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CFHA 2014: Looking Back to Move Forward

Posted By Parinda Khatri, Thursday, January 9, 2014

(This is the first blog in an ongoing series that highlights what CFHA leaders are thinking and planning for the future. Check back in the future for more. The first post is by Dr. Parinda Khatri, current CFHA president.)

As I start 2014 as President of CFHA, I can’t help but remember my first CFHA conference: Newport, Rhode Island, November 2006. I remember it was November because it was really, really cold (at least for someone born in India and raised in Southeast. Those of you from cold climates feel free to smirk).  I was a few years into my job as Director of Integrated Care at Cherokee Health Systems (CHS), a comprehensive community healthcare organization that is a Federally Qualified Health Center and Community Mental Health Center in east Tennessee. While we at CHS were marching forward with integrating behavioral health into primary care, at the time there were few avenues for learning, sharing, and talking about integration and collaborative care in the usual circles.  At that CFHA conference, I was able to learn, share, and talk about integration and collaboration with brilliant people doing amazing things for two whole days.  It was exhilarating, validating, and comforting.  I had found my professional home.

Since then, integration and collaborative care have experienced exponential growth as progressive approaches to transforming healthcare delivery, health education, and scholarly inquiry.   The concepts that were considered "novel” by all but a handful of vanguard healthcare professionals have morphed into commonly used terms and ideas highlighted in countless conferences, presentations, publications, and initiatives at the local, national, and international level.  Integrated and collaborative care, an area which developed organically at the grass roots level by people in the trenches, now attracts a cadre of clinicians, researchers, educators, and administrative professionals from a wide range of settings. 

Like an adolescent transitioning from childhood to adulthood, the field of integrated care is exploring and testing limits as it grapples with its identity and role in the world.   Like the field, CFHA is also in transition.  Initially an entity founded and led by visionaries who gave their time, energy, money, and probably some tears just to get it off the ground, CFHA is now a formal association with 500 members, an annual conference, affiliated journal, and a host of initiatives in support of its mission.   It has a basic governance structure, with staff leadership (including a stellar executive director, Polly Kurtz) and board of directors. Now, CFHA is on the cusp of its next developmental challenge – to transition from a budding society to a mature organization with a refined governance structure, sound financial footing, and well-designed programs while it maintains its foundational mission. To remain viable, relevant, and grow, CFHA must, in the words of Jim Collins, "preserve the core while it stimulates progress.” 

No sweat, right?

Well, maybe some sweat (okay, a lot of sweat) but hopefully also some movement forward.  To this end, we will be rolling out several initiatives to meet the evolving needs of CFHA’s membership and expand the organization’s impact on clinical service delivery, research, policy, and education. Here are a few upcoming ventures: 

1) In January, CFHA will launch two special interest groups (SIGs), a Families and Health SIG co-chaired by Randall Reitz and Kaitlin Leckie, and a Primary Care Behavioral Health (PCBH) SIG co-chaired by Chris Hunter and Jeff Reiter.  These SIGS will provide a forum for active dialogue, knowledge dissemination, and networking for CFHA members. If one of your favorite parts of the CFHA conference are the "post-session” hallway huddles with colleagues, these SIGs are a great way to keep the conversation going throughout the year. Be on the lookout for information on regular conference calls and other initiatives from these SIGs in the coming month. 

2) CFHA is also actively working on a policy agenda that will identify the priority issues for advocacy at the local and national level. If we, as educators, clinicians, researchers, and administrators in the field, truly believe that integrated behavioral and primary care is critical to an effective and efficient health care delivery system, we will have to be vigorously involved in policy change in this arena. This policy agenda is intended to be a stimulus and guide for the organization as well as individual members to help transform the rules, regulations, and procedures that affect the work we do every day.

There is more to come. CFHA’s 2014 annual conference (Oct. 16-18 – save the date!) is shaping up to be a pivotal event, strategically planned to be in the nation’s capital, Washington, D.C., during this year of ACA implementation and this era of healthcare reform. CFHA will continue to promote dialogue and knowledge dissemination through its blogs and journal, Family, Systems, and Health, through the course of the year.  
You will play a key role in CFHA’s strength and evolution 

Because CFHA is a member organization and is essentially a product of its membership, we ask that each of you become more engaged with CFHA.  Whether you write a blog, submit an article to the journal, become involved in the SIGs, participate in the conference, or contribute to CFHA’s mission through other activities, you will play a key role in CFHA’s strength and evolution as an organization. In turn, you will be part of a group of professionals who share your mission and passion to improve the health and quality of life of your community. If you, like me, think of CFHA as your professional home, the reward you will receive, professionally and personally, will far outweigh your investment. And that is a pretty good way to start off 2014. 

Happy New Year!!

Parinda Khatri, Ph.D., is Director of Integrated Care at Cherokee Health Systems, a comprehensive community healthcare organization with 56 clinical sites in 13 counties in Tennessee.  She earned her doctorate in Clinical Psychology at the University of North Carolina at Chapel Hill and completed a Post-Doctoral Fellowship in Behavioral Medicine at Duke University Medical Center.  As Director of Integrated Care at Cherokee Health Systems, she provides oversight and guidance on clinical quality, program development and management, workforce development, clinical research, and clinical operations for blended primary care and behavioral health services within the organization. Dr. Khatri also trains, consults, and presents extensively on integrated care. She also leads Cherokee's APA Accredited Psychology Internship Program and APPIC member Health Psychology Post-Doctoral Fellowship.  Dr. Khatri is currently President of the Collaborative Family Healthcare Association.  She also serves on the National Integration Academy Council for the Academy for Integrated Mental Health and Primary Care, is Co-Chair of the Behavioral Health Special Interest Group for the Patient Centered Primary Care Collaborative, a member of the Behavioral Health Steering committee for the National Quality Forum, and a member of the Research Advisory Committee for the Transdisciplinary Collaborative Centers for Health Disparities at Morehouse School of Medicine. 

