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Integrated Care Learning Community – New England Style

Posted By Bill Gunn and Julie Schirmer, Thursday, December 6, 2012
Updated: Monday, December 3, 2012

What the heck is a "learning community?” The definition we are using is: a group of like- minded individuals working together to learn what’s working, what’s not working, and how to change our systems to be more collaborative. This collaboration is necessary with patients, families, health care teams and systems.

Management consulting guru, Peter Vaill, describes the constantly changing world we are in as being in "constant white water”. There are no pools to recover and rest before the next set of rapids. We just need to learn how to paddle the boat better through the white water of change. Rather than just working harder, Vaill proposes strategies of working smarter, specifically working "reflectively smarter” and "collectively smarter”. The learning community model uses both strategies. The integrated care "river” is moving forward all over the country. In the aftermath of the election and the move towards population-based "accountable care organizations", we all need to work "collectively smarter.”

White water

"There are no pools to recover and
rest before the next set of rapids. 
We just need to learn how to
paddle the boat better through the
white water of change."

There are other organizations using this strategy. For example, The Institute for Healthcare Improvement (IHI) sponsors ” learning collaboratives”, bringing in hospitals, clinics and other organizations to provide technical assistance for their change efforts. The National Council of Behavioral Healthcare sponsors learning communities among behavioral health organizations, which provide integrated primary care health services for the severe and persistently mentally ill.

We need to look for partners in our local systems and in our geographic regions to share sustainable models, influence new policies, and collect mutually agreed upon data to discern the impact of different models of care. CFHA has been a leader in conducting national meetings held in regions where there is strong interest and activity in integrated care. Each of the meetings has held a local "summit” that has brought together leaders from the region to learn together and ideally create integrated care workplans.

We know that many folks from other parts of the country think that in New England "good fences make good neighbors”, but our experience with integrated care has shown this not to be true. We have created a steering committee and workgroups around training, advocacy and quality improvement with representatives from Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. We have had monthly steering committee phone calls, two face-to-face meetings, and plans for more to work on projects of common interest in the region. These projects are in the areas of training, advocacy, and quality improvement.

There is another organization, the Family Medicine Education Consortium (FMEC), whose mission is to move important primary care health projects along and to promote family medicine. The goals of FMEC and CFHA overlap around integrated behavioral health care. The two organizations sponsored two preconferences in the fall of 2011 and 2012 on Supporting Sustainable Integrated Care. The 2011 meeting kicked off the New England Learning Community. The 2012 meeting in Cleveland, Ohio set the stage for a state-wide Ohio Learning Community and planted the seeds to bring together the 4-5 Pennsylvania integrated care state-wide organizations in the fall of 2013.

The Ohio proceedings included lessons learned from providers, administrators, funders, and foundations. Jennifer Hodgson started the meeting with an overview of the impact of the Accountable Care Act on behavioral health integration and the cutting edge advocacy work taking place in North Carolina. The panelists and discussions were very dynamic. The meeting ended with learning community strategies for the states represented at the meeting. The Ohio group has created a listserve and is approaching a couple of groups in northern Ohio to "house" a state-wide learning community, connecting it to the good work of Janice Bogner and colleagues at the Health Foundation of Cincinnati Susan Labudo-Schrop at the University of Ohio College of Medicine Family Medicine Department (NEOMED).

One of the surprise outcomes of this Ohio meeting was identifying the North East Learning Community Theme Song. We had not yet read Randall Reitz's blog regarding a theme song for the CFHA. So, although we "ain't got much money", we do have fun AND a theme song! If you are at all curious, click here to view the original Youtube version. We really like the chorus. It's catchy, great to dance to. Yet we need to rewrite the rest of the lyrics As with behavioral health integration, we aren't satisfied with the traditional organization of the song. An integrated care transformation is needed to benefit patient satisfaction, clinical outcomes and cost! Maybe selling the rights to the new lyrics will bring in money to support our efforts. Stay tuned!

In southwest Virginia, another regional effort is taking place, sponsored by Radford University and the primary care clinics in that area. Cathy Hudgins and Bill McFeature have organized an annual conference and provided technical assistance to clinics and behavioral health organizations in that area.

Through the North East, our hopes are to connect these efforts: informing our care, strengthening our ability to learn from each other, uniting to influence policies to improve care, and "taking it to the streets". We have an assumption that there are many more efforts local and regional efforts to promote integrated care and we hope this blog will encourage others to let us all know what you are doing.


Bill Gunn

Bill Gunn PhD is a faculty member of the NH/Dartmouth Family Medicine Residency in Concord, NH and holds a clinical appointment at Dartmouth Medical School. He is a board member of the Collaborative Family Healthcare Association. Bill is a co-author of Models of Collaboration (2006) and The Collaborative Psychotherapist (2009). He coordinates with Julie Schirmer, LCSW an integrated care "learning community” in New England which meets regularly. He is membership co-chair of CFHA, and co-chair with Nancy Ruddy, PhD of the Division 38 primary care subcommittee.



Julie Schirmer
Julie Schirmer, LCSW is Director of Behavioral Health at the Family Medicine Department of Maine Medical Center and Assistant Director of the Family Medicine Clerkship at Tufts/Maine Medical Center School of Medicine. She is Co-chair of the North East Regional Integrated Care Learning Community, Past President of the Family Medicine Education Consortium, and upcoming Director of the Behavioral Science/Family Systems Educator Fellowship of the Society of Teachers of Family Medicine. She is author and co-editor of Behavioral Health in Primary Care: A Global Perspective(Radcliffe, 2010).

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Larry Mauksch Receives CFHA's 2012 Don Bloch Award

Posted By Larry Mauksch, Thursday, November 29, 2012

Larry Mauksch 

The Don Bloch Award, CFHA's highest honor, was presented to Larry Mauksch by a group of his colleagues, Barry Jacobs, Valerie Ross and Randall Reitz on October 5, 2012 at the CFHA annual Awards Luncheon. In his acceptance speech, Larry Mauksch shared thoughts on his experience in the collaborative care movement over the last twenty years.

