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Health care records on your iPhone?

Posted By Matthew P. Martin, Friday, January 26, 2018

Yup, Apple is making the foray into health care.

One of the biggest companies on the planet wants to give you access to your medical records using the popular iPhone. This feature will be available once the iOS 11.3 update rolls out later this year. 

Check out the article link above for details on how it works (basically using a phone app that links with care systems that have opted into an agreement to share records; patients have to opt in as well).

The implications for this development are enormous. Patient portals via web browser have been around for several years but many of these portals are limited in stability and scope. Moreover, clinical researchers have been challenged for years in gathering more patient-reported data to evaluate health interventions. A new phone app like this one may be the break they need.

Maybe the biggest implication is that electronic health records may now finally be streamlined into an easily accessible platform for both patients and physicians. Imagine interacting with patients more often outside of a medical or behavioral health visit. Imagine collecting additional health outcome data from them or family members. 

The rollout for this new app is quite small but hopefully will gain momentum in the near future. Stay tuned listeners ...

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Addressing Fidelity in Primary Care Behavioral Health with the PPAQ: Measurement Matters

Posted By Greg Beehler, Thursday, January 11, 2018

(Brief History)

My colleagues and I at the VA Center for Integrated Healthcare (CIH) first developed the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to address a fundamental question: What do PCBH providers do every day?  We all know that variation in clinical practice is common.  In short, clinicians don’t perfectly follow conceptual models or detailed protocols in their usual practices for any number of reasons. Thus, we developed the PPAQ with the goal of creating a self-report measure of PCBH provider fidelity. 

Fidelity typically refers to the degree to which a model of care (or a specific treatment) is implemented as intended. To craft our measure, we started with an expert consensus study to help identify the essential components of the PCBH model that could be measures by self-report. This expert consensus study (1) ensured that we included the right survey items in our measure. A subsequent study ensured that the measure had adequate technical quality in terms of reliability and validity (2). Additional research showed that the PPAQ was effective at classifying PCBH providers as engaging in high or low fidelity practices (3). 

 

(Description)

The PPAQ is a 48−item self-report measures that uses a 5−point, Likert-type response scale ranging from “never” to “always.” It sounds long, but don’t worry! It only takes about five minutes to complete. The PPAQ includes essential items, which measure behaviors that are highly consistent with the PCBH model, and prohibited items, which measure behaviors that are inconsistent with the PCBH model. The items are organized into four content domains:

1.     Clinical Scope and Interventions

2.     Practice and Session Management

3.     Referral Management and Care Continuity

4.     Consultation, Collaboration, and Interprofessional Communication

The PPAQ can be used for research and evaluation, but to make it easy to use as a quality improvement tool, we also converted it into a toolkit that was found to be highly acceptable as a self-assessment to frontline PCBH providers (4). 

The best way to get to know the PPAQ is to visit our webpage to download the PPAQ Self-Report Form and various versions of the toolkit to take a look for yourself: https://www.mirecc.va.gov/cih-visn2/PPAQ.asp.

 

(Rationale)

So why should you care about fidelity and the PPAQ?  I think the answer to this question is quite simple: fidelity is an indicator of care quality. Consider the following:

       Monitoring fidelity means you are keeping an eye on quality of services

      Areas of low fidelity can indicate targets for quality improvement initiatives which are key to improving service delivery

       We can advance the knowledge base in PCBH by addressing fidelity in our research and evaluation

      Formally linking provider behaviors to patient and system outcomes will help us determine what aspects of care provided by PCBH providers matter most

       Fidelity assessment can enhance training and implementation efforts

      PCBH is a challenging and complex model. Using a measure like the PPAQ can assist providers with understanding what behaviors constitute high quality practice

It also should be noted that high fidelity practice doesn’t mean providing the same service to all patients every single time in a mindless, if technically correct fashion. Purposeful modifications to high fidelity practice can ensure high quality, patient-centered care.

 

(Future steps)

Currently, the VA has undertaken a huge step in addressing competencies among integrated primary care providers.  In summer of 2017, experts at CIH have developed a comprehensive competency training program that will be completed nationally by all VA Primary Care Mental Health Integration providers. The PPAQ is being used as part of an evaluation plan to assess changes in provider behavior as a result of the training program (…and early results are encouraging.) Initial competency training will be conducted at all VA healthcare systems through December 2018 with ongoing training occurring for new providers thereafter.

Also in 2018, the PPAQ-2 will be made available. Since integrated primary care comes in many shapes and sizes, the PPAQ-2 has been expanded and re-validated to include new subscales to address essential components of collaborative care management.  The PPAQ-2 will now be useful for both PCBH providers and care managers.

I hope you will consider embracing fidelity measurement in PCBH. It’s a chance to make care quality better.

