When Bob Dylan wrote this iconic song, many felt that it captured
the spirit of social and political upheaval of the 1960s, much in the same way
that we view mental health as “a-changin'.” And these changes require
mental/behavioral health providers to change the manner in which they deliver
Reports over the past
decade have brought attention to the current mental health crisis:
In addition, over the
past few years far too many catastrophic events have brought attention to this
mental health crisis, resulting in a public outcry, demanding that changes are
made to prevent future tragedies.
But change isn't easy.
The relatively brief
history of community mental health services has been a challenging one. Just a
few months ago, as we celebrated the 50th anniversary of President John F. Kennedy's signing the
Community Mental Health Bill into law, the
conversations quickly progressed to the subject that is on the minds of
virtually all behavioral health providers—and an unusually large number of the
general public and policy makers, given the historical lackluster interest in
the topic—mental health is in dire need of change.
The economic downturn in
the US in 2008 resulted in massive budget cuts in all but a few states.
The March 2011 NAMI report, State Mental Health Cuts: A National Crisis, demonstrated the cumulative cut to mental health services
in the U.S. during that time was nearly $1.6 billion. Community mental health
services plummeted from being barely adequate to the critical point in many
states. Safety-net providers were forced to close programs due to the slashed
budgets. Many of those affected ended up on the streets or in jail.
The recent announcement
on the anniversary of the Sandy Hook tragedy, of
the planned infusion of dollars into help repair our broken mental health
system, is encouraging. However, the entire mental health system is in dire
need of an overhaul. One that looks at the broader healthcare picture and
strategically plans for mental health and substance use disorder treatment to
be included. A person-centered, whole health approach to treatment is necessary
for improving the patient experience of care; improving the health
of populations; and reducing the per capita cost of health
care: the Triple Aim.
Dr. Dale Klatzker knows that,
although it isn't easy, change is vital for community behavioral health
It’s exciting to be able to offer a look at integrated care from the perspective of a provider, particularly a provider who has demonstrated leadership excellence in integrating behavioral health and primary care services. Dr. Klatzker currently serves as the Chief Executive Officer of The Providence Center in Providence, Rhode Island. He has been a leader in behavioral healthcare for more than 35 years. Since becoming president/CEO of The Providence Center in 2004, Dr. Klatzker, a visionary, has transformeWe need to be proud of what we do, but also to expand it and extend itd the system of care, quality of service delivery, and social policy decision making at The Providence Center and the state of Rhode Island. Click here for Dr. Dale Klatzker's bio.
a good thing. Most CMHCs haven’t changed a lot. They haven’t prepared
themselves to change a lot and have marginalized themselves and the people that
they serve by not being more a part of the mainstream. We have sets of skills
that are integral to wellness and to health across a wide spectrum. We need to
be proud of what we do, but also to expand it and extend it because this is the
perfect time for this. We have a lot of things to offer that others are trying
don’t stay static. You have to look though the windshield but also through the
rear-view mirror. You have to know where you are but you also have to know
where you’re going.
executive director/CEO of a behavioral health organization, you have the
obligation to push yourself, and that will push your organization, to do what
is necessary so that your mission is reinforced but also to serve the needs of
the community. It’s hard to do that if you’re doing the same thing you did 20
years ago. We do our consumers a disservice if we do that.
We need to be proud of what we do, but also to expand it and extend it
approach to care
Klatzker: What we’ve embraced here
– what’s part of the DNA of the organization at The Providence Center –
we believe in a person-centered approach to care. No two people are
exactly the same. The people that we work for deserve as much access to a wide
array of both health and social supports as anyone. That’s how you have to
guide yourself. When you’re thinking of those things, primary care integration,
working much more toward the mainstream of traditional healthcare is imperative
we’ve found is, if you can build those relationships and find the right
connections, then others will embrace you and value you for what you bring to
the table. In fact, we bring a lot. Partnership is always the first choice, the
We don’t chase dollars, we don’t create programs because it’s the idea du jour from some funder somewhere, we consciously look on our mission as our touchstone and build upon that to provide as much choice to the people we serve. We can be very person-centered because there aren’t many gaps in what we’re providing. (They provide a wider array of services than the average CMHC) We’ve consciously built out a wide array because we think it’s the right thing to do. Rather than to take a “no,” if we can’t partner, we build.
Example of a successful integrated care partnership Dr.
Klatzker: The Providence Center is
closely connected to one the largest federally qualified health center in the
state of Rhode Island, the Providence Community Health Center. We have
become the largest community mental health center. Neither had a desire to
replicate the services that the other provided. Over the years we’ve built this
into a “no wrong door” integrated collaborative effort so that in the mental
health center, the FQHC runs a full-service practice with 1100-1200 patients.
In the FQHC, we are integrated in their physician practices building and we
also have a separate section of their building where we provide longer term
care and some other types of specialty care. We’ve integrated our records with
each other. We meet frequently to process and to try to figure out how to make
our care efficient and effective. We are working closely with them now on
adopting our health home model to integrate a modified health home into the
Yes, the times they are a-changin'. And so are healthcare providers. (At least the forward-thinking providers like The Providence Center.) They are heeding the findings from the numerous expert reports and research. They are thinking outside the box, adopting a person-centered approach that enables better outcomes for the many who place their trust in them—trusting them to take care of their whole-health needs.
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
Growing up professionally in the field of integrated care has certainly been one heck of a ride over the last eight years. As a student and now as a professional, I have had the privilege of helping to design, implement, and refine collaborative/integrated care programs in a wide variety of primary and specialty settings. However, being a student for most of that experience, my focus was oriented primarily on outcomes (clinical hours for licensure, fulfilling the expectations of my supervisors, completing my thesis/dissertation, etc.), which left very little time and energy to think about the process of how those outcomes were achieved.
After graduating with my PhD and landing my first “grown up” job as the director of behavioral science for a family medicine residency program, however, that very myopic focus was forced to expand. Not only was I tasked with teaching behavioral science but also with building an integrated care curriculum and complementary clinical model for our organization’s family medicine center. So, somewhere between my immense excitement with such a wonderful opportunity and the mind numbing fear of…well, blowing such a wonderful opportunity, I resolved to put some intelligible structure to my process. I spoke with colleagues and faculty alike asking them for their insights, and yet I was still lost. However, it was only after a chance conversation I had with my father (the car salesman) that I finally realized what I had been doing for so long without knowing it, and what any behavioral health provider should not only know, but more importantly, embody when building an integrated model.