 


 

I want to thank the CFHA board for this great honor. Recognition from one’s peers is about as a high an honor as one can receive perhaps only eclipsed by recognition from one’s family. Today I am a fortunate man as both my professional and personal family members are present.

I feel a deep sense of gratitude receiving this award. I called Don Bloch to express my thanks for his contributions and his influence on me and on the field. My thoughts also go to many others who have in one or more ways helped me learn and grow. I started making a list. Behind me on the screen is a Wordle. When text is inserted, it arranges the words in different ways allowing you to choose designs and colors. One other feature of a Wordle is that it alters the size of the word to reflect the number of times it appears. I listed everybody once, except for Don, in his honor. Many people in this Wordle are in this room. Family members are listed with first and last names, colleagues are listed by last name, sometimes with a first initial. To all of you I wish to express my deepest appreciation for your gifts. I needed your encouragement, your voices, and your care.

In reflecting on your gifts it occurred to me that they affect different aspects of my growth and at the risk of being too personal, I want to share some of this with you. In 1982, when I was fresh out of graduate school, two family physicians took me into their practice and trusted me with their patients. This was truly a gift. The referrals came fast and I sought supervision, at one point from 4 different people at the same time, each with different areas of expertise. One supervisor was a former graduate school faculty member. We met weekly at a local health food cafe. He allowed me to buy him a whole-wheat cinnamon role and a latte but at first would not accept payment. I would tell him about my patients, like the woman who complained about her husband and tried to convince me that he would not participate in counseling. My supervisor suggested I call the husband in front of the woman and say, " Mr. Thompson, I am the counselor who is working with your wife. I can tell she loves you and I know that you two are struggling with some things. I miss your voice and I have no question that your perspective on this relationship is really important. Would you be willing to join us next week?” Then we would talk about theory and strategy. What stayed with me was his voice. He taught me from the inside out, starting with application and demonstration of skill. This gave me confidence, clarity, and direction. I used his words with my patients. As the years went by, I helped patients by sharing my voice. Saying what seemed helpful, then conceptualizing what came out of my mouth, became a way to tap into my own wisdom. I have shared phrases with trainees just like my teacher did with me. In fact, when I now lapse into first person dialog, acting as a therapist or a physician or a medical assistant, I look around and people are writing down my phrases. It helps people get started talking about hard topics like trust and abandonment and inadequacy and risk behavior and love. We need to share our voices to help our clinical team members take the risk of trying new skills. Taking these new steps helps lesser trained clinicians go to interpersonal places that feel uncomfortable. This is part of what one colleague in this room described in a mountain climbing metaphor as "the belay of collaboration1."

If a large part of my career was spent working on finding a voice as a clinician and teacher an equal or greater part of time has been devoted to finding a scholarly voice. Writing is terrifying. It is personal. Comparing myself with those who are well published is intimidating. The prospect of rejection and criticism can be disabling. New knowledge is old before it’s published. Conducting research means accepting incompleteness, uncertainty, imperfection, and compromise. In this audience, and elsewhere, including many anonymous reviewers, are people who gave me the gift of honest, and usually kind, feedback. One life long friend suggested I might benefit from reading William Zinsser’s classic, "On Writing Well”. He was right. I learned to cut out the lard. There are also some in this room and elsewhere who gave me the gift of scholastic opportunity and responsibility. They asked me to co-author papers, write reviews, chapters, and even to a co-author a book. Others taught me research methods. I recall one physician executive who spent hours helping me understand reimbursement models beyond fee-for-service. Hurrah.

I can honestly say that embracing scholarship has taught me to cherish my mistakes as ways to continually learn. Sharing the failures, limitations, challenges and responsibilities of scholarship with collaborators has made my learning easier, more efficient, and much more meaningful.

Collaboration is the last gift I want mention. In this room and elsewhere are many people who have offered me the opportunity to build a new curriculum, transform a clinic system, and lead an organization. These are incredible gifts. They forced me to think at many levels. How do you lead an organization that has a great mission but financially is barely surviving? One of you offered the "pilot light approach” that emphasized holding on to relationships, mission, and conserving resources for the right time. How do you help a clinic system where the biopsychosocial mission and commitment of its providers is inspiring but also leaving them exhausted and frustrated? This clinic, with full board support, brought me in for an entire year. Their clinicians allowed me to watch them interact with patients. The executive leadership agreed to regularly cancel half days of clinic and hire locum tenens support so everyone could participate in my system wide educational sessions. These experiences stretched my intellectual and interpersonal abilities. Eliciting the ideas of others took on new meaning because I at once had to make people feel heard and move forward in ways that might be new or risky. With their trust, I was able to challenge students and fellow board members, medical assistants and physicians, and administrators and faculty, to learn new skills or even entertain new cultural values.

Today, we in CFHA are part of an amazing cultural transformation in health care. People are experimenting with new team designs, financial models, and interpersonal skills. Behavioral health integration is common place in safety net settings and other clinical arenas with a knowledge base that fills the curricula in multiple training programs. We look to broader and deeper impact on systems, families and policies. The collective wisdom in our organization represents incredible potential to learn and make a difference in how health care is provided in our country. I share my experience with you because I hope that all of you can exchange similar gifts with fellow clinicians, teachers, students, scholars and leaders: teach them, share your voices, celebrate their ideas, and help them take on new responsibilities. Once again, thanks for your feedback, your time and encouragement, your trust, your voices, your friendship and so much opportunity.