References

1. Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8, 19. (Link to PubMed Abstract)

2. Beehler, G. P., Funderburk, J. S., Possemato, K., & Dollar, K. (2013). Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Translational Behavioral Medicine, 3, 379-391. (Link to PubMed Abstract)

3. Beehler, G. P., Funderburk, J. S., King, P., Wade, M., & Possemato, K. (2015). Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns. Translational Behavioral Medicine, 5, 384-392. (Link to PubMed Abstract)

4. Beehler, G. P., & Lilienthal, K. R. (2017). Provider perceptions of an integrated primary care quality improvement strategy: The PPAQ Toolkit. Psychological Services, 14, 50-56. (Link to PubMed Abstract)

 

Gregory P. Beehler, PhD, MA is the Associate Director for Research and a Clinical Research Psychologist at the VA Center for Integrated Healthcare in Buffalo, NY. He is an adjunct assistant professor in the Department of Community Health and Health Behavior and the School of Nursing at the University at Buffalo. Dr. Beehler is a licensed psychologist and medical anthropologist currently conducting research in the following areas: improving the implementation of primary care-mental health integration, fidelity assessment, measurement-based care, developing and implementing brief interventions for chronic pain, and promoting wellness among cancer survivors.

 

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Current State of Integrated Care: Collaborative Care in Kentucky

Posted By Xiaodi Chen, Thursday, January 4, 2018

Kentucky has a long history of healthcare innovation. In May of 1993, it submitted its first 1115 waiver (under section 1115 of the Social Security Act, the federal government may grant the state flexibility to experiment with projects that are likely to promote the same objectives as the federal program – for more information, see this key fact sheet), called the Health Care Partnership Program.

 

In 1997, implementation of the project began. The demonstration project was set to create eight partnerships of public and private providers, one for each identified geographic region, to deliver Medicaid acute services through managed care arrangements. One of the hopes was that by developing a capitated payment system, under which the fee is based on enrollment rather a fee-for-service scheme, and improving coordination of care, the rate of Medicaid expenditure growth would decrease.

 

Ultimately, only two of the eight partnerships were fully implemented. In 2000, one of those two terminated its contract, leaving only the partnership in charge of the Medicaid delivery system for Louisville and surrounding counties. The commonwealth of Kentucky filed for extensions several times, and the waiver eventually expired December 31, 2012. A report by the CMS hypothesized that low population density meant many regions simply did not have the membership base to be financially viable. In addition, setting feasible capitation rates was an important strategic choice that determined the fate of the two established partnerships.

 

Although that particular demonstration did not go completely as planned, Kentucky seemed to continue to move in the direction of improved care coordination. According to a report by the state government, by September 2014, Kentucky had over 200 National Committee for Quality Assurance (NCAQ) recognized Patient Centered Medical Home (PCMH) clinicians, as well as 21 – 61 PCMHs.

 

Furthermore, Kentucky participated in the CMS’ Comprehensive Primary Care Initiative (CPCI) from 2012 to December, 2016. This is a multi-payer initiative that fosters collaboration between public and private health care payers to strengthen primary care, which, historically, has been underfunded. Under this model, participating primary care practices receive a monthly non-visit-based care management fee and have the opportunity to share in any net savings.

 

In addition, Kentucky was part of the project lead by TransforMED that won the Health Care Innovation Award in 2012. This was a three-year initiative to create “medical neighborhoods” to promote care coordination among PCMH, specialty practices, and hospitals. This project used a sophisticated analytical engine to identify high-risk patients and coordinate care across the medical neighborhood to provide comprehensive care while reducing costs. Outcome research conducted by the CMS suggests that, overall, the project had statistically significant favorable effects in terms of service use, while having no substantive effect on quality-of-care processes or spending.

 

In 2015, as winner of the State Innovation Model Initiative Model Design Awards Round Two, Kentucky received 2 million dollars from the CMS to improve statewide health care quality and access while reducing costs. Kentucky planned to enhance delivery system for behavioral health, long term services and support, and end-of-life care. Innovation projects include the introduction of Complex Chronic Condition Health Homes, the Episode of Care (EOC) payment model, telehealth to connect primary care providers and patients in rural areas with specialists, and “Citizen Portal” for consumer direct access of personal health records as part of the Health Information Exchanges (HIE) expansion. The projected saving from the project is $104.1 million to $270.5 million. The state proposed a two-year implementation timeline. (For more information on this initiative, you can read the state’s grant application.) [In my research, I found that the CMS website has a very interesting interactive map, where you can select a state and see all the innovation models run at the state level.]

 

In 2015, Kentucky also won an award of nearly a million dollars from the Substance Abuse and Mental Health Services Administration (SAMHSA) to, as part of the initiative to integrate behavioral health with physical health, promote evidence-based practices and increase access to high quality care.