My father has been in the car business for over 30 years, and for the last 15 years his “forte” has been the restoration of failing dealerships. To think of it in terms of reality shows, he’s been a “Chef Ramsey” of sorts for dealerships struggling financially. By all accounts he excels at what he does, and not only do these dealerships recover but often end up stronger than when they were performing at their best. So, I made the remark that he must be a “master salesman.” After all, he has devoted half of his professional life to selling entire groups of people on the idea of change. I figured he would take this as a compliment, but his reply was more along the lines of “Son, you really have no idea what I do, do you?” That was when my father told me what his job really entails.
There are two types of salesmen in the world
He said that there are two types of salesmen in the world: the first, and I am sure we have all had the unpleasant experience of meeting this type, converge on customers when they walk into a dealership like a second year grad student on a Starbucks venti Caramel Macchiato. They seem to already think they know what the customer wants and knows more about those wants than the customer themselves…“Oh, you don’t want that one, you want this over here…No, no, no, that might seem like an added expense, but you really SHOULD get the extended warranty…” No matter what the customer thinks, no matter what their reasoning, if it deviates from that of the salesman, the goal becomes “selling” the customer on the salesman’s idea of what REALLY is best.
Sound familiar and, more importantly, sound annoying?
The second type of salesman, he said, sits back and watches customers when they come into the dealership. They pay attention to everything the customer looks at, they look for patterns in what models they go to first, what aspects of the cars they look at longer than others, and only after they have watched them for an extended period of time do they approach. “I noticed you spent quite a bit of time looking at that model, is there anything in particular about it you are interested in?”
Notice the difference?
These types of sales people spend the vast majority of their time asking questions, being interested, and letting the wants/needs/desires of the customer guide what they eventually show them. This, my father said, is the key to what he does and why he hates the idea of selling anyone on anything.
In the end, my dad said that great salesmen don’t actually sell anything; they GIVE the customer what they ask for. Instead of walking into a dealership and telling employees what they NEED or SHOULD do differently, he watches, waits, and then asks what they WANT to be different. Only after he feels like he has understood those wants does he help formulate a plan of change, a plan that incorporates those same wants as the main outcomes. So, what my father has devoted the last 15 years of his professional existence to hasn’t been selling outcomes but giving organizations a process for changing their inter-organizational relationships.
Great salesmen don’t actually sell anything; they GIVE the customer what they ask for
Now, what does any of this have to do with integrated/collaborative care? The short answer….everything….
More than once, I have seen well-intentioned behavioral health providers try and “sell” a healthcare system on their brand of collaboration, integration, or the like. We all have done it at some point, and we might even do our sales-dance very well most of the time. We proselytize about research on the effectiveness of collaboration and integration in treating behavioral health and medical issues. We point to increased patient and provider satisfaction, and we even throw out cost effectiveness as another benefit. Ultimately, we tout integration as a panacea for “everything that ails ya,” but how often do we ever stop to ask what that “ailment” really is before offering our brand of cure?
To be honest, I have no idea how an integrated model should or needs to look at a site, but I do know the process that needs to happen in order for integration to be useful- and it is a process exclusively about building, supporting, and maintaining relationships. Now I know that is not very sexy (yes, I just used that term), I know that it does not carry the same weight as some of the other buzz words we have come to know and love when selling integrated care- a rather overlooked aspect of our IC “lexicon.” However, the quality of relationships between members is at the very foundation and heart of any successful team. We know this implicitly- even our seminal works about integration are littered with terms like understanding and appreciation1, which are inherently systemic and more appropriately, relational in nature.
Yet even with this relational knowledge we continue to “sell” integration as a model- a shiny new car that will make you thinner, have a fuller and richer head of hair, and will make you down-right more likable as a person. Up to this point our sales technique has been one of telling about features; telling about research, telling about effectiveness, telling about cost savings. In all of my time involved in this field I have yet to hear us asking- WHAT would YOU like this model to look like, HOW do YOU think this way of doing things might be useful to you, WHAT do YOU want to achieve by practicing this way. You see, at the end of the day we have been working so hard to create models that we have forgotten that it is not about building something successful- it is about building something useful; and utility is never about selling people on what we think they need, it is about giving them what they ask for.
So, at the end of the day what kind of salesperson for integrated care are you?
1Doherty, W. J., McDaniel, S. H., Baird, M. A. (1996). Five levels of primary care/behavioral health collaboration. Behavioral Healthcare Tomorrow, 5(5), 25-28.
Dan Marlowe, PhD, LMFT, is the Director of Behavioral Health at Campbell University School of Medicine. He holds a doctoral degree in Medical Family Therapy and master's degree in Marriage and Family Therapy from East Carolina University in Greenville, NC. Dr. Marlowe has primarily been embedded in medical settings over the course of his professional career, working alongside physicians to help manage the mental and behavioral health needs of their patients. Dr. Marlowe has published both nationally and internationally on interprofessional collaborative care, as well as presented at regional, state and national levels on collaborative care program development, teaching integration in graduate medical and behavioral health education, and the use of family therapy as a practice change model in healthcare settings.
Posted By Theodora Ooms, Jana Staton,
Tuesday, April 29, 2014
This blog post was originally posted on the Families & Health blog. Because of it's importance, we are posting it on the CFHA blog as well.
It is seldom that family-centered health care professionals get an opportunity to directly influence national health care policy. Alerted by Theodora Ooms and Jana Staton, several members of CFHA recently saw an opening when Senators Ron Wyden (D-OR) and Johnny Isakson (R-GA) introduced the Better Care, Lower Cost Act on Jan 15, 2014. (A companion bill, HR 3890 was introduced in the House.) This bi-partisan, bi-cameral legislation is aimed at providing better, more coordinated and integrated care at lower cost to the millions of Medicare beneficiaries with multiple chronic conditions. (In 2010, 68% of Medicare enrollees suffered from two or more chronic conditions and accounted for 93% of Medicare spending annually.) The Act amends the Medicare Program to set up a new model of financing and delivering services dubbed the Better Care Program, to create more effective networks of integrated, multidisciplinary health teams. These teams are aimed at keeping chronically ill patients as healthy as possible in their own homes and communities. However, the Act as introduced does not mention spouse or family caregivers, or consider them as an integral part of the health care team, serving as the “backbone or glue” of the long term/chronic illness care system.