1. Lorenz, A. (1999). Reflections: The belay of collaboration. Families, Systems, & Health, 17(1), 133-135.

 

Larry Mauksch and Ben Miller 

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Larry Mauksch Nominated for CFHA's Don Bloch Award by Three Colleagues

Posted By Barry J. Jacobs, Valerie Ross, and Randall Reitz, Thursday, November 29, 2012
Larry Mauksch et al



At the 2012 conference in Austin, the CFHA Board of Directors presented the Don Bloch Award to Larry Mauksch.  This award is the association's highest recognition for contributions to the field of integrated and collaborative care that are pioneering, or in some way help bridge the mind-body gap and pursue a more humane, egalitarian and interdisciplinary healthcare system. Three of Larry Mauksch's colleagues presented the nomination at the conference awards luncheon:

 

Barry Jacobs

   Barry J. Jacobs


Let me make the case for Larry Mauksch, M.Ed for the Don Bloch Award for this year. Without his service to CFHA as a board member and later president in the '90s and early 2000s, our organization wouldn't exist today. He gave us passion and selfless leadership during his tenure--a time when the survival of CFHA was in question. He served as the crucial bridge between the vision of our founders and the more pragmatic, membership-oriented organization we are currently. Even after he stepped down as president, he has remained engaged with CFHA as a conference attendee and participant and key advisor to the board and board staff members.

Larry’s contributions to the field of collaborative family healthcare go well beyond his service to CFHA. Through his long-time association with the Department of Family Medicine at the University of Washington, he is one of the best known and most highly regarded behavioral science faculty members in the country. His 2-year tenure as a visiting clinician at the Marillac Clinic in Colorado helped make that community health center one of the early models for community-centered collaborative family healthcare. In the past decade he has co-written important articles in the major primary care journals on patient-centered communication and, more recently, integrated healthcare teams. He currently provides trainings around the country on those subjects and serves as a national champion for behavioral healthcare within the PCMH.

In addition to these many accomplishments, Larry is one of the warmest, funniest, most generous people I've encountered in the collaborative family healthcare field. I've benefitted from his encouragement and mentoring. He has been the Yoda to many budding collaborative Jedi.



Randall Reitz

    Randall Reitz


Larry Mauksch is the warm, generous heart of the collaborative care movement. When I asked his colleagues across the nation to describe him. They called him visionary, caring, diligent, energetic, determined, and thoughtful.

I describe him as an ideal mentor. Through a lucky accident, Larry took me under his wing back in 2000. I was fortunate to complete my PhD internship at Marillac Clinic shortly after Larry’s year-long sabbatical during which he established Marillac’s collaborative care program. My internship was funded through a 5-year RWJ grant Larry had co-authored. During my years there, Larry returned to Grand Junction yearly to offer training and conduct research. My first published research was with him as a first author, and my early professional presentations included him as co-presenter. On multiple occasions I’ve slept in his home, eaten at his table, and soaked in his rooftop hot tub. I’ve called him for advice before each major decision of my career. He personally nominated me when I was invited to join CFHA’s board.

I share my experience with Larry because I have personal knowledge that he has provided similar tutelage to many, many young collaborators. This room is full of people for whom Larry has had a deep and enduring impact.

In thinking about a story to share that would typify Larry, the most poignant memories are actually of hearing Larry brag on his wife and children. If allowed, he will share stories of their academic success, deep humanity, and outdoor adventures for hours. Larry lives the family in collaborative family healthcare. His family is with us today and I’d like to thank Sally, Claire, and Eli for sharing your remarkable husband and father with us for these many years.



Valerie Ross

   Valerie Ross

I have been asked to reflect on my experience of Larry as a teacher and educator. It’s been my privilege to be both Larry’s student, colleague, and friend for the past 15 years.

Larry is one of the most generous and creative people I know. His work is infused with a deep understanding of collaboration and coaching.

  • In 1985 Larry took over the behavioral science program in the UW Family Medicine residency. The position became a base for his almost 30 year- exploration in training healthcare professionals.

  • In 1996 he started an Internship for Master’s level therapists in Collaborative Care. To date 19 therapists have graduated from the program, myself among them, many of whom are working in medical settings and involved in healthcare change.

  • His scholarly work as an educator has focused on defining, describing and teaching skills at the interface of time management and quality patient centered care.

  • He has been influential in developing methods for innovative clinical training, marrying skill articulation with, direct observation and feedback, video review, and self-reflection.

A few of Larry’s contributions include:

  • Training materials in patient centered communication such as "The Patient Centered Observation Form” and accompanying on-line videos

  • The Paired Observation Video Editing Course: a course that utilizes peer observation and has been adapted in medical schools around the country.

  • Recently Larry served on the Competency Task Force for the Council of Academic Family Medicine. He is developing new training materials in response to this experience.

  • His focus in clinical training is evolving from an individual to a team focus. He is working with health systems around the country to promote well functioning teams in the medical home.

Larry’s impact on me has been profound, both professionally and personally. Barry asked me tell you all some anecdotes that help to capture who he is. I thought to myself: "Well, we have been on this big adventure together – an adventure we all in CFHA are on -- trying to figure out how to change the healthcare system. For me, a formative part of this adventure has taken place in conversations in Larry’s office. Not a setting for dramatic story telling. So I tried to think of archetypes to more dramatically capture what it has been like to take part of this adventure with Larry.

  • Like Harry Potter, Larry is a leader among peers, a change agent from within guided by the values of social justice, compassion and the importance of relationship

  • However, in age he is closer to Dumbledore. He shares the qualities of a wise supportive mentor who is there when you need him and moves out of the way when it’s time to let his student grow. He is caring, challenging, and his door is always open.

  • There is little bit of Yoda in him too. He is a guide with a big picture view

  • Then again he does have an edge – like say – Hans Solo. He is a great co-pilot, he does not let the rules, or that fact that he is in an imperfect ship get in the way of his creativity or taking risks.

  • And then there is his style; which is really a little more like Columbo (without the cigar) : a bit rumpled in appearance, messy office, he always greets you with a big warm smile on his face, a twinkle in his eye signaling delight, and he is always thinking outside the box.

Recently Larry and I were talking about something that happened in the department that seemed like a step backwards, reversing some of the important work we had both done in the residency. That step backwards was bothering me. Larry leaned back in his chair and said: "I have really come to think of my work as just a grain of sand in a much bigger evolution.” Then we set to work planning how to move forward again. This is one of the most important lessons I learned form Larry. I will just call it: Think Zen.