 

One challenge facing the commonwealth of Kentucky is the cost of operation, especially after their recent expansion of Medicaid eligibility. In 2014, Kentucky expanded its Medicaid program to cover all newly eligible adults with income below 138% of the federal poverty level (FPL), as part of the Affordable Care Act (ACA). The number of insured people in Medicaid/CHIP increased 107.65% percent from 606,805 in 2013 to 1,260,001 in 2017.

 

This cost challenge was one of the driving forces behind Kentucky’s second application for a 1115 waiver. Under the new proposal, adults with income below 138% of the FPL would generally no longer be automatically insured through the Medicaid program. Instead, enrollment would be provided through their employment, with the state offering employers a premium assistance program. To make it a consumer-driven health plan, each person would have a deductible account and a reward account. The state would contribute $1000 a year toward the deductible account to help consumers afford the deductible required by various plans. In the reward account, individuals could receive enhanced healthcare benefits such as vision, dental, over-the-counter medications, and gym memberships by completing specified health-related or community engagement activities. A decision on the application will come soon, and should significantly impact the healthcare landscape in Kentucky!

 

From this overview of Kentucky’s recent healthcare initiatives, it is clear that the commonwealth has been actively exploring alternatives to improve the efficiency and quality of its healthcare system.  At this stage, it is difficult to know the outcome of Kentucky’s newest proposal. If the most recent 1115 waiver is accepted, we will be watching closely to see how it works out!

 

As always, it is important for clinicians to understand the changing landscape and advocate from their perspective, so policy-makers and administrators can better plan and implement relevant proposals.  Please leave us a comment if you would like to share more about what is going on in Kentucky or another state regarding Collaborative Care!

 

Note: Special thanks to Jessica Beal, who has provided valuable insights and support in writing of this blog.

 

Xiaodi Chen, MSMFT, is a recent graduate of Northwestern University's program in Marriage and Family Therapy, where she had extensive clinical training at The Family Institute's Bette D. Harris Family and Child Clinic.  She previously received a Bachelor of Arts in Economics from Cambridge University and a Master of Education focusing on Human Development and Psychology from Harvard University's Graduate School of Education.  Ms. Chen is particularly interested in interdisciplinary work to promote patient-centered healthcare.

 

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Current state of integrated care: An opportunity in England

Posted By David Humphreys, Monday, December 4, 2017

A recent article in Context, the house magazine of the Association of Family Therapy (AFT), raises questions about the future of family therapy as an accredited profession in the UK. A variety of threats to the profession are described, which include a lack of clarity about what the family therapists do and with which client groups. The recognition and accreditation by AFT of the systemic practitioner role. This can be achieved with the completion of the first two years i.e. intermediate level, of the four-year family therapy training.

 

AFT argue that they are responding to an increase in intermediate level training being provided by private, voluntary and NHS providers. This is attractive to organizations because training can be delivered in house to existing staff, who can be skilled up for specific projects. Further the nature of the requirements permit the two years to be delivered in one.  

 

 There has been a reduction in the numbers on qualifying training courses and several courses have moved to bi-annual intakes. In recent years one private training provider, Kensington Consultation Centre (KCC) closed because of financial issues. There is also some suggestion that universities providing qualifying level training are losing money on these courses. This in a climate where those same organizations have closed other courses because of insufficient numbers.

 

There would seem to be many reasons for the changes, including the ways that the NHS and Social Services departments have responded to several years of having to make efficiency savings. They are the major employers of family therapists in the UK, the majority of whom are employed in children’s services. In a bid to buy more, with less, many of them have adopted a re-banding strategy. An example of how this works can be seen in a large mental health trust of 3000+ staff close to London.  A layer of middle managers was removed, and their tasks were given to senior clinicians below them, requiring them in turn to reduce their clinical caseload by passing it down and so on. At the same time a new grade of clinician was created, with a lower level of training, using manualised approaches to work with less complex clients, and being supervised by the senior clinicians.  The economics are straightforward depending on grading you can buy 2.5 -3 junior clinicians for one middle manager.

 

It could be argued that one of the effects of these strategies might be to increase the demand for qualified family therapists as supervisors. This might be the case, but to ensure compliance that would require a binding agreement that systemic practitioners could only be supervised by qualified family therapists.  That doesn’t exist; and already that role is often fulfilled by other clinicians such as clinical or counseling psychologists, who may have completed a systemic element in their training. All of this would support the argument that the profession may be facing a serious reduction in numbers of qualified practitioners and an associated reduction in dedicated posts.

 

Into this bleak description of the future, maybe consideration needs to be given to current developments in the NHS, and where most of the resources are being allocated. One of these is primary care; the launch in 2015 by NHS England of the Vanguard project; initially establishing 23 trial sites. These are Multi-Speciality Community Providers and Primary and Acute Care systems, trialling integrated care structures. They are bringing together physical and mental health treatment in a variety of structures including within GP practices.  These are large sites serving big populations providing primary physical and mental health care, and outreach secondary services. They are looking to collaborative integrated primary care models in the US, such Intermountain Healthcare and Southcentral Foundation for ideas and inspiration. In 2017 there are over 50 trial sites with a variety of models and configurations across the country. Recent feedback is very interesting.

