Posted By Susan McDaniel,
Thursday, April 4, 2013
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Susan's post is the first
in a 5-part series on
WHAT I WISH I’D KNOWN
WHEN I STARTED:
Vision and the Evolution of a Collaborative Leadership Style
I could start this story with my Family of Origin-- my
energetic, Ob/Gyn father and my strong-willed, arts activist mother. I also have a competitive and very successful
journalist/businesswoman sister. But
I’ll spare you the details on all that, and start with 1982. I was 30, and got my first academic job in
Family Medicine. It was .35FTE and I was
the first female and first non-MD on the U of Rochester Family Medicine faculty. The Chair encouraged me not to "worry about
coming to faculty meetings.” Somehow (perhaps because of the structural
family therapy training I had complained about as a postdoc) I knew not to
listen, and told him I’d be there. First lesson: Try to hone your skills about when to listen
to others and when to have the courage of your own convictions. (I was also discouraged from several
people about taking a job in Family Medicine as "it’s the stepchild of
medicine.” And earlier, the
psychologists I worked for during my year as a research assistant after college
urged me to go into Law rather than Psychology.
I’m sure glad I didn’t listen to them.)
Really, I do seek a lot of advice and I
usually take it. But when I really
believe in what I’m doing, I take the risk; then at least it’s my fault, not
someone else’s, if it doesn’t work out.
I just went to a Tribute at the Fort Lauderdale Museum of Art for my
mother who died 12/24/12 In addition to
comparing her to Scarlett O’Hara, one of the speakers talked repeatedly about
her "courage” in advocating for the arts in Fort Lauderdale and across the
state. When they broke ground on the big
new Museum of Art 25 years ago, there was a photo of 6 men and my mother, all
with shovels. I hope I inherited some
amount of courage from her, as it’s critical when you’re going against the
tide. From a family systems view, I
think we’d say that individuation is critical for healthy collaboration.
Medicine was and is a wonderful laboratory for someone like me interested in
biopsychosocial medicine. I was so
fortunate to work with pioneering people like Lyman Wynne (a psychiatrist and
father of family therapy) and George Engel (and internist and the father of
biopsychosocial medicine) during the first 25 years of my career. They were wonderful mentors--educating,
coaching, supporting, and challenging me.
Second lesson: Seek out experienced people you respect and
ask to work with them, no matter their discipline. The mentoring will come naturally. I learned so much from these two men. Their work forms the foundation of mine. To say I stand on their shoulders would be an
beginning, it was clear to me and many of the faculty and residents in Family
Medicine that family therapy has so much to offer patient care and
education. The key was really learning
about primary care. That took connecting
with a key collaborator. For me, it was
family physician, Tom Campbell. We were
both young and new. (It helps to be
idealistic, energetic, and somewhat stupid early on. You see the world with fresh eyes. I just couldn’t understand how medical care
could be delivered without attention to psychosocial issues. Actually that’s still true….) In the early 80s, Tom taught me about family
medicine ("I don’t care about theory.
Just tell me what to do.”), and I taught him about family therapy ("Slow
down. I want to know the history and the
relationships. Give me a
genogram.”) Together we developed a
family-oriented curriculum for primary care that eventually became a book. Third
lesson: Choose your smartest, healthiest
collaborators. This is as important
as your marital or life partner. You
need many of the same attitudes and skills:
respect, communication, conflict management, problem-solving. It’s a very intimate relationship, in the
professional sense of the word. I did
and do learn a tremendous amount from Tom.
Then through professional meetings, I became close with family
therapists, Jeri Hepworth and Bill Doherty, who were (and are) working in Connecticut and Minnesota. The three of us were fortunate to be at a Family Process quadrennial in 1988 in Costa Rica, and we talked once again (a favorite topic of ours) about how we now
knew how to teach primary care physicians about psychosocial medicine and
family systems, but we were frustrated about how all our mental health
colleagues didn’t understand biopsychosocial medicine. It was a one-way street far too often. For some reason, maybe the palm trees or the
drink beside the pool, Jeri didn’t join in complaining this time. Rather, she challenged us: why don’t we write a book for mental health
professionals about this work? The 3 of
us flew together from Costa Rica to the Family Medicine Amelia Island meeting
via Nicaragua (where there were soldiers with machine guns outside the plane,
but we didn’t stop working). By the time
we landed in Jacksonville, we had an outline for
the first edition of Medical Family
Therapy. Like any good partner, once
you find good collaborators, don’t let them go!
It took some major arm-twisting at various points to get Bill and Jeri
to do the 2nd edition of this book, which will come out this
summer. But collaborators that they are,
once on board they were fully on
board. And what a beautiful product it
and are many, many challenges to this work.
I left out all those stories in order to tell you these. And that brings me to the Final lesson: Persistence! If you have a vision, challenges help
clarify what it truly is. Some projects
take weeks, others months, still other decades.
I’ve often thought persistence may be my strongest talent. For new professionals, having the long view
can really help when the inevitable difficulties and hard times arrive. Collaborative care is not yet the dominant
paradigm, so challenges are to be expected, endured, even occasionally
embraced. And they make the successes
that much sweeter.
Dr. McDaniel is the Dr Laurie Sands Distinguished Professor
of Families & Health, the Director of the Institute for the Family in the
Department of Psychiatry, Associate Chair of the Department of Family Medicine,
and the Director of the Patient- and Family-Centered Care Physician Coaching
Program at the University of Rochester Medical Center, where she has been since
beginning her career in 1980. Her career
is dedicated to integrating mental/behavioral health into healthcare. Dr McDaniel is the author of numerous journal
articles and 13 books, translated into 8 languages. She was co-editor of Families, Systems & Health for 12 years, and is now an Associate Editor of the American Psychologist. She is very excited about her latest book,
co-authored with Bill Doherty and Jeri Hepworth. Medical Family Therapy and Integrated Care, 2nd Edition, is
In Press and will be published late this July--21 years after the 1st
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Posted By Larry Lantinga,
Thursday, March 28, 2013
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Larry's blog is the fourth
post in a series on
integrated care for
military and veterans.
Hawaii, Homelessness & Collaborative Care!
These three concepts can’t possible be included in a blog for CFHA, can
they? Well yes, I think they can and here goes.
While vacationing in
Hawaii with my lovely wife, children and grandkids I awakened early
Sunday morning, brewed a pot of Kona coffee, and grabbed the Honolulu
Star Advertiser to begin my Sunday morning ritual. The front page
headline in 44 point type read: $77 million Proposed for Homeless! The sub-headline read: Honolulu’s Sidewalk Blight!
The story led with findings from a recent survey that Waikiki tourists’
number one complaint was the presence of the homeless near many of the
best hotels in town and how these poor travelers are often forced to
"….walk out of their way or into the street to avoid getting too close
to homeless campers who are blocking sidewalk access and loitering near
the convention center.”
Although I wasn’t among those doing the
complaining, I didn’t feel very good about being a tourist at that
moment. The story went on to report that a local city councilman was
proposing $77 million dollars be used to address this problem with the
most prominent proposal being the creation of a tent city, well removed
from the areas frequented by those poor tourists. I felt like
calling the Honolulu paper and telling them "don’t let your politicians waste
your money on a tent city, spend it instead on healthcare for your
homeless and specifically make that collaborative healthcare!"
I say that? Let me explain.
among Veterans is an important issue. Approximately 76,000 Veterans
are homeless on any given night in America. And over the course of a
year, approximately twice as many will experience some episode of
homelessness. Eliminating Veteran homelessness is one of VA’s top
priorities and is a challenge that Veterans, their families, and VA have
been working to overcome for a number of years. In 2009 the Secretary
of the Department of Veterans Affairs, Eric Shinseki announced VA’s goal
to end homelessness among Veterans within five years. We are not there
yet, but each year the number of homeless Veterans has been decreasing
as VA has increased homeless Veterans’ access to permanent supportive
housing, supportive employment and benefits, and well designed and
Homelessness is caused by some illnesses, e.g.,
mental illness, substance abuse, disabling medical conditions.