Don’t take your self too seriously, recognize that your work may be but a flicker of light or grain of sand in the evolution of healthcare, AND invest 110% or more of yourself in that work. Don’t get hung up in judging whether a situation is good or bad. Look for openings to move towards creation of a more humane and quality system…whether it is teaching, or attending a faculty meeting, or trying to change a culture …listen… think systemically… do your research …get to know your collaborators … and take risks. You never know what will come of it.

I have tremendous gratitude for my relationship with Larry and all he has taught me and I am so pleased that CFHA is honoring him in this way.


 The text of Larry Mauksch's acceptance speech is available here.

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Collaborative Care is an Evidence Based Treatment Model for Depression and Anxiety

Posted By Pamela Williams, Thursday, November 22, 2012

As readers of this blog are well aware, depression and anxiety "are a major cause of disease burden and disability with depression projected to become one of the three leading causes of burden of disease by 2030.” It is estimated that 90% of people who suffer from depression and anxiety are treated solely by their primary care physician, and the majority of these interventions are exclusively pharmacological. Many people also report being unsatisfied with the level of care they receive. While these facts point toward collaborative care being a logical and effective treatment model for depression and anxiety, there was not enough research that provided conclusive evidence to support recommending collaborative care for those with depression and anxiety problems until this year. 

A recent review summarized in the Cochrane Library and authored by Janine Archer, Ph.D. of the school of Nursing, Midwifery and Social work at The University of Manchester in the U.K. provides promising results for collaborative care as an evidence based treatment for anxiety and depression. Reviews from the Cochrane Library are widely considered the gold standard of evidence-based medicine.

As described on the Cochrane website:

Cochrane Library Logo

"Collaborative care is associated with significant improvement in depression and anxiety
outcomes compared with usual care, and
represents a useful addition to clinical pathways
for adult patients with depression and anxiety.”

"Each systematic review addresses a clearly formulated question; for example: Can antibiotics help in alleviating the symptoms of a sore throat? All the existing primary research on a topic that meets certain criteria is searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment."

The collaborative care review looked at seventy-nine randomized control trials (which included 24,308 patients) that compared the collaborative care treatment model with either standardized care or alternative treatments. The review required four key criteria to be considered part of the collaborative care model: 1) a multi-professional approach to patient care, 2) a structured management plan, 3) scheduled patient follow-ups, and 4) enhanced inter-professional communication.

The results suggest that "collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.” Patients who were treated with a collaborative care model also reported being more satisfied with their level of treatment than their counterparts receiving standard or alternative care. Research increasingly supports a systemic approach to healthcare and a collaborative care model that also provides patients with a high level of satisfaction.

 

Pamela Williams
Pamela Williams is a graduate student at the University of San Diego obtaining her masters degree in marital and family therapy. She is passionate about collaborative care and working with families with young children and hopes to combine these two passions in her future work.
 

 Reference:

Archer J., Bower P., Gilbody S., Lovell K., Richards D., Gask L., Dickens C., Coventry P. (2012) Collaborative care for depression and anxiety problems. Cochrane Database of Systematic Reviews, 10. DOI:10.1002/14651858.CD006525.pub2.


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The Need for Collaborative Care

Posted By Golnoush Yektafar-Hooshvar, Wednesday, November 21, 2012
Updated: Monday, December 10, 2012

As a new doctoral student in Marriage and Family Therapy with a concentration on Medical Family Therapy, I have been expanding my understanding of the social context of illness. I have read about the ways in which Western society has placed an important concern on the medicalization of an illness, emphasizes the biological aspects of the physical malady rather than considering the psychosocial-spiritual impacts of illness on the individual and family, and emphasizes the medical provider as the "expert.”

As I continue to learn from the literature about how social context of health impacts health and collaborative care overall, I am also better understanding my personal experiences and how they relate to these ideas.

From the time that I had the ability to comprehend what being "sick” entailed, I came up with a few observations. I often associated "sickness” with medications of sorts, visits to doctors, and feelings of fatigue and irritability. These were the things that I experienced growing up because my father was diabetic and had chronic cardiovascular disease. Ironically, looking at my father’s appearance, he was the epitome of health. A tall and slender man who enjoyed playing tennis and going for daily runs. To my father’s misfortune, the cause of his poor health was based on genetics. My paternal grandparents had both died from sudden heart attacks, and at the time of their death, their social context was a key contributing factor to their inability to gain access to the appropriate medical attention they needed. Living in Iran, a foreign country where the socioeconomic gap between the rich and poor is a problem that still exists today, it was apparent that the wealthy had more privilege in issues related to healthcare access and advanced technologies. Inevitably, these and other social factors prevented my grandparents and father from gaining knowledge on preventative measures when dealing with chronic illness.

Fast forward to three years ago when my father was admitted to the hospital by his primary care physician who after running numerous tests concluded that congestive heart failure (CHF) was the diagnosis. Since my father had a history of chronic cardiovascular illness and diabetes, the doctor informed my family and me that it would be best for him to remain in the hospital overnight. That evening, the cardiologist came in and poked and prodded my father. After asking a few questions, he concluded that the diagnosis of CHF was correct. As he was writing down notes he informed my family that he would be adding a new medication to my father’s existing medication regimen.

 I remember the nurse coming into the room late one night and simply handing my father a cup of water and a small plastic container with about ten different pills. This routine continued for another three days, however the morning of the fourth day was different. As I entered my father’s hospital room I was greeted by a primary physician, a cardiologist, and a nephrologist. They all looked concerned and began their interaction with my family by saying that my father may not be released as early as my family had hoped for. With a panicked look on his face and a trembling in his voice, the primary care physician said that according to recent lab results, my father’s kidneys appeared to not be functioning. A new diagnosis was blurted out; they said it was end-stage renal failure and an immediate procedure had to be done in order to insert a fistula so my father could begin hemodialysis. I remember having a million questions running through my mind, but I could not verbalize a single one. As I muttered out a quiet "Why?” the cardiologist said that the only answer he has is that one of the medications that my father was given to treat the CHF had an adverse effect on the kidneys. Since he was diabetic, he already had under functioning kidneys, but the medication had worsened the existing functioning capabilities of his organs. As the three physicians left the room all I kept thinking and questioning in my mind was how a doctor could not know what medication was contraindicated with another.