Seeing this opportunity to educate national health policy leaders about this critical component of health care, Frank de Gruy, Susan McDaniels, Barry Jacobs, John Rolland and Bill Doherty enthusiastically joined Ooms, Staton and Mary Myrick, of the National Healthy Marriage Resource Center (NHMRC) to sign a three-page letter of comments to the Senators, pointing out the bill’s failure to acknowledge the critical role of spousal and family caregivers in the prevention, care and treatment of the chronically ill. The letter included a separate list of recommended changes in the legislative text to promote collaboration with spousal and family caregivers, identify caregivers in medical records, and conduct caregiver assessments along with the patient's in the Welcome to Medicare and annual Wellness visit. These suggestions also include setting up a national working group to develop curricula for training health care professionals in how to collaborate with family members.
For many Medicare patients the spouse is the most likely day-to-day caregiver
As their letter points out, family caregivers are spouses, partners, adult children, siblings, friends and neighbors who provide many kinds of support, assistance and, increasingly, help with medical procedures so as to enable millions of persons to remain living in their homes and communities. The term "family caregiver" however obscures the unique legal, emotional and social characteristics of caregiving between spouses. Spousal presence and influence on chronic illness prevention, care and treatment is much more common than generally acknowledged. In fact as the 2010 Census shows, the majority of those 65 to 75 years are still living with a married partner in the home. And if cohabiting partners (heterosexual and same sex) were included the numbers would be larger. (Even among those older than 75, 38% of women and 73% of men still live with a spouse, as Ooms and Staton point out in a 2012 CFHA blog post). For many Medicare patients, therefore, the spouse is the most likely day-to-day caregiver; some competent and willing, others unable or uncooperative, but in either case, a direct influence on patient health.
As Frank deGruy pointed out at the 2008 Wingspread Conference on Making Connections Between Relationship Quality, Marriage and Health, sponsored by the NHMRC, "Illness is individual; health is always social." If we're going to improve health outcomes and lower costs for the Medicare population by preventing or reducing serious chronic illness, better care needs to include collaboration with the patient's most intimate partner or close family member, both for the sake of the patient and for the sake of the well-documented health consequences for family caregivers.
Senator Wyden is the new Chairman of the powerful Senate Finance Committee and he is known for his passionate interest in improving care for the chronically ill and his ability to work across partisan lines. No one expects this bill to be enacted soon and it will go through a lot of changes, but it could be an initial step to significant Medicare reform. In our communications with several leading health policy experts, they agreed that the absence of any mention of family caregivers in the Act is a major drawback, and something that will certainly get attention eventually. And if Medicare opens the door to substantial collaboration with spouses and family as part of health care for chronic illness in seniors, the potential for even greater progress in illness prevention and care with younger patients is enormous. Fortunately, CFHA's 2014 Conference in Washington DC "From Fragmentation to Integration" is coming at a perfect time for members to make their voices heard about the crucial role that intimate partners and families can play in a truly integrated health care system.
The letter to the Hill was initially drafted by Ooms and Staton, co-coordinators of the Wingspread Conference on Marriage, Couple Relationships and Health sponsored by the NHMRC. (De Gruy, McDaniels and Doherty were key presenters at this conference). It is available on line here.
Theodora Ooms, a social worker and family therapist, has worked for thirty years in Washington DC to integrate a family systems perspective into federal and state policy and programs. She was a participant in the founding CFHA Wingspread conference in 1993 and is very happy to be reconnected.
Jana Staton, has her doctorate in counseling psychology, and currently works as a marriage and family therapist and couples educator in Montana. She is the co-author of A Few Months to Live: Different Paths to Life’s End.
Posted By Eboni C. Winford,
Thursday, April 24, 2014
This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!
Over the past 7 months, I have transitioned from being a student trainee to becoming an early career professional at my first “real job.” I work as a Behavioral Health Consultant at Cherokee Health Systems, a comprehensive community health organization that is both a Federally Qualified Health Center and a Community Mental Health Center. In these 7 months, I have encountered challenges related to the development of my professional identity. I figured I couldn’t be the only person to ever have these struggles, so I wanted to address these in this month’s edition of our early career professional blog and specifically focus on four tips that I’ve found helpful as I’ve come to embrace my role as a professional.
1. Introduce yourself the way you want to be addressed—own your role
Throughout my training as a student, I grew accustomed to introducing myself as “Eboni Winford; I’m a practicum student/intern;” however, upon completing school and starting my first “real job,” I had a harder time than I imagined learning to introduce myself as Dr. Winford. You’d think that after working for so many years to earn the title, I’d be screaming it at any and everyone who would listen, but I ultimately found that old habits die slowly. I frequently found myself saying to a patient, “Hi, I’m Eb…I mean, I’m Dr. Winford” only to be confronted with a host of confused faces. I’m sure it had to be interesting to be a patient hearing the so-called doctor coming in and not even knowing her own name.
After several awkward patient interactions, I spoke with a mentor (see below) about how she handled this transition. One piece of information she gave me was, “You have to own your title and who you are now. Whenever you get a chance to introduce yourself, make yourself say Dr.” Another piece of advice she suggested was that I request others to call me by my title. I’ll admit, I felt uncomfortable with this at first. I didn’t want to be “that person” who came across as narcissistic but at the same time, I knew that having others refer to me according to my title would be an important step in solidifying my professional identity. Needless to say, those two pieces of advice have proven effective in helping me to more seamlessly introduce myself without coming across as confused about who I am.
You have to own your title and who you are now
2. Identify a mentor (or two)
I’m not sure I would have had such a smooth transition had I not been linked up with mentors. I’d recommend looking for at least one mentor who is not too far removed from your experience in terms of years (ideally, someone who is 1-2 years ahead of you in his or her own professional development) as well as a more seasoned mentor, someone who has worked in your field greater than 10 years.