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Integrated Care Thought Leader Series: Benjamin Miller, PsyD

Posted By Cheryl Holt, Friday, January 3, 2014

(This blog post is a reprint of a piece by Cheryl Holt on November 5th, 2013. Click here for the original post. Reprinted with permission)

"If we really think about how to change healthcare to make it more accommodating for integration, we must have comprehensive payment reform that pays for the whole, and not the part. We must recognize that administrative structures in health policy entities often perpetuate fragmentation inadvertently. And we must have a way to collect data that can inform not only the clinical case for why integration is good, but the business case for why integration is inevitable."

Healthcare policy plays a crucial role in integrated care. Our current healthcare system contains barriers that prevent successful implementation of behavioral health and primary care integration. We will not be able to effectively adopt whole-health approaches to healthcare until critical changes are made in existing health policy. Thankfully, we can be grateful for those who are out there, tirelessly advocating for changes daily.

Dr. Benjamin Miller has graciously agreed to offer his insights on this important topic for the Integrated Care Thought Leader Series. He has made significant contributions to the healthcare industry and health policy, and continues to collaborate with a number of organizations focused on driving the necessary change for creating a more effective healthcare system. Dr. Miller has been the source of considerable inspiration to many (including me). It seems very appropriate, somehow, that I first met him through Twitter. His many tweets on healthcare, policy, and integration, with excellent links to current resources, provide me and many others with an education like no other. I have learned the value of Live Tweeting and Tweet Chats through his example. Thank you, @miller7!

Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. Dr. Miller is a principal investigator on several federal grants, foundation grants, and state contracts related to comprehensive primary care and mental health, behavioral health, and substance use integration. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care projectas well as the highly touted Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon.

He received his doctorate degree in clinical psychology from Spalding University in Louisville, Kentucky. He completed his predoctoral internship at the University of Colorado Health Sciences Center, where he trained in primary care psychology. In addition, Miller worked as a postdoctoral fellow in primary care psychology at the University of Massachusetts Medical School in the Department of Family Medicine and Community Health.

He is the co-creator of the National Research Network’s Collaborative Care Research Network, and has written and published on enhancing the evidentiary support for integrated care models, increasing the training and education of mental health providers in primary care, and the need to address specific healthcare policy and payment barriers for successful integration. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Miller is the past President of the Collaborative Family Healthcare Association, a national not-for-profit organization pushing for patient-centered integrated healthcare.

Having long been a firm believer in the need to provide healthcare in a unified manner, Dr. Miller has determined that three barriers prevent integrated care from becoming more widespread: financing, policy, and data.


Dr. Miller: If you ask people why integration is or is not making a larger stand in healthcare, it usually comes out that they aren't able to sustain their clinical innovation. So practices try to figure out ways that they can sustain themselves through all kinds of workarounds. Here in Colorado about three years ago we did a survey of integrated practices and found that 77% of those we surveyed were solely funding their integrated efforts through grants. I don’t think that’s uncommon. Actually, I think it’s very common across the country. A lot of practices that are doing this got funding from foundations, federal government, etc., to make it work. They’re only able to keep their doors open for the program while they've got those dollars. I wanted to figure out, why is that such a big deal? Why can’t we just pay for health? We proposed a project to test out a global payer model for primary care that includes the cost of mental health, just to see if we were to pay primary care a lump-sum of money that includes the cost of that primary care provider, could they sustain themselves? That’s where the Sustaining Healthcare Across Integrated Primary Care Efforts or SHAPE came from. We wanted to see if paying for primary care differently with mental health, behavioral health, substance abuse providers, working in that integrated context could be sustained. We’re about a year into that and the answer is going to be unanimously, yes.

Large Scale Policy Issues and History

Dr. Miller: If you look at how healthcare is set up, it’s set up to continue to perpetuate fragmentation. It’s set up so that administratively, it’s easier to manage pieces rather than a whole. Our states, communities, and government have done something, in an attempt to manage multiple systems, which has really hurt our attempts to integrate. I’ll give you a very high-level example of that: If you just look at most states, they usually have a different department or division for mental health. We decided to take all the dollars that were going into institutions for folks that had mental health issues and put it back into the community in established community mental health centers. The dollars didn't really follow the patients in that experiment. Community mental health centers actually didn't get a whole lot of money to do the job that they were intended to do. And so you have entire systems at state levels that manage mental health. When you want to try and integrate, whether it be in primary care or in the community mental health center with primary care, there are multiple administrative structures that you have to figure out how to align. And often, from a policy perspective, it doesn't make sense fiscally as to how to align these and what to do with the administrative entities. There are a lot of policy issues. Mainly, how we've set up our systems to deliver care at the policy level.

Data, Research, and Infrastructure

Dr. Miller: The other reason I think integration hasn't been taken to scale nationally as much as we would like, is that practices are relatively immature in their ability to collect data, especially as it relates to collecting that informs the outcome around the whole person and not just a physical health outcome or mental health outcome. If you go into a primary care practice and want to determine how effective a behavioral health provider is, often the electronic medical record and how they are tracking the data are in forms that don’t allow you to extract those data. They’re in free-text notes, or they’re in something that just makes it difficult to get at the data to show what they did and how effective it was. In the same vein, if you look at community mental health centers, it’s even worse. With vast amounts of EHRs, if they even have an EHR, are built around this old-fashioned, almost antiquated, "I need to tell the whole story for the patient” model. That’s good on the clinical level. However, if you’re looking at making a case for something, you need to be able to extract data from those electronic medical records and then tell a story with your data. Many of the community mental health centers simply are not there. They have an opportunity here to advance themselves by collecting better data at the practice level.