As I fast forward to one year after that incident, I have experienced my father not only go through the physical disadvantages that result from chronic illness, but psychological difficulties in dealing with the social context of his illness. The way society perceives him as "ill,” the way our family views him, his role in our family system shifting from breadwinner to someone who is unable to work, and a plethora of other setbacks that had contextual factors that were socially based.

Looking back on this experience as a doctoral student who is interested in medical family therapy, I can clearly see the need for collaborative care between physicians and all those involved with the patients. I have learned firsthand how important it is those nurses, physical therapists, family therapists, and anyone else who interacts with a patient work together in order to provide the patient with the best overall care. My hope is that one day, the social context of illness can be transformed in such a way that all medical professionals work collaboratively with other medical caregivers, patients, and family members in order to best treat the whole patient- mind, body, and soul.

Tags:  collaboration  family medicine  family therapy  Integrated Health 

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Somatization: From Biomedical to Sociocultural

Posted By Wendy Bradley, Thursday, November 15, 2012

One of the biggest challenges in any health care setting is how to manage somatic symptom disorders. Studies show that one third to one half of all visits to primary care have no identifiable primary cause. These visits cost the US health system over 100 Billion annually due to overuse. Presenting concerns often have components of some sort of pain or a check for some odd symptom.

Often the most frustrating aspect of this condition is the presentation in clinic. These encounters often include:

  • High levels of dissatisfaction and overall distress,
  • Vague and dramatic reporting of medical history,
  • Reactions to psychosocial distress with physical symptoms,
  • Frequent moves from complaining of one symptom to another,
  • Seeking care from multiple providers, failing to keep appointments,
  • Denying psychological influences and referrals to therapy,and
  • Disappointment and frustration when nothing is found.

A fundamental attribution to this dilemma is the overarching perception of what ‘health’ is. "The ‘usual’ medical system and patient expectations have evolved into an ‘evidence based’ system for the physical body where if the right tests are ordered, the right diagnosis made, and the right medications prescribed, health will follow” (Eby, 2011).

Southcentral Foundation logo

As Southcentral Foundation is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships.

Through listening to our patients and examining our own behavior we have discovered that we have reinforced the idea that it is the health care team’s responsibility to ‘fix it’. This has become a set up for both providers and patients---as both have difficulty tolerating ambiguity because of this expectation. As long as we make the focus about "physical solutions” to these complex issues we will continue to prescribe new medications, take more tests and make referrals to specialty clinics to find out what is ‘wrong’ with them. We will continue to be frustrated with the patient for not listening to us. As long as we are working harder to ‘fix’ them, we leave no space for them to take responsibility of their own health and begin to learn how to manage the symptom or the distress surrounding the symptom.

As Southcentral Foundation (SCF) is owned and operated by the Alaska Native people the idea of ‘health’ (mental, emotional, spiritual and physical) is centered on the idea of long- term, trusting, personal relationships. This philosophy has created the foundation for how we approach our patients that visit our system the most and have unexplained somatic symptoms. Instead of seeing those patients as a "problem to be solved” we focus on working with that patient to determine the "context” that a condition is occurring in. The focus moves away from trying to figure out the symptom to supporting the patient in learning how to manage the distress the symptom is causing. This approach has resulted in us taking a step back and assessing the entire picture of health

We have been practicing full integration for over 8 years in a level 3 medical home model and it has taken time for this philosophical shift about what ‘health’ is to take place, for both ourselves and our patients. We have learned that managing those patients with somatic symptom disorders cannot fall on the integrated behavioral health consultant alone. Care becomes fractured and teams respond out of frustration and a sense of helplessness. We had to move towards a seamless approach that involved our entire management and clinical staff to use a very different and expanded skill set from the ‘usual’ medical practice.

In response, we designed a process that the main emphasis is on how we communicate and work towards a relationship built on shared responsibility. Teams needed to learn how to effectively manage "dilemmas” (when there is no known medical diagnosis to treat or when what the customer wants what can’t be done safely or is necessary) and move away from trying to "solve the problem”. We provide skills and tools that allow teams to truly engage customer-owners while staying objective. We challenge them to look at what they bring into the exam room that influences outcomes (i.e. countertransference, frustration). We intentionally train and coach teams to listen to and acknowledge the ‘fears’ behind the patient visit and have honest conversations about what is happening. They then use encouragement and questions to support the patient and family to develop a plan on how to manage the condition or distress.

We continually encourage teams to have conversations that encourage health ownership. We found that we needed to spend time discussing expectations. Conversations revolve around who is responsible for what and which parts of ‘health’ the team can support and which part the patient will need to make choices about. It also means having intentional discussions about all factors that impact health and what outcomes are possible. Though the behavioral health consultant is still heavily involved, the entire team practices and reinforces the same approach.

Ultimately, we know that while this approach may not ‘fix’ the dilemma of somatic symptom disorders, we can alter the way ‘usual’ medical care is delivered thus expanding the range of opportunity and options that can influence health outcomes. Through placing our emphasis on the whole person, putting the physical, behavioral, emotional and spiritual back together rather than pulling them apart and our continued engagement in long term, trusting, personal relationships with our patients, we can offer the space for health and wellness to happen.

 

Wendy Bradley LPC is clinical improvement advisor at Southcentral Foundation in Alaska. She developed and provided clinical oversight to behavior health integration in primary care--the program has been successfully established for the past 8 years.

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CFHA Annual Conference: What's in it for students?

Posted By Jodi Polaha, Thursday, November 8, 2012

Each Fall I teach a course called "Primary Care Psychology 1” to our doctoral students at East Tennessee State University (ETSU), covering the gamut of current health care policy, rationale for integration, models, research, innovation, and administration. Each Fall, I ask my Department Chair to offset some of the CFHA travel costs for the students in the course. The conference is a perfect content match, and they love hearing talks given by the authors of their readings! This year, once again, Dr. Dixon came through, and that, combined with scholarship and volunteer opportunities within CFHA, made it possible for three class members to attend.