 

These developments would seem to offer a potential demand for mental health clinicians skilled in relational working, trained to think about and engage with the network and system at an organisational, team, familial and individual level, aiming to build collaborative working across disciplines. Family therapists would seem to be well placed to meet these demands.

 

Primary care has not historically been a place of employment for family therapists, there are a number of reasons for this. The first is that the majority of family therapists were, as previously mentioned employed in secondary children’s services in dedicated posts. Until 10 years ago mental health provision in primary care was inconsistent and of variable quality. There was little guidance offered to GPs about the variety of therapeutic modalities and the most effective evidence based treatments. At the same time secondary services especially for people with mild to moderate depression and anxiety disorders were very sparse and often non-existent. The combined effect was an increasing untreated population of adults, with many GP’s trying to treat people with medication and informal supportive counseling.

 

This changed 10 years ago, when following the publication of the Depression report,  teams of CBT therapists were established across England contracting with GP practices to provide time limited evidence based treatments. Although they are based in secondary care, they see some people in the primary care setting.   Interestingly in the original report family therapists had been identified as one of the professions to be trained to work in primary care, regrettably it didn’t happen.  One of the reasons may be that when in the 1990’s, Susan McDaniel and others in the US, described a Medical Family Therapy role working in primary care. It was dismissed by some in the UK family therapy establishment, on the basis that they were already using that approach in secondary care had been for 40 years.  

 

Whilst acknowledging that it wasn’t used in primary care, maybe the time has come to take another look at MFT and consider the possibilities that might be created in the Vanguard sites, it is not too late. The Vanguard sites provide the opportunity to implement change, MFT provides a model to learn from and Family Therapists have the professionalism and the motivation to drive the change to integrated care.

 

David Humphreys, MSc., is a registered family therapist working in a primary care practice in Hertfordshire in the UK. He is a 2016 Winston Churchill Fellow and visiting lecturer at the University of Hertfordshire. 

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New Editors at Families, Systems, & Health

Posted By Matthew P. Martin, Friday, November 24, 2017

Congratulations to the new incoming editors at Families, Systems, and Health: Drs. Jodi Polaha and Nadiya Sunderji. We are looking forward to some great work!

This signals an end to the productive and expansive era of the former editors, Colleen T. Fogarty and Larry Mauksch. CFHA would like to thank Colleen and Larry for their visionary leadership. Under their watch, the journal published significant research including a recent special issue "Strategies for Evaluating Integrated Care in the Real World" that featured Jodi Polaha as a guest editor.

For information about the history of the journal, click here. If you're interested in submitting a manuscript click here

FSH publishes research, literature reviews, health policy briefs, conceptual explorations, educational and clinical models, narrative essays and poetry at the intersection of family functioning, systems thinking and health and health care.

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Current state of integrated care: Interview with a family physician in South Korea

Posted By Jeehee Sung, Wednesday, November 15, 2017

In 2007, my education in marriage and family therapy (MFT) in the US began. After a year of course work, my clinical experience as a MFT intern started at the University of California San Diego Family Medicine Residency, which had well-established integrated care. For me, it was a novel and exciting experience working as a mental health provider in a medical setting. I was amazed by the service the collaborative care clinic provided and somewhat envious of patients who came to the clinic, thinking of Koreans who did not have such service. 



After 10 years of studying and practicing in the field, I became curious about whether there has been any movement toward integrated care in Korean medicine. I decided to make this one of my projects and applied for CFHA mentorship program. I was paired up with a mentor, Dr. Laurie Ivey, who is Director of Behavioral Health at the Swedish Family Medicine Residency in Colorado. With her guidance, I started to search ways to get familiar with the family medicine field in Korea.  I tried to broaden my professional network in medicine there, which, of course, was/is quite challenging. I tried to join one of the major family medicine organizations in Korea-- the Korean Academy of Family Medicine, but it was a physician-only organization. I tried to find Korean physicians through the CFHA listserve and other physicians’ organizations, but still no luck. Both in Korean and English, I looked for articles that discussed the concept of integrated care or collaborative care (there is no established terminology to identify this model in Korea). Unfortunately, there was a dearth of literature on this subject.  



I still wanted to pursue my curiosity about integrated care in Korea, so I took a different route in approaching the family medicine field. I shared my interest with one of my friends who recently finished medical school in family medicine in Korea. Surprisingly, through her, I was introduced to a great family medicine doctor, Dr. Jong-Sung Kim. 