Though many in the healthcare industry see policy as something beyond their responsibility and concern, the reality is that it has an impact on each of us. Unless we collectively express our concerns, voice our professional opinions, demand the necessary changes, legislators will continue to make uninformed decisions that have significant impact on healthcare delivery.

While there remains a long way to go before the needed changes outlined by Dr. Miller are in place, the industry as a whole is making significant strides in the right direction. Policies are slowly beginning to change.

Perhaps the perfect storm is approaching for healthcare

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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The Social Work Hat of Behavioral Health Consultation

Posted By Preston Visser, Thursday, December 26, 2013

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!

Imagine with me for a moment that you are on a journey hiking through Yosemite National Park (the government stays open in this imaginary world). On day 2, a surprise snowstorm forces you to veer off your trail. On day 3, you have lost your map and are becoming increasingly convinced that each step you take gets your more lost. At the brink of desperation, to your great relief you spot someone wearing that iconic Park Ranger hat. The friendly Ranger gives you a map with directions to get back to your trail, and in a few minutes you are headed "True North” (the Ranger bore a striking resemblance to Kirk Strosahl). Technically, you are still far from your original trail. Also, the Ranger was too busy to accompany you, so you are alone again. Nonetheless, your brief encounter with someone that understands the park helped you make sense of things, which changed everything.

Each patient we encounter is on his or her own life course. While we do not choose this course, we can be of assistance in reducing unnecessary detours and pains. Unlike traditional therapists, behavioral health consultants (BHCs) are generally too busy to accompany patients for long on their journeys. Therefore, our best function is often to help patients get their bearings set. This process often occurs through brief interventions that help patients connect to values that guide their choices. Increasingly, however, I see that we also have a great opportunity to help patients understand, navigate, and even benefit from complicated social systems.

As an early career psychologist, the last few years of my clinical work have been dominated by efforts to rectify the great predicament affecting us all: how to address the tremendous need we encounter despite substantial limitations of time and resources. My struggles with this ubiquitous issue have helped me to broaden my own professional identity to include the belief that I need to maintain a good understanding of the systems and resources affecting patients in my community. I think of it as wearing a social work hat.

In an insightful CFHA blog series on the topic of "Professional Identity” earlier this year, Tom Bishop and Jeff Ellison reminded us that, perhaps more so than other professionals, we BHCs need to view ourselves broadly in the context of the diverse teams with which we work. My role in integrated care teams involves more than being a good therapist and diagnostician. As the BHC, I need to be able to help patients determine what factors, personal and systemic, can be altered to get them closer to the health they want.

Throughout graduate school, I had little experience interacting with social service agencies, insurance companies, residential treatment facilities, nonprofit organizations, and other entities that patients often engage during their treatment. I now fully recognize my ignorance in these matters, so I ask a lot of questions. I frequently call organizations to ask for guidance, and I am blessed with a spouse that is a social worker and with colleagues that work hard to obtain and share information about systems and organizations.
I need to maintain a good understanding of the systems and resources affecting patients in my community

Here are a few real-world examples of interventions that seem to involve a social work hat:

  • Patient is experiencing early to middle-stage Alzheimer’s symptoms, and family does not understand the diagnosis: Connect family to Spanish-speaking support groups and information
  • Family is dealing with alcoholic father: Provide information about Al-Anon group to attend
  • Patient with mental retardation (MR) describes major stressor is that the payee for his social security income is abusing him and stealing his money: File report of abuse with appropriate office, and contact Social Security Administration to learn about options for changing one’s payee
  • Elderly patient is suffering physically and psychologically due to difficulty caring for her niece that has severely uncontrolled schizophrenia: Assess available familial supports, help patient problem-solve about why her attempts to transfer niece to residential care have failed in past, and call hospital and legal authorities to help patient plan for transfer of care
  • Patient is considering applying for deferred action in order to attend college, but fears that she will be deported in future: understand White House executive order in order to help the patient explore pros and cons
  • Patient is distressed by unplanned pregnancy: connect to appropriate support services
  • Young adult obtains custody of 2 younger siblings after her mother and grandmother both pass away, and their house is in foreclosure: connect patient with appropriate social services
  • Patient’s primary concern is inability to find employment: help patient locate unemployment programs
  • Patient with schizoaffective disorder and alcohol dependence is fired from psychiatry for continued alcohol abuse: help patient locate a substance use program close enough to his home, and call patient periodically to encourage adherence to treatment plan
  • Patient feels stuck in relationship with violent partner due to fear of homelessness and deportation: Connect patient to "Mujeres Latinas en Acción,” an organization for such women
  • Mother is worried about academic performance of child that appears to have learning disability: Help mother to understand and follow protocol for requesting IEP evaluation
  • Mental Health Referrals: Unless you are fortunate enough to work somewhere with both integrated care and co-located therapy (ahem, Cherokee), then you will need to have a list of places to refer patients needing long-term therapy/psychiatry. In Chicago, maintaining such a list can be challenging, particularly since mental health resources seem to change frequently. Our department set aside admin time to create a large excel file with referral sources and relevant information, including insurances accepted, languages served, sliding scale fee, etc. We also took a field trip to the place that we refer most patients for psychiatry and therapy services. I wish we could take a similar trip to all of our referral locations.

By disposition and training, BHCs are generally good communicators and capable of helping patients connect to adaptive coping skills and guiding values. I believe we can maximize our impact by becoming comfortable wearing a social work hat. Better knowledge of systems and context will help us create better maps for getting patients back on trail.

