Posted By Natalie Levkovich,
Sunday, March 10, 2013
As the name of our association proudly declares, Collaborative Family
Healthcare Association has always seen the patient & family as integral to
collaborative care. Long before the language of Patient-Centered Medical Home
seeped into our lexicon, CFHA endorsed the centrality of the patient, the
family and the community as determinants in the health of the population. Through research, policy and practice, CFHA
has steadfastly advocated for the universal adoption of the values and
practices that integrate a patient-centered perspective into the delivery of
care. Effective adoption of this perspective requires providers to be proficient,
efficient, present, compassionate and empathic in the practice of their
So, as providers collaborate with patients, families and colleagues, what
impact does their daily experience have on them as individuals, on their
practice, on their families? As they offer support to their patients, absorb
their stories, apply their professional judgment and implement
empirically-supported interventions to help patients reflect on their goals and
adopt more effective problem solving strategies, who helps the provider to
reflect on the impact their work has on them? CFHA blogs and presentations have
been devoted to the needs of family caregivers. What about the needs of
professionals? Regrettably, in many if not most settings, little attention is
paid or time set aside for clinical or reflective supervision.
|Reflective supervision (RS) is particularly well suited to address
the impact that repeated exposure to vulnerable patients and stressed
environments has on the practitioner. RS seeks to embed reflective practice in
the supervisory experience as a way to model parallel process and the
inter-relatedness of all the relationships involved in collaborative care,
including those of providers with supervisors as well as providers with patients/families
and colleagues. ||Reflective supervision is particularly well suited to address
the impact that repeated exposure to vulnerable patients and stressed
environments has on the practitioner.|
In fact, the supervisory relationship should mirror the desired
relationship between provider and patient. RS specifically attends to the emotional
content of the work and how providers’ emotional responses directly affect the care
they deliver. RS practices involve establishing an expectation of regularity,
emotional safety, validation and collaboration that includes a supervisor
guiding the supervisee, in the context of case review, to examine his/her own
feeling and values and how to use that self-awareness to serve the best
interests of the client.
While the mode and nomenclature of RS grew out of early childhood services, the
importance of reflective practice as a critical component of effective practice
is also noted in literature about education and supervision of healthcare practitioners
(see Patricia McClure’s article
"Reflection on PRACTICE) Growing evidence of the
importance and efficacy of RS for
identifying and reducing burnout, vicarious trauma and secondary traumatic
stress is resulting in its gradual spread to other fields of human service. To
learn more, read a brief but excellent white paper that outlines the practices
and values of RS as a trauma-informed practice and provides additional
references. Further, The National Child
Traumatic Stress Network endorses RS as a critical component of preventing and
addressing secondary traumatic stress among workers who are affected by
repeated exposure to their clients’ traumatic histories, see here.
CFHA has begun to include sessions on trauma and trauma-informed
practice in recent conferences. The Adverse Childhood Experiences Study was
discussed at several sessions during the 2012 Annual Conference in Austin, TX. Now,
as we continue to expand our audience and partnerships, the time has come for
CFHA to integrate the needs of providers, beyond self-care, into our education
and advocacy for strengthening systems of collaborative care. I hope that CFHA will take up the cause of
making supportive supervision both a provider right and a necessity when striving
for the gold standard in health care. Our 2013 Annual Conference in Denver
presents an opportunity to advance this conversation. As the conference committee
considers workshop proposals to accept and plenary speakers to invite, they should include clinical supervision as a priority. I challenge the conference
planners and prospective presenters to consider this question with the same
thoughtful approach that CFHA devotes to all of its work.
See here, for an example of Reflective Supervision relevant to an integrated care setting.
Natalie Levkovich is a CFHA Board Member and was a co-chair of the 2011 CFHA conference in Philadelphia. She has served as the executive of the Health
Federation of Philadelphia (HFP) for nearly three decades. HFP is the SE
Pennsylvania network for community health centers that provides comprehensive
primary care to nearly 300,000 low income and underserved individuals per year.
Under her leadership, HFP has experienced remarkable growth through the
development of many innovative, collaborative initiatives
such as the integration of behavioral health in primary care, including
widespread implementation of a sustainable clinical, payment and professional development
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Posted By Amy Davis,
Thursday, March 7, 2013
Hi CFHA community,
I had the honor and privilege last
week of interviewing young family therapists to come join the ranks of new
learners and lifetime learners at St. Mary’s Family Medicine Residency in Grand
Junction, Colorado. We, a team of physicians, behaviorists, nurses,
and educators chatted it up around a table smiling and proudly described our
environment to the interviewee. He asked us to each explain what we
enjoyed most about our clinic. Each of us responded without pause…relationship...relationship
with each other and with our patients.
What does this have to do with CHFA
I think this has everything to do
with this conference. Ideally, the plenaries, discussions,
workshops, networking hopefully all ultimately lead to a most positive, healthy
environment for those we serve and for ourselves too. When Randall Reitz
asked me to help plan this conference, I was a bit intimidated (and actually
remain so!). However, I am passionate about the work of collaboration and
of dynamic change to a "healthier” healthcare system, so with a deep breath, I
have joined with Laurie Ivey on the program committee for CHFA
2013. In order to forge ahead with promise and creativity, we need
the collective power of all of your hard work in your various disciplines.
The conference dates are October
10-12, 2013. The theme for the conference is "Disrupting Status Quo”
which we think parallels changes in the health care political, economic, and
clinical environments. We as providers and consumers are readying
to embrace what will hopefully be a metamorphosis of healthcare. These
changes are likely to be disruptive and uncomfortable but offer great hope and
promise for those of us who advocate for collaboration in healthcare delivery.
In contrast to our "disrupting”
theme, the conference will be set against the backdrop of the Flat Iron
Mountains between Denver and Boulder, Colorado. Western poetry
emanates from the open sky, crisp air and the rolling range leading to the
foothills. I encourage you to consider submission, to come dialog,
debate, and share…then relax under a clear Colorado sky. Make us think,
make us squirm, challenge us to a better way.
The call for presentations began February 1st and will close March 15th.
Please submit them at the CFHA
website. We look forward to reading them!
|Amy is Family Physician who has
lived a varied professional life with public service in the IHS, residency
education, work with under-served communities, and 13 years of collaborative
care experience. She currently is the Medical Director of the SMFM
Collaborative HIV clinic and works in primary care at the VA in Grand Junction,
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Posted By Tina Runyan and James B. Anderson,
Thursday, February 28, 2013
"Collaborative care is done in many
ways, by many people, in many settings—it is not ‘just one thing.’”
promises not only opportunity to care for patients more holistically, it also
provides a living laboratory for training practitioners across disciplines.
Notwithstanding the vastly different training paradigms across disciplines,
integrated settings offer rich opportunities to borrow and exchange ideas from
the training traditions of other disciplines. Narrative medicine has been a time-honored
component of family medicine residency training as a mechanism to enhance
reflection, self-awareness, and process nuances of the physician-patient (or
trainee) relationship. Analogous to "A Piece of My Mind” in JAMA, U Mass Family
Medicine hosts a Thursday Morning Memo
comprised of personal vignettes submitted by faculty, residents, and medical
students; the popularity of the essays is demonstrated by a distribution list that
has grown to over 450 readers. Included here are three reflective essays
grounded in collaborative care practice and training.
_ _ _
I made it to my car before I
broke down in tears. I had just come from the hospital having seen a young
woman in the hospital with acute fatty liver disease who nearly died in
childbirth a few weeks earlier. I felt as tightly pulled in so many directions
as the skin atop a snare drum. I was supposed to be home an hour ago and my
daughter had already called twice. I had a grant report due by five o’clock,
and too many e-mails in my in-box asking about something due or overdue. I felt
as if I was letting everyone down and I couldn’t wait for the day to come to a
close so I could just lie in bed and read stories to my children. And then it
came to me … the three questions. One of the favorite stories in my home is a
children’s adaptation of Leo Tolstoy’s short story about a little boy who poses
three questions to the wise old turtle because he often finds himself unsure if
he is doing the right thing.
The three questions are:
1. When is the best time to
2. Who is the most important
3. What is the right thing to
|All I knew about the woman I
went to see in the hospital was a little bit of history about her disease, the
medical events to date, and that she was refusing to see her baby which was
concerning to all involved in her care and upsetting her family. There was
worry about severe post-partum depression or psychosis. I entered the room to find a listless and
soft-spoken woman with dull yellow eyes, too weak to reach for her water glass.
Her husband and soul mate of 20 years, steadfast by her bedside for weeks, left
us alone to talk.||Reflective writing and the use of narrative medicine can offer nascent practitioners a glimpse into
the humanities of their |
mentors and peers, help break down barriers across
disciplines, and cultivate mutual respect.