I personally have more than two mentors who collectively fall within each of these two categories. Meeting with these individuals has not only helped me to overcome immediate challenges including state licensure procedures but also in helping me see examples of successful professionals and learning from their past successes and failures. There have been countless times when I have gone to one or all of my mentors and asked something along the lines of, “Is it normal to feel x?” or “How long did you have to wait before you received all of your paperwork for x?” On each occasion, I walked away feeling “normal” and/or with specific information regarding next steps to take to address a specific dilemma.
3. Become a mentor
In the same way that having a mentor has been instrumental to my transition, I’ve found that becoming a mentor has been equally effective in my development as a new professional. As professionals, we spend so many years studying and practicing the skills that we’re learning but we often doubt how much we really know. I’ve fallen victim to this “imposter syndrome” where I questioned whether I really knew what I was doing or wondered how long it would take before someone “found me out.”
We often doubt how much we really know
Serving as a mentor to a group of students 1-2 years behind
me in their professional development has helped to cure this imposter syndrome,
if you will. My confidence in my knowledge and my abilities has grown rapidly
as I’ve filled the role for them that my mentors have filled for me. These
students have inquired about a wide variety of topics including specific
recommendations for patient care to the transition from practicum student to
intern. Speaking with them has served two functions: it addresses the student
inquiries, and it also reinforces the quality of the training I’ve received,
which, in turn, reassures me of my right to work in the role in which I work.
4. Find others like you
Network, network, network! I never really believed in the value of networking until I tried it. Since transitioning from student to professional, I’ve been fortunate to connect with fellow early career professionals through CFHA. It has been so reassuring to discuss with them some of these challenges. In the same way that I try to normalize feelings and thoughts with patients and my mentors have normalized feelings for me, speaking with peers further normalizes my own reactions to transitioning and has shown me that I’m not weird. And sometimes knowing you’re not weird is all you need!
I hope these four points are helpful for others who are either in my position or approaching it. If you’ve ever felt this way, you’re not weird. Your identity as a professional, like every other aspect of your identity, takes time to develop. In addition to having patience and experiencing what may, at times, feel like awkward situations, it is important to know that the process of developing your professional identity works best within an environment of support and encouragement. This supportive environment may not always offer itself to you; instead, you may have to be proactive and persistent. If mentors are not readily available, consider utilizing colleagues in CFHA. I’ve learned that CFHA serves as a great resource for soliciting help, support, and guidance via our listservs and through formal and informal networking at conferences. Additionally, if mentorship does not exist at work, perhaps you can reach out to students from your graduate program and assist them in some way toward their transition from student to intern to professional. In sum, developing one’s professional identity is a big first step toward solidifying one’s place within the professional world. It is my hope that these 4 tips provide a framework to help you navigate this new area and to develop a comfort with the new, professional you.
Until next time, Dr. Winford ;-)
Eboni Winford, Ph.D. is a Behavioral Health Consultant and provisionally licensed psychologist at Cherokee Health Systems in Knoxville, TN. In addition to behavioral health consultation, she is involved in research assessing health outcomes associated with substance abuse during pregnancy, particularly neonatal abstinence syndrome. Dr. Winford currently serves as a co-secretary to CFHA’s Primary Care Behavioral Health Special Interest Group as well as a member of the Early Career Professionals Task Force. Her research interests include the relationship between religion, spirituality, and the process of meaning-making in the context of chronic illnesses. Her clinical interests center on primary care behavioral health, integrated care, refugee and minority health care issues, and psychopharmacology. She earned her degree in Clinical Health Psychology from the University of North Carolina at Charlotte.
Posted By Mara Laderman, Kedar Mate,
Thursday, April 10, 2014
Behavioral health integration is becoming the standard of care; in the not-too-distant future, “non-integrated” primary care practices we predict will become rare or even extinct. So, where is the frontier now? Where are innovators in the field focused at this point in time?
Where is the frontier now?
We believe there are currently four areas of primary innovation. The first is deployment of integration into high-risk specialty clinics which often serve as the health homes for patients living with chronic conditions such as heart failure or spinal injuries. In such settings, while the principles of integration are similar to those employed in primary care, care can be more episodic which can challenge consistent behavioral health service delivery. The second area is around scaling up integration to entire communities, regions, and even states. Solving structural challenges of measurement, interoperability of records, and behavioral health resource availability at scale is an important area where innovation is needed. Current efforts in Colorado, Washington, and New York are leading the way to tackling these state-level challenges. Third, significant innovation work will be needed to understand how much integration costs and what financial models and alternative payment methods will allow integration efforts to thrive.
Finally, as we describe in a recent article, while the majority of integration work has
focused on individual clinics, this may overemphasize the clinic environment
itself and not the functions of the primary care practice, which include an
emphasis on providing continuous supportive care beyond the clinic encounter,
navigating community support systems, and engaging family and relationship
support systems. More comprehensive
primary care systems are designed to support patients in the many thousands of
hours patients spend outside of the clinic, living with behavioral illness and
co-morbid medical disease. Much thinking is being done right now about the
so-called “5000+ waking hours”1 that patients live with their chronic conditions outside of their clinic visits
and face-to-face time with medical providers. We strongly believe that this is
where the frontier is in behavioral health integration in primary care.
To guide innovation in this area, we turned to some of the work that is beginning on chronic disease care outside of the clinic visit.2 3 This thinking led us to a conceptual model for full-spectrum integrated care that identified three key components: 1) frequency of the points of interaction, 2) where is the service provided, and 3) who it is provided by. We identify five layers of potential service using these three dimensions. All are needed for a complete care system for patients living with behavioral and physical chronic conditions. In this model, costs are reduced as the service moves closer to patient self-management.
The first layer, Acute Care, applies to patients during a hospitalization. Many hospitalized patients are not evaluated for behavioral health problems as their medical needs supersede other issues. However, the need for intervention remains. There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomes; for example, St. Charles Health System implemented an intervention in which a behavioral health consultant routinely rounds in the NICU to work with parents of premature infants to teach what to expect, how to stimulate neurodevelopment, and how to care for their children. The intervention reduced NICU utilization (measured by earlier discharge) with better outcomes and retention in post-natal care.