Homelessness causes other illnesses, e.g., exposure, infestation-related
disorders, and exposure to infectious diseases such as TB. And last
but certainly not least, homelessness exacerbates management of other
diseases such as diabetes and hypertension. Homeless individuals are
three to six time more likely to become ill than housed individuals.
And within the VA, the cost of providing healthcare to homeless Veterans is
three times the cost of care for non-homeless Veterans. Thus, the
provision of accessible, comprehensive, coordinated and collaborative
care is essential to the effective treatment of the homeless.
research literature pretty strongly suggests that traditional primary
care is not a particularly effective health care delivery system for
our homeless Veterans. However there is a growing number of studies
that show strong support for a model of care in which primary care
services are linked with care management, embedded mental health, and
housing support. Sounds like collaborative care to me! In a
Chicago-based study a program using this approach, a 29% reduction in
hospital days and a 24% reduction in emergency department use were
is betting that its new and improved primary care system known as PACT,
in combination with dedicated and embedded services for the homeless,
will provide a better alternative to address the healthcare needs of its
Veterans with multiple medical problems and chronic states of
homelessness. PACT is the acronym for Patient Aligned Care Team—VA’s term for patient centered, team based, collaborative primary care. PACT
is each Veteran working together with health care professionals to plan
for the whole-person care and life-long health and wellness, with a
focus on partnerships with Veterans, access to care using diverse methods, coordinated care among team members, and team-based care
with Veterans as the center of their PACT.
To make PACT even more
relevant to the care of homeless Veterans, VA created a new program
known as H-PACT --Homeless-PACT teams. H-PACTs are uniquely
formulated to meet the healthcare needs of homeless Veterans. There are
several different H-Pact Models being "field tested” in VA at the
present time. These models vary depending on geographic location and
estimated numbers of homeless Veterans. The most comprehensive H-Pact,
suited for larger VAs in urban areas with a large homeless Veterans
population, combines a full blown PACT and a comprehensive Homeless
Veteran Treatment Team that are co-located and fully integrated and have
their own panel of homeless primary care Veterans. And yet another
H-PACT model targets those Veterans who are chronically homeless,
treatment and service disengaged, or treatment resistant Veterans. This
latter model is usually located in the areas frequented by the
homeless, often near the non-VA community shelters that are operated in
is a very new program, that was initially started as a small pilot. VA
is considering expanding the number of H-PACT teams nationally, if it
can find the most effective type of H-PACT from among the several
variations that have already started. The Center for Integrated
Healthcare will be assisting VA’s Homeless Program Office in conducting
some of the initial evaluation work, so stay tuned. Perhaps in a future
blog I’ll have more information for you. For now, just remember that
collaborative care is at the heart of H-PACT.
Dr. Lantinga is a licensed psychologist who has worked for VA for over
40 years and is currently the Associate Director of the Center for Integrated
Healthcare. In this role
he is responsible for the day-to-day leadership of the Center, in
support of the Executive Director. He also closely collaborates with the
researchers and educators in the Center. Dr. Lantinga maintains
academic affiliations with faculty positions in the Psychology
Department at Syracuse University and in the Departments of Psychiatry
and Urology at the State University of New York Upstate Medical
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Posted By Katherine Dollar,
Thursday, March 28, 2013
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Kathy's blog is the third
post in a series on
integrated care for
military and veterans.
When I began my training as a clinical
psychologist, I did not envision myself working for the Department of
Veterans Affairs. In fact, I would have predicted that I would end up
in almost any other setting. The myths or stereotypes described by Dr.
Pomerantz’s prior blog predominated my thinking. As I suspect happens
to many of us, my early career projections were wrong, as were my
stereotypes of the VA.
the lens of a clinician, I hope that I can further dispel some of the
common myths and present a clear picture of integrated care within the
VA. There is a great deal of variation across our large network of
facilities, and my thoughts may not be consistent with the experiences
of clinicians at every location. However, I do believe that there are
common themes experienced in most VA integrated care settings.
it has been my experience that providers within the VA care deeply
about Veterans and Veteran healthcare. I consistently see primary care
colleagues going to extraordinary lengths to ensure high quality,
patient-centered care. In a recent hallway conversation with two of my
primary care colleagues, we ended up discussing the overwhelming sense
of duty and responsibility to provide exceptional care for the Veterans
and how this translates not only into direct service delivery, but also
into interactions with patients in hallways, over the phone, and in
the community. The reality is that VA employees care tremendously about
Veterans and about providing high quality care.
We also have a high
degree of accountability built into the system through policy and
programmatic expectations. It is experienced as a system of checks and
balances with multiple requirements and high levels of accountability
and oversight. Integrated care, including both collocated collaborative
care and care management, are not options, but programmatic
integral part of functioning as a behavioral health provider in a VA
primary care clinic is communicating and working closely with all
primary care team members. Typically, this means that days begin with a
team huddle, including the primary care provider, the RN, LPN,
administrative support, and other primary care-based professionals
(e.g., dieticians, pharmacists, medical social workers). Fully
consistent with the tenants of the medical home, we are implementing
team-based care. Skills in collaborating with other medical professions
are necessary to be successful. Indeed, several of my colleagues who
were not used to team-based care have had to change their practice
management styles or risk becoming irrelevant to the clinic.
huddles we usually review patients who are scheduled to be seen by the
team that day and discuss the plan for care. As the integrated
clinician, and the behavioral change expert, I provide input for mental
health concerns as well as medical conditions that have a strong
behavioral component. I might discuss potential ways for the other team
members to approach these concerns, offer to join the provider or one
of the nurses in their appointment with the patient, or offer to see
the patient individually the same day.
day, or open/advanced access is another integral component of
integrated care within the VA. There are many ways this can be
achieved and this has been structured differently in various locations.
The clinics in which I have become most familiar, have structured
schedule grids such as scheduled 30 minute appointment slots on the
hour, with the back half of the hour usually unscheduled. This allows
access to appointments for Veterans the same day that they see their
primary care team.
Although there is much variation in implementation,
Veterans and the other primary care team members value this scheduling
feature. It provides direct access to a behavioral health specialist not
only allowing the Veteran to start an intervention the same day that
symptoms were identified by the primary care team, but also allows the
primary care team members to have direct communication and
consultation with a mental health provider. This process de-mystifies
mental health service delivery.
the VA primary care setting, we see a surprisingly diverse population
of Veterans, including women, reservists, individuals who served in the
National Guard, and younger individuals recently returning from active
duty who have young families. If you visit expecting to find the image
of the Veteran conjured up from the song, "Take Me to the Mountains”,
you will be surprised. Clinics are busy, vibrant locations with diverse
patient populations, that have dramatically moved beyond the
stereotypical view of Veteran healthcare settings.
part of meeting the needs of the diverse population we have
incorporated technology into our communication and interventions for
patients. We routinely use telephone, video teleconferencing, and
secure instant messaging to communicate with Veterans and provide
service delivery. As the Veteran population has shifted to include
younger individuals, who communicate primarily through advanced
technological platforms, the VA has embraced these technologies and has
remained relevant to this population by finding ways to incorporate
technology into care within and outside of the primary care setting.
Further, these innovative advancements allows us to increase access to
and communication with Veterans living in rural locations, who may not
be able to make routine visits to medical centers to obtain mental
health services. As a clinician, I like having to capacity to serve
Veterans who may not be engaged in treatment without the use of
types of services being provided in VA integrated care are
complementary. Through the provision of collocated, collaborative care,
and care management, we combine same day access to a therapist who may
provide a brief intervention, with the use of evidence-based screening,
assessment, decision support, and symptom monitoring . Thus, patients
receive a unique blend of evidence-based services that are tailored to
their individual needs, are tracked over time, and adjusted based on
symptom severity. This system, when optimally functioning, creates a
feedback loop between the patient and all team members.
closing, I hope through a combination of our posts, we have dispelled
many of the myths and outdated stereotypes about VA service delivery
while providing a picture of a modern, patient-centered, results-driven
healthcare system. I am honored to work for the Department of Veterans
Affairs, as are my colleagues and co-team members. I am thankful that
my career projections were just as erroneous as my stereotypical views
of the VA. Through continued implementation of the medical home model,
the VA continues to be a leader in patient-centered, team-based,
results-driven, innovative care.