She didn’t start with "the story.” Instead, she told me all
about the life she and her husband had built together. She told me about her
family. She described her longstanding uncertainty and the numerous
conversations she and her husband had about whether to even have children. She
told me about her birthing classes and her labor plan with a doula and her
hopes for the baby’s first hours after delivery. She cried. She detailed the
weeks leading up to the diagnosis and C-section and her emotions towards her
obstetrical doctors. She explained how defeated she felt and how she does not
have the stamina to even sit upright in a chair for any length of time. I tried
not to cry. She kept telling me how dismissed she has felt and how no one was
listening to her -- everyone was saying how good she looked and she still felt
as rotten today as a few weeks ago when she nearly died.
An hour and a half
later as I stood to leave, she looked me tearfully in the eye and asked "Will
you come see me tomorrow?” Even though I was feeling time slip through my hands
like dry sand, I looked right back and said "Of course I will.” So as I sat in
my car it was exquisitely clear that the best time to do things was now, in
this only moment we know to be certain, the most important one is the one you
are with, and the right thing to do is to do good for the person you are with.
I took a deep breath and took comfort in knowing I was exactly where I needed
to be this afternoon. My drive home was serene. And the bedtime story that
night goes without saying.
_ _ _
On a cold winter morning with the plows finally moving for the
first time this winter, I set off for the long drive to the Barre Family Health
Center. Despite a long weekend, I felt a
bit sluggish starting the day, perhaps because of the random text message that
woke me early in the morning threatening to turn me into the police because of
repeated harassing messages (I didn’t do it, I swear!).
I went through my morning, seeing a typical panel of behavioral
health patients at the health center: A woman struggling to control her weight
and mood following bariatric surgery, recurrent major depression, a middle-aged
couple struggling to save their marriage, and a newly referred patient
adjusting to her newly prescribed suboxone while also trying to find a way to
re-narrate her life while free of drugs.
While I felt some sense of competence and satisfaction after seeing this
variety of patients, I also felt tired. After this clinical session, I entered
into our monthly panel of meetings. As
they do at times, the meetings bled into each other in my head. Finally, we got to the last meeting of the
day—the providers meeting.
was led by our chief resident, who is pregnant.
Earlier this month, she found out she had been accepted to join a
prestigious fellowship program. In the
middle of the meeting, she was pulled out by our lead nurse to tend to a
patient who had been unexpectedly added to her schedule. Her colleague and fellow resident seamlessly
took over the lead of the meeting.
Towards the end of the gathering, I had the chance to present a project
that my mentor and I are trying to initiate at the health center.
One of the attending docs, who has been at
the health center since about the time I started pre-school, literally leaned
forward in his chair to listen to the project description and offer incredibly
insightful and concise advice about how to make it work. This man had been seeing patients all day
since 8:30 and still was full of energy.
Another doctor, this one a young woman just years out of residency, also
provided helpful advice, while making a warm-hearted joke to keep the mood
light even after a day full of meetings.
Following discussion of the project I am trying to develop, two other
docs piped in with their own ideas of how to improve our community, with ideas
of a health center-based patient library and ways to help low-SES patients get
transportation to and from the health center when they don’t have a car. One of these doctors is a Harvard product who
selflessly and tirelessly devotes himself to medicine, the health center, and
under-served populations. The other is a
very young doctor who manages a full patient panel while running our resident
in-patient service and raising a beautiful young daughter on her own.
As I drove home after the long day, I felt happy and inspired,
feelings of fatigue from earlier in the day gone. I feel lucky to work with providers who are
as energetic as they are competent. Not
only do they have strong knowledge of a wide-range of medicine, but they also
truly believe in the importance of behavioral and community health for overall
patient wellness. As a psychology fellow
at the beginning of a career that could have taken many different directions,
these doctors and their actions reminded me of the importance of this work, and
the privilege it is to work with such outstanding doctors and people.
_ _ _
This final essay was written jointly written by Tina Runyan, PhD (italics) and High Silk, MD (plain text) about a notorious and
divisive patient in our health center, the day after the presidential election
this past Fall.
Waking to the news of
Obama’s re-election this morning brings rekindled hope for the future of
healthcare in the US. Still, the health and well being of many Americans hangs
in the balance of a transformed primary care system. This new system of care
promotes comprehensive, coordinated, whole-person, and patient-centered care.
But let’s not forget quality. Quality as defined by metrics and thresholds
chosen by insurance companies and linked to remuneration. As we sit and talk
with our patient, looking back and forth from her to each other, we both know
that we have accomplished something. Something that would never be detected
from the types of quality measures the insurance companies value.
The young woman
before us had not identified any with any health care provider in her first 30
years. In fact she had deep disdain for them all! And now, she
had bonded with the two of us and was actually making progress on health
goals.She had been handed a lot in life - diabetes at a young age,
sexual trauma, an anger management issue, being overweight, and a predilection
for alcohol. This constellation of health issues had been making life
worse for her for years: a miscarriage, relationship issues, uncontrolled
sugars and generally dissatisfaction with life. Many tears had been shed in
this office; many rants about how unfair life is; many moments of despair and
giving up. Now here was a woman sitting up taller than before. She
was talking about "getting control of her life". Her tears contained
near joy now. Her sugars had come down a little but more importantly, she was
feeling good about lifestyle changes. Minimal alcohol,walking frequently,
not drinking soda, and eating healthier - she was setting goals to get pregnant
understanding fullwell what this would entail.
After the visit, Tina
said that I should be proud to have moved her in the right direction over the
last 5 years. Sure, I had not given up. Sure, I maintained full respect
for her even at her meanest moments. But who was I fooling. This was a team
effort. We had seen her back and forth like a ping pong tournament, caring for
her week in and week out - listening, empathizing, prodding, tinkering with
medications, accepting and congratulating small accomplishments. Together we
had helped this woman make progress. We have both always been strong supporters
of co-management between primary care providers and behavioral health, but this
was the pinnacle. We had worked together, stopped each other in the hallway
frequently for consultation and updates, supported one another's ideas and
nurtured each other along. The success was not in her HbA1c, in fact we had
failed miserably on that front alone. The success was in the transformation of
the person, in the teamwork, and in progress and process. There is no quality
measure on the scorecard for these outcomes … but there it was. And we sat in
that room for a while longer, the three of us - it felt very good. It felt
rewarding. It felt like quality care. Our patient felt it too.
PS – I saw our
patient today. She is, for the first time since I met her, consistently taking
all of her medications and checking her blood sugars. She has not had any
alcohol in a couple months. She explained that she chooses not to have any
around because she knows she cannot stop at just one drink. And she knows
alcohol is not good for the baby she is now carrying. She wanted me to tell Dr.
Silk the good news.
_ _ _
Reflective writing and the use of narrative medicine to process
rich and emotionally intense experiences in training and practice are not novel
for any of the helping professions. However, sharing those musings,
particularly with those in training, can offer nascent practitioners a glimpse into
the humanities of their mentors and peers, help break down barriers across
disciplines, and cultivate mutual respect. Over time, this cannot help but to shape
a culture of interdisciplinary collaborators who find various creative outlets
for the emotional experiences intrinsic to the practice of (integrated)
medicine. In our Thursday Morning Memos,
we have discovered gratifying solace and empathy among one another.
Runyan is an associate clinical professor in the Department of Family
and Community Medicine at the University of Massachusetts Medical
School. She is
the Director of an APA accredited, two year Post-doctoral fellowship in
Clinical Health Psychology in Primary Care and the behavioral science
director for the Worcester family medicine residency. . She
recently joined the Board of CFHA and when not writing, practicing,
training or talking about integrated care she
enjoys being a mom, trail running, and practicing yoga.|
|James B. Anderson is an assistant professor and licensed psychologist in
the Division of General Internal Medicine in the Department of Medicine
at the University of Massachusetts Medical School. He is a recent
graduate of the APA-accredited, two-year post-doctoral
fellowship in Clinical Health Psychology in Primary Care in the
Department of Family Medicine and Community Health at UMass (directed by
none other than the co-author of this blog, Dr. Christine Runyan).
James received his PhD in clinical psychology from
Western Michigan University in 2010. When not working on integrated
care, he enjoys playing hockey, SCUBA diving, and travel.|
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Posted By Sandy Rose and Peter Fifield,
Thursday, February 21, 2013
Being patient-centered means respecting patient confidentiality
The DSM-V hasn’t shown-up in bookstores yet, so hopefully I can still convince the APA to add one more diagnosis to the tome: CFR 42.2 GAD (Code of Federal Regulations Section 42, Part 2 Generalized Anxiety Disorder). This diagnosis is narrowly defined, but is apparently spreading virally among mental health professionals. It originates from the effort to adhere to state licensing laws and professional ethical standards while practicing in integrated settings. It is, of course, primarily triggered by those stringent regulations imposed by 42CFR Part 2 ("Part 2”)’ which regulate the confidentiality of alcohol and drug information. Unlike HIPAA, Part 2 provisions require stringent confidentiality protections even for information used only for healthcare or payment purposes.