During my stay in Korea in the summer of 2017, I met with Dr. Kim, Chairman of family medicine at Chungnam National University Hospital. Chungnam National University Hospital is located in Daejeon, the fifth-largest metropolis in South Korea. Daejeon has a population of over 1.53 million and serves as a hub of transportation. Before serving his current position, he was the head of an alcohol treatment center in Daejeon, where individuals and their family members are treated from an integrated approach. Despite being in an integrated center, he shared that one of the main struggles he experiences is uncertainty and unwillingness on the part of the psychiatrists with whom he works, toward the integrated approach to treatment.  He stated this is particularly challenging for the psychiatrists that are new to his team because integration is a new concept for them. He said that it has taken him almost three years to help the psychiatrists open up and be fully on board with him.



Dr. Kim is a well-known family physician and holds a strong family-centered perspective. While he was making me a cup of tea, I looked around his book shelf. I was impressed by so many family therapy books on the shelf. He shared that he taught genogram, family dynamics, and family interview to family physicians in Korea during the Korean Academy of Family Medicine conference twice every year-- spring and fall. When I asked how much interest he noticed on this subject among Korean family physicians, he said, “not much.” His assumption was they were so busy with medically related topics that the family factor was a non-priority to them. He also said that family physicians were aware of the benefit of the integrated treatment, but the priority was still to protect their high-bar field and a system that is provider-centered, not patient-centered. 



Through this experience, I learned that unfortunately the medicine field in Korea is a quite private and non-inclusive community. However, when you keep trying using various approaches, the door can open. I also learned that family medicine in Korea has much work to do in the future in order to create a successfully integrated system. Finding answers will take time, effort, and people who are interested in this subject. If you happen to know any Korean family physician, please let me know. It would be greatly appreciated! 


Jeehee Sung, Ph.D., is an assistant professor in Marriage and Family Therapy Program at Mercy College in New York. She is a licensed marriage and family therapist and American Association for Marriage and Family Therapy approved supervisor.


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Collaborative Medication Management: Tips for Working with Pharmacists

Posted By Kelly Valdivia, Casey Gallimore, Tuesday, October 31, 2017

A day-in-the-life

The day: Wednesday. The time: 8:50 am. I (KV) just received a handoff from a provider, the 9 am patient has arrived, and I am in the middle of a coordination of care phone call with a school nurse who is attempting to help facilitate proper dosing of a stimulant for a 15 y/o patient seen in the clinic yesterday.

Just twenty minutes earlier I am walking through the clinic, writing my name on the white board to indicate that I am present and available for providers. I greet my colleagues: reception, clinic manager, medical providers, registered dietician, Spanish interpreters, lactation consultant, and triage nurses.

After documenting the phone call and routing the information to those involved in this adolescent’s care, I check in with the handoff who has been non-adherent with their recently prescribed SSRI given fear of potential side effects (thank you WebMD) and concern about the cost. I provide psycho education on potential side effects, benefits, and expected response time for this particular medication. At the end of our visit I walk the patient down to our community resource staff to discuss applying for the clinic discount to ensure that this medication will be affordable for the patient and then follow up with the medical provider who gave me the handoff before rooming and seeing the 9 am patient.

Now let’s step back and imagine how this same day looks when a pharmacist is integrated into the clinic.

The day: Wednesday. The time: 8:50 am. I just received a handoff from a provider, the 9 am patient has arrived, and I am fielding a call from a school nurse. I notice my pharmacist colleague is seated at a work station just across the office. Once I determine the nurse is calling with a question regarding stimulant dosing for a 15 y/o patient, I ask the pharmacist if she has time to talk with the nurse, quickly explain the situation, and am able to hand the phone call over to her. This frees me up to move on to the provider’s handoff.

Just twenty minutes earlier I am walking through the clinic, writing my name on the white board to indicate that I am present and available for providers. I notice the clinic pharmacist’s name is also on the board, and make a mental note that she is available today to help with medication issues. I greet my colleagues: reception, clinic manager, medical providers, registered dietician, Spanish interpreters, lactation consultant, triage nurses, and pharmacist.

Back to the present…I check in with the handoff who has been non-adherent with their recently prescribed SSRI given fear of potential side effects and concern about the cost. I ask the patient if he would be willing to talk with a pharmacist teammate about his concerns. He agrees so I go back to the office where the pharmacist has just finished-up the phone call and hand the patient off to her to provide psycho education on potential side effects, benefits, and expected response time for this particular medication. I ask if at the end of the visit she could walk the patient down to our community resource staff to discuss applying for the clinic discount to ensure that this medication will be affordable for the patient.

I am off to room and see the 9 am patient! At the end of the visit I run into the pharmacist in the hall and we go together to follow up with the medical provider who originally gave me the handoff. When I get back to my computer, I notice the pharmacist has documented the telephone call from the school nurse and routed the information to myself and those involved in this adolescent’s care. I am able to finish documenting the 9am patient visit before I receive a handoff for a well-child check.