There are opportunities for behavioral health interventions to affect both behavioral and physical health outcomes
The second, the Clinic Visit, is the focus of most integration models. Innovations here might include group visits—a concept that has been employed for substance abuse disorders, in ‘centering pregnancy’ models, and for multiple chronic conditions. Integration innovators in this arena might purposely build patient groupings of individuals living with both depression and diabetes, for example, who would meet together to discuss coping and living strategies. Another innovative model, the Ambulatory Intensive Care Unit, pioneered in California by Arnie Milstein and others, might utilize smaller panel sizes of patients with co-morbid mental illness and employ primary care “specialists” to help manage these patients more intensively in the ambulatory setting.
In the third layer, Community Care, innovators might use Community Health Workers (CHWs), a category of interventions that have long been used in resource-poor environments for supervision of therapy for tuberculosis and HIV. These are being applied by novel programs like PACT and Commonwealth Care Alliance in Boston to target high-risk, high-cost patients to help with their management. Behavioral health issues are often the hardest to solve for these programs, but CHWs with training in behavioral health could assist with co-morbid disease. This layer may also include group visits in community based-settings. Finally, in this layer, alternative service providers such as “community paramedics” like those being deployed by MedStar Ambulance system in Fort Worth, Texas might be mobilized to care for patients living with comorbid physical and mental illness to assist in keeping them healthy at home.
The fourth layer, Family Engagement, has been used for some time to help with the management of infectious diseases and chronic conditions. Training family members to also help with the management of co-morbid behavioral illness would provide a near continuous asset to the integration process.
Finally, Self-Management would put the patient at the center of their care. New technologies to track movement (pedometers), sleep (sensors), mood (SMS technology), weight (scales), blood pressure (BP cuffs) in the home and wirelessly transmit them to providers are allowing patients to see their own data and manage their conditions themselves. These solutions may not be for everyone, but they can often passively collect substantial amounts of data and help patients and providers better characterize contexts that affect both their physical and behavioral ailments. Tools like the Big White Wall, a web-based platform to assist patients in finding community and consultative support in the home, can greatly assist patients with self-management.
We have not encountered, to date, anyone in the field looking at this full spectrum of “complete care integration” for behavioral health and primary care. While many organizations are still in the early stages of implementing integration we believe that those innovators on the frontier are and will be thinking seriously about how to address some of these key issues to achieve the Triple Aim of better health, care, and lower per capita costs for patients with comorbid medical and behavioral health needs.
Asch DA, Muller RW & Volpp KG. Automated Hovering in Health Care – Watching Over the 5000 Hours. New England Journal of Medicine. 2012;367:1-3.
Logan AG et al. Mobile Phone-Based Remote Patient Monitoring System for Management of Hypertension in Diabetic Patients. American Journal of Hypertension. 2007;20(9):942-948.
Koehler F et al. Impact of Remote Telemedical Management on Mortality and Hospitalizations in Ambulatory Patients with Chronic Heart Failure. Circulation. 2011;123:1873-1880.
Jaber R, Braksmajer A & Trilling J. Group visits for chronic illness care: Models, benefits, and challenges. Family Practice Management. 2006;13(1):37-40.
Mara Laderman, MSPH, is a Research Associate at the Institute for Healthcare Improvement (IHI). She leads IHI’s work in behavioral health, developing content and programming to improve behavioral health care in the U.S. and globally. In addition, as a member of IHI’s innovation team, she researches, tests, and disseminates innovative content to inform IHI programs and further IHI’s strategic priorities within the Triple Aim for Populations focus area. Prior to IHI she managed a nationally representative psychiatric epidemiologic study investigating the effect of social and environmental factors on the behavioral health outcomes of vulnerable populations. Ms. Laderman received a Master of Public Health from the Harvard School of Public Health and a Bachelor of Arts in Psychology from Smith College.
Kedar Mate, MD is an Internal Medicine physician and an Assistant Professor of Medicine at Weill Cornell Medical College and a Research Fellow at Harvard Medical School’s Division of Global Health Equity. In addition, he serves as the Vice President for Innovation at the Institute for Healthcare Improvement and the Regional Vice-President for the Middle-East and Asia-Pacific. In addition to his clinical expertise in hospital-based medicine, Dr. Mate has developed broad expertise in health systems improvement and implementation sciences. In his leadership role at IHI, Dr. Mate has overseen the developments of innovative new systems designs to implement high quality, low cost health care both in the US and in international settings. He graduated from Brown University with a degree in American History and from Harvard Medical School with his medical degree. He trained in internal medicine at the Brigham and Women's Hospital in Boston and currently resides in Virginia.
medical home) initiatives are familiar to many of us. In fact, some have
probably considered getting those four letters tattooed in large gothic style
on some part of their bodies. Why is there so much support? Because medical homes
promise so much. In theory, the PCMH
is a team-based model of primary care designed to improve quality, efficiency,
and patients’ experiences. Considering the lack of quality
in our current health care system, such a model should be a godsend. Indeed, some of the
recent PCMH studies are promising. For those of you unfamiliar with PCMH, read the Joint
Principles for a nice introduction. For a quick rundown see this video.
What do we learn from this most recent study then? According
Schwenk, PCMH may be “best deployed in a more concentrated approach for
patients with costly conditions and high use” like the chronically ill. And according
to the Patient-Centered
Primary Care Collaborative, the NCQA-recognized pilot practices did not go
far enough in transforming care practice. For example, weekend and evening
hours were rarely offered to patients and there were no financial incentives to
control costs. Marci Nielsen, the PCPCC CEO, even wonders if these pilot
practices had yet transformed to be true medical homes.
Here are some other lessons:
Clinic managers need to know what patients need and want from their primary care service (e.g., expanded clinic hours, walk-in slots). Few if any of the pilot practices in the JAMA study received feedback on their patients' care utilization.
key features of the medical home should be measured (e.g., patient engagement,
behavioral health integration, team-based care). Several of these features were
not measured by the authors.
need longer, larger PCMH studies with better practice comparisons. This recent
study was from 2008 to 2011, only three years. Also, the response rate for the “control”
group was only 24% compared to 91% for the “intervention” group.