- Loss of sleep for operations managers attempting to write policy (i.e. locking down access in EMR’s, obtaining appropriate informed consent);
- Anger among exasperated medical records staff ;
- Deflated self-esteem among clinicians;
- Misery loving company with equally obsessive colleagues;
- Recreational or therapeutic usage of wine among all involved;
- Frequent co-morbidity with Part 2 Avoidance Disorder.
In this spirit, I offer the perspective of one non-legal, neurotic worrier and BHI provider/administrator in an FQHC. My case will be that, while Part 2 is arduous to implement as written, it is doable. And further, at its heart, it is a worthy regulation that protects patients and holds healthcare systems accountable to a reasonable standard for confidentiality.
There is indeed plenty of information to weigh in this debate. If you missed CFHA’s annual meeting this year, you can still find some great information on confidentiality issues from CFHA website posts and catch the March special edition of Family, Systems and Health featuring ethical issues in integration. SAMSHA-HRSA’s Center for Integrative Health Solutions site includes resources on understanding 42CFR. The Legal Action Center has a useful compilation of information including books, webinars, power points and free downloadable forms for compliance.
Why is adherence challenging but possible -- even with Part 2? For one, most generalist BHPs like myself are not considered Part 2 "programs”, even though we may diagnose and treat substance use disorder (SUD) conditions. As such, we are not required to do all that covered providers ("programs” in Part 2 language) must do to protect SUD information. The sticky part comes when receiving SUD information from a Part 2 provider, such as an LADC or methadone clinic that receives federal funds. A health center must still protect these records via Part 2 standards.
What does this mean? Well, a number of factoids leading to temporary 42GAD. My colleagues and I must still obtain a Part 2 release even to submit a SUD diagnosis for billing if received from a Part 2 (i.e., specialized) "program”. Most problematic for integration, a LADC or other Part 2 "program” operating as part of a team within a health center cannot freely exchange protected information with others outside of their specialized alcohol and drug unit at the center, except in limited circumstances, without Part 2 protections.
As we do employ an LADC within our group, we present authorization forms for her patients at intake, using the unified HIPAA and Part 2 authorization template form available for download by the Legal Action Center at www.lac.org. Our protocol requires her patients’ consent for billing and for exchange of information with the team and agency. As for any records obtained by her or other "programs”, it is easy enough at least in my setting to secure her notes using our EMR’s locking capabilities. This allows our medical records staff to identify these and other protected "SUD” notes, which require the special authorization for re-release outside our agency.
Our new patient portal holds further promise for reducing the barriers to compliance, once workflows and mechanisms for communication with patients through this system are in place. With secure email for authorization requests and signatures, the process of consent could be quicker and more efficient. If you assume as I did that under-served patients are not likely to afford or use email or texts, consider that nearly 30% of the predominately Medicaid funded patient population in one sample primary care group used secure messaging for their health care needs.  Half of the author’s patients and even geriatric patients were on board.
Alternatively, a center may opt to establish a Qualified Service Authorization Agreement (QSOA) with outside parties that the center frequently uses, (or between the LADC and the health center) such as for referrals or billing. With these agreements in place, a patient’s authorization is not required for release of Part 2 information.
Our center also includes in its registration paperwork (which the patient is provided at the time of establishing care) signature lines for patients to indicate that they know that their BHP (if utilized) documents in one medical chart along with medical providers, and that their clinical information may be sent to referred providers for healthcare reasons, and that this includes, where applicable, alcohol and drug information. Our registration materials also include information about mandatory reporting. We feel this covers BHPs in the case of warm handoffs and unscheduled intakes. 
Practicing the serenity prayer so well known to Part 2 patients, I am well beyond wishing the law away. It is here to stay. In fact I see the need for the law’s strong protections, given the very real discrimination and stigma these patients must endure, such as in employment, custody battles and procurement of needed pain medications or procedures. I have seen providers omit diagnoses in the medical chart where protections don’t exist. This of course may lead to the same black hole that occurs when patients don’t disclose their SUD or seek treatment.
And, holes are costly. As we all know, lethal drug interactions occur, and inaccurate diagnoses or omitted information about SUDS lead to time and dollars wasted. Not surprisingly, hospital access to behavioral health records is associated with significantly lower readmission rates. 
Given compelling arguments for and against security protections, no wonder the angst. And if health care continues to evolve, we will have blessedly more information to safeguard. The prescription drug monitoring program just passed last summer in NH as in other states should no doubt increase SUD detection rates, as will the SBIRT program our center is rolling out next month. 
Contrary to popular opinion the law was not written to create 42GAD and thus drum up more business. Written into the code is its critical rationale--"so patients will not be made more vulnerable by reason of the availability of his or her patient record than an individual who has an alcohol or drug problem and who does not seek treatment”.  And, patient centered care is after all grounded in the belief that patients are fully informed and engaged in decision-making, after weighing information pertinent to care, including risks involved in treatment.  Why shouldn’t this include risks of having one’s information disseminated to third parties, when such release might impact on their care or reputation?
The solution is not to override patient choice for the sake of expediting treatment "for their own sake”. Nor should their choice be eradicated for the ease of providing care. Medical decisions are grounded on patient choice: Consent for disclosure of sensitive information is no different. Let’s work harder to make the choice more efficient and speedier, rather than the release. It is simply and only the patient who should decide where and how much their information gets disclosed. Given the chilling effect otherwise, it is well worth the technical fixes, extra paperwork and workflow headaches to enable this.
Being Type A and returning home from a one week vacation without internet, you can imagine my reaction to yet another New Hampshire power outage as I type this, and the prospect of hours, if not days of no home internet. Yet I will begrudgingly accept the speed limits along the way to the nearest Starbucks outlet and wi-fi to plug in my computer. After all, even ambulances slow down at dangerous junctures.
||I think Dr Rose may need therapy...|
The new DSM-V may not include Dr. Rose’s proposed CFR 42.2 GAD diagnosis but as we continue to navigate the pathways of sharing patient information across the integrated spectrum of care, I’m continually reminded that there is potential for a diagnosable "CFR 42.2 Delusional Disorder”. Subtypes include but are not limited to the following:
- Bizarre Delusions that involve common medical culture phenomena that are totally implausible such as a fully integrated health record
- Delusional Jealousy regarding the perception that Behavioral Health personnel do not have the same free flow of information sharing that medical provider’s do.
- Grandiose Delusions related to one member of the medical team having delusions of inflated worth, power, or higher status.
- Of Being Controlled Delusions where data entry in the EHR, face-to-face communications and other interaction are being monitored and controlled by a higher force.
My colleague and co-presenter deserves respect for her comprehensive investigation of this topic and subsequent informed opinions regarding confidentiality and consent. She however, may have gone a bit over the deep end this time. The core issue here regards assuring that we do the best thing for patient at all points of contact right? Right! And, if accurate and relevant information does not flow freely between agencies how can we, the providers of integrated care, the disciples of medicine self-chosen to transcend all the boundaries of traditional patient care—be it biological, psychological or social—ensure the best care for the patient has been accomplished? How can we know that medications are not being duplicated, misused, abused or prescribed in an unsafe manner? How can we ensure that patients are checking their A1C’s, are eating healthy foods and exercising three times a week or not overusing emergency services?
I try to imagine what a physician would do with an incomplete EKG reading or an MRI that only showed the upper left quadrant when the issue was in the lower right? Providers need the right information to make the right decisions and with humans being so complex it is safe to say the more information we have, the easier it would be to make a safe, calculated decision. It would be wonderful to believe in the conceptual comforts of patient controlled information sharing but I can’t help but wonder if patients really control their information? More importantly, if they had the opportunity, would they really want that level of responsibility? How could they know what is best for them regarding the complexity of most chronic illnesses? I guarantee that there is not a provider out there that has not experienced the increased hypochondriasis happening just from patients overindulging in a simple WebMD! How do patients know what information is relevant to their overall health? Providers are trained to care for patients and to do this they need full access to the patient’s biopsychosocial history.
One of Dr. Rose’s concepts I think we can all get behind regards the futility of wishing away the laws. In this case, the Serenity Prayer may not be as effective as Mother Necessity. We need to get creative. One key element Dr. Rose mentioned pertained to 42 CFR Part 2 and the exchange of information between "program” specialists and providers. Why in anyone’s right mind would they hire a specialist such as a LADC if it is going to inhibit the flow of information? What we are talking about here in the first place is short-term solution focused interventions. We do not need a specialist license for that.