Preston Visser is an early career psychologist working at a federally qualified health center located in an underserved neighborhood in Chicago, Illinois. He was part of the inaugural class of students in the integrated primary care psychology doctoral program at East Tennessee State University. Preston completed his predoctoral internship through the Chicago Area Christian Training Consortium, with his primary rotation at Lawndale Christian Health Center (LCHC). He later completed his postdoctoral fellowship at LCHC and is now a licensed behavioral health provider at the clinic. At LCHC, he works collaboratively with primary care providers to address behavioral health concerns of patients diverse in age, culture, and language (English and Spanish). Since graduating, he has been developing coping skills for managing withdrawal stemming from a lifelong dependence on school. He is 18 months sober, but with the RxP movement underway, relapse seems possible.

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Mentorship: A More Generous Approach to Those Needing Guidance on Their Professional Journeys

Posted By Deborah Taylor, Thursday, December 19, 2013
"A lot of people have gone further than they thought they could because someone else thought they could.” – author unknown

To me, this is the foundation of the best mentoring experiences for which I am grateful to have received. How many of you would agree?

Another favorite guiding quote says that:

"There will always be a reason why you meet people. Either you need to change your life or you’re the one who will change theirs.” - author unknown

Dr. Jeri Hepworth, Vice Chair at the U. of Connecticut Dept of Family Medicine, and I recently co-presented a workshop entitled "Intentional Mentoring: Paying It Forward as a Family Medicine Behavioral Science Educator” at The Forum on Behavioral Science in Family Medicine conference. Using a modified World Café technique, we captured great wisdom from engaged attendees worth sharing with a larger audience….that would be you!

One theme that strongly emerged was that Family Medicine educators are much more comfortable in the role of mentee vs mentor, especially those early in their academic career. The more senior faculty were helpful in convincing the more junior faculty of their value as mentors. Mentoring areas identified by senior faculty included use of technology, innovations in information delivery methods and social media as a communication and teaching tool.

Another embraced thread was that "forced mentoring” – being "required” to participate in a mentor-mentee relationship that is imposed upon you with little room for autonomy or choice - was not perceived as being particularly helpful from either side of the mentoring relationship. Even when someone in authority defines a need for "forced mentoring”, mentee being afforded some control over the choice of mentor yields a stronger and more helpful outcome according to both mentee and mentor.

The last wisdom from our audience that struck us was how many barriers seem to be in their way around devoting time and energy to a mentoring relationship. Time was obviously #1, but others barriers emerged including lack of allotted resources available for identified mentee needs, dyadic power issues that prevent the mentee from being authentic/honest, and a lack of structure affecting the clarity of roles, goals and expectations.

I am sure you will agree that our students inspire us. I would encourage you to consider ways to gather the wisdom of your learners (who are often identifying you as a mentor) and in turn transform the bidirectional influence of your professional connections.

The best mentors are those who show you where to look but do not tell you what to see.
- Alexandra Trentor

In closing, please take a moment to reflect on the following questions to help you be more intentional in your mentoring efforts:

  • How can you increase your mentoring activity in your professional home?
  • Who or what people/groups can you identify that would benefit from what you have to offer?
  • How will you make yourself available (addressing issues of time and resources)?
  • What is your intention (i.e., what do you think you have to offer/share)?
  • What are potential challenges that will need to be addressed in order to be successful as a mentor?

Happy intentional mentoring!

Dr. Deborah Taylor has been a Behavioral Science Educator and Associate Program Director at Central Maine Medical Center FMR (a community based program with a rural training emphasis) for the past 21 years. She received her PhD in Clinical Psychology from the U. of Kansas and has worked in medical education for the past 25 years. Deborah recently "retired" as a Co-Director of the STFM Behavioral Science/Family Systems Educator fellowship.


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A Poem

Posted By Natercia Rodrigues, Monday, December 2, 2013

This is the first in a new blog series by early career professionals and trainees. Check back each month for a new post by up and coming professionals!

Smiling, he told me he didn’t know
That his heart had stopped in the ICU

I probably didn’t need to mention it
But here he is, with newly diagnosed end-stage everything
And he’s still smiling.

Wow, he breathed.
I know, I said. Crazy.

A year later, his teeth still shone
He wore three pairs of pants to keep his skinny legs warm in the Rochester winter

I saw him sporadically
He had his calendar filled with doctors for each organ

One evening, when I was on call for our practice a page came through with his name
Seven hours of vomiting with no fever.
He never gets a fever, I remembered.

He said he had a ride to the ED and that he’d go now.

The next day, with no ED visit recorded, our nurse called to check in on him. There was no answer.
The next day, the coroner’s office called.

I called all of his specialists. I told my close colleagues.
It was therapy, repeating the story and its abrupt ending

I sought no reassurance, just shared shock

On my last phone call, my eyes rested on the new green surrounding the trees outside the window.
A Scarlet Tanager, bright red and sparrow-shaped, jumped from branch to branch.
Fearless, open to predators, and not caring to blend into upstate gray
It stayed in my view for 30 seconds.
I relayed its movements, like a sportscaster to the gracious ear
It kept jumping, brilliant wings aflutter until it flew west
The branch bounced and I grew quiet 

Wow, I breathed.
I know, She said, Crazy

I'm a 3rd year resident at the University of Rochester Family Medicine program where my patients' stories become a part of my life.  I like writing, taking photographs in Iceland and buying produce at the public market.

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Integrated Care Thought-Leader Series: Larry Fricks

Posted By Cheryl Holt, Thursday, November 21, 2013

(This blog post is a reprint of a piece by Cheryl Holt on September 18th, 2013. Click here for the original post. Reprinted with permission)

"When you look at people holistically and start valuing their mind-body resiliency, I think there is a level of excitement, and better outcomes.”