Katherine M. Dollar, PhD is the Clinical Coordinator at the VA Center for Integrated Healthcare (CIH) and a Research Assistant Professor, in the Department of Community Health & Health Behavior at SUNY Buffalo. Dr. Dollar is also a Consultant to the VA Office of Mental Health Operations (OMHO). CIH is VA Center of Excellence
devoted to advancing research, education, and clinical consultation to
enhance the integration of mental health and primary care services for
America's Veterans. She provides consultation, education,
and technical assistance, for facilities, networks, and individuals
requesting program assistance to achieve full implementation of VA
integrated care components.
This post has not been tagged.
Posted By Andrew Pomerantz,
Thursday, March 21, 2013
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Andy's blog is the second
post in a series on
integrated care for
military and veterans.
"Found him on VA ward, feelin’ kind of low.”
"A pardon from a VA ward, just ain’t so easy done…but a good old friend and doctor there said it could be done.”
Those lines, from the old song "Take Me to the Mountains,” invariably conjures images that were popular a generation or two ago when the Veterans Administration hospital system was the last vestige of hope for combat Veterans who had fallen off the rails of society. Whether the image was true even then is arguable and I don’t think worth discussion now. Suffice it to say, the Veterans Health Administration (one of three arms of the Department of Veterans Affairs, created 30 years ago) is now a highly developed single payer capitated healthcare system and the largest healthcare system in the United States, with over 8 million enrolled Veterans and nearly a thousand VA facilities and community based outpatient clinics in the US, Puerto Rico and the Philippine Islands. Now, more than half of VA care occurs in community based outpatient clinics and, by quality measures, is outperformed by no other systems.
Old perceptions die hard (and slowly), so, as we take a little time for a
few of us in VA to provide perspectives on this blog, a couple of myths
need to be tended to.
- "You can do that in the VA because you are part of the military and can do whatever you want”:False. VA is distinct from the military healthcare system and is held accountable to the same standards as any other healthcare entity.(It should note that the military health system is also an integrated care leader).
- "Only combat Veterans can get care in VA”: False again.Just about anyone who has been honorably discharged from the military can enroll for care, as can many others, like active duty national guard members returning from combat. Some Veterans have a co-pay for some of their care, just as they do in the private sector.
- "VA facilities get as much money as they want. When they need more, Congress gives it to them.”Wrong again. We do have to live within our budgeted appropriation from congress and each facility’s budget is based on workload. At times, seed money (similar to grants in the private sector) is earmarked for new program development but after a few years, the special funding ends and the programs stand or fall on their results (yes just like grants).
These myths are only the tip of the iceberg but are the three most common statements I hear when I talk with people outside of the federal sector about the development of integrated care in this system. VHA provided special funding 5 years ago to help facilities develop integrated care programs, which are now mandated to be present in every VA medical center and the larger community based clinics. Many facilities are working now to develop innovative ways to integrate mental health and primary care in the smaller and more rural clinics.
There are two core components to integrated care in the VA, both resulting from local innovations and research whose results were so positive that went viral and became requirements.
1.Collocated collaborative care: This refers to the mental health clinicians (nurses, psychiatrists, social workers, psychologists) who are members of the primary care (medical home) team. They provide consultative advice and education, as well as direct assessment and treatment as part of the primary care treatment plan. CCC clinicians have a patient-centered, problem/function focused approach that streamlines care for patients identified (clinically or by routine, required screening) in primary care, Open or advanced (same-day) access is an important feature of the program. Despite broad variation in program development and function across the country, almost half of the primary care patients seen in integrated care last year never needed referral to specialized mental health care.
2.Care Management:This is the familiar telephone based care that provides disease registries, assessment, ongoing monitoring, medication management, problem solving and behavioral activation for patients treated for depression, anxiety and at-risk drinking. Similar protocols for chronic pain and other problems are currently being honed. The CM programs are based on the familiar RESPECT, IMPACT and other integrated approaches that have shown strikingly positive results over 20 years of research. The Behavioral Health Laboratory is a care management program developed within VA and has modules for all of the above disorders plus a referral management module. TIDES (Translating Initiatives for Depression into Effective Solutions) is the VA adaptation of the other programs in the research literature.
Two related programs are also part of VA integrated care. These include health behavior coordinators and health promotion/disease prevention programs that help Veterans achieve and maintain healthy lifestyles. They provide a wide range of services including training for providers, direct clinical care (MOVE! is an effective intervention for obesity and is often provided via telemedicine), health coaching and other interventions.
As the National Mental Health Director for Integrated Services it has been my privilege not only to develop policy but also to work closely with dozens of programs across the country as they grow and mature. I have learned a great deal as I see many programs adapting the core components to fit a wide variety of local environments. Having once been a primary care physician who went into psychiatry wanting to be able to do more, it’s almost enough to make me go back to primary care. But not quite.
Some of my national colleagues are going to follow this tome with more details of integrated primary care in VA. I would also refer you to the summer, 2010 issue of Families, Systems and Health, which was dedicated to the VA programs.
S. Pomerantz, MD is the VA’s National Mental Health Director for
Integrated Services, Associate Professor of Psychiatry at the Geisel School of Medicine at Dartmouth and a current member of the CFHA board
of directors. He has been a primary care physician, Consultation and
Geriatric Psychiatrist and was Chief of Mental Health at the VA in
Vermont for nearly 20 years. He has received many local and national
awards for his work integrating mental health and primary care and other
programs and is a Distinguished Life Fellow of the American Psychiatric
Association. He telecommutes from his home base in Vermont..
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Posted By Chris Hunter,
Friday, March 15, 2013
| Comments (0)
Chris's blog is the first
post in a series on
integrated care for
military and veterans.
In a recent article, the president of the American Medical Association highlighted the importance of integrating mental and physical health care. He noted important policy, finance and paradigm service delivery changes that make today ripe for such change. He further argued the importance of providing integrated care for at risk individuals with a special emphasis on retooling health care service providers so they can deliver efficient and effective whole person care. He goes further to highlight the importance of ensuring these services are available for our military service members. I couldn’t agree more and am pleased to report that the integrated care for our active duty and retired military service members as well as their families has been available for the last 13 years, and has continued to grow and improve.
Integrating behavioral health services into primary care in the Military Health System (MHS) is not a new concept. In 2000, the Air Force launched its Behavioral Health Optimization Program (BHOP). This program embedded behavioral health providers (primarily psychologists) into primary care clinics to provide integrated behavioral health services using a Primary Care Behavioral Health (PCBH) model of service delivery. In 2003 the Navy launched a 2-year demonstration project building on the work of the Air Force BHOP. The Army launched the Re-Engineering Systems of Primary Care for PTSD and Depression in the Military (RESPECT-MIL) feasibility study in 2004. This was a systems-level, care management model approach to improve recognition, management, and follow-up of depression and post-traumatic stress disorder.
|Despite the early work done in the Air Force, Navy and Army, the Department of Defense (DoD) MHS had no shared vision or implementation strategy across Services for integrating behavioral health services into primary care. The need for an enterprise-level vision and strategy was amplified when the Report of the DoD Task Force on Mental Health in 2007 recommended the integration of mental health professionals into primary care settings to improve the access and outcomes of behavioral healthcare. |
"As AMA president, I will note the need to
better integrate mental health care into
other aspects of medical care – to provide
more resources to treat more people."
"Just like we'll need you to make a
concerted effort to help our returning
troops, veterans and their families."
Inaugural address of AMA President,
Jeremy A. Lazarus
It was clear that if the DoD was going to move forward with a shared vision and strategy there needed to be a DoD level lead. To that end a DoD Program Manager for Behavioral Health in Primary Care position was created. I was fortunate to be hired to fill this role.
Over the last 4.5 years a number of milestones have been reached.
1. Agreement on "minimum” staffing levels…a minimum of 1 behavioral health provider (BHP) in clinics with 1500-7499 enrollees using a PCBH model of service delivery and 1 BHP and 1 Care Manager using a blended model of care with enrollments of 7500 or greater.