Furthermore, why would we not adhere to the KISS [keep it so simple] model and just hire non-specialist BHS providers that could communicate between providers without all of these complicated policy and licensing barriers? Reimbursement models for licensed specialists are not that robust to begin with, never mind being unsustainable. We could simply continue Behavioral Health tax write-offs and hire less skilled BHS providers. Why do we need a highly skilled, highly specialized Ph.D level Psychologist to deliver generalized short term brief therapy? We could simply have our highly integrate-able, non-licensed, non-specialized BHS providers send a note to the medical provider explaining the rationale behind giving the patient the substance use or even mental health diagnosis and the medical provider could enter in the chart. Workaround complete!
One concept worth mentioning is the idea of Regional Health Information Exchanges [RHIE] and how they are designed to access and distribute patient information. RHIEs could be designed so patients have to opt-out of the privilege, not opt-in. Giving them the opt-in option will only increase their skepticism of the beneficence of their shared information. Various countries in Europe designate organ donation as opt-out. The results are that some countries have donation rates as high as 99% while other countries have opt-in policies resulting in organ donation rates as low as 14%. If what we are looking for is getting the information out there to share, we need to reduce the number of hurdles in the way as well as proactively create opportunistic policies to maximize the number of people in the system.
I honor Dr. Rose’s reverence and optimism towards confidentiality. She mentioned that a solution is not to "override the patient choice for the sake of expediting treatment for their own sake and to focus on working harder to make the choice of release of information more efficient and speedier for the patient”. This may be falling on deaf ears. We have been trying this approach for years and no one seems to listen! All the guilds want their control. The Substance Abuse people won’t meet with the Mental Health folks; the Mental Health folks won’t meet with the Primary Care folks; this proverbial sandbox is a mess and no one is playing well together. It appears that the folks in the sandbox don’t want true equality across the spectrum of care as much as they want to be the one with the best sandcastle.
Although the biopsychosocial model was officially postulated in the late 70’s, common sense has supported the integrative nature of healthcare way before we started officially silo-ing providers. Our grassroots movement that has been growing and expanding over the past two decades has hit a ceiling. Above us now sits the three-siloed thrones of care--medicine, psychology and substance abuse--none willing to heed advantage to the other. None willing to collaborate from the top down to meet the grass root efforts growing upward like vines.
The ultimate question is this: Do we really want a patient centered medical home where the patient has "real” control of the information? In the end, consumer choice typically leads to over-consumption, confusion and waste of resources. So regardless of what end of the spectrum your beliefs lie, ultimately, we need to focus patient care the triple aim—improving health, reducing costs and improving the patient experience. All of the above could be attained by paying more attention to access to, not permission for, complete patient information.
||Sandy Rose is a psychologist and Director of Behavioral Health for Goodwin Community Health, an FQHC in the Seacoast area of NH. She is past president of the New Hampshire Psychological Association and served two terms on the Council of Representatives of the American Psychological Association. She is currently a Psychology Advisory Member of the New Hampshire Board of Mental Health Practice.|
||Peter Fifield is an integrated Behavioral Health Consultant at Families First Health and Support Center; an FQHC in Portsmouth NH. He presented with Sandy Rose on this topic at the 2012 CFHA conference and they are co-authoring an article in the upcoming special iethics issue of Families, Systems, and Health. |
 The Federal Law for Confidentiality of Alcohol and Drug Abuse Records.
 Steve Arnault, Cathy Hudgins, and Peter Fifield—see our upcoming article on ethical issues in the Family, Systems and Health special addition on ethics due March, 2013.
 See Legal Action Center’s Confidentiality and Communication, A Guide to the Federal Drug and Alcohol Confidentiality Law and HIPAA (2012) for internal program communications, pp. 72-73.
 Franklin, R, (2013, Jan/Feb). Secure Messaging, Myths, Facts and Pitfalls. Family Practice Management Magazine.
 Apparently (and hopefully) peculiar to NH, we have prescribed language for informed consent under our licensing law and so we are bound to provide informed consent documents specific to MH at time of scheduled intakes.
 SAMSHA’s interpretation of Part 2 excludes SBIRT information as requiring Part 2 protections if arising outside of a "program”—See FAQs-revised, Q10.
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Posted By Jerica Berge and Tai Mendenhall,
Thursday, February 14, 2013
Including Significant Others in Health Care Visits: Here to Stay…
Or, like Valentines Day, a Short-lived Temporary Celebration?
With an entire recent issue of Contemporary Family Therapy focused on
Medical Family Therapy (MedFT), a second edition of Medical Family Therapy by McDaniel, Doherty, and Hepworth coming
out, and several MedFT training programs (Ph.D.’s, post-docs, certificates, and
fellowships) being established around the country, we have hit a high point in
the field. It appears that Marriage and Family Therapy (MFT) and health care delivery
entities (e.g., Primary Care, Pediatrics, Internal Medicine) may have finally
tied the knot regarding the importance of systemic thinking and relational
involvement at the center of care-provision.
For example, the value of
including a significant other in the health care of a partner—while not standard
medical practice yet—is no longer questioned. It is common for a primary care
provider to request a patient with diabetes to bring in their significant other
to be included in treatment planning. Furthermore, many of the Patient
Protection and Affordable Care Act (PPACA) requirements lend themselves to
supporting a relational view of health care. "Team” and "group visit”
approaches used in federally-qualified Health Care Homes rely on a systemic and
relational view of a patient’s health. Additionally, the new CPT (Current
Procedural Terminology) codes 90832, 90834 and 90837 are defined as
"psychotherapy with patient and/or family member” and the 90846 and 90847 are
defined as "family psychotherapy with or without the patient”. Even
reimbursement systems are embracing the move towards systemic and relational
care. Thus, including significant others in care (i.e., mental and/or physical
health) visits may become the "gold standard” in the near future.
are many advantages of including a significant other in a partner’s health care
visit, from getting their buy-in and support for (and involvement in) the
patient’s treatment plan, to perturbing their worldview about why their partner
has a certain condition. Including a significant other in a patient’s health
care visit may ultimately allow the provider an opportunity to increase the
likelihood of treatment compliance, understand more about the health care
motivations of their patient, and establish trusting relationships which
promote collaborative efforts between the patient/significant other/provider
subsystem to be mutually invested in a patient’s health and well-being.
see examples of this type of collaboration often in the residency clinic where
I work. Residents are encouraged to bring in patients’ significant others to
team visits to get a better perspective of the presenting problem(s). Faculty
doctors have couples they have seen for years and model the importance of
systemic and relational care to their residents. Patients either bring in their
significant other themselves or suggest bringing them in. It seems that providers,
patients and significant others all can see the vision of systemic and
relational thinking in health care delivery!
I Beg to Differ
my long-term collegial sibling, I must counter your enthusiasm with all of
this. To be clear: I agree that it is good to see MedFT’s visibility increasing
in academic literature and professional circles, and the fact that many health
care sites are beginning to recognize the utility of including patients’
significant others in care is a long-awaited change. As a MedFT provider and
educator, myself, I am happy to see our guiding tenets gaining some traction
after so many years of spinning our wheels. But to be honest, I think that you
are looking through lenses here that a bit too rose-colored.
do not think that we are anywhere near the mainstream or
"gold standard” yet. To begin, medicine as we know it is still
rigidly-structured around a one-patient-at-a-time model. Our diagnostic and
billing codes reflect this, insofar as those "belonging” to individual patients
(e.g., 296.32 / Major Depressive Disorder, Recurrent, Moderate Severity or
250.02 / Diabetes Mellitus, Type 2, uncontrolled) are generally paid-for by 3rd-party
payers and those having anything to do with patients’ relationships or
psychosocial situations (e.g., V61.2 / Partner-Relational Problem or V62.2 /
Occupational Problem) are not. Further, our new ICD-10 mental health billing
codes require even more cumbersome documentation that identifies when
significant others’ involvement is disruptive (e.g., 90785 for factors "complicating”
care delivery), but not when it is helpful.
this, most biomedical and mental health care providers are still not required
in their training to gain experience with or confirm competency in systemic
interventions. To my knowledge, MFT (and within this, MedFT) is still the only
camp that mandates a large percentage of logged patient care to include family
members and/or significant others. And – health care home movement
notwithstanding – these systemically trained providers (like you and me!) still
tend to earn less than their Psychology counterparts, and their services are
still not as broadly recognized as reimbursement-worthy by major payers (e.g.,
Medicare) in many states.