September is Recovery Month. This year’s theme is Join the Voices for Recovery: Together on Pathways to Wellness. It is very fitting that Larry Fricks is our featured Integrated Care Thought Leader this month, as he is one of the nation’s greatest leaders in peer-led services, wellness, and recovery. An amazing individual who has devoted his life to helping others, Mr. Fricks was gracious enough to his insights into the importance of whole health wellness and resiliency and the vital role of engaging with people who have the lived-experience to provide support through the process. He offered insight into the role that a whole health approach plays in improving health outcomes and managing wellness. Drawing from his own experiences, Mr. Fricks identified many factors that contribute to a person’s recovery process. Acknowledging that factors such as race, socioeconomic status, and personal support system play a crucial role: "I don’t think you can underestimate what social determinants do to break somebody down.

Larry Fricks is Director of the Appalachian Consulting Group and Deputy Director of the SAMHSA-HRSA Center for Integrated Health Solutions. For 13 years he served as Georgia’s Director of the Office of Consumer Relations and Recovery in the Division of Mental Health, Developmental Disabilities and Addictive Diseases. A founder of the Georgia Mental Health Consumer Network and Georgia’s Peer Specialist Training and Certification, he has a journalism degree from the University of Georgia and has won numerous journalism awards. He is a recipient of the American Association for World Health Award and the Lifetime Achievement Voice Award from the Substance Abuse and Mental Health Services Administration for the development and adoption of multiple innovative, community recovery-oriented programs and services. Mr. Fricks’s recovery story and life’s work to support the recovery of others was published by HarperCollins in the New York Time’s best-selling book Strong at the Broken Places by Richard M. Cohen. (Click here for video of Mr. Fricks’s interview on the Today Show.) He is also the creator of the Whole Health Action Management (WHAM) training, a best practice model which strengthens the peer workforce’s role in healthcare delivery.

From Peer Support to Whole Health and Resiliency

I first met Mr. Fricks in 2000 in Rockford, Illinois. He was the keynote speaker at the Consumer Family Forum, addressing a group who receive behavioral health services, their families, and behavioral health professionals from across the state. His passion resonated among the 300+ attendees as he shared his personal recovery story, urging others to believe that recovery is possible. I vividly recall (and have frequently shared with others) a very moving story that he shared about an initiative that has grown to be The Gardens at Saint Elizabeths: A National Memorial of Recovered Dignity, honoring the hundreds of thousands of people who died and were buried in unmarked graves on the grounds of psychiatric hospitals…and were forgotten:

Larry Fricks: Their graves were decimated and desecrated and they have no markers and people didn’t care about maintaining their graves. They walked the Earth and they had a life. Mothers, husbands and wives, children. They had wonderful things happen, and they saw miracles, and they had heartbreak, and you’re just honoring that experience. I just really believe that the Memorial is drawing people that I never expected to draw…very inspiring.

Through the years, Mr. Fricks has traveled from state to state, providing inspiration to so many, sharing his vision, and leading the way to transforming the way behavioral health organizations provide services. He led the national initiative to include peer-led services as a core feature, and is now working with states to embed Peer Support Specialists and Family Peer Specialists in integrated healthcare efforts as well. He currently divides his time between his work with the Appalachian Consulting Group based in Georgia, and his work in Washington, DC, as Deputy Director with the SAMHSA-HRSA Center for Integrated Health Solutions which has included testifying at Congressional Hearings on Mental Health.

Larry Fricks: We now know that things like a social network and service to others are huge health and resiliency factors. People who are in service to others tend to be healthier and they tend to live longer. Also they tend to be more resilient toward relapse or illness. So my life striving to be in service to others to strengthen their health and maybe strengthen their skills in recovery has had the benefit of strengthening my own recovery.

While his earlier work has focused on the role of Peer Support in the recovery process, Mr. Fricks’s work has broadened the focus to include a whole health approach. With startling reports that people with serious behavioral health conditions are dying decades earlier on average than the general population, he led a team at the SAMHSA-HRSA Center for Integrated Health Solutions to create a training called Whole Health Action Management (WHAM) that is designed to address this disparity though self-management supported by peers. Mr. Fricks has great praise for the effort in Georgia to develop Peer Support, Wellness, and Respite Centers that are reducing hospitalizations.

Larry Fricks: Let me tell you about what excites me. Georgia has three of these Peer Support, Wellness, and Respite Centers and they’re going to open two more. I’m very excited about what’s going on in those centers. Basically, if you feel early warning signs of your illness, or your addiction, you can go to one of these peer respite centers where you have your own bedroom and you can stay up to seven nights, chill out, and you’re surrounded by peers trained holistically to support your wellness. I think it’s really cutting the need for more intense crisis services and hospitalizations. So I had a chance to actually pull a shift in one of them, I answered the warm line and experienced what it was like to provide healing support by simply listening, or maybe just ask a few questions for deeper reflection like we are trained to do. These peer support wellness centers are returning us to whole health. Removing some of the stigma, giving us a sense of owning our recovery and being proactive, and really engaging peer support to be successful. Georgia is leading the nation. With three we had more than any state, and with five we’ll really be out in front.

What’s next on the horizon?

Larry Fricks: I’m really excited about epigenetics. On April 2 of this year, Time magazine had a cover story on curing cancer, and this whole science on epigenetics basically says DNA does not have the last say. There are mind-body resiliency factors and there’s more and more research on epigenetics. "Epi” means over and the epi is the cell structure over your genome, over the DNA. And what they’re saying here is: Things that you do, like what you eat and managing stress to stay well, it determine which genes switch on and switch off. And so being aware of this thing, if you look at the WHAM training, we include ten health and resiliency factors which we got from Dr. Greg Fricchione who used to run Mrs. Carter’s Mental Health Program [at the Carter Center], and now he’s director of the Benson-Henry Institute for Mind Body Medicine. These prevention doctors are big on something called the Relaxation Response, and so we’re looking at the things you can do to switch on and switch off gene markers; and they can impact the next generation.