 

Putting it all together

The above narrative portrays ways in which a pharmacist can be utilized in a collaborative fashion within an integrated setting. While this may seem simple or obvious, jump starting successful integration of a new specialty within a practice setting can be challenging. Reflecting on two basic questions prior to integration can go a long way in facilitating successful collaboration: 1) why integrate pharmacy into the primary care site? (i.e. how can a pharmacist help the care team?), and 2) which personal skills support pharmacy integration in a way that maximizes collaboration and impact?

The importance and utility of integrating pharmacy into primary care is spoken to in Table 1. This provides ideas and suggestions of specific areas in which a pharmacist can help facilitate care already being provided by an integrated team. Table 2 references skills and characteristics that encourage collaboration among clinicians. Notice how similar these attributes are to those of a BHC or any specialty provider striving to work in a collaborative setting. 

 

Kelly Valdivia, Psy.D., is a licensed clinical psychologist working at Access Community Health Centers (Access) in Madison, Wisconsin, providing primary care behavioral health services.  In addition to direct patient care and supervision of trainees she manages the consulting psychiatry service including training of psychiatry residents to practice within integrated care teams.

 

Casey Gallimore, Pharm.D., M.S. is an Associate Professor at the University of Wisconsin-Madison School of Pharmacy. She joined the University of Wisconsin-Madison School of Pharmacy in 2007 and currently teaches in the areas of mental health pharmacy and pharmaceutical care skills.  Dr. Gallimore practices one day per week at the Access Community Health Centers in Madison where she works with primary care clinicians and the behavioral health team to provide psychiatric pharmacy services.

 

 

 

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Friday Plenary Session

Posted By Matthew P. Martin, Tuesday, October 24, 2017

If you missed the Friday morning plenary session at the 2017 CFHA Annual Conference in Houston, you missed a fantastic presentation by Len Nichols, PhD, Professor of Health Policy at George Mason University. Dr. Nichols described how we got to the current state of affairs in healthcare and what reform may look like in the near future. He mixed policy talk with humor and wit, offering a delightful experience for conference attendees.

 

Current data, according to Nichols, shows that the number of uninsured dropped by one third following the implementation of the Affordable Care Act. National health spending increased from 17 to 18% while readmission rates went down as hospitals began identifying and addressing social determinants of health. However, Nichols reports that some hospitals have begun to give up on reducing readmissions suggesting that hospitals are willing to suffer the subsequent financial penalties. All these recent developments point to some progress as well as uncertainty as politicians and policymakers continue to grapple with health reform.

 

“So, how did we get here?” Nichols asks. He cites historical examples of Democrats, Republicans, and even former Governor Romney of Massachusetts attempting sweeping changes in healthcare regulation. He argues that the ACA or Obamacare is not socialism but draws from Republican plans in the 1990s and 2000s like Romney care (which actually demonstrated universal coverage and lower mortality rates.  But the question still looms: why did Republicans take control of Congress and the White House even when the ACA is more popular than ever? And what can we do today to move healthcare reform in the right direction? Nichols suggests that “we have to get better at explaining ourselves to others”.

 

There are powerful philosophical underpinnings in the healthcare reform that drive deep political divides. Examples include: Rules versus Liberty; All versus Some; Population health versus personal health choices; Compensating for disadvantages versus Reducing tax burden. Constituents have strong opinions about these ideas and tend to vote based on their beliefs. Reforming healthcare means coming face to face with hot-button issues that can sink incumbents fast.

 

Despite the political divide, Nichols offers several points on which we all can agree: first, healthcare and insurance premiums cost way too much; second, the Affordable Care Act is a disaster except for the parts we each individually like; third, fixing the ACA is severely complicated especially since reform can mean removing coverage for voters who have long memories come election time. Despite the fact that Republicans have complete control of the legislative and executive branches, they can’t seem to agree upon which changes to make.

 

Subsequently, there is abundant uncertainty and sabotage in the works. Republicans are weary of attempting reform and may be ready to give up. However, President Trump ended cost sharing reduction payments forcing Congress to make hard choices. There are now bi-partisan efforts underway to stabilize the ACA long enough to kick the proverbial can down the road. In the meantime, hospitals seem to have learned their lessons from readmission penalties while criminal justice systems are now champions for expanding treatment coverage to victims of the massive opioid crisis.

 

Nichols concludes with a prediction and some solutions. He predicts the CHIP will be reauthorized and that states will get more discretion to reform healthcare. He points out though that the US taxes 8% of GDP less than the average of many other developed countries. In other words, Americans are not taxed nearly as high as other countries yet we have an inbred resistance to any hike in taxation. He further points out that any future reform must invest in addressing social determinants of health and that the government must build trust between voters and representatives. Without trust, the entire experiment of a functional and free society falls apart.