our physicians, those who are more likely to work systemically (e.g.,
Pediatrics, Family Medicine) are paid significantly less than all other
medicine specialties. I mean, let’s be real: Have you ever compared the cars or
houses (plural) owned by cardiologists, dermatologists, and surgeons to those
owned by a family-doc? And, coming full-circle, it gets even worse when you
compare that to what we MedFTs live in or drive. Put simply, those who focus
biomedically on one-patient-at-time are rewarded handsomely for it. Those who
dive into patients’ complex interpersonal and psychosocial worlds are not.
when we get right down to it, Jerica, you know that many providers find working
with individual patients (sans significant others) to be more comfortable. Conversations
are more simple, chaos and conflict are less likely, and visits/sessions are
more "smooth.” Even our MFT and MedFT colleagues attest to this (I know that you’ve
heard them!), recognizing that their individual patient at such-and-such
time during the day represents a "break” of sorts from the comparative
intensity of couple- or family- work.
think that we all see the utility of including significant others in care, but the
reality is that many (or even most) providers do not do it until they "have”
to. When their 1:1 services do not seem to be working, when their patients are "noncompliant”
with whatever they are telling them to do, or when they (providers) are
overwhelmed and frustrated because the course of care is not going the way that
they would like to see it go – only then do they begin asking questions like
"What is your wife’s take on all of this?”, "Could you bring your mother in
with you next time?”, or "My thinking is that it would be best to talk with
both of you about how to eat well with this new ‘diabetes diet’.”
think that all of us (providers and patients alike) tend to take the people who
are most important in our lives for granted – at least until we’re "supposed”
to appreciate them (like on Valentine’s Day or their birthday), until we really
need them (because of the support that they can offer), or after it’s too late (because
we have lost them). I see much of health care following this very path. Including
significant others because we’re incentivized to do so, or because we don’t
know what else to do, is good. But it’s not ideal. Maybe someday we will all do
this naturally. But my sense is that this is still a very long way off.
Jerica Berge, PhD, MPH, LMFT, CFLE
is an Assistant Professor
at the University of Minnesota in the Department of Family Medicine and
Community Health. She received her PhD in marriage and family therapy from the
University of Minnesota. Dr. Berge is a Medial Family Therapist at the North
Memorial Residency Program and Research Faculty at the University of Minnesota
Medical School. Dr. Berge’s research interests include childhood obesity
prevention and community-based participatory research around child and family
Tai Mendenhall, PhD, LMFT is an Assistant Professor
at the University of Minnesota (UMN) in the Department of Family Social
Science, Director of the UMN’s Medical Reserve Corps’ Mental Health
Disaster-Response Teams, and Associate Director of
the UMN’s Citizen Professional Center. He works actively in the conduct of collaborative
family healthcare and community-based participatory research (CBPR) focused on
a variety of public health issues, including more than a dozen community-based
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Posted By Cassidy Freitas,
Thursday, February 7, 2013
"I just want to sleep…I
just want to go rent a hotel room, and go to sleep.”
"I’m not strong enough
"I look at my twins
and I don’t know them, shouldn’t I feel differently?”
"I’ve never felt so
dark and low. Sometimes I wonder if they’d all be better off without me.”
"I can’t stop
worrying, I can’t even bathe him. What if I drowned him…”
"I wouldn’t have said
anything if my doctor hadn’t asked…”
Fluctuating hormones. Little or no
sleep. A fledgling maternal identity filled with self-doubt. These are the
experiences of almost all new mothers, not just the ones who
experience a Postpartum Mood and Anxiety Disorder (PMAD). Typical statistics regarding the prevalence of PMADs
vary anywhere from 10 to 20%, but I don’t believe they capture the full picture.
What would happen if we accounted for those mothers that may not meet DSM criteria?
What about those mothers that never come forward due to shame or fear? What
about those mothers who experience Psychosis? Where do we account for them?
|According to the American Pregnancy
Association, approximately 6 million pregnancies occur in the U.S. each year (I report the number of pregnancies rather
than the number of live births because every postpartum mother is at risk for
PMADs despite the outcome of her pregnancy.) While postpartum mental health
issues are far more common than gestational diabetes, every woman will get
screened for diabetes during her pregnancy and not nearly as many new mothers
will get screened for postpartum mental health issues. ||Postpartum|
The University of California San Diego’s (UCSD) Department
of Family Medicine has come a long way in addressing these issues. With
trailblazers like Dr. Katie Hirst (who teamed up with LMFT Amber Rukaj to found
the Maternal Mental Health Clinic at UCSD in 2007), we have implemented
screening, educational resources, and interventions that are helping postpartum
mothers and their providers. As a Medical Family Therapist Intern at this site,
I’ve had the special privilege of working with primary care physicians and
psychiatrists who believe in what my presence can offer which affords me the
opportunity to work with women and their families during pregnancy, postpartum,
While changes in the treatment of
maternal/pregnancy/postpartum, etc. are called for, it is also important to
consider the financial ramifications of these pressing issues. The U.S. has not
really tried to quantify the cost of postpartum mental health disorders, but
Australia has. Their nationwide organization Post and Antenatal Depression
Association found that perinatal depression alone will cost them an estimated
$433 million dollars in 2012. This number includes health care costs, lost
productivity and foregone tax. Let’s also note that Australia has a population
of 22.6 million people, and we have 311.6 million. Do the math. Not caring for
our mothers is costing us, big time.
it’s due to stigma, limited skills and training, a fast paced schedule, or lack
of resources, not enough providers are talking to mothers about postpartum
mental health risks and disorders. In order to address these important issues, I
suggest a collaborative approach between physicians and mental health
clinicians to increase detection and treatment.
If you are
looking to help this population, a way to begin coordination in this area is to
get in contact with your local postpartum health organization. In San Diego we
have the Postpartum Health Alliance, an organization whose entire mission is to
connect mothers and providers to each other and to the vast array of resources
that exist out there. I’ve been lucky enough to serve as one of their warmline
volunteers, and through the process have run into some amazing resources that
you can find at the bottom of this post.
that untreated postpartum mental health issues have long term costs for
mothers, their children, and their families. Whether it’s the personal or financial
costs that make you cringe, that doesn’t
matter to me. What matters to me is that we do something. Let’s amplify the
voices of our hurting mothers. Let’s tell them that they’re not alone, that we
care, and that we are taking action.
|Cassidy Freitas is a Marriage and Family Therapy doctoral student at
Loma Linda University as well as an AAMFT Minority Fellow. Along with her
PhD she is pursuing a certificate in Medical Family therapy offered by
the doctoral program at Loma Linda. She is currently working at the UCSD
Department of Family and Preventive Medicine as an MFT Intern.|
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Posted By Laurie Ivey,
Friday, February 1, 2013
Hi CFHA community,
It’s that time of year again—time for you to help us create the best CFHA conference yet! The conference dates are October 10-12, 2013 in Broomfield, Colorado. Disrupting Status Quo is our theme and we are ready to shake things up. I am one of the co-chairs of the CFHA 2013 conference and with Amy Davis, am leading the program committee to develop an exciting curriculum for presentations next fall. I have attended many CFHA conferences and find them inspiring. I helped out with the planning process when CFHA came to Denver in 2008 and was excited to do so again when Randall Reitz approached me to be a part of the Denver planning team.
We have spent a lot of time as a group talking about how to energize the 2013 conference and how to breathe some fresh air into our days together next fall. We chose the theme "Disrupting Status Quo” because we wanted to highlight the fact that it is time to bring new energy to our conference, particularly for the long-time attendees. We are all facing many disruptions in the workplace, from the institution of electronic health records, the changing demands resulting from the patient centered medical home movement, and from changes imposed by health care reform. Continuing to weave integrated care into this disruption is both challenging and exciting as we find successes and improvements in our delivery systems. Disruption is the norm for many of us right now and we wanted to capitalize on the notion and use it to give momentum to CFHA 2013.
The good news about our conference location is that you’ll be breathing in some good old Colorado Mountain air, as we have chosen a beautiful location in the foothills of Boulder. We are out of the city bustle this year and in the relaxing open space and sky of Broomfield, Colorado, with spectacular views of the Flat Irons of Boulder. The resort-style hotel is situated between Boulder and Denver for those of you who would like to explore both places. We plan to provide transportation to Boulder by bus for our traditional dine-around night. Our hotel is spectacular with outdoor heated pools and hot tubs. There is a beautiful outdoor reception space in which we will showcase a fun, beer tasting fund-raiser to benefit the CFHA scholarship program—Colorado style.
We need your help with fresh, new presentations. Consider being creative this year and bring us new ideas and new presentation formats. Let’s get the audience engaged. We need a few basic presentation that educate new attendees about Integrated care 101, but otherwise, we have an audience of repeating attendees who needs to leave refreshed and ready to go home and shake up their routines and practices with new thoughts about moving integration forward and through the twists and turns of the changing climate of health care. We have also had requests for excellent presentations on clinical topics.