And in parting:

Larry Fricks: I’m aware that there are just people and things that happen in your life that, if you’re open to it, you work on staying connected and having faith, your life can experience great meaning and purpose.

Dr. Martin Luther King, Jr. said "We’re all bound in a mutual destiny and I’m not all I can be until you’re all you can be, and you’re not all you can be until I’m all I can be.” We should be about connection. We should be about cooperation, and there’s a spiritual power to that, and when you’re open to it, positive things just seem to happen. And you’re inspired by it.

Sometimes you want to shake your head and say, "Oh my gosh, why don’t I have more faith?

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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Teach Us How to Innovate! Graduate Students’ Impressions from Their First CFHA Conference

Posted By Jodi Polaha, Thursday, November 7, 2013

(This post is the second in a two-part series of blog posts following up on the 2013 CFHA Annual Conference. Click here for the first post.)

Taking students to the CFHA annual conference is, in my 7th year, a kind of ritual. I start in April, selling our first year students on the mission match for CFHA and ETSU’s doctoral program. Over the summer, I badger our Chair for department funds to cover student travel and badger the students to apply for CFHA scholarships. In the fall, when we begin to meet weekly for my course, "Primary Care Psychology 1,” I strategically note the contributions of CFHA members in this advancing field. Mid-semester, we finalize our plans and attend the conference. And then I worry about them. Will they learn? Have fun? Think it was worthwhile? I take them out to dinner, introduce them to people, and offer to share a cab to the airport.

It’s a lot to take on. At some point I find myself asking "Why am I doing this?”

Over the years, I’ve generated plenty of satisfying answers to this question, but this year Dannel and Katelyn stopped me in my tracks with a new one. Their thoughts, in sum, were:

Yes, they met lots of great people and even the authors of some class readings.
Yes, they heard someone (besides me) talk convincingly about the burgeoning opportunities in integrated care.
Yes, they saw the data that supports integrated care models.
Yes, they felt there were ample opportunities to exchange ideas.

It was all the best stuff of any great conference. "But,” they wondered aloud, "how do we learn how to innovate? Everyone keeps talking about it. We want to know how to do it.”

Instinctively, my students’ interest in learning how to disrupt status quo made me glow. That the CFHA conference effectively conveyed the value of disrupting status quo is a new and singular reason for taking them along, no matter the work involved, the badgering, and the logistics.

Their question is also a challenge to me as an educator. Should I teach my students to innovate? And, if so, how?

Choosing to teach my students to innovate means I’m betting that "innovating” will be a marketable skill in the health care workforce of the future. Will it? As an educator in this ever-changing landscape, I am faced with a curious objective: to prepare providers with skills for tasks, roles, and milieus yet unknown. In his oft-cited TED talk,Sir Ken Robinson, a leading expert on innovation and human resources makes the same case regarding the education of our children:

I have a big interest in education, and I think we all do, we have a huge vested interest in it, partly because it’s education that’s meant to take us into this future that we can’t grasp. If you think of it, children starting school this year will be retiring in 2065. Nobody has a clue, despite all the expertise ….{ }, what the world will look like in five years’ time. And yet we’re meant to be educating them for it. So the unpredictability, I think, is extraordinary.

Student reflections on the need for new skills (to innovate!) are always a sign to me that my target has moved. Educators like me and even CFHA as an organization have to be sensitive to feedback about that moving target. My students and many others are beginning to come to the conference convinced of the concept, armed with the supporting data (sometimes from their own dissertations!), and with a business plan, job offer, and grant in hand. Our students are graduating from programs where they take interdisciplinary courses, watch integrated practices in action, start up their own integrated practices, and conduct studies evaluating integrated care. The unpredictability of how these skills and experiences will play out IS extraordinary. To do this job right, we educators will need to be reconnoitering, reallocating, and re-aiming for new training targets every step of the way.
"Innovating” will be a marketable skill in the health care workforce of the future
As a testimony, my syllabus for my Primary Care Psychology 1 Class changes every semester. Last year, I added a week on Dissemination and Implementation Science. This year I added a week on Ethics in Primary Care. Next year: "Innovating” thanks to Dannel and Katie. As the "integrated care” concept has taken off, I’ve had email requests for my syllabus, which I am happy to share, but perhaps it should contain a disclaimer or, better yet, an expiration date.

In its "educator role,” CFHA has to make its best predictions about what data, models, and skills will be needed in the future; a tall order in the context of this dynamic health care landscape. Those predictions can be based on policy, practice, research, and student input. They can’t pay much, if anything, and may not have great content-related expertise to add to the meeting, but they are worth the effort. Students’ fresh eyes and personal stake in training for the future workforce bring a valued contribution and one we need to integrate. Personally, I am looking forward to doing it all again next year.

Dr. Polaha would like to thank her students, Dannel Petgrave and Katelyn Todaro, for their input on this blog post.

Jodi Polaha, PhD, is an Associate Professor in the Department of Psychology at East Tennessee State University where her primary professional interest is research, training, and workforce development in rural integrated practice.

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Disruption. Movement. Beauty.

Posted By Lauren DeCaporale-Ryan, Thursday, October 31, 2013

(This post is the first in a two-part series of blog posts following up on the 2013 CFHA Annual Conference. Be sure to return next week for the second post.)

Disruption. Movement.Beauty.

Everyday I find myself using metaphors in my clinical work and role as an educator. Just days after my return from Denver, still actively reflecting on all I had learned and the ideas generated, a patient reminded me of the power of metaphor. He reflected on his artistic work, and said "To be successful at writing, you must do so collaboratively. You must create inspiration. If you work together, you will find beauty and you will move things forward.” This statement, on the heels of messages about disruption, reminded me so much of the work that we are all trying to do.