A little seed money for student travel and conference costs goes a long way. Isolated "course content” is transformed by a "culture” of professional engagement: when we arrived in Austin, we were joined by two recent ETSU graduates and two advanced students, most of whom attended in prior years on this patched-together "gift trip.” On Friday night, the eight of us had dinner with two ETSU faculty from Family Medicine. What a delight to sit and reflect on what we’d all learned that day! As you will read in the reflections below, the students in our program struggle with professional identity: "Are we psychologists or behavioral health consultants?” " "How do we be both?” The CFHA annual conference was a place for them to explore this creatively and with the supportive sounding board of "comrades” from their home institution.

 

Matthew Tolliver

Matthew Tolliver


As a second year student in a clinical psychology doctoral program with an emphasis on rural integrated care, I am beginning to develop my own sense of professional identity. Attending the CFHA conference furthered that development, inspiring me to think critically about the role of the Behavioral Health Consultant (BHC). In particular, I was surprised to hear several BHCs identify more closely with Family Medicine and the provision of primary care than Psychology or mental health services. I found myself asking questions such as: What are the ethical, legal, and professional implications of the shift in professional identity that comes with working as a BHC in primary care? What implications does this have for training BHCs? In what ways can BHCs who are just starting their careers develop a strong sense of professional identity, especially those who work in rural areas and who may have limited contact with their peers? I was fortunate to participate in a lunch discussion with Dr. Patricia Robinson and discuss some of these questions. One particularly salient suggestion that Dr. Robinson raised involved the need for and value of mentoring BHCs in order to foster a strong sense of professional identity. Overall, I plan to take what I have learned at the conference back to ETSU to promote increased collaboration between students in psychology and other academic health sciences. The conference was a great experience, and I am especially grateful for the volunteer and scholarship opportunity, which allowed me to attend.




Courtney Lilly


As a doctoral student in a clinical psychology with a special focus on rural integrated care, I found the CFHA conference to be highly rewarding. Some concepts were familiar, such as integrated healthcare models and the function of a behavioral health consultant. Other topics were new to me, such as electronic medical records, legal issues, and specific ethical considerations. I learned a great deal; however, a few things stand out. The first of these is the lack of standardization for integrated care models and the role of the BHC, which seems, in some cases, to vary in critical ways by primary care context. As a student in rural east Tennessee, my future work as a BHC will likely differ greatly from a BHC in an urban area. Given the importance of contextual factors, in what ways should the role and training of a BHC be standardized? A second point that stands out relates to the use of technology to advance integrated care. I greatly appreciated the focus on social media and technology as means for patient and provider engagement. The idea of provider consultation via technology was especially new to me. Within smaller integrated care networks (especially in rural areas), it is likely that the BHC will be relatively isolated having few opportunities for consultation on difficult cases. Technology allows for communication between providers worldwide, which can improve both job satisfaction and patient outcomes. A final focal point for me relates to ethical standards and guidelines. As integrated care and technology become standard components of behavioral healthcare there will be a vital need for more research and guidance in this area.




Catherine Rowe


My experiences at CFHA bolstered my conviction that I have chosen to engage an exciting field, burgeoning with new opportunities for mental health professionals and new promises to improve the quality of care for many in our country. As a doctoral student in psychology ETSU, I am being trained in integrated primary care for rural areas. This emphasis is both challenging and inspiring. Many sessions at CFHA helped me close my own mental "gap” between the traditional approach to clinical psychology and the application of these principles to the primary care setting. There were numerous sessions that focused on real world problems that behavioral health consultants may face in their journey for fully integrated care that gave shape to many of the questions that I sometimes find myself asking. One of the highlights, for me, was the opening plenary by Sarah Kliff regarding the opportunities that are currently developing for further integration of mental and behavioral health services into primary care. Ultimately, my experiences at CFHA left me feeling very aware of critical problems in our current healthcare system as well as aware of the potential solutions.

Hooray for growing traditions … we’ll see you next year in Denver!

 

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


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MENTORING is the Cat’s Meow…The Bee’s Knees… (am I showing my age?)

Posted By Deborah Taylor, Thursday, November 1, 2012


Dr. Taylor's post is the final installment of a 5-week collaborative series hosted by the blogs of
CFHA and STFM.

Please read all the previous posts.

 

One of my greatest professional joys has been my connection to STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF) steering committee. Most "seasoned” behavioral science educators remember the "jump and build wings on the way down” training model for our discipline. The BFEF is an effort to create a more supportive/less isolated model to increase retention and career satisfaction. As with most acts that appear altruistic, those of us on the steering committee quickly found ourselves experiencing increased energy/enthusiasm and dedication to our work. In promoting a fellowship model of mentorship intended to be an offering, we receive far more than we contribute.

The term "mentor” has its roots in Homer’s epic poem, The Odyssey. In this myth, Odysseus, a great royal warrior, has been off fighting the Trojan War and has entrusted his son, Telemachus, to his friend and advisor, Mentor. Mentor has been charged with advising and serving as guardian to the entire royal household. As the story unfolds, Mentor accompanies and guides Telemachus on a journey in search of his father and ultimately for a new and fuller identity of his own.

Mentor Jar
The term
"mentor” has
its roots
in Homer’s
epic poem,
The Odyssey

At times, throughout the story, Athena, goddess of wisdom, who presides over all craft and skillfulness, whether of the hands or the mind, manifests herself to Telemachus in the form of Mentor. The account of Mentor in The Odyssey leads us to make several conclusions about the activity that bears his name. First, mentoring is an intentional process. Mentor intentionally carried out his responsibilities for Telemachus. Second, mentoring is a nurturing process, which fosters the growth and development of the protégé toward full maturity. It was Mentor’s responsibility to draw forth the full potential in Telemachus. Third, mentoring is an insightful process in which the wisdom of the mentor is acquired and applied by the protégé. Some argue it was Mentor’s task to help Telemachus grow in wisdom without rebellion. Fourth, mentoring is a supportive, protective process. Telemachus was to consider the advice of Mentor, and Mentor was to "keep all safe.”