PCMH model needs integrated behavioral health care. Recently, one working
group developed principles for integrating behavioral health care into the
PCMH. Whether PCMH evolves into a model for the chronically ill or stays more
general and comprehensive, patients should have access to behavioral health
Is this recent study a nail in the coffin for medical homes
everywhere? I don’t think so. Undoubtedly, it is true that proponents of PCMH have
a tough row to hoe. They must convert all the enthusiasm and activity for medical
homes into a sustainable, evidence-based model. They must also decide if this
model is a “one-size fits all” or a disease- or population-specific model or something else entirely. This
study seems more like a clarion call for a more refined PCMH model that is
supported by bigger, better research.
Personally, I am optimistic. I believe in the progression of
science, that research will help us identify those key PCMH features and
processes that lead to the greatest outcomes. Such research will require more
time, energy, and money to determine which patients benefit the most from a
team-based, care management model.
But I am still left with a few nagging questions. How we
will know if this entire “medical home” approach is the wrong direction? Is
this style of medical care what patients want these days? There are a lot of
urgent care clinics in my town and they seem awfully busy. Moreover, will we
have the primary care workforce that we need to run medical homes? Even if
research shows that medical homes are awesome, will there be anyone to run
them? Although these questions are interesting and somewhat important, maybe
the most important question right now is: does PCMH deliver on its promises?
Matt Martin, PhD, LMFT is a licensed marriage and family therapist and current Director of Applied Psychosocial Medicine at the Duke/Southern Regional AHEC Family Medicine Residency Program in Fayetteville, NC. He is current editor of both CFHA blogs. His research interests include integration of behavioral health services in primary care settings, behavioral science curriculum development, family-centered primary care, and self-awareness development in family medicine residents. Email: firstname.lastname@example.org
Posted By Natasha Gouge,
Thursday, February 27, 2014
This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!
I grew up in a rural community where the only exposure I had to “psychology” was through local churches where it was described as being equivalent to “witch craft”. (I’m not joking.) In college I was exposed to the psychological “witch craft”, and I learned very quickly that I liked it and that I seemed to excel with the material (gasp!). This didn’t exactly gain me any prestige among the local pastors, but my professional atlas had finally begun to narrow in direction.
I was naïve going into the field of psychology as a first generation college student. First, I thought psychologists got training in everything from palm reading to forensic profiling (both of which sounded like fun!). And second, I assumed you were a “psychologist” when you graduated college with your four-year degree and you left graduation on Saturday to enter the workforce on Monday. Needless to say, my professional atlas was missing a few pages.
A few months before completing my undergraduate degree a professor began encouraging me to apply to graduate school and my eyes were opened to another world of possibilities (and to the fact I had spent four years working on a degree that didn’t make me a “psychologist”!) In exploring graduate school options, I had my first exposure to primary care psychology—I believed I had finally found my professional direction. What took place over the next half decade was a combination of quality course work and training, excellent mentorship (shout out to Jodi Polaha!), innovation, and probably some serendipity that resulted in the creation of my dream job in the integrated workforce.
Appreciate it’s not just busy work
I truly believe the graduate training program at East Tennessee State University (ETSU) set many of my successes in motion because of its mission, focus, and commitment to training and preparing students for the integrated workforce. Among the mass of reaction papers, article reviews, and assigned research projects (at times seeming like “busy work”), I was exposed to viewpoints and curriculum through nursing, pharmacy, medicine, social work, anthropology, and public health. I had classes that were incredibly innovative and pragmatic that allowed me to see standardized patients in real time with evaluations based on patient contact, case formulation, chart documentation, and debriefing the referring primary care provider. I had courses that required multiple business pitches about integrated care to a variety of audiences: physicians, office managers, insurance companies, etc. Through this I became energized around the idea of creating a position in an integrated setting close to home, but I found with each business model pitch I completed I was met with the same general response: “integrated care sounds wonderful—now how do we pay for it?”
Integrated care sounds wonderful— now how do we pay for it?
Develop a professional mantra
That question would haunt me in my sleep. I mean, I am passionate about what I do, but I’m also passionate about making enough money to eat, play, do fun things with my husband and our kids, and dare I mention the S-L words? (student loans!) So working as a behavioral health provider (BHP) for free just wasn’t going to cut it, but how do we pay for it?! This question became the driving force for my dissertation research.
Put on your business hat
I believe it is important to explore the indirect ways in which having a BHP onsite can impact clinic revenue. Through studying a pediatric primary care practice that offered a one-day-a-week integrated model, I found that even in the absence of direct billing from the BHP the clinic was able to generate over $1,000 average in extra income on days that a BHP was providing services on site. How was this possible? Mostly through time savings benefits. As the providers handed off behavioral health concerns to the BHP, they were able to see (and bill) for additional acute visits which came in the form of extra walk in appointments and additional double-booking strategies on integrated care days.
This data, along with many other nuanced findings, tied together nicely for the development of a business pitch—a business pitch in which I could finally offer some current, real-life suggestions to answer that reimbursement question that always comes at the end. And even more exciting, a way to answer that question without relying on direct BHP billing and the barriers therein.
Throw it out there
Because of my training experiences through ETSU, I was well connected with some pediatricians who I met at my practicum placement. I sent a text message out inquiring about where they were working and whether their current offices were interested in hearing my business pitch. Guess what? They all were interested! And the first clinic I pitched to offered me a full time position!
I’ve been at my current job now close to 6 months and we continue to rely on time-savings rather than direct billing to offset my salary and benefits. Although my ongoing data collection and program evaluation is still underway, (stay tuned friends!) I can report that recently a provider told our finance manager that my service allowed her to see at least 6 additional acute patents a day. Those visits add up folks! If you haven’t compared the reimbursement rates for what a physician might bill for 6 acute patients versus what a BHP might bill for 6 sessions, I encourage you to do so!
To make a short story long, my blog post is an early career professional’s story about ways to get in the integrated workforce. Surely there is no one right way. After all, my journey began with “witch craft”.