In one of the final sessions, Drs. Colleen Fogarty and Larry Mauksch (co-editors of Families, Systems, & Health) led a discussion on scholarship and peer reviewed publication. As part of their presentation, they encouraged the group to consider what gaps existed in the collaborative literature. The room generated a substantive list, which included the dissemination of information about how integrative and collaborative work had been applied to specific clinical areas. I left the conversation feeling inspired, with a desire to write more about my experiences and hope that all of you left the conference with similar aspirations in mind. Each of you is doing something creative each day, whether as a clinician or a teacher. Find ways to share this work, to demonstrate to others it is possible to have a collaborative vision and to make it happen. Tell your story.Write or present about the models of disruption that you are using in your everyday life. Not sure how? Start by finding a mentor or just sitting down and writing


Disruption and dissemination can also occur through sharing what we know in the classroom, practicums, and other learning environments. Many students, trainees, and early career professionals participated in a pre-conference workshop focused on Career Innovation. They were encouraged to consider how they can be the next generation of pioneers, with well-established speakers reflecting on their own experiences in integration. Though we know there are often barriers to this work, trainees learned how some of these have already been overcome. Many have since remarked that they left excited to try new things, to implement new ideas, and to help create energy in their unique settings. Movement is created and maintained when we teach others and continue to learn ourselves. How can you create movement? Who can you teach? And who can help you grow and learn?


Seven presenters kicked off this year’s conference PechaKucha presentations. Though they each spoke of disruption, these presentations also provoked thoughts of movement and hope for beauty. We were reminded of the importance of righting wrongs, approaching each patient as unique, and acknowledging that they have families, histories, and stories that are naturally a part of their care.  Laura Sudano reminded us that "transparency empowers” and Dr. Toby Long encouraged us to "foster hope.” These messages articulated that even in the face of challenges and barriers, there is beauty and positivity. We have a chance to create wonder and hope everyday.  

And so I ask you: What will you do in the weeks (and yes, years) ahead to create disruption, movement, and beauty

Lauren DeCaporale-Ryan, PhD is a Family Geropsychologist and Senior Instructor in the Departments of Psychiatry, Medicine & Surgery at the University of Rochester Medical Center. She completed her graduate training in clinical psychology with specialization in geropsychology at the University of Missouri-St. Louis, and most recently completed a two-year fellowship in primary care psychology with specialization in geriatrics and internal medicine at the University of Rochester Medical Center. Her clinical work is focused on providing care to older adults and the chronically ill, and she provides coaching on patient-family centered communication skills to residents and faculty. 

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October 1st, Healthcare, and You?

Posted By Benjamin Miller, Monday, September 30, 2013

Health Insurance Exchanges will likely bring more patients to the doors of all providers

Depending on what radio talk show you listen to or what news talk shows you watch, tomorrow, October 1st, is either going to be a smashing success bringing help to millions or a cataclysmic failure bringing death and destruction. Yes, I am referring to the health insurance exchanges.

Before we dive into those weeds, let me back up just a few feet and discuss how we got here.

Health care is broken.

Healthcare is expensive.

Healthcare doesn’t give us the outcomeswe should get for what we pay.

Many people do not have any access to health insurance and medical care.

Some of you may recall a small piece of legislation that was passed into law called the Patient-Protection and Affordable Care Act. This law was intended to fix many of the problems highlighted above. There are quite a few moving pieces in PPACA, and it is important to understand the law as a whole before breaking it down into the specifics around implementation (and the impact that will have on mental health and primary care, which I will not do here). There are many substantial overviews that can be found online that explain PPACA in detail (e.g. Waits et al.). I encourage those of you who do not about the law to read through this document as there is everything you would want to know about "ACOs”, "PCMH”, and other fun and exciting acronyms.

A few more small details.

It is important to also remember that many of the provisions of PPACA are on the public side (CMS – Medicare and Medicaid). Take for example Medicaid expansion using the state I live in and CFHA will land in next week. In Colorado, there will be Medicaid expansion starting January 2014. Of course, other states have not gone the same route as Colorado leaving local and state politics to decide what will and will not happen with expansion.

Back to the exchanges.

Health insurance exchanges are going to have an impact on everyone
Health insurance exchanges are going to have an impact on all healthcare folks in all types of practices. In Colorado, for the approximately 800k uninsured, there is going to be an option for them to gain access to health insurance. Recently, the Colorado Division of Insurance announced the rates of the plans (including those on the exchange). You can find that info here(and it gives you a good idea as to which plan may be chosen by those who have not had insurance before). Also, you can find out more about the exchange in general here. The point is that there will be an influx of new patients looking for providers who can help them with their problems.

Ironically, patients most likely to benefit from the exchanges starting tomorrow are those often least aware.

So, the exchanges will likely bring more patients to the doors of all providers (and remember, mental health parity was in the ACA, too).

What will happen tomorrow? Well, it is expected that "most federally run exchanges will offer more plans, lower premiums than expectedone HHS report shows. Those states that are setting up exchanges on their own (e.g. Colorado), we will have to see their impact starting tomorrow.

Bottom line: Having more people covered (with choices) is likely to help get people the care they need. Do health exchanges fix healthcare? No, but they do solve a problem that is so pervasive in our country – they help connect those with no insurance to a plan they can afford that will cover them.

Some progress is better than no progress.

Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care project as well as the Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon. He is the co-creator of the National Research Network’s Collaborative Care Research Network and is the past President of the Collaborative Family Healthcare Association. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Dr. Miller’s research interests include models of integrating mental health and primary care, health behavior interventions, primary care practice redesign, using practice-based research networks to advance whole person healthcare, and healthcare policy.