2. Funding began in FY 2012 to hire and train 470 behavioral health personnel to meet those minimum staffing levels by the end of FY 2016.
3. Clinical, Administrative, and Operational Standards for delivery of behavioral health services in primary care to include a phased training process with over 21 hours of in person intensive didactic and role play training to meet minimum core competency standards prior to the BHP engaging in any service delivery in primary care. This is followed by in-clinic training and feedback to facilitate acquisition of additional core Clinical, Administrative, and Operational competencies.
4. Currently 61% (207 of 336) of MHS adult primary care clinics have full-time staffed integrated care programs:
Percent of Clinics with Specific Model:
Care Management Model Only: 32.8% (68 of 207)
PCBH Model Only: 46.3% (96 of 207)
Blended Model: 20.7% (43 of 207)
Electronic medical record (EMR) BHP screening, assessment and clinical documentation and service delivery templates for mental health, substance misuse and health behavior problems (e.g., tobacco, pain, obesity) are in the process of beta and pilot testing. Once pilot testing is complete, behavioral health personnel in 120 military treatment facilities (which can have more than one primary care clinic) will be trained to use the EMR templates and expected to use the templates on every patient encounter per Army, Navy and Air Force practice standards. These notes allow for centralized data pulls in common fields with the same medical terms and screening/assessment scores across the Army, Navy and Air Force.
Program evaluation plans are well under way and are expected to start within this fiscal year. Evaluation is centered around the Quadruple Aim….improved readiness to deploy, better outcomes, patient and provider satisfaction, and cost management. Both process and outcome metrics will be collected, through enterprise wide program assessment as well as discrete process improvement projects in selected clinics across the Army, Navy and Air Force.
Ensuring that our active duty and retired Service members and their families have outstanding healthcare is a top priority. Integrating full-time behavioral health services in our MTF Patient-Centered Medical Homes, is an important part of that outstanding care. A great deal of work has been and is still left to be done. However, I’m confident that the programmatic clinical, operational, administrative, financial and program evaluation components in place will facilitate meeting Quadruple Aim goals and provide easy access to evidence-based behavioral health services in primary care.
Additional information can be found in: Hunter C. L., & Goodie, J. L., (2012). Behavioral health in the department of defense patient-centered medical home: History, finance, policy, work force development and evaluation. Journal of Translational Behavioral Medicine, 2, 355-363.
Dr. Hunter graduated from the University of Memphis specializing in behavioral
medicine. He is board certified in clinical health psychology and works for
TRICARE Management Activity (TMA) as the DoD Program Manager for Behavioral
Health in Primary Care. He is a previous Chair for the Society of Behavioral
Medicine’s integrated primary care special interest group and has been
Collaborative Family Health Care Association board member. In
2002 he received the Arthur W. Melton Early Career Achievement Award
from AP Division 19 (Military Psychology). He has published several research articles and book chapters and in is
the lead author on the book Integrated
Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and
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Posted By Natalie Levkovich,
Sunday, March 10, 2013
| Comments (2)
As the name of our association proudly declares, Collaborative Family
Healthcare Association has always seen the patient & family as integral to
collaborative care. Long before the language of Patient-Centered Medical Home
seeped into our lexicon, CFHA endorsed the centrality of the patient, the
family and the community as determinants in the health of the population. Through research, policy and practice, CFHA
has steadfastly advocated for the universal adoption of the values and
practices that integrate a patient-centered perspective into the delivery of
care. Effective adoption of this perspective requires providers to be proficient,
efficient, present, compassionate and empathic in the practice of their
So, as providers collaborate with patients, families and colleagues, what
impact does their daily experience have on them as individuals, on their
practice, on their families? As they offer support to their patients, absorb
their stories, apply their professional judgment and implement
empirically-supported interventions to help patients reflect on their goals and
adopt more effective problem solving strategies, who helps the provider to
reflect on the impact their work has on them? CFHA blogs and presentations have
been devoted to the needs of family caregivers. What about the needs of
professionals? Regrettably, in many if not most settings, little attention is
paid or time set aside for clinical or reflective supervision.
|Reflective supervision (RS) is particularly well suited to address
the impact that repeated exposure to vulnerable patients and stressed
environments has on the practitioner. RS seeks to embed reflective practice in
the supervisory experience as a way to model parallel process and the
inter-relatedness of all the relationships involved in collaborative care,
including those of providers with supervisors as well as providers with patients/families
and colleagues. ||Reflective supervision is particularly well suited to address
the impact that repeated exposure to vulnerable patients and stressed
environments has on the practitioner.|
In fact, the supervisory relationship should mirror the desired
relationship between provider and patient. RS specifically attends to the emotional
content of the work and how providers’ emotional responses directly affect the care
they deliver. RS practices involve establishing an expectation of regularity,
emotional safety, validation and collaboration that includes a supervisor
guiding the supervisee, in the context of case review, to examine his/her own
feeling and values and how to use that self-awareness to serve the best
interests of the client.
While the mode and nomenclature of RS grew out of early childhood services, the
importance of reflective practice as a critical component of effective practice
is also noted in literature about education and supervision of healthcare practitioners
(see Patricia McClure’s article
"Reflection on PRACTICE) Growing evidence of the
importance and efficacy of RS for
identifying and reducing burnout, vicarious trauma and secondary traumatic
stress is resulting in its gradual spread to other fields of human service. To
learn more, read a brief but excellent white paper that outlines the practices
and values of RS as a trauma-informed practice and provides additional
references. Further, The National Child
Traumatic Stress Network endorses RS as a critical component of preventing and
addressing secondary traumatic stress among workers who are affected by
repeated exposure to their clients’ traumatic histories, see here.
CFHA has begun to include sessions on trauma and trauma-informed
practice in recent conferences. The Adverse Childhood Experiences Study was
discussed at several sessions during the 2012 Annual Conference in Austin, TX. Now,
as we continue to expand our audience and partnerships, the time has come for
CFHA to integrate the needs of providers, beyond self-care, into our education
and advocacy for strengthening systems of collaborative care. I hope that CFHA will take up the cause of
making supportive supervision both a provider right and a necessity when striving
for the gold standard in health care. Our 2013 Annual Conference in Denver
presents an opportunity to advance this conversation. As the conference committee
considers workshop proposals to accept and plenary speakers to invite, they should include clinical supervision as a priority. I challenge the conference
planners and prospective presenters to consider this question with the same
thoughtful approach that CFHA devotes to all of its work.
See here, for an example of Reflective Supervision relevant to an integrated care setting.
Natalie Levkovich is a CFHA Board Member and was a co-chair of the 2011 CFHA conference in Philadelphia. She has served as the executive of the Health
Federation of Philadelphia (HFP) for nearly three decades. HFP is the SE
Pennsylvania network for community health centers that provides comprehensive
primary care to nearly 300,000 low income and underserved individuals per year.
Under her leadership, HFP has experienced remarkable growth through the
development of many innovative, collaborative initiatives
such as the integration of behavioral health in primary care, including
widespread implementation of a sustainable clinical, payment and professional development
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Posted By Amy Davis,
Thursday, March 7, 2013
| Comments (0)
Hi CFHA community,
I had the honor and privilege last
week of interviewing young family therapists to come join the ranks of new
learners and lifetime learners at St. Mary’s Family Medicine Residency in Grand
Junction, Colorado. We, a team of physicians, behaviorists, nurses,
and educators chatted it up around a table smiling and proudly described our
environment to the interviewee. He asked us to each explain what we
enjoyed most about our clinic. Each of us responded without pause…relationship...relationship
with each other and with our patients.
What does this have to do with CHFA
I think this has everything to do
with this conference. Ideally, the plenaries, discussions,
workshops, networking hopefully all ultimately lead to a most positive, healthy
environment for those we serve and for ourselves too. When Randall Reitz
asked me to help plan this conference, I was a bit intimidated (and actually
remain so!). However, I am passionate about the work of collaboration and
of dynamic change to a "healthier” healthcare system, so with a deep breath, I
have joined with Laurie Ivey on the program committee for CHFA
2013. In order to forge ahead with promise and creativity, we need
the collective power of all of your hard work in your various disciplines.