I was surprised to learn that mentoring begins to appear in the professional literature only in the last 15-20 years. Mentoring is now clearly identified as an important influence in professional development in both the public and private sector, including health care. Documented benefits of mentoring include increased performance, retention, commitment to the organization (local and sponsoring), and the presence of paying it forward by mentees.

I am consistently struck with the opportunities we have to "walk the talk” about mentoring’s value -- the mentor as teacher, as counselor, as a "travel” guide and one who promotes the development of others. I encourage you to reflect on the myriad mentoring opportunities that present to us as members of residency programs, family medicine departments, health care organizations, and regional/national professional development groups like STFM and CFHA. Be open to seeking mentoring relationships as well as offering your expertise and professional friendship, and "promote” others in need.

I hope you have or will enjoy being on the giving and receiving end of some valuable mentoring in your life – it has been my "cat’s pajamas” and my "bee’s knees” (my mom’s 2 favorite descriptors)! Thanks for engaging – I really appreciate your time.


Deborah Taylor
Dr. Deborah Taylor has been a Behavioral Science Educator and Associate Program Director at Central Maine Medical Center FMR
(a community based program with a rural training emphasis) for the past 20+ years. She received her PhD in Clinical Psychology from the U. of Kansas and has worked in medical education for the past 25 years. Deborah currently serves as the Co-Director of the STFM Behavioral Science/Family Systems Educator fellowship.


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The Joy (and Jostling) of Team-Based Care

Posted By Barry J. Jacobs, Thursday, October 25, 2012


Dr. Jacobs's post is the fourth in a 5-week collaborative series hosted by the blogs of
CFHA and STFM.

Please check back
each week.

 

In the early-‘90s, at the outset of my career as a psychologist in medical settings, I spent 5 years at a physical medicine rehabilitation hospital on what I was sure was a team of perennial all-stars. During our weekly clinical meetings, daily curbside dialogues in the hallways and cafeteria, and co-care in the PT gym and patients’ rooms, I always marveled at the competence, youthful confidence and innumerable skills of the doggedly optimistic physical and occupational therapists, canny speech therapists, hardy nurses and street-smart social workers on my assigned squad.

At the head of this team was usually a gray-haired, white-coated physiatrist, wizened and patient, offering subtle guidance to team members but generally allowing us to practice our crafts. Not that harmony always reigned. We would have table-pounding debates about treatment plans. Rivalries simmered about who best evaluated cognition or ambulatory status. But the team worked proudly and effectively and patients usually thrived.

Barry J. Jacobs
I like the interdisciplinary spirit embodied in the phrase, "All for one and one for all.”

I eschew the
trans-disciplinary credo of
"All are one.

I’ve been waxing nostalgic recently about those years because of family medicine’s ostensible move toward team-based care. The Patient-Centered Medical Home is intended to be a collaborative, integrated, multidisciplinary place where family physicians work shoulder-to-shoulder with behaviorists, pharmacists, case managers, social workers, medical assistants and administrators to deliver improved, cost-effective, chronic disease management. But the culture of family medicine, in my opinion, is not yet team-driven. What is second nature in physical medicine rehab is of necessity first nature for us—a new set of spiffy dress-up clothes without the well-worn comfort of habitual garb. I think there is much we can learn from rehab medicine’s decades-long experience with teams:

--:”Multidisciplinary” isn’t "interdisciplinary”: An oft-cited truism in the field of integrating behavioral health services into primary care is that "co-location isn’t integration”--that is, proximity by itself doesn’t lead diverse clinicians to work in tandem toward better patient outcomes. I think this truism extends to team-based care in general. A multidisciplinary PCMH just connotes different disciplines under the same roof which are working on their own respective and possibly divergent goals. Rehab was distinctly interdisciplinary—different disciplines working on commonly agreed upon goals. I believe that the PCMH likewise needs to be interdisciplinary in order to best blend the talents and skills of multiple specialists striving together. That means, like rehab, there needs to be processes in place for ongoing team communication and decision-making. (An EHR alone, in my opinion, won’t suffice.) That means somehow creating team meeting times out of the hectic primary care work flow

--"Interdisciplinary” shouldn’t become "trans-disciplinary”: In my years in brain injury rehab, we experimented with "trans-disciplinary” care—clinicians from different disciplines taking on aspects of each other’s jobs to reinforce one another’s interventions in order to better achieve clinical goals. For instance, the physical therapist might counsel the stroke patient about his depression. I might reinforce ambulation techniques with that patient when he walked back and forth to my office. While this model seemed promising in theory, in practice it led to a diffusion of team member roles that exacerbated underlying rivalries. It seemed we all needed some protected territory we could stake out as our own. While the integrated PCMH certainly requires some delegating of responsibilities—e.g., having the medical assistants and not the behaviorists administer a depression screening instrument—we ought to maintain the kind of role distinctions that allows us to protect our professional identities (and egos). I like the interdisciplinary spirit embodied in the phrase, "All for one and one for all.” I eschew the trans-disciplinary credo of "All are one.”

--Leadership is a skill-set: Past STFM president Perry Dickinson and his colleagues at the University of Colorado-Denver developed well-conceived competencies for family physicians to lead the interdisciplinary team. They include setting expectations for performance and change, sharing information and being receptive to others’ ideas, and managing interpersonal issues. But these will remain little more than abstract and somewhat daunting concepts to family medicine residents unless we give them practical real-life experiences. As part of their training to become physiatrists, PM&R residents spend abundant time observing their attending physicians leading team meetings. Later, those residents lead the teams themselves. They come to know well the nuances of the various specialties around the table, as well as the ebb and flow of team dynamics. Family physicians need that kind of socialization to step into the team leadership role.

