collaborative (PCPCC; is to share evidence in a way that is useful. They have a website that maps the programs and evidence in each state.  This is helpful when talking to policy makers. 

The number of PCMHs has quadrupled. To sustain this model we need to change from a fee for service to a value-based reimbursement system. Need to partner with healthcare specialists, pull in care coordinators, and public health specialists. We have to know when to “raise hell” and “hold our fire” to be able to work together effectively and align our interests vs being diametrically opposed. 


BHLowering per capita costs requires hot-spotting. But we can’t stop there. We need prevent people from falling in the river in the first place. We have to be convenient and compassionate. We also have to work on the population health level through data sharing and improved care coordination. 

JHWe have data on how to lower healthcare costs…with first initial savings done with hot spotting but DON’T STOP THERE! We also need to be preventing people from getting to the point of high utilization. This is all relational! We have to also be convenient – group visits for example! 

We need EHRs/technology that unifies rather than divides care! Period!


BHThere are PCPCC slides on behavioral health in primary care that are available for download.

JHThree types of models: Consultative, co-located, and collaborative (embedded) ….this requires partners between all types of medical providers and behavioral health providers… with health coaches/care managers being the glue. 

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

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.