The conference dates are October
10-12, 2013. The theme for the conference is "Disrupting Status Quo”
which we think parallels changes in the health care political, economic, and
clinical environments. We as providers and consumers are readying
to embrace what will hopefully be a metamorphosis of healthcare. These
changes are likely to be disruptive and uncomfortable but offer great hope and
promise for those of us who advocate for collaboration in healthcare delivery.
In contrast to our "disrupting”
theme, the conference will be set against the backdrop of the Flat Iron
Mountains between Denver and Boulder, Colorado. Western poetry
emanates from the open sky, crisp air and the rolling range leading to the
foothills. I encourage you to consider submission, to come dialog,
debate, and share…then relax under a clear Colorado sky. Make us think,
make us squirm, challenge us to a better way.
The call for presentations began February 1st and will close March 15th.
Please submit them at the CFHA
website. We look forward to reading them!
|Amy is Family Physician who has
lived a varied professional life with public service in the IHS, residency
education, work with under-served communities, and 13 years of collaborative
care experience. She currently is the Medical Director of the SMFM
Collaborative HIV clinic and works in primary care at the VA in Grand Junction,
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Posted By Tina Runyan and James B. Anderson,
Thursday, February 28, 2013
| Comments (0)
"Collaborative care is done in many
ways, by many people, in many settings—it is not ‘just one thing.’”
promises not only opportunity to care for patients more holistically, it also
provides a living laboratory for training practitioners across disciplines.
Notwithstanding the vastly different training paradigms across disciplines,
integrated settings offer rich opportunities to borrow and exchange ideas from
the training traditions of other disciplines. Narrative medicine has been a time-honored
component of family medicine residency training as a mechanism to enhance
reflection, self-awareness, and process nuances of the physician-patient (or
trainee) relationship. Analogous to "A Piece of My Mind” in JAMA, U Mass Family
Medicine hosts a Thursday Morning Memo
comprised of personal vignettes submitted by faculty, residents, and medical
students; the popularity of the essays is demonstrated by a distribution list that
has grown to over 450 readers. Included here are three reflective essays
grounded in collaborative care practice and training.
_ _ _
I made it to my car before I
broke down in tears. I had just come from the hospital having seen a young
woman in the hospital with acute fatty liver disease who nearly died in
childbirth a few weeks earlier. I felt as tightly pulled in so many directions
as the skin atop a snare drum. I was supposed to be home an hour ago and my
daughter had already called twice. I had a grant report due by five o’clock,
and too many e-mails in my in-box asking about something due or overdue. I felt
as if I was letting everyone down and I couldn’t wait for the day to come to a
close so I could just lie in bed and read stories to my children. And then it
came to me … the three questions. One of the favorite stories in my home is a
children’s adaptation of Leo Tolstoy’s short story about a little boy who poses
three questions to the wise old turtle because he often finds himself unsure if
he is doing the right thing.
The three questions are:
1. When is the best time to
2. Who is the most important
3. What is the right thing to
|All I knew about the woman I
went to see in the hospital was a little bit of history about her disease, the
medical events to date, and that she was refusing to see her baby which was
concerning to all involved in her care and upsetting her family. There was
worry about severe post-partum depression or psychosis. I entered the room to find a listless and
soft-spoken woman with dull yellow eyes, too weak to reach for her water glass.
Her husband and soul mate of 20 years, steadfast by her bedside for weeks, left
us alone to talk.||Reflective writing and the use of narrative medicine can offer nascent practitioners a glimpse into
the humanities of their |
mentors and peers, help break down barriers across
disciplines, and cultivate mutual respect.
She didn’t start with "the story.” Instead, she told me all
about the life she and her husband had built together. She told me about her
family. She described her longstanding uncertainty and the numerous
conversations she and her husband had about whether to even have children. She
told me about her birthing classes and her labor plan with a doula and her
hopes for the baby’s first hours after delivery. She cried. She detailed the
weeks leading up to the diagnosis and C-section and her emotions towards her
obstetrical doctors. She explained how defeated she felt and how she does not
have the stamina to even sit upright in a chair for any length of time. I tried
not to cry. She kept telling me how dismissed she has felt and how no one was
listening to her -- everyone was saying how good she looked and she still felt
as rotten today as a few weeks ago when she nearly died.
An hour and a half
later as I stood to leave, she looked me tearfully in the eye and asked "Will
you come see me tomorrow?” Even though I was feeling time slip through my hands
like dry sand, I looked right back and said "Of course I will.” So as I sat in
my car it was exquisitely clear that the best time to do things was now, in
this only moment we know to be certain, the most important one is the one you
are with, and the right thing to do is to do good for the person you are with.
I took a deep breath and took comfort in knowing I was exactly where I needed
to be this afternoon. My drive home was serene. And the bedtime story that
night goes without saying.
_ _ _
On a cold winter morning with the plows finally moving for the
first time this winter, I set off for the long drive to the Barre Family Health
Center. Despite a long weekend, I felt a
bit sluggish starting the day, perhaps because of the random text message that
woke me early in the morning threatening to turn me into the police because of
repeated harassing messages (I didn’t do it, I swear!).
I went through my morning, seeing a typical panel of behavioral
health patients at the health center: A woman struggling to control her weight
and mood following bariatric surgery, recurrent major depression, a middle-aged
couple struggling to save their marriage, and a newly referred patient
adjusting to her newly prescribed suboxone while also trying to find a way to
re-narrate her life while free of drugs.
While I felt some sense of competence and satisfaction after seeing this
variety of patients, I also felt tired. After this clinical session, I entered
into our monthly panel of meetings. As
they do at times, the meetings bled into each other in my head. Finally, we got to the last meeting of the
day—the providers meeting.
was led by our chief resident, who is pregnant.
Earlier this month, she found out she had been accepted to join a
prestigious fellowship program. In the
middle of the meeting, she was pulled out by our lead nurse to tend to a
patient who had been unexpectedly added to her schedule. Her colleague and fellow resident seamlessly
took over the lead of the meeting.
Towards the end of the gathering, I had the chance to present a project
that my mentor and I are trying to initiate at the health center.
One of the attending docs, who has been at
the health center since about the time I started pre-school, literally leaned
forward in his chair to listen to the project description and offer incredibly
insightful and concise advice about how to make it work. This man had been seeing patients all day
since 8:30 and still was full of energy.
Another doctor, this one a young woman just years out of residency, also
provided helpful advice, while making a warm-hearted joke to keep the mood
light even after a day full of meetings.
Following discussion of the project I am trying to develop, two other
docs piped in with their own ideas of how to improve our community, with ideas
of a health center-based patient library and ways to help low-SES patients get
transportation to and from the health center when they don’t have a car. One of these doctors is a Harvard product who
selflessly and tirelessly devotes himself to medicine, the health center, and
under-served populations. The other is a
very young doctor who manages a full patient panel while running our resident
in-patient service and raising a beautiful young daughter on her own.
As I drove home after the long day, I felt happy and inspired,
feelings of fatigue from earlier in the day gone. I feel lucky to work with providers who are
as energetic as they are competent. Not
only do they have strong knowledge of a wide-range of medicine, but they also
truly believe in the importance of behavioral and community health for overall
patient wellness. As a psychology fellow
at the beginning of a career that could have taken many different directions,
these doctors and their actions reminded me of the importance of this work, and
the privilege it is to work with such outstanding doctors and people.
_ _ _
This final essay was written jointly written by Tina Runyan, PhD (italics) and High Silk, MD (plain text) about a notorious and
divisive patient in our health center, the day after the presidential election
this past Fall.
Waking to the news of
Obama’s re-election this morning brings rekindled hope for the future of
healthcare in the US. Still, the health and well being of many Americans hangs
in the balance of a transformed primary care system. This new system of care
promotes comprehensive, coordinated, whole-person, and patient-centered care.
But let’s not forget quality. Quality as defined by metrics and thresholds
chosen by insurance companies and linked to remuneration. As we sit and talk
with our patient, looking back and forth from her to each other, we both know
that we have accomplished something. Something that would never be detected
from the types of quality measures the insurance companies value.