Natasha Gouge, PhD currently works as the full time BHP with Mountain States Medical Group Pediatrics in Kingsport, TN. Dr. Gouge graduated from East Tennessee State University, Department of Psychology, within the Clinical PhD Program and completed her internship through the East Tennessee South West Virginia Psychology Internship Consortium. Dr. Gouge is passionate about integrating behavioral health among primary care settings, prevention of and early intervention for behavioral health problems, and research and consultation regarding the development and sustainability of integrated health care programs. She appreciates a good dose of competition and sarcasm, as well as being outdoors, traveling, participating in sports, and spending time with her husband, son, and step-son.
way to work the other day, I was listening to an interview of an efficiency
expert on NPR. He spoke about his work consulting with companies on how to be
more efficient. Some recommendations were fairly obvious, some were more
obscure, but one was stunningly brilliant and forever changed my life -- put
creamer in the coffee first.
coffee every day. I had always poured my coffee first, then added creamer, then
stirred with a spoon. Granted, I’m not as alert before the coffee, but it had
never occurred to me to put the creamer in first. Look around – most everyone
does it this way. If you put the creamer in the cup first, the magic concoction
is blended as you add the coffee. There is no need for the spoon!
how much greener this is. How much less energy will I use in my lifetime by not
washing a dirty spoon? How much less
polluting detergent will be used? How much less landfill will be created? Not
to mention what’s involved with wiping up that bit of mess on the counter, or
the time it takes to find a spoon, and wash it.
know it’s a simple analogy, but here’s my point – How many simple changes are
there right in front of us that can make our lives easier, more efficient, and
greener? In particular, how many health
care practices are done the traditional way – like using a spoon -- but could
be done more efficiently and greener much of the time? Even more specifically,
and to really push the analogy, what is the right mix, and what is the right way
to mix, the Behavioral Health Consultant (BHC) and the Medical Provider? Who
should see the patient first? Should a triage person see the patient first and
then direct them to the professional that makes the most sense? Should they
come in the room together? Should a BHC always see them last to ensure
understanding and agreement about how to move forward?
this time, most all of us have seen the advantages of shared location. Nothing
beats great access of the "other” health care professional. Sometimes it’s a
quick question; sometimes it’s a curbside consult; sometimes it’s an important
update; and, sometimes it’s an urgent need to see someone now. There is some
debate, and of course practical considerations, to decide between shared
building, shared floor, shared hallway, or even shared office. Joint
appointments are the best, if you can swing it (both financially and
operationally), if even only for a few minutes of shared time.
25 years ago, Michael Glenn, MD1 experimented with a medical provider and
behavioral health consultant seeing all patients together, at least initially.
I think we still don’t have that initial bit right. There are some out there
who have tried "on the fly” triage. How is that working? There are some out
there who have had a BHC stop in to visit with each patient for a "medical”
visit either before or after the face-to-face with the medical provider. There
are some who have experimented with universal availability of behavioral health
consultants. Perhaps some have experimented with the scheduling person asking
about the need for co-consultation during the visit when the appointment is
made. Chime in.
Think outside the cup
purpose here is to stir things up for those who are more separated,
traditional, and in their own silos. I would like to encourage those who have
thought "outside the cup” to speak up. I am particularly interested in the mix,
from point of first contact to checking out. It’s probably even more than that
-- what is the wording in the brochures, signs in the waiting room. Maybe there
is something simple, right in front of us, that we can change that would
simplify our lives, lead to better care, and conserve resources. Let’s mix it
up and see what happens. Like the creamer in the coffee, it’s not just what the
right proportions are, but what is the best way to mix together.
that the everyday coffee drinking behavior of some readers has changed, let’s
think about why it took us so long to figure out how to put wheels on suitcases
(1) Glenn, M.L. (1987). Collaborative heath care: A
family-oriented model. New York: Praeger.
Lorenz, MD is a charter member of CFHA and now works at the University Health
Service at the University of Rochester where he is an Associate Professor in
both the Departments of Family Medicine and Psychiatry.
Posted By Joshua Bradley,
Thursday, January 30, 2014
This is part of an ongoing blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!
Innovation as Critical
Dr. Polaha recently highlighted the importance of innovation in primary care psychology and especially in newly integrated settings, which has been the case with my employer. Stone Mountain Health Services is a federally qualified health center with clinics in Southwest Virginia that has recently expanded the behavioral health program and currently has 6 licensed psychologists, 2 licensed social workers and a post-Master’s social worker, 2 pre-doctoral psychology interns, a psychiatric nurse practitioner, and a social work intern. Many of the primary care clinics have only recently become integrated, which has led to both exciting opportunities and challenges. As a further exciting, yet challenging development, at the site where I work, the medical providers, pharmacist, and myself are all early career professionals. One of the first hurdles that required innovation was finding ways to demonstrate that behavioral health providers can help patients with chronic health conditions. A second challenge has been addressing appointment and treatment adherence.
Increasing Chronic Health Condition Utilization
Although there is nothing innovative about interdisciplinary collaboration in integrated care settings, it soon became clear that there were tremendous opportunities to increase ways for different types of providers to work together in our clinic in new and creative ways. We knew that we had a large number of patients with diabetes so we developed a plan to increase behavioral health and pharmacy involvement in diabetes treatment. In fact, even the idea of "Diabetes Day” was a collaborative effort between myself, Olivia Bhutia, M.D., Natasha Gouge, Ph.D., and Crystal Kilgore, Pharm.D. During the winter of 2012, Dr. Kilgore mentioned the idea of collaborative treatment days, which led me to think about how this could decrease patient time with medical providers while simultaneously increasing quality of treatment. I began to think about how this might look in practice and talked to Dr. Bhutia about the idea.
I handed the project development to Dr. Gouge, who was then a predoctoral psychology intern at our site, and she ran with the idea and developed a comprehensive proposal for what would be called Diabetes Day. In short, Diabetes Day would occur once every two weeks on Wednesdays and would include one total hour of care, where patients would rotate among the medical provider, pharmacist, and behavioral health provider, depending upon provider availability. Each patient would spend 20 minutes with each provider addressing the various aspects of diabetes-related care. This plan would increase the number of patients medical providers could see because of the shared responsibility of patient care and could increase the amount of care each patient received because of the teamwork.