--Follow which leader?: The 2010 "Joint Principles for the Medical Education of Physicians as Preparation for Practice in the PCMH” calls for "physician-directed medical practice”—i.e., physicians as leader of the clinical team. This was always the case in rehab as well. But others have questioned whether physicians needs always take the lead. In a workshop at the 2012 Collaborative Family Healthcare Association conference, Jeri Hepworth, immediate past president of STFM, and Susan McDaniel of the University of Rochester Departments of Family Medicine and Psychiatry suggested that team leadership can be handled in more egalitarian fashion by rotating leadership among team members. They contended that this flattens team hierarchy and ultimately leads to more trusting, cohesive and coordinated team care.

--Bring patients and family members on board: Because rehab medicine is to a large degree about transferring skills to enable patients to better function in their home environments, PM&R teams work intensively with patients and their family members to provide them with education, hands-on experience, and emotional support. If patients and family members aren’t quite full-fledged clinical team members, then they are fully deputized partners in care. Family medicine’s approach to teams needs to likewise embrace patients and family members. This goes beyond "patient activation” or reflexively documenting patients’ goals for medical visits. This means including patients and family members in team deliberations through regular communication and feedback loops. It also means involving patients and family members in the running of our PCMH practices by asking them to serve on advisory boards and volunteering to assist us with our quality improvement projects. The measured performances of rehab teams rest firmly on the quality of the lives of patients and family members. The performances of family medicine teams—interdisciplinary, prevention-focused, functionally oriented—need to as well.

 

Barry J. Jacobs, Psy.D. is the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA and a CFHA board member. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Loved Ones While Helping an Aging Parent.


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Aligning our Efforts to Transform the System

Posted By Rob Cushman, Thursday, October 18, 2012


Dr. Cushman's post is the third in a 5-week collaborative series hosted by the blogs of
CFHA and STFM.

Please check back
each week.

 

As a long-time member of STFM and the incoming President of CFHA, I am both excited and a bit anxious about taking on this role at this time, because we are truly at a critical juncture. As healthcare providers and educators, we offer clinical services in a "system” that is about to either continue making important strides forward toward becoming a true SYSTEM achieving meaningful outcomes, or to slip backward into the free-for-all chaos that has complicated delivering good, patient-centered care for decades. We need to work together as members of STFM and CFHA to navigate through these twists and turns, or plow through some obstacles, so that we, our trainees, and our patients and communities, come out in better shape on the far end.

I want to share one of the "clinical pearls” I learned in my residency, which has served me well as a "compass,” and which I have quoted (with attribution!) many times to my own trainees as I precept them in the hospital and the office. I offer it now because it is applicable beyond the direct patient care process. I can still hear Tom Campbell saying, "When you’re stuck, expand the system.

He of course meant to explore more into the patient’s family and community context, gathering the perspective of some of those folks that make up that social network, or enlisting their assistance in changing parts of that context in order to achieve change for the patient. He also meant to ask for input and additional, new and different perspectives and suggestions from one’s professional colleagues, both diagnostically and for interventions. This approach has proved hugely valuable to me, repeatedly. And I think the current emphasis on team-based care is a result of a collective recognition that this systemic approach is valuable and more effective than "going it alone.” Rob Cushman
We need to invite others who are not yet fully aware of
the models we
are implementing
to join us and
learn along with
us as we change
our systems.

I want to challenge us all to continue to "Expand the System” in three ways. I want us to Expand our Concept of Teams, to Expand our Measurements of what we’re doing, and to Expand our Reach. Let me elaborate briefly on each of these.

First, Expanding our Concept of Teams. Too often we lapse into thinking of the team as the "clinical team”, those who are based in our practices and/or in other agencies. I would encourage us instead to remember that every patient needs to be at the center of the "team” that coalesces to address their physical and mental health needs. The person that is that patient/client/consumer should be thought of as a co-captain in setting the agendas for the team. Only then will our primary care practices have truly become Patient-Centered Medical Homes. I fear that label is currently thrown about far too liberally, and unconsciously shortened to "medical home” because being truly patient-centered is way harder!

Second, we need to Expand our Measurements. By this I mean that we need to more consistently, more systematically collect, track, and analyze meaningful data about what were are doing (our processes) and the impacts we are achieving with and for our patients and their families and communities (our outcomes). Some folks emphasize measuring outcomes over process, and that has some validity in the long run. However, while we are in the middle of striving to find the best ways to do things, collecting information about process may help us to determine more rapidly which aspects of different approaches we try may be the critical components in determining the success or failure of an approach. The outcomes measures are then important for making the case that that change is ultimately worth doing.

Finally, we need to Expand our Reach. By this I mean that, as CFHA and STFM members, we need to expand our conversations about collaborative, integrated care to others in our workplaces and communities. We need to invite others who are not yet fully aware of the models we are implementing to join us and learn along with us as we change our systems. We need to decide how we can best coordinate and partner with each other and other organizations who share many similar values and positions, in order to join our collective voices in advocacy, and even to undertake joint initiatives to help "make our case.” We need to share our success stories, and be able to provide the data coming from our own, and our collective, measurements and research about the value of this holistic model of care. This is what advocacy is, distilled down: telling illustrative stories, backed up by data. Each of us has a role in advocating for the continued expansion of collaborative, integrated care. Together, we can make this happen.

So, don’t just expand the system when you’re feeling stuck. Instead, let’s strive to Systematically Think (and Work) Systemically.

 

Robert A. Cushman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Connecticut School of Medicine and Saint Francis Hospital and Medical Center. He has been an active member of STFM since 1987. He was consistently active in the Group on Family and the Group on Community Medicine, and served on the Steering Committee for the Group on Family, including serving as Conference Chair for the STFM Conference on Families and Health in New Orleans in 2008. Since that time he has become increasingly involved in CFHA, as well, and joined its Board last year as Treasurer and President-Elect. The text above is adapted from his inaugural address as CFHA President.



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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA
info@CFHA.net

What We Do

CFHA is a member-based, 501(c)(3) non-profit organization dedicated to making integrated behavioral and physical health the standard of care nationally. CFHA achieves this by organizing the integrated care community, providing expert technical assistance and producing educational content.