The young woman
before us had not identified any with any health care provider in her first 30
years. In fact she had deep disdain for them all! And now, she
had bonded with the two of us and was actually making progress on health
goals.She had been handed a lot in life - diabetes at a young age,
sexual trauma, an anger management issue, being overweight, and a predilection
for alcohol. This constellation of health issues had been making life
worse for her for years: a miscarriage, relationship issues, uncontrolled
sugars and generally dissatisfaction with life. Many tears had been shed in
this office; many rants about how unfair life is; many moments of despair and
giving up. Now here was a woman sitting up taller than before. She
was talking about "getting control of her life". Her tears contained
near joy now. Her sugars had come down a little but more importantly, she was
feeling good about lifestyle changes. Minimal alcohol,walking frequently,
not drinking soda, and eating healthier - she was setting goals to get pregnant
understanding fullwell what this would entail.
After the visit, Tina
said that I should be proud to have moved her in the right direction over the
last 5 years. Sure, I had not given up. Sure, I maintained full respect
for her even at her meanest moments. But who was I fooling. This was a team
effort. We had seen her back and forth like a ping pong tournament, caring for
her week in and week out - listening, empathizing, prodding, tinkering with
medications, accepting and congratulating small accomplishments. Together we
had helped this woman make progress. We have both always been strong supporters
of co-management between primary care providers and behavioral health, but this
was the pinnacle. We had worked together, stopped each other in the hallway
frequently for consultation and updates, supported one another's ideas and
nurtured each other along. The success was not in her HbA1c, in fact we had
failed miserably on that front alone. The success was in the transformation of
the person, in the teamwork, and in progress and process. There is no quality
measure on the scorecard for these outcomes … but there it was. And we sat in
that room for a while longer, the three of us - it felt very good. It felt
rewarding. It felt like quality care. Our patient felt it too.
PS – I saw our
patient today. She is, for the first time since I met her, consistently taking
all of her medications and checking her blood sugars. She has not had any
alcohol in a couple months. She explained that she chooses not to have any
around because she knows she cannot stop at just one drink. And she knows
alcohol is not good for the baby she is now carrying. She wanted me to tell Dr.
Silk the good news.
_ _ _
Reflective writing and the use of narrative medicine to process
rich and emotionally intense experiences in training and practice are not novel
for any of the helping professions. However, sharing those musings,
particularly with those in training, can offer nascent practitioners a glimpse into
the humanities of their mentors and peers, help break down barriers across
disciplines, and cultivate mutual respect. Over time, this cannot help but to shape
a culture of interdisciplinary collaborators who find various creative outlets
for the emotional experiences intrinsic to the practice of (integrated)
medicine. In our Thursday Morning Memos,
we have discovered gratifying solace and empathy among one another.
Runyan is an associate clinical professor in the Department of Family
and Community Medicine at the University of Massachusetts Medical
School. She is
the Director of an APA accredited, two year Post-doctoral fellowship in
Clinical Health Psychology in Primary Care and the behavioral science
director for the Worcester family medicine residency. . She
recently joined the Board of CFHA and when not writing, practicing,
training or talking about integrated care she
enjoys being a mom, trail running, and practicing yoga.|
|James B. Anderson is an assistant professor and licensed psychologist in
the Division of General Internal Medicine in the Department of Medicine
at the University of Massachusetts Medical School. He is a recent
graduate of the APA-accredited, two-year post-doctoral
fellowship in Clinical Health Psychology in Primary Care in the
Department of Family Medicine and Community Health at UMass (directed by
none other than the co-author of this blog, Dr. Christine Runyan).
James received his PhD in clinical psychology from
Western Michigan University in 2010. When not working on integrated
care, he enjoys playing hockey, SCUBA diving, and travel.|
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Posted By Sandy Rose and Peter Fifield,
Thursday, February 21, 2013
| Comments (0)
Being patient-centered means respecting patient confidentiality
The DSM-V hasn’t shown-up in bookstores yet, so hopefully I can still convince the APA to add one more diagnosis to the tome: CFR 42.2 GAD (Code of Federal Regulations Section 42, Part 2 Generalized Anxiety Disorder). This diagnosis is narrowly defined, but is apparently spreading virally among mental health professionals. It originates from the effort to adhere to state licensing laws and professional ethical standards while practicing in integrated settings. It is, of course, primarily triggered by those stringent regulations imposed by 42CFR Part 2 ("Part 2”)’ which regulate the confidentiality of alcohol and drug information. Unlike HIPAA, Part 2 provisions require stringent confidentiality protections even for information used only for healthcare or payment purposes.
- Loss of sleep for operations managers attempting to write policy (i.e. locking down access in EMR’s, obtaining appropriate informed consent);
- Anger among exasperated medical records staff ;
- Deflated self-esteem among clinicians;
- Misery loving company with equally obsessive colleagues;
- Recreational or therapeutic usage of wine among all involved;
- Frequent co-morbidity with Part 2 Avoidance Disorder.
In this spirit, I offer the perspective of one non-legal, neurotic worrier and BHI provider/administrator in an FQHC. My case will be that, while Part 2 is arduous to implement as written, it is doable. And further, at its heart, it is a worthy regulation that protects patients and holds healthcare systems accountable to a reasonable standard for confidentiality.
There is indeed plenty of information to weigh in this debate. If you missed CFHA’s annual meeting this year, you can still find some great information on confidentiality issues from CFHA website posts and catch the March special edition of Family, Systems and Health featuring ethical issues in integration. SAMSHA-HRSA’s Center for Integrative Health Solutions site includes resources on understanding 42CFR. The Legal Action Center has a useful compilation of information including books, webinars, power points and free downloadable forms for compliance.
Why is adherence challenging but possible -- even with Part 2? For one, most generalist BHPs like myself are not considered Part 2 "programs”, even though we may diagnose and treat substance use disorder (SUD) conditions. As such, we are not required to do all that covered providers ("programs” in Part 2 language) must do to protect SUD information. The sticky part comes when receiving SUD information from a Part 2 provider, such as an LADC or methadone clinic that receives federal funds. A health center must still protect these records via Part 2 standards.
What does this mean? Well, a number of factoids leading to temporary 42GAD. My colleagues and I must still obtain a Part 2 release even to submit a SUD diagnosis for billing if received from a Part 2 (i.e., specialized) "program”. Most problematic for integration, a LADC or other Part 2 "program” operating as part of a team within a health center cannot freely exchange protected information with others outside of their specialized alcohol and drug unit at the center, except in limited circumstances, without Part 2 protections.
As we do employ an LADC within our group, we present authorization forms for her patients at intake, using the unified HIPAA and Part 2 authorization template form available for download by the Legal Action Center at www.lac.org. Our protocol requires her patients’ consent for billing and for exchange of information with the team and agency. As for any records obtained by her or other "programs”, it is easy enough at least in my setting to secure her notes using our EMR’s locking capabilities. This allows our medical records staff to identify these and other protected "SUD” notes, which require the special authorization for re-release outside our agency.
Our new patient portal holds further promise for reducing the barriers to compliance, once workflows and mechanisms for communication with patients through this system are in place. With secure email for authorization requests and signatures, the process of consent could be quicker and more efficient. If you assume as I did that under-served patients are not likely to afford or use email or texts, consider that nearly 30% of the predominately Medicaid funded patient population in one sample primary care group used secure messaging for their health care needs.  Half of the author’s patients and even geriatric patients were on board.
Alternatively, a center may opt to establish a Qualified Service Authorization Agreement (QSOA) with outside parties that the center frequently uses, (or between the LADC and the health center) such as for referrals or billing. With these agreements in place, a patient’s authorization is not required for release of Part 2 information.
Our center also includes in its registration paperwork (which the patient is provided at the time of establishing care) signature lines for patients to indicate that they know that their BHP (if utilized) documents in one medical chart along with medical providers, and that their clinical information may be sent to referred providers for healthcare reasons, and that this includes, where applicable, alcohol and drug information. Our registration materials also include information about mandatory reporting. We feel this covers BHPs in the case of warm handoffs and unscheduled intakes. 