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Opening Plenary Session

Posted By Matthew P. Martin, Saturday, October 21, 2017

Welcome to the opening plenary session for the 2017 CFHA Annual Conference in beautiful Houston, Texas. Our fearless leader, Tina Runyan, began with a “state of the association” speech describing the strong financial footing of CFHA. She expressed appreciation for the vibrant, member-driven community. “I don’t know of an organization where you can post a question and get responses from some of the founders who will pepper you with their wisdom. It’s emblematic of the passion that people bring to this cause. It’s so rich.”

 

She announced that the Technical Assistance product line at CFHA is off the ground now. “The goal is to share our expertise and get our brand on the national scene,” she said. Natalie, Levkovich, past CFHA president, was instrumental and initially spearheaded this effort to market CFHA expertise. “Within six months we were already off the ground, thanks in large part to Natalie’s work”.

The new Executive Director of CFHA, Neftali Serrano, was the plenary speaker Thursday evening. “We made it!” he exclaimed walking onto the stage and describing the time period when Hurricane Harvey threatened to cancel the conference. “We are talking today with the backdrop of a devastating hurricane. Thank you for being here. We have a great conference in store for you.”

 

The theme of the plenary was “The Future of Integrated Care”. Neftali immediately debunked any preconceptions about his ability to peer into the future of the field. He related his postdoctoral experience at a large FQHC on the west side of Chicago where he struggled to develop a brand new integrated care service. His failures eventually led him to success and to finding a home at CFHA. “No matter where you are working in this field, CFHA can be your home.”

 

Using a colorful and sharp-looking slide deck, Neftali continued by listing several trends that suggest where the field is headed. First, “Integrated Care Everywhere”: Neftali argues that we must support integrated behavioral health wherever the patients go whether it is the emergency room, a community mental health clinic, long-term care, or specialty medicine. The field cannot just stay in primary care. Second, “Data Explosion”: modern technology is capturing enormous amounts of health data. How do we use all this available data? What technology is available for us now to use?

 

Third, “Getting Out of the Exam Room”: telehealth will continue to grow as a viable alternative to traditional medical visits. How do we stay connected with patients beyond the exam room? How can our treatment plans extend beyond just face-to-face time? Fourth, “Workforce Development”: How do we support care organizations in training their employees in IBH? Is there value in creating a specialization for IBH? Neftali cites the special interest group within the American Psychological Association for psychologists working in primary care. He also argues that this work should be fun and attractive for new trainees. Can we avoid the soul-crushing aspects of current work?

Fifth, “Paradigm Shifts in Chronic Disease Management”: Neftali warns we must keep up with and assimilate new research that challenges old and current paradigms regarding integrated care. For example, the field is recognizing the need for offering both mental health and substance use through behavioral health integration. Sixth, “Payment Reform”: Neftali admits this subject can be boring and high-level. “Most of you want to just see the patient. But it’s important to know what changes are coming down the pike”. Value-based payment is the future. Click here for a review of the recent policy summit on value-based payments.

 

Finally, “Model Wars”: Neftali predicts that the field will continue to increase sophistication in identifying core elements of integrated care that cut across models. Today, though, all the models contribute to the big picture. How can we incorporate a new piece of a particular model into our care? We wrestle with these models and that is a good thing, he notes. But he rejects the scarcity hypothesis that there is not enough work or demand for particular models. “If you bring your passion to the field, the field will return that passion with opportunity”.

 

“There is no turning back”, Neftali concludes. “We have tasted the future and we are not going back”. He announced that CFHA will continue to share expertise through Technical Assistance, Online Forums, and the New Newbie Friendly Pages. He also announced a new forthcoming website that will host podcasts, blogs, webinars, a video channel, and more social media. It’s an exciting time to be a part of CFHA. Continue to come back to the blog for future plenary session reports. 

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Texas Policy Summit on Integrated Health Care

Posted By Matthew P. Martin, Friday, October 20, 2017

On October 19th, 2017, stakeholders from across Texas and beyond gathered for the annual policy summit that take place in conjunction with the CFHA Annual Conference. This year the policy summit focused on value-based payments and was supported by several organizations including The Meadows Foundation, Mental Health America of Greater Houston, Health Management Associates, and CFHA.

 

Neftali Serrano, the CFHA Executive Director, opened the summit saying “There are two bottlenecks in our field right now: payment reform and workforce development. You need a trained and sustained workforce and then payers who feel confident in what they are funding”. Alejandra Posada, Chief Program Officer of Mental Health America of Greater Houston, also opened by saying “CFHA met in Austin five years ago when we were just starting many initiatives. We have indeed made progress since then”.