The call for presentations just opened and ends March 15, 2013. So, click here and start typing up your best ideas. We look forward to reading them!
|Laurie Ivey is the Director of Behavioral Health for Swedish Family Medicine Residency and The Colorado Health Foundation. She enjoys teaching both family medicine residents and post-doctoral fellows to work and thrive in the integrated primary care environment. She lives in Denver Colorado with her partner and twin sons. |
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Posted By Catherine Jones-Hazledine,
Thursday, January 31, 2013
Updated: Monday, February 4, 2013
|Cate's blog is the |
last post in a
care in rural settings.
Read the entire
Much has been
written about the advantages of integrated or co-located behavioral health care
in rural primary care settings. At this
point, most in the field understand the practical benefits of this model,
especially in our most rural and underserved areas. There is a growing understanding,
as well, that there are many factors to consider in successfully implementing
this model. Dr. Joe Evans and Dr. Rachel
Valleley wrote very eloquently about some of these in a blog post earlier
this month. And they would know. Over the years, they have worked to establish
these services in many settings across our 99% rural, and 87% underserved state
of Nebraska. I would like to think of
myself as one of their success stories.
Almost 9 years ago
now, after working with the Munroe-Meyer Institute Rural Outreach Program for
two years as an intern, and obtaining my Ph.D. in Psychology, I made the decision to return to my own home
area of the state. Dr. Joe Evans and Dr.
Jodi Polaha were instrumental in helping make that happen. We originally established three integrated
behavioral health clinics within primary care settings in small, isolated
communities along Hwy 20 in the far northwestern corner of Nebraska. Our services were well received by the local
family physicians and over the next few years the three clinics grew to five,
and ultimately turned into a privately-owned network of clinics called Western
Nebraska Behavioral Health.
|Over these years, as well, we began to take on
practicum students and interns from a small nearby college. These students were mostly Nebraska natives,
many from the immediate area, who were training to receive a Master’s Degree in
Community Counseling. Many of them ended
up staying on with the clinic network after graduation, with the result that
several of our clinicians, myself included, now find ourselves working in our home
communities – a fact that has proven to add many layers to the collaborative
care/integrative care model. |
How many Master’s or
are dying to move to
One of the
challenges of rural practice highlighted in another blog earlier this month (by
Alysia Hoover-Thompson and Natasha
Gouge) is the amount of turnover among those who decide to go into the
area of rural integrated care. It is an
unfortunate fact that many initial placements of clinicians into rural areas
across the nation do not last much past the training phase or, as the authors
indicated, the loan repayment phase.
This obviously happens for many reasons:
family obligations, spousal careers, health issues, financial concerns,
lack of resources and support. One fact
that contributes to the problem, I think, is that most of our training
facilities for clinicians – especially doctoral level clinicians – exist in
urban (or at least more urban) areas. As
a result, individuals can be identified who express rural interest or
commitment, but many of them are not actually from, or familiar with, truly
rural settings. Even those who are from rural
settings end up living for an extended period in the urban area to complete
their training, and develop ties there that make it more difficult to jump out
to a rural setting when the time comes.
rural settings have many advantages:
clean air, simplicity of life, wide-open spaces, good people. They also, however, have many peculiarities
that make them challenging for those not accustomed to the lifestyle: lack of resources, lack of anonymity and
privacy, distrust of outsiders, sometimes a slowness to open to new ideas,
etc. Rural individuals exist in a web of
interconnectedness that those from larger areas are often simply uncomfortable
with. I once attended a meeting of psychologists
at which a provider in a larger community was telling about the awkwardness of
going to a home improvement store on a weekend, dressed casually and
unshowered, only to run into a client.
This was a rare event to hear about for many of the providers at the
meeting, but our contingent was struck by surprise that it had only happened
once to that provider. In our own rural
area, it is the case that we rarely leave our homes without seeing a client or
member of a client family
We see our clients
outside of session more here because the population and communities are so
small, and this issue would occur for
us regardless of where we were from. Being
originally from the area ourselves means that we are also more likely to know
our clients or patients before they come to see us, or have some other level of
connection to them. This web of
connections is not limited to client connections, either.
Several years ago, I was contacted by a local
woman who was in the process of getting her degree in community counseling (from the small local college I mentioned) and
needed a practicum placement. I recalled
that many years before that, when I was a middle school student and she was a precocious
preschooler, our families had been next door neighbors. Further, her father (now retired) was my
dentist, her older brother and my younger brother were very good friends in
high school, her sister-in-law ran a
local daycare that my children had attended as infants, and her nephews were in
the same grade and school as my own children. None of these connections were
close enough that it felt problematic to train the student, and few other
options were available to her, and so she ultimately did a practicum placement,
a pre-master’s internship, and an advanced training placement to accrue
licensing hours within our clinic.
Further, she continues on with us to this day - providing services in a clinic just blocks
from where she used to run through my yard as a preschooler, pretending to be a
horse. Having so many connections
locally, she has no plans of living anywhere else. She is also well versed in the challenges of
rural life, and very comfortable with that web of interconnectedness.
story is a common one in our clinic at this point, and it definitely raises
issues to consider. It frequently occurs
that our collaborating physicians refer a patient to us that one or more of our
clinicians has some other connection (current or historical) to. This requires careful thought and supervision
about the closeness of the connection, and any way in which it might be
ethically problematic. A large number of
our referrals end up being cases that, were we in an urban area, would be
referred to another provider due to the additional connection. There is a fabulous model that we often refer
to by Kitchener (1988) that helps us determine which connections are too close
to be ethical for us to work with. This is an ongoing area of thoughtfulness in
these multiple levels of connectedness to be a serious drawback in rural work. I remember hearing in graduate school the
recommendation that if you were to work in a rural setting you should not live
in the same community. Or, if you did
live there, you should refrain from participating in local life (communities,
organizations, etc). Being from a rural
area myself, this struck me as silly. I
remember thinking about most of my rural neighbors growing up, and realizing
how they would perceive someone who kept themselves so distant from the
community they meant to serve. Now,
being in practice here for several years, I can tell you anecdotally that it is
often the case that individuals come to see us BECAUSE we are known to
them. There are many conservative rural
residents who would be unlikely to seek "behavioral health” or "mental health”
services (even at their physician’s recommendation) but who end up following
through because the identified clinician is "Gene and Carol’s daughter” or was
in their brother’s graduating class. We
are a known, and therefore often a more trusted, quantity. Because they exist all the time within a
closer web of connections, our rural clients are also just naturally more
comfortable with the additional connections and casual interactions that occur
outside of clinic.
Summarizing all of
this thought, then, it seems that another key to the successful establishment
of integrated behavioral health in rural settings involves greater recruitment
of local individuals, as well as training of these individuals from the
beginning within the rural settings they will eventually practice in. Not only does this seem likely to reduce
turn-over and offer better preparation for real-life work scenarios, but it
also provides additional job opportunities for rural individuals – thereby reducing
the problems of de-population, unemployment and poverty in rural settings.
So positive have
our experiences been of training locally raised clinicians, that we have
recently taken things a step farther.
Working with support from BHECN (the Behavioral Health Education Center
of Nebraska) we have designed a program to help identify and mentor rural high
school students in particularly isolated areas who have an interest in
behavioral health careers. By catching
them early in their education, we hope to help provide a pathway for them to
access the training to eventually provide much-needed services in their home
communities –spots that would have considerable difficulty drawing trained
providers. How many Master’s or Ph.D.
level clinicians, after all, are dying to move to Cody, Nebraska, population
155? It will be some time before we have
available data to tell how successful this approach is, but we are excited to
Kitchener, K.S. (1988). Dual
role relationships: What makes them so problematic? Journal of Counseling and
Development, 67, 217 – 221.
|Dr. Catherine Jones-Hazledine is a psychologist and the owner of
Western Nebraska Behavioral Health, PC, a network of five integrated behavioral
health clinics in rural western Nebraska which are affiliated sites with the
University of Nebraska Medical Center’s Munroe-Meyer Institute Rural Outreach
Program. She is also adjunct faculty
with Chadron State College, in Chadron, Nebraska.|
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Posted By James L. Werth,
Thursday, January 24, 2013
blog is the
Read the entire
As the Director of a doctoral program in Counseling Psychology since 2007, I have attempted to keep up with the literature, anecdotal reports, and personal opinions regarding the future of psychology as a profession so that I could help our students be ready when they graduate. I started hearing about "integrated care” almost immediately upon assuming my position but it was not until I served on the American Psychological Association's Committee on Rural Health that I fully appreciated the importance of integrated care for the field, especially for practitioners who would be working in rural areas. My colleagues helped me understand the value of integrated care for the patient, family, medical providers, and psychologists and other behavioral health professionals. As a result, I became convinced that we had to try to provide training opportunities in integrated care settings for our students.