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Integrated Care Thought Leader Series: Benjamin Druss, MD, MHP

Posted By Cheryl Holt, Thursday, September 26, 2013

(This blog post is a reprint of a piece by Cheryl Holt from August 6th, 2013. Click here for the original post. Reprinted with permission)

"That’s the next direction that [organizations] need to go, bringing substance abuse back into the discussion. We need to go past just the integration of primary care and mental health care to a more Whole Person Care."

It has been my pleasure to talk with Dr. Benjamin Druss for this edition of the Integrated Care Thought Leader Series. Having had the privilege to work with Dr. Druss on various integrated care projects over the past few years, I have come to respect not only his keen insight into what’s needed beyond the horizon for the care of people with behavioral health disorders, but the compassion and dedication he brings. His humility and brilliance are evident upon introduction; he’s a true visionary. Dr. Druss, my mentor and my friend, has provided inspiration to me in my work and outlook on the world of healthcare, integration, and beyond.

Dr. Druss, world-renown researcher in health policy, has made a significant contribution to healthcare and the integration of behavioral health and physical health. He has impacted the lives of many individuals as a result. As the first Rosalynn Carter Chair in Mental Health, Dr. Druss is working to build linkages between mental health, general medical health, and public health. He works closely with Carter Center Mental Health Program, where he is a member of the Mental Health Task Force and Journalism Task Force. He has been a member of two Institute of Medicine Committees, and has served as an expert consultant to government agencies including the Substance Abuse and Mental Health Services Administration, the Centers for Disease Control, and the Assistant Secretary for Planning and Evaluation. He serves as professor at Rollins School of Health Policy and Management at Emory University.

Dr. Druss’s research focuses on improving physical health and healthcare among persons with serious mental disorders. He has published more than 100 peer‐reviewed articles on this and related topics, including the first randomized trial of an intervention to improve medical care in this population in 2001. His research is funded by grants from the National Institute of Mental Health and the Agency for Healthcare Quality and Research, and he serves as a standing member of an NIMH study section. He has received a number of national awards for his work.

Dr. Druss, Dr. Silke von Esenwein, and their colleagues at Emory University are currently conducting an exciting NIMH research trial, The Health Outcomes Management and Evaluation (HOME) Study. As described on the website: There is an urgent need to develop practical, sustainable approaches to improving medical care for persons treated in community mental health settings, this study will test a novel approach for improving mental health consumers based on a partnership model between a Community Mental Health Center and a Community Health Center. When this study is completed, it will provide a model for a medical home for persons with severe mental illness that is clinically robust, and organizationally and financially sustainable.

Dr. Druss received his bachelor’s degree from Swarthmore College in 1985, earned his medical degree from New York University in 1989 and later his master’s in public health from Yale University in 1995. He is also board certified in psychiatry. He trained as a resident in general internal medicine at Rhode Island Hospital and in psychiatry at Yale University School of Medicine. Click here for more information about Dr. Benjamin Druss.

Advancement in integrated care through the years

Dr. Druss was one of the first to address the physical health concerns among people with serious mental illness and substance use disorders, particularly among the public sector populations in urban regions. During our discussion on integrated care, he addressed areas of change over the past 18 years that has had the greatest impact on the advancement of healthcare for people with serious mental illness. He described the world of Health Information Technology as a frontier that, over the past 10 years, has resulted in changing policies and procedures in healthcare. These changes have had significant impact on the ability for healthcare organizations to share information, resulting in improved care for patients.

Dr. Druss advises that the next stage needed for healthcare is to begin "broadly looking at other social determinants of health.” The focus should be on an approach to healthcare that is person-centered. The concept of addressing population health and creating a system of care will be a more effective approach to improving health outcomes moving forward. He recommends that substance abuse must be brought back into the discussion, and to go past just the concept of integration of physical health and mental health, toward a more "whole person care” approach.

What do you foresee for the field as we move forward?

Dr. Druss: Clearly there’s going to be major changes in how care is delivered. I think there’s a lot of opportunity moving forward with new public sector models, Medicaid, patients with medical homes, and also the promise of new technologies moving forward as well.

I’m very optimistic; I think things will certainly be very different five years from now. We’re in a period where things are evolving very quickly and we don’t know exactly what the world will look like, but I think we can say that things will look different—and that things will look better.

Research has to change as well. I’m mostly a researcher and lot of what we’ve been doing is slow-paced. The slow-paced process by which we develop a model, and then test it over a five year period. You apply for a grant and then you test it for five years, then it’s another two years before it’s published. So we’re going to have to be looking for more ways for understanding data and evaluating programs. I think the new technologies will help, their more wide-spread availability will help. Just as the health system needs to change—and is changing—health research is going to need to change as well.

The funding agencies still are gradually coming to that point. NIMH has a new program that they are looking to fund that looks at natural experiments out in the community. So I think that’s the sort of research that we’re going to need to see more of in the coming years—good, careful, thoughtful evaluations of some of the demonstration projects going on out in the community.

What barriers to integration to you currently see?

Dr. Druss: I’d say that a lot of community mental health centers are still on this part of the learning curve in terms of learning about integration, such as how potential partner organizations work, [such as] Federally Qualified Health Centers. [CMHC’s] often lack information technology infrastructure that makes it easier to do the work. There are some places, some community clinics, and other organizations that are out in front on these issues, that are early adopters, and there’s some that are trying to figure it out and hopefully will learn from the experience of those organizations that are further ahead.

Thank you, Dr. Druss, for your dedication to improving the health and quality of life of so many who live with serious behavioral health conditions. Click here for a list of research projects and publications by Dr. Druss.

Be sure to check back soon for our next Thought Leader, Larry Fricks, pioneer in the Peer Support movement.

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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Contact Us

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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.