Practicing the serenity prayer so well known to Part 2 patients, I am well beyond wishing the law away. It is here to stay. In fact I see the need for the law’s strong protections, given the very real discrimination and stigma these patients must endure, such as in employment, custody battles and procurement of needed pain medications or procedures. I have seen providers omit diagnoses in the medical chart where protections don’t exist. This of course may lead to the same black hole that occurs when patients don’t disclose their SUD or seek treatment.
And, holes are costly. As we all know, lethal drug interactions occur, and inaccurate diagnoses or omitted information about SUDS lead to time and dollars wasted. Not surprisingly, hospital access to behavioral health records is associated with significantly lower readmission rates. 
Given compelling arguments for and against security protections, no wonder the angst. And if health care continues to evolve, we will have blessedly more information to safeguard. The prescription drug monitoring program just passed last summer in NH as in other states should no doubt increase SUD detection rates, as will the SBIRT program our center is rolling out next month. 
Contrary to popular opinion the law was not written to create 42GAD and thus drum up more business. Written into the code is its critical rationale--"so patients will not be made more vulnerable by reason of the availability of his or her patient record than an individual who has an alcohol or drug problem and who does not seek treatment”.  And, patient centered care is after all grounded in the belief that patients are fully informed and engaged in decision-making, after weighing information pertinent to care, including risks involved in treatment.  Why shouldn’t this include risks of having one’s information disseminated to third parties, when such release might impact on their care or reputation?
The solution is not to override patient choice for the sake of expediting treatment "for their own sake”. Nor should their choice be eradicated for the ease of providing care. Medical decisions are grounded on patient choice: Consent for disclosure of sensitive information is no different. Let’s work harder to make the choice more efficient and speedier, rather than the release. It is simply and only the patient who should decide where and how much their information gets disclosed. Given the chilling effect otherwise, it is well worth the technical fixes, extra paperwork and workflow headaches to enable this.
Being Type A and returning home from a one week vacation without internet, you can imagine my reaction to yet another New Hampshire power outage as I type this, and the prospect of hours, if not days of no home internet. Yet I will begrudgingly accept the speed limits along the way to the nearest Starbucks outlet and wi-fi to plug in my computer. After all, even ambulances slow down at dangerous junctures.
||I think Dr Rose may need therapy...|
The new DSM-V may not include Dr. Rose’s proposed CFR 42.2 GAD diagnosis but as we continue to navigate the pathways of sharing patient information across the integrated spectrum of care, I’m continually reminded that there is potential for a diagnosable "CFR 42.2 Delusional Disorder”. Subtypes include but are not limited to the following:
- Bizarre Delusions that involve common medical culture phenomena that are totally implausible such as a fully integrated health record
- Delusional Jealousy regarding the perception that Behavioral Health personnel do not have the same free flow of information sharing that medical provider’s do.
- Grandiose Delusions related to one member of the medical team having delusions of inflated worth, power, or higher status.
- Of Being Controlled Delusions where data entry in the EHR, face-to-face communications and other interaction are being monitored and controlled by a higher force.
My colleague and co-presenter deserves respect for her comprehensive investigation of this topic and subsequent informed opinions regarding confidentiality and consent. She however, may have gone a bit over the deep end this time. The core issue here regards assuring that we do the best thing for patient at all points of contact right? Right! And, if accurate and relevant information does not flow freely between agencies how can we, the providers of integrated care, the disciples of medicine self-chosen to transcend all the boundaries of traditional patient care—be it biological, psychological or social—ensure the best care for the patient has been accomplished? How can we know that medications are not being duplicated, misused, abused or prescribed in an unsafe manner? How can we ensure that patients are checking their A1C’s, are eating healthy foods and exercising three times a week or not overusing emergency services?
I try to imagine what a physician would do with an incomplete EKG reading or an MRI that only showed the upper left quadrant when the issue was in the lower right? Providers need the right information to make the right decisions and with humans being so complex it is safe to say the more information we have, the easier it would be to make a safe, calculated decision. It would be wonderful to believe in the conceptual comforts of patient controlled information sharing but I can’t help but wonder if patients really control their information? More importantly, if they had the opportunity, would they really want that level of responsibility? How could they know what is best for them regarding the complexity of most chronic illnesses? I guarantee that there is not a provider out there that has not experienced the increased hypochondriasis happening just from patients overindulging in a simple WebMD! How do patients know what information is relevant to their overall health? Providers are trained to care for patients and to do this they need full access to the patient’s biopsychosocial history.
One of Dr. Rose’s concepts I think we can all get behind regards the futility of wishing away the laws. In this case, the Serenity Prayer may not be as effective as Mother Necessity. We need to get creative. One key element Dr. Rose mentioned pertained to 42 CFR Part 2 and the exchange of information between "program” specialists and providers. Why in anyone’s right mind would they hire a specialist such as a LADC if it is going to inhibit the flow of information? What we are talking about here in the first place is short-term solution focused interventions. We do not need a specialist license for that.
Furthermore, why would we not adhere to the KISS [keep it so simple] model and just hire non-specialist BHS providers that could communicate between providers without all of these complicated policy and licensing barriers? Reimbursement models for licensed specialists are not that robust to begin with, never mind being unsustainable. We could simply continue Behavioral Health tax write-offs and hire less skilled BHS providers. Why do we need a highly skilled, highly specialized Ph.D level Psychologist to deliver generalized short term brief therapy? We could simply have our highly integrate-able, non-licensed, non-specialized BHS providers send a note to the medical provider explaining the rationale behind giving the patient the substance use or even mental health diagnosis and the medical provider could enter in the chart. Workaround complete!
One concept worth mentioning is the idea of Regional Health Information Exchanges [RHIE] and how they are designed to access and distribute patient information. RHIEs could be designed so patients have to opt-out of the privilege, not opt-in. Giving them the opt-in option will only increase their skepticism of the beneficence of their shared information. Various countries in Europe designate organ donation as opt-out. The results are that some countries have donation rates as high as 99% while other countries have opt-in policies resulting in organ donation rates as low as 14%. If what we are looking for is getting the information out there to share, we need to reduce the number of hurdles in the way as well as proactively create opportunistic policies to maximize the number of people in the system.
I honor Dr. Rose’s reverence and optimism towards confidentiality. She mentioned that a solution is not to "override the patient choice for the sake of expediting treatment for their own sake and to focus on working harder to make the choice of release of information more efficient and speedier for the patient”. This may be falling on deaf ears. We have been trying this approach for years and no one seems to listen! All the guilds want their control. The Substance Abuse people won’t meet with the Mental Health folks; the Mental Health folks won’t meet with the Primary Care folks; this proverbial sandbox is a mess and no one is playing well together. It appears that the folks in the sandbox don’t want true equality across the spectrum of care as much as they want to be the one with the best sandcastle.
Although the biopsychosocial model was officially postulated in the late 70’s, common sense has supported the integrative nature of healthcare way before we started officially silo-ing providers. Our grassroots movement that has been growing and expanding over the past two decades has hit a ceiling. Above us now sits the three-siloed thrones of care--medicine, psychology and substance abuse--none willing to heed advantage to the other. None willing to collaborate from the top down to meet the grass root efforts growing upward like vines.
The ultimate question is this: Do we really want a patient centered medical home where the patient has "real” control of the information? In the end, consumer choice typically leads to over-consumption, confusion and waste of resources. So regardless of what end of the spectrum your beliefs lie, ultimately, we need to focus patient care the triple aim—improving health, reducing costs and improving the patient experience. All of the above could be attained by paying more attention to access to, not permission for, complete patient information.
||Sandy Rose is a psychologist and Director of Behavioral Health for Goodwin Community Health, an FQHC in the Seacoast area of NH. She is past president of the New Hampshire Psychological Association and served two terms on the Council of Representatives of the American Psychological Association. She is currently a Psychology Advisory Member of the New Hampshire Board of Mental Health Practice.|
||Peter Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. He presented with Sandy Rose on this topic at the 2012 CFHA conference and they are co-authoring an article in the upcoming special iethics issue of Families, Systems, and Health. |
 The Federal Law for Confidentiality of Alcohol and Drug Abuse Records.