Fortunately, such an opportunity arose when the Executive Director of two of the local free medical clinics contacted me and asked if we had any students who would want to work alongside their providers who struggled with some of the psychological issues presented by patients. At about the same time I was contacted by the Development Director of a federally qualified health center who wanted to apply for a Rural Workforce Development Grant and hoped to use the grant to expand their provision of behavioral health services.
These two collaborative efforts have led to a popular advanced practicum placement site at the free clinic and an internship site at the FQHC. Even more, these sites are helping to provide training and experience that our students will be able to take with them as they move into their first jobs while also filling some significant needs in these Health Professional Shortage Areas.|
For those of us in rural
areas, the challenge may
be especially important to
meet because of the
difficulty recruiting and
in these communities.
Based on the facts that one of the American Psychological
Association's three strategic goals is to expand psychology's role in
healthcare, that the Affordable Care Act promotes interprofessional care, and
that insurance payments for psychological services are falling in many
locations, I am convinced that psychology graduate students must receive the
training necessary to work in integrated care settings. I am fully aware of the
challenges associated with setting up these types of training sites but I
believe faculty will need to be proactive in finding or creating sites in order
to ensure their graduates will be employable. This may mean that faculty
members will have to go into the community and provide supervision for students
at sites that do not have psychologists or other mental health professionals on
site. We need to expand the types of sites that we have considered for
practicum and internship to include physician offices, emergency rooms, and
university health centers.
For those of us in rural areas, the challenge may be
especially important to meet because of the difficulty recruiting and retaining
professionals in these communities. Even with the National Health Service Corps
loan repayment program available for psychologists and other providers, many
outlying areas do not have access to sufficient numbers of mental health
professionals. However, if we can get trainees into these areas and provide
them with learning opportunities, especially on internship, we have a greater
chance that they will stay. Setting up a private practice in a rural area may
not be feasible but continuing to work at a FQHC or in a community mental
health center that has begun to recruit medical personnel or at a VA's
community-based outpatient clinic could provide employment options.
On a related note, I have noticed that in our FQHC training
sites, where both psychology and social work interns have begun providing
primary care-based services, we have uncovered other needs in the community.
The most obvious ones are referrals for traditional mental health services and
psychological assessment. Our behavioral health providers in these rural
clinics have ended up having to move away from the typical brief behavioral
approach to more of a blended model where they also provide longer-term
sessions on a weekly basis because there are no referral options, or at least
no options without a several month waitlist. The need for assessment, especially
neuropsychological assessment, is even greater. Without university-based
training clinics that operate on sliding scales and sometimes waive fees
entirely, many people would not be able to get the testing needed for
appropriate care. Thus, appropriately trained behavioral health professionals
could collaborate with clinics to provide these additional services.
One final area that has been increasingly on my mind as I
have thought about training psychology graduate students for the future and
about the needs of rural communities is the contentious matter of prescription
privileges for psychologists. The military and Public Health Service as well as
the states of New Mexico and Louisiana allow properly trained psychologists to
prescribe (or unprescribe) psychotropic medications. This is a hotly contested
issue and until I started practicing in a rural area where there are virtually
no psychiatrists or psychiatric nurse practitioners, I did not think I would
ever be interested in this if it were to become a reality in my state.
I have changed my mind and now think that if I and my psychologist-colleagues
had the appropriate training and our state law allowed it, we could provide
significant help to patients as well as the medical providers who are reluctant
to prescribe these medications. In fact, I think that hospitals, FQHCs, free
clinics, and other primary care practices would be perfect places for pilot
programs because of the collaborative relationships with medical personnel.
Thus, I hope that psychology trainees will receive significant training in
psychopharmacology and that psychologists and medical providers in rural areas
can work together for policy change in order to expand the numbers of trained
personnel who can meet the psychiatric needs of underserved individuals.
In conclusion, I hope that we will see more graduate
programs in behavioral health preparing their students for practice in
integrated care settings.
programs, such as psychology, this would also include ensuring sufficient
training in psychopharmacology. If this happens, then perhaps at least some of
the significant needs of people living in rural areas would be met through
collaborative efforts between training programs and health care facilities.
James L. Werth, Jr., Ph.D., ABPP is currently Director of the Psy.D. Program in Counseling Psychology at Radford University (located in Southwest Virginia). For the past several years he has been collaborating with Stone Mountain Health Services, an FQHC in the Westernmost counties of Virginia and is leaving Radford this fall to become Stone Mountain's Psychology Director. He may be reached at
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Posted By Joe Evans and Rachel Valleley,
Thursday, January 17, 2013
|Joseph and Rachel's |
blog is the third post
in a month-long series
on integrated care in
Read the entire
Recently, while preparing yet another grant application, I
resurrected one of my favorite quotations related to integrated behavioral
health care. Dr. David Lambert, of the Rural Health Research Center at the
University of Southern Maine, stated, back in 1999, that, "Integrated
behavioral health care is a concept that is frequently discussed, but seldom
implemented.” Over the years, this quotation has resonated with me and
colleagues as we attempt to prepare students to work in integrated pediatric
primary care practices. Just what is it that makes an integrated behavioral
health clinic in primary care successful? What are the essentials that we need
to pass on to our trainees as they enter the field, particularly those who opt
to work in rural primary care?
The concept of integrated behavioral health in primary care is
certainly far from a "new” idea. Dr. Nick Cummings and his associates have been
espousing this notion for over three decades.
As noted by Alexander Blount, the integration of physical and mental
health care seems to be such an "obvious” and necessary part of the overall
health care system that few can argue with its theoretical underpinnings and
utility. Why, then, has the implementation of such a beneficial approach to
healthcare taken so long in being recognized and implemented. Why have attempts
to integrate behavioral and physical health care failed in the past? What makes
some practices extremely successful in this venture while others have
experienced major difficulties? Are we looking at the essential and necessary
components for positively integrating behavioral healthcare and can we learn
from successful implementations by others in the field?
|Using the approach of "translational research”, Carol
Trivette of the Puckett Institute in Morgantown, North Carolina, has emphasized
identifying the "kernels, nuggets, and gems” from research findings that are
applicable to applied practice. Identification of those characteristics of
programs and practices that "stand out” as most important in successful
practices is an approach that we, as a field, have not yet applied to
integrated behavioral health care, particularly in rural settings. While we all have ideas of what should be
involved in an integrated behavioral health practice in primary care, we have
not conducted investigations into what factors truly differentiate what makes a
practice successful versus unsuccessful in integrated care.|
During our Nebraska experiences in
implementing integrated behavioral health into 17 rural primary care practices,
we have had our share of successes and disappointments.
By way of example, Wolfe and colleagues at the Achievement
Place Project in Kansas conducted an analysis of the necessary components of a
treatment group home program for delinquent adolescents following an initial
"failure” of the program to be replicated. While, initially, it was felt that
their well – researched token economy would be the most essential component of
the treatment program, further investigation revealed that it was actually the
"relationship” and "teaching style” of the group home Teaching Parent staff that
was most important in the implementation of the program. Based on this finding, the training component
of the program shifted emphasis to development of "teaching skills” with the
token economy being a secondary "tool” in the social skills educational
process. This program has now been
successfully replicated in literally hundreds of agencies in the USA and in
Similarly, in the area of integrating behavioral health into
primary care practice, we need to examine some of the parameters that have
separated successful versus unsuccessful implementations of the integrated care
approach. We may also need to assess whether there are "differences” in the
necessary components for Pediatric versus Family Medicine versus Geriatric
primary care practice. Our experiences would lead us to propose that there may
be significant differences in successful implementation of an integrated
behavioral health approach in a Pediatric or Geriatric setting where much of
the intervention implementation is mediated by caregivers (parents and nursing
staff) versus direct intervention with the patient as is typical in adult Family
Medicine integrated MH care.
Some attempts have been made at identifying commonalities of
integrated behavioral health care services by examining existing programs. A study
funded by the Robert Wood Johnson Foundation, (2007) reviewed 16 programs that,
in various ways, identified themselves as providing integrated behavioral
health services. Findings suggested that "Integration implementers and goals
varied,” and "Integration approaches vary.” Differences in definitions of
integrated behavioral health care, a variety of funding mechanisms, and
differing target service populations made
the task of identifying commonalities difficult to impossible. Additionally, almost
all of the programs reviewed operated in major urban areas and focused on "publicly
funded” mental health care for severe mental illness.