We quickly learned that systematic change is difficult and requires significant flexibility
Well you know what they say about best laid plans. Getting the plan approved by administration was relatively easy. The administration was supportive and encouraged us to move forward. In fact, the Medical Director decided to implement a variation of the idea in her clinic. We discussed the plan with support staff and everything seemed to be in place for a successful and smooth transition. Unfortunately, we quickly learned that systematic change is difficult and requires significant flexibility. Everything from making changes to our scheduling templates to patient communication about how Diabetes Day appointments were different from standard medical appointments became challenges that had to be managed on an ongoing basis. The professional staff could clearly see the benefits of the service and many patients were extremely happy and often surprised that they were receiving such comprehensive care. Still, there were a few patients who complained about only having their diabetes-related care managed because they were used to having multiple medical conditions and prescriptions written at the same medical appointment. In addition, the change seemed most difficult for support staff and their struggles affected the treatment team members.
One largely overlooked problem was that we had underestimated the importance of having an office manager. Our site manager had left just before the implementation of Diabetes Day and the clinic was left without someone to troubleshoot the challenges we faced on an ongoing basis and who had the authority to handle the issues. Another unanticipated development was the fact that once patients had been to a Diabetes Day, they would not necessarily need to return for another Diabetes Day because patients often thought they received the additional information and care they needed to manage their condition in one Diabetes Day visit. Therefore, we began running out of patients and found that biweekly Diabetes Days would not be necessary to meet the needs of our patient population. As a result, we have decided to expand Diabetes Day to include other health conditions that would benefit from the collaborative care approach (e.g., hyperlipidemia, obesity, COPD) and change the frequency to once a month and call them "Wellness Days.”
Behavioral Health and Treatment Adherence
The next opportunity for innovation was addressing the problem of patients who repeatedly no-show. Because we are a federally qualified health center who serves people who are poor, our administration did not think that charging patients for missed appointments was the right thing to do. The administration also did not want to dismiss patients because of excessive no-shows out of fear that patients would have no other source for medical services. As a result, in collaboration with other treatment team members, I developed a "Treatment Investment Plan.” Basically, after a patient missed 3 appointments he or she would only be allowed to attend same day appointments until meeting with a behavioral health provider to talk about treatment adherence and the importance of attending appointments. Based on an examination of data in our electronic record system, it was clear that same day appointments were attended at a much higher rate than previously scheduled ones. From a financial perspective, decreasing no-show appointments by just 2 a day could increase revenue by approximately $80,000 a year.
While a comprehensive proposal has been developed, there are technology related problems that appear to have slowed the approval of the Treatment Investment Plan. However, there are an increasing number of medical and behavioral health providers within the organization asking about ways to address the no-show problem and we hope to get our plan approved in the near future.
Learning and Growth
Below are a few of the important learning points for me during the period of transition to an integrated program:
The significant changes associated with integrating behavioral health services and the addition of diabetes day likely added to existing clinic stressors and co-workers may seek out the behavioral health provider. I found it important to set boundaries early on as co-workers may not understand our ethical limitations related to multiple relationships. While I cannot provide treatment services to co-workers I can be a friend and a supportive co-worker.
When making systemic changes in the way the clinic practiced it was important to include the whole clinic staff in feedback related to integration of behavioral health services. I found it useful to utilize a 360 degree evaluation that sought feedback and input from providers, nurses, front desk staff, and medical records personnel.
Ultimately, the greatest lesson for me was that models and plans don’t always hold true and that there is a vast space between what the textbooks say integrated primary care is supposed to look like and what actually works. In that space is the struggle and the learning necessary to become an integrated primary behavioral health provider.
Joshua Bradley earned his Psy.D. from Radford University in the summer of 2012 and was licensed as a psychologist in November of 2012. Joshua works for Stone Mountain Health Services and his home office is located in St. Paul, Virginia. The St. Paul clinic was recently recognized as a Level 3 Patient Centered Medical Home. He provides integrated primary care services and is the only psychologist in Russell County, Virginia. In August of 2013 he took on coordination duties for the East Tennessee/Southwest Virginia Predoctoral Psychology Internship Consortium. Joshua oversees the weekly didactic trainings and is the clinical supervisor for group supervision. His current clinical interests include sustainability in rural integrated primary care clinics where the context of clinical practice may necessitate a hybrid system of providing behavioral health services.
During the recent annual CFHA conference in Colorado, we
collected responses to a survey to help improve the CFHA blogs. Thirty
individuals participated (23 identified as female while 7 identified as male).
When asked what word described their professional identity, 33 used clinician
(e.g., psychologist, social worker, physician, therapist), 7 used educator, 3
used researcher, 3 used administrator, 1 used student, and 1 used insurance company
contractor. The average age was 43.7 years while the median age was 40.
are the six survey questions and results.
asked survey participants to list topics they would like to see covered in the
future and ideas for improving the blog overall. We got some good suggestions!
list any topics you would like to see covered in future blog posts:
blogs” "Things for educators to share with trainees”
"Useful measures, assessments, & tools for practice” "Outcomes,
"Integrated care, health care policies at international
level” "Best practices for addressing MH”
"Hospital reform - purchase of PCP practices, upcharging for
outpatient office visits”
"Assessment tools” "Ethics of integrated care, informed
consent, confidentiality” "Outcome measurement for integration” "Policy piece
with data/evidence paired with a clinical story”
Please list any ideas you think would help to improve the
"Fewer more poignant rather than many of marginal quality”
"More info in email announcing blog posts”
"Time constraints for
reading - shorten messages into brief sentences.”
"Collection of articles, blogs that are user-friendly
categorized by topic - easy access to resources” "Get some back-&-forth
blogs going, pitching different perspectives on similar issues/themes”
Overall, it seems that most people are mostly interested in
and satisfied with the blogs. However, it also seems that most of the blogs are
not useful to readers. Our goal is to incorporate this feedback to improve the
overall quality and utility of the blog posts. The specific ideas for topics
generated by survey participants will especially help future blog posts. Thank
you to all of the survey participants! If you have any additional ideas, please
share those ideas with us in the comment section below.
P. O. Box 23980,
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What We Do
CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.