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What I Wish I'd Known When I Started

Posted By Susan McDaniel, Thursday, April 4, 2013

Susan's post is the first
in a 5-part series on
leadership in
collaborative care.


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.

Family 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 understatement.

From the 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 is!

There were 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.


Susan McDaniel

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 edition appeared.

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Hawaii, Homelessness & Collaborative Care

Posted By Larry Lantinga, Thursday, March 28, 2013
Military and Veterans

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!"

Why would I say that? Let me explain.

Homelessness 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 coordinated healthcare.

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.

The 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 achieved.

VA 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 many cities.

H-PACT 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.


Larry Lantinga

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 University.

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VA Myths and Stereotypes: Myth Busting Continues

Posted By Katherine Dollar, Thursday, March 28, 2013
Military and Veterans

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.

Through 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.

Firstly, 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 expectations.

An 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.

During the 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.

Same 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.

Within 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.

As 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 technology.

The 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.

In 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 Dollar

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.

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Myth Busting at the VA

Posted By Andrew Pomerantz, Thursday, March 21, 2013
Military and Veterans

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.


Andrew Pomerantz

Andrew 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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Primary Care Behavioral Health Services for Active Duty and Retired Military Service Members and Their Families

Posted By Chris Hunter, Friday, March 15, 2013
Military and Veterans

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.

Brief Background:

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)

Under Development:

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.

Take Home:

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.


Chris Hunter

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 Interventions.


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We are very good at taking care of others… but how well do we prioritize care of ourselves and our colleagues?

Posted By Natalie Levkovich, Sunday, March 10, 2013

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 profession.

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
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

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 model.

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Healing Relationships, Conference Relationships

Posted By Amy Davis, Thursday, March 7, 2013

 2013 conference logo

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 2013?

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 Davis


Amy Davis
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, Colorado.

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Observations from a Living Laboratory of Collaborative Family Medicine

Posted By Tina Runyan and James B. Anderson, Thursday, February 28, 2013

"Collaborative care is done in many ways, by many people, in many settings—it is not ‘just one thing.’”

-C.J. Peek

Collaborative care 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.

   _ _ _ 

 The Three Questions

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 do things?

2. Who is the most important one?

3. What is the right thing to do?

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.

The 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.

Caring Together

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.

Christine Runyan

Tina 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 Anderson
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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Point / Counter-Point 2.2

Posted By Sandy Rose and Peter Fifield, Thursday, February 21, 2013

Being patient-centered means respecting patient confidentiality

Sandy Rose


 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”)’[1] 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.

Symptoms include:

  • 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[2];
  • 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.[3]

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 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. [4] 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[5].

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. [6]

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. [7]

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. [8]

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”. [9] 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. [10] 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...

Peter Fifield


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. 

[1] The Federal Law for Confidentiality of Alcohol and Drug Abuse Records.

[2] 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.

[3] 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.

[4] Franklin, R, (2013, Jan/Feb). Secure Messaging, Myths, Facts and Pitfalls. Family Practice Management Magazine.

[5] SAMSHA (2004) The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Use Programs. Retrieved on February 3 at

[6] 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.

[7] Bakalar, N. (2013, January 7). Sharing Psychiatric Records Helps Care. The New York Times.

Retrieved January 7 from

[8] SAMSHA’s interpretation of Part 2 excludes SBIRT information as requiring Part 2 protections if arising outside of a "program”—See FAQs-revised, Q10.

[9] 42CFR 2.3(b)2.

[10] Peikes, D,and Torda, P (2011). The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care Retrieved 2.2.12 from

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Point / Counter-Point 2.1

Posted By Jerica Berge and Tai Mendenhall, Thursday, February 14, 2013

Including Significant Others in Health Care Visits: Here to Stay…

Or, like Valentines Day, a Short-lived Temporary Celebration?

Jerica Berge

 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.

There 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.

I 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

Tai Mendenhall

Jerica, 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.

I 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.

Alongside 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.

With 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.

And 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.

I 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’.”

I 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 and Tai

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 health issues.

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 projects.

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