Examination of components of
successful integrated care practice in rural areas may have some distinct advantages due to commonalities
found in rural practices. First, the majority of health care in rural areas is
provided by Family Medicine or Pediatric primary care physicians. Secondly,
there is generally a lack of local "MH specialists” to whom primary care
physicians can refer within the immediate area, particularly psychiatrists.
Thirdly, most primary care practices in rural areas have a small number of
physicians (with an increasing number of Nurse Practitioners and Physician’s Assistants).
Fourth, these primary care physicians are expected to address the full range of
health problems, with very few having any type of "specialty” clinical
practice. Finally, rural primary care physicians generally have a ready
"network” of specialists to whom to refer, frequently at University Medical
Centers, for various severe conditions. (In the case of behavioral disorders,
however, scheduling for appointments can take weeks or months.) Because of these commonalities, finding
necessary components of rural integrated care implementations may be more
During our Nebraska experiences in
implementing integrated behavioral health into 17 rural primary care practices,
we have had our share of successes and disappointments. The remainder of this
blog will discuss some components that we feel are necessary for successful
integration of behavioral health into primary care and we will provide some
examples of factors that seemed to undermine our attempts. First, a necessary component, in our
experience, is the establishment of positive relationships by the behavioral
health specialist with not only the primary care physicians but also office
staff (nurses, billing clerks, receptionists, etc.). In one of our first
replication attempts, some office staff initially viewed our presence as a
"burden” and would frequently neglect to notify our behavioral health provider
of patients in the waiting room. After "earning her spurs” by successfully
treating one of the children of a support staff member, however, relationships
improved markedly and staff became some of our greatest supporters. Lesson
learned: be sure to develop relationships with staff by chatting, bringing
"treats” on occasion, and providing reinforcing comments for cooperation and
services provided, no matter how menial. With physicians, reinforcing the
"appropriateness” of referrals and information about treatment successes
greatly contributes to relationship building.
Secondly, communication with
primary care physicians and staff is paramount for establishing a consistent
flow of patient referrals when implementing integrated care. In many cases,
physicians are unaware of the types of services and skills that are possessed
by behavioral health providers. During their training, most primary care
doctors receive one to two months of rotations in psychiatry during their
residency years. Depending on their experiences during these rotations, primary
care physicians frequently place behavioral health providers into a single
category, dealing with only the most severe disorders. Communication about the
"types” of services that can be offered should occur during the first 6-12
months of program implementation. Noon conferences, presentations to local
hospital "rounds,” and "sitting in” on patient sessions can all be forums for
providing information to physicians and staff. Recently, by way of example, a
family presented in a new clinic with a behavioral concern about "head banging”
by their four-year-old child. Following the physician’s citation of the percent
of children who engage in this behavior and reassurance that the child would
eventually outgrow this activity, our behavioral health professional was able
to indicate having some skills in reducing potentially self – injurious
behaviors and was able to "solve” this problem in only two sessions using
parental differential attention and timeout.
Following this episode, the number of "warm handoff referrals” (a la Kirk
Strosahl) increased. Other methods for
increasing communication include timely intake reports, discussions of combined
medical and behavioral plans, notes about when an outside referral needs to be
made, offering assistance in behavioral diagnostics, and monitoring of
psychotropic medication effects.
It is important to note that
communication can best be achieved through physical proximity and seeing
patients in examining rooms in the primary care practice. In one instance, an
office manager, in an attempt to provide better "clinic space,” assigned a room
at the end of the hall to our behavioral health provider. While accommodations
were better for seeing patients, contact with physicians, nurses, and office
staff was reduced and referrals dropped markedly. Using examination rooms on
physicians’ days off allows contact with other doctors as well as providing
access to support staff.
A third critical component in
implementing Integrated care, in our estimation, relates to the "economics” of
primary care practice. Behavioral health providers need to have enough
"business acumen” to understand the financial pressures and incentives in
primary health care. A number of models of funding for behavioral health
reimbursement exist (and may increase with the implementation of the Affordable
Care Act). Capitated care, fee for service, Medicaid, co-pays, sliding scale
payments, HMOs, and insurance panels are all examples of how behavioral health
services can be reimbursed. Providers need to understand the number and "mix”
of patients being seen in the primary care practice according to payment source
and reimbursement allowed. Negotiating "overhead” costs for space and staff
support should also be taken into consideration. These factors help determine
estimates of potential income and number of patients that need to be scheduled. Consideration of the economics for primary
care providers should also be a point of awareness for integrated behavioral
health providers. Initially, we
recommend keeping staff demands and supports at a minimum until the overall
"value” of integrating behavioral healthcare into primary care physicians’
practices is established. This can be
done by the behavioral health provider transcribing his/her own notes, handling
return schedules, making reminder calls, and performing billing and collection
functions. As the benefit of having behavioral health available in the
practice, many of these functions can be absorbed into the day-to-day
activities of support staff.
Data that we have collected over
the years indicates that primary care pediatricians spend literally double the
amount of time on behavioral referrals as compared to acute care episodes or
well – child visits. When collectible fees for providing behavioral health
services by physicians were analyzed in one of our studies, physicians unable
to utilize mental health codes in their billing. This resulted in reimbursements that were
only 45% of "typical” collections for acute and well – child care. Following this logic, physicians should be
able to be 15-20% more productive with time freed up when a behavior specialist
is available to deal with mental and behavioral health issues within the
practice. In our experience, once the that physicians recognize the amount of
time savings, economic benefit, and improved diagnostic and treatment
capacities resulting from having a behavioral professional in the practice,
referrals flow steadily and benefit all parties: primary care physicians,
behavioral health professionals, and patients.
Finally, and possibly the most
important component in preparing behavioral professionals for primary care
practice, is knowledge and skills necessary to treat behavioral problems
presenting in primary care physicians’ offices.
Unfortunately, there is not a direct correspondence between graduate
education in many behavioral health graduate training programs and medical
practice in the community. Training in
addressing the most common behavioral problems presenting in primary care is a
necessity. Most psychology training programs are not located in, nor do they
collaborate with, colleges of medicine. In integrated pediatric primary care,
by way of example, behavioral providers need to be able to accurately assess
and treat the most commonly presenting problems of childhood and adolescence.
Specific protocols for diagnosing and providing therapy for sleep disorders,
feeding disorders, thumbsucking, nocturnal enuresis, learning disabilities,
ADHD, habit disorders, childhood depression, aggression, anxiety, school
motivation problems, medical compliance, and the psychological effects of
chronic conditions such as diabetes, epilepsy, cystic fibrosis, and genetic
conditions should be mastered in order to be successful in integrated pediatric
primary care practice. We recently had a student in a pediatric practice in an
underserved, high need poverty area. Her training did not include education in
many of the behavioral conditions noted above and she spent a good deal of her
time doing assessment and then referral out of the practice. This simply added
another "layer” of delay between the physician and eventual treating agent.
Similarly, we have had students who are well trained in standardized and
"manualized” therapeutic programs requiring consistent attendance at 10-12
consecutive sessions. In primary care, this is a practice that is rarely
successful and often leads to treatment failure. In our estimation, short –
term, evidence – based, protocol driven and prescriptive therapies are the
"norm” in pediatric integrated primary care practice.
In summary, as educators of future
integrated behavioral health specialists, we are very interested in sharing and
hearing the experiences of others, both positive and negative, who have been
successful in implementing integrated care programs. We have attempted to share
some of our successes and "tales of woe” that will hopefully be of benefit to
you in your future endeavors.
Joseph Evans is a Professor at the Munroe-Meyer Institute (MMI) and in
the University of Nebraska Medical Center's (UNMC)
Department of Pediatrics. He is the Director of the Psychology
Department at MMI and the Division Director of Pediatric Psychology in
the UNMC College of Medicine. Dr. Evans administers a staff of eleven
Psychologists, nine Doctoral Interns, five Post-doctoral
Research Associates, four graduate students in Applied Behavior
Analysis, and support staff. He is an active clinician and manages the
ADHD Clinic conducted at MMI as well as serving as a staff psychologist
for the DHHS Children with Special Health Care Needs
J Valleley, Ph.D., is a licensed psychologist in the Department of
Psychology at the Munroe-Meyer Institute for Genetics
and Rehabilitation and Associate Professor in Pediatrics and the
Munroe-Meyer Institute at the University of Nebraska Medical Center. Her research and clinical
interests revolve around behavioral health in primary care.
Specifically, she is interested in the impact that behavioral health
problems have on primary care, demonstrating the effectiveness
of the integrated model on behavioral health, and the unique
contributions that behavioral health specialists can have upon primary
care. She is currently Coordinator of MMI’s Outreach Behavioral Health
Clinics, overseeing 13 rural clinics, 7 Omaha area clinics,
and 4 collaborating sites. She has published nearly 20 scientific
papers and chapters related to children with behavioral health and
academic concerns. |
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