 Steve Arnault, Cathy Hudgins, and Peter Fifield—see our upcoming article on ethical issues in the Family, Systems and Health special addition on ethics due March, 2013.
 See Legal Action Center’s Confidentiality and Communication, A Guide to the Federal Drug and Alcohol Confidentiality Law and HIPAA (2012) for internal program communications, pp. 72-73.
 Franklin, R, (2013, Jan/Feb). Secure Messaging, Myths, Facts and Pitfalls. Family Practice Management Magazine.
 Apparently (and hopefully) peculiar to NH, we have prescribed language for informed consent under our licensing law and so we are bound to provide informed consent documents specific to MH at time of scheduled intakes.
 SAMSHA’s interpretation of Part 2 excludes SBIRT information as requiring Part 2 protections if arising outside of a "program”—See FAQs-revised, Q10.
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Posted By Jerica Berge and Tai Mendenhall,
Thursday, February 14, 2013
| Comments (3)
Including Significant Others in Health Care Visits: Here to Stay…
Or, like Valentines Day, a Short-lived Temporary Celebration?
With an entire recent issue of Contemporary Family Therapy focused on
Medical Family Therapy (MedFT), a second edition of Medical Family Therapy by McDaniel, Doherty, and Hepworth coming
out, and several MedFT training programs (Ph.D.’s, post-docs, certificates, and
fellowships) being established around the country, we have hit a high point in
the field. It appears that Marriage and Family Therapy (MFT) and health care delivery
entities (e.g., Primary Care, Pediatrics, Internal Medicine) may have finally
tied the knot regarding the importance of systemic thinking and relational
involvement at the center of care-provision.
For example, the value of
including a significant other in the health care of a partner—while not standard
medical practice yet—is no longer questioned. It is common for a primary care
provider to request a patient with diabetes to bring in their significant other
to be included in treatment planning. Furthermore, many of the Patient
Protection and Affordable Care Act (PPACA) requirements lend themselves to
supporting a relational view of health care. "Team” and "group visit”
approaches used in federally-qualified Health Care Homes rely on a systemic and
relational view of a patient’s health. Additionally, the new CPT (Current
Procedural Terminology) codes 90832, 90834 and 90837 are defined as
"psychotherapy with patient and/or family member” and the 90846 and 90847 are
defined as "family psychotherapy with or without the patient”. Even
reimbursement systems are embracing the move towards systemic and relational
care. Thus, including significant others in care (i.e., mental and/or physical
health) visits may become the "gold standard” in the near future.
are many advantages of including a significant other in a partner’s health care
visit, from getting their buy-in and support for (and involvement in) the
patient’s treatment plan, to perturbing their worldview about why their partner
has a certain condition. Including a significant other in a patient’s health
care visit may ultimately allow the provider an opportunity to increase the
likelihood of treatment compliance, understand more about the health care
motivations of their patient, and establish trusting relationships which
promote collaborative efforts between the patient/significant other/provider
subsystem to be mutually invested in a patient’s health and well-being.
see examples of this type of collaboration often in the residency clinic where
I work. Residents are encouraged to bring in patients’ significant others to
team visits to get a better perspective of the presenting problem(s). Faculty
doctors have couples they have seen for years and model the importance of
systemic and relational care to their residents. Patients either bring in their
significant other themselves or suggest bringing them in. It seems that providers,
patients and significant others all can see the vision of systemic and
relational thinking in health care delivery!
I Beg to Differ
my long-term collegial sibling, I must counter your enthusiasm with all of
this. To be clear: I agree that it is good to see MedFT’s visibility increasing
in academic literature and professional circles, and the fact that many health
care sites are beginning to recognize the utility of including patients’
significant others in care is a long-awaited change. As a MedFT provider and
educator, myself, I am happy to see our guiding tenets gaining some traction
after so many years of spinning our wheels. But to be honest, I think that you
are looking through lenses here that a bit too rose-colored.
do not think that we are anywhere near the mainstream or
"gold standard” yet. To begin, medicine as we know it is still
rigidly-structured around a one-patient-at-a-time model. Our diagnostic and
billing codes reflect this, insofar as those "belonging” to individual patients
(e.g., 296.32 / Major Depressive Disorder, Recurrent, Moderate Severity or
250.02 / Diabetes Mellitus, Type 2, uncontrolled) are generally paid-for by 3rd-party
payers and those having anything to do with patients’ relationships or
psychosocial situations (e.g., V61.2 / Partner-Relational Problem or V62.2 /
Occupational Problem) are not. Further, our new ICD-10 mental health billing
codes require even more cumbersome documentation that identifies when
significant others’ involvement is disruptive (e.g., 90785 for factors "complicating”
care delivery), but not when it is helpful.
this, most biomedical and mental health care providers are still not required
in their training to gain experience with or confirm competency in systemic
interventions. To my knowledge, MFT (and within this, MedFT) is still the only
camp that mandates a large percentage of logged patient care to include family
members and/or significant others. And – health care home movement
notwithstanding – these systemically trained providers (like you and me!) still
tend to earn less than their Psychology counterparts, and their services are
still not as broadly recognized as reimbursement-worthy by major payers (e.g.,
Medicare) in many states.
our physicians, those who are more likely to work systemically (e.g.,
Pediatrics, Family Medicine) are paid significantly less than all other
medicine specialties. I mean, let’s be real: Have you ever compared the cars or
houses (plural) owned by cardiologists, dermatologists, and surgeons to those
owned by a family-doc? And, coming full-circle, it gets even worse when you
compare that to what we MedFTs live in or drive. Put simply, those who focus
biomedically on one-patient-at-time are rewarded handsomely for it. Those who
dive into patients’ complex interpersonal and psychosocial worlds are not.
when we get right down to it, Jerica, you know that many providers find working
with individual patients (sans significant others) to be more comfortable. Conversations
are more simple, chaos and conflict are less likely, and visits/sessions are
more "smooth.” Even our MFT and MedFT colleagues attest to this (I know that you’ve
heard them!), recognizing that their individual patient at such-and-such
time during the day represents a "break” of sorts from the comparative
intensity of couple- or family- work.
think that we all see the utility of including significant others in care, but the
reality is that many (or even most) providers do not do it until they "have”
to. When their 1:1 services do not seem to be working, when their patients are "noncompliant”
with whatever they are telling them to do, or when they (providers) are
overwhelmed and frustrated because the course of care is not going the way that
they would like to see it go – only then do they begin asking questions like
"What is your wife’s take on all of this?”, "Could you bring your mother in
with you next time?”, or "My thinking is that it would be best to talk with
both of you about how to eat well with this new ‘diabetes diet’.”
think that all of us (providers and patients alike) tend to take the people who
are most important in our lives for granted – at least until we’re "supposed”
to appreciate them (like on Valentine’s Day or their birthday), until we really
need them (because of the support that they can offer), or after it’s too late (because
we have lost them). I see much of health care following this very path. Including
significant others because we’re incentivized to do so, or because we don’t
know what else to do, is good. But it’s not ideal. Maybe someday we will all do
this naturally. But my sense is that this is still a very long way off.
Jerica Berge, PhD, MPH, LMFT, CFLE
is an Assistant Professor
at the University of Minnesota in the Department of Family Medicine and
Community Health. She received her PhD in marriage and family therapy from the
University of Minnesota. Dr. Berge is a Medial Family Therapist at the North
Memorial Residency Program and Research Faculty at the University of Minnesota
Medical School. Dr. Berge’s research interests include childhood obesity
prevention and community-based participatory research around child and family
Tai Mendenhall, PhD, LMFT is an Assistant Professor
at the University of Minnesota (UMN) in the Department of Family Social
Science, Director of the UMN’s Medical Reserve Corps’ Mental Health
Disaster-Response Teams, and Associate Director of
the UMN’s Citizen Professional Center. He works actively in the conduct of collaborative
family healthcare and community-based participatory research (CBPR) focused on
a variety of public health issues, including more than a dozen community-based
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