 

Joan Henneberry, vice president of Health Management Associates, set the stage with a national perspective of value-based payments. “We do this work because we know it costs the system more to care for patients with medical and behavioral health problems. We do this because patients can take better care of themselves and their chronic diseases when mental health is addressed”. Much of the progress is happening in the public sector.

 

She argues that now is a great time for payment reform and that many states are experimenting with multiple models. “Even private sector payers are beginning to have their “aha” moments with integrated care”. However, many states worry that health plans are not taking on enough risk and will continue to use fee-for-service (FFS) models without helping providers change delivery models. The solution is for health plans to contract with community organizations and high value providers that know the community and needs of patients.

 

“So, what are value-based payments (VBP)?” she asks. There is a long continuum and it depends on how much risk an organization wants to take. In Denver, Joan’s group started with a per-member-per-month (PMPM) capitation model for pediatric care with specific standards. That was an easy place to start. Where she thinks this is all moving is toward a varying rate of reimbursement. “If you as a practice do not embrace the Triple Aim in the future, then you may get a lower reimbursement rate from your payer.”

 

But what if providers don’t want to participate in VBP? Joan cites a 2016 physician survey that found that even though 80% of physicians did not support a change in reimbursement, many did admit that the FFS model does not offer value. Moreover, 71% said they would participate in VBP if offered financial incentives but that they don’t want to be held accountable for outcomes they can’t control. The survey even suggests that hospitals are willing to try VBP. “It’s a little harder to engage hospitals, but not impossible.”

 

Finally, Joan identifies some states that are succeeding with shared a savings approach (Colorado, Oregon, Vermont). However, these states learned that you cannot just do one pilot project after another. The change needs to be systemic but scaled down to the needs of each clinic. Maryland has moved toward an “All Payer” model by setting payment rates for Medicare in addition to regulating the states market. As a result, 95% of hospital revenue is in a global budget with all 46 hospitals joining into the change.

 

Ellen Breckenridge, faculty associate at the University of Texas School of Public Health, continued the summit by sharing results from a large study of integrating medical services into community mental health centers. This study was made possible by the Section 1115A waiver and the Delivery System Reform Incentive Payment (DSRIP) initiatives in Texas. Ten sites participated although a few struggled to report final results due to data restrictions.

 

There were several challenges for the participating sites: some did not have shared medical records; four had tried integration in the past but without success; four sites did not have a physician for the first four months of the study (it was difficult to find willing and able physicians); managed care contract delays prevented billing for services; and the patient population was very poor.

 

Despite these challenges, the sites were able to provide medical services for thousands of patients. By the end, all ten sites were using team-based care, eight were using shared records, warm handoffs, and morning huddles, and seven were sharing treatment plans and organizing all care onto the same floor. Staff and patient feedback was very positive. Staff believed the care was now more holistic and patients felt more comfortable and healthy. Screening rates and health outcomes improved dramatically while hospital encounters and hospital stays dropped by 18% and 32%, respectively. Sustainability is a concern, though, since 62% of the patient population does not have insurance.

 

Heidi Schwarzwald was the next speaker and described the use of VBPs at the Center for Children and Women (CCW), part of the Texas Children’s Health Plan. The CCW uses a capitated, 100% risk model with comprehensive, team-based services including behavioral health integration.  Since offering integrated care, the CCW has excelled in ADHD stimulant initiative and maintenance as well as 7-day psychiatric hospitalization follow-up. We are having success, she remarks, but we are only reaching a small portion of all patients in the entire health plan. The next step is to expand even farther.

 

All the previous speakers including Ernest Buck, Chief Medical Officer from Driscoll Health Plan, Lisa Kirsch, Senior Policy Director at the Dell Medical School, and Dawn Velligan, from UT Health San Antonio, joined in a panel discussion that included topics ranging from incentivizing small, rural clinics to participate in VBPs to using peer specialists and community health workers to training all stakeholders to buy into VBP rationale. All panelists agreed that progress is being made, but that we need more evidence to make smart decisions.

 

The final speaker was Andy Vasquez, Deputy Associate Commissioner for Texas Health and Human Services Commission, who presented an impressive roadmap for VBP in Texas. This roadmap details numerous VBP initiatives at the state level focused on quality and efficiency to achieve the Triple Aim. Most are underway, but many still in development. The roadmap is too large to summarize here. So, I will refer the reader to read the attachment below.

 

Finally, the policy summited ended with a number of small groups tackling big issues like sharing health data between different systems, building capacity and technical assistance for integration, and specific policies needed for making VBPs easier for all levels of care. Look in the future for a final report from the Mental Health America of Greater Houston with specific recommendations for how to prepare your state for value-based payments.

 

  Matt Martin, PhD, LMFT, is clinical assistant professor at the Arizona State University Doctor of Behavioral Health Program. He is also blog edit for the Collaborative Family Healthcare Association. Please contact Matt if you want to contribute to the blog.  

 

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What We Do

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