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No Margin No Mission: Sustainability in Behavioral Health – Primary Care Integration

Posted By Cheryl Holt, Thursday, May 31, 2012
Most posts on the CFHA Blog describe integration into primary care settings. Many of these services are provided through collaboration with the community behavioral health center. Or, in some communities the integration happens in reverse, by integrating primary care services into the existing community behavioral health center. This blog examines integrated care from the perspective of the community behavioral health center.

 

Of the many challenges in integrating primary care services into behavioral health organizations, the one that garners the most apprehension and concern is sustainability. It is also the most frequent reason for hesitation in moving forward. Healthcare is not set up to address this. Primary care and behavioral health have different billing codes with no easily decipherable means of venturing outside the confines to include payment for integrated services. The mere thought of the process required to begin to tear down the barriers separating the two worlds strikes fear in the hearts of the most courageous administrators.

Healthcare administrators are presented with conflicting demands and are struggling to reconcile the next step. They can:

  1. Ignore the ever increasing focus on healthcare integration and hope it is just another passing fad; or
  2. Place even more burden on the ever-shrinking budgets and hope for the best.

Let’s take a closer look at the options:

Ignoring healthcare integration seems like the easiest solution. Behavioral health administrators can align themselves with like-minded peers creating a support group who reinforces the notion that it will all just fade away if they merely wait it out. This group gets considerable pleasure in observing the early adopters from a distance, filled with certainty that these risk-takers are all making huge mistakes. They pat themselves on the back encouragingly as they watch their naïve peers make the occasional fumble, while attributing any successes they might have to sheer (unsustainable) luck.

Over-burdening the current budget seems to be irresponsible. Behavioral health administrators have been faced with budget cuts in unprecedented amounts over the past few years. While they have either become masters at doing more with less or have chosen to leave the field entirely, taking on a new business-line during the increasing uncertainty of their organizations’ financial states seems to be overly risky and counterintuitive.

Yet the pressure is on.

Nationally, more and more behavioral health conferences are featuring healthcare integration tracks. The same is becoming true of primary care conferences and conventions as well. With more and more research and reports being released that provide the necessary data to support the need for integration, it’s becoming more and more difficult to write it off as a passing fad. The recent report from the SAMHSA-sponsored, National Survey on Drug Use and Health, Physical Health Conditions among Adults with Mental Illnesses provides further evidence supporting earlier reports demonstrating the need for integration.

 The current model of providing behavioral healthcare may be on its way to becoming obsolete. Now is the time for behavioral healthcare administrators to begin the discussion of how to address the whole-health needs of the people they serve. Whether through collaborative partnership agreements or bi-directional integration with primary care organizations, or hiring primary care staff for expanding to fully integrated services, this issue can no longer be ignored. There are many changes that can be implemented right away (focusing on billing codes and maximizing billing opportunities) while others will require advocating changes at the state and federal level. (Click here for helpful billing tools created by the SAMHSA-HRSA Center for Integrated Health Solutions.) Daunting though this may seem, the climate is right for these discussions with your state Medicaid and behavioral health offices. They are faced with the task of making the necessary changes to move into the new era of healthcare integration. Strategically, it’s far better to be a part of discussions on creating this new structure than to have it imposed on your organizations. The Georgia Association of Community Services Boards has partnered with the Carter Center to create a forum for change in Georgia via their Integrative Healthcare Learning Collaborative. Not only have they included the public behavioral health providers and their primary care partners, they also have representation from the Georgia Primary Care Association and area medical schools. They recognize that in order to develop sustainable programs everyone must be at the table.

Let’s not lose sight of the goal: we must work together to make a difference in improving health outcomes of the people we serve. We CAN ensure that the margin is there to continue the mission. Be a part of the solution!

What are your strategies for sustaining healthcare integration?
I'd love to hear from you. Please enter your comments/suggestions/ideas below or email: behavioralhealthintegration@gmail.com.

 

Cheryl Holt

Cheryl Holt, MA, NCP, BCCP currently serves as the Director of Training and Technical Assistance with SAMHSA-HRSA Center for Integrated Health Solutions for the National Council for Community Behavioral Healthcare. She is moderator of the Behavioral Health – Primary Care Integration Listserv, manages the Behavioral Health Integration blog, and is active in social media: Twitter, @cherylholt and @BHPCIntegration; and Facebook, Behavioral Health Integration

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Changing our Thinking about Changing our Patients

Posted By Suzanne Bailey, Thursday, May 24, 2012
Poor treatment adherence is a systemic problem. It impedes treatment outcomes, complicates treatment planning, and frustrates providers. I have yet to meet a healthcare provider who entered the field to argue with their patients, but I have met many passionate providers who are frustrated with the seemingly apathetic responses of seriously ill patients. A primary care colleague recently commented regarding a mutual patient with a history of nonadherence with his diabetic treatment regimen, "I have told him a thousand times. He just doesn’t care.”

The management of most chronic conditions requires behavior change. However, patients often underestimate their ability to modify their lifestyle and positively impact their health status. Instead, they expect their visit to the doctor to result in a prescribed treatment or medication that will cure their condition or at least alleviate their symptoms. Thus, when the prescribed treatment involves behavior change, resistance is often created. "I have pain every day and you are telling me to exercise and eat healthily?”

Prochaska and DiClemente (1984) described a model of assessing patients’ readiness to change and tailoring interventions to enhance patients’ willingness and ability to engage in behavior change. As healthcare providers, we are always in the "action” stage. We assess and diagnosis conditions and prescribe behavior change interventions to improve health status.

Suzanne Bailey
Viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease.
 However, our focus on overall health may not be patients’ priority and patients are often not in the "action” stage. Many of us can relate to the patient with an A1C of 13 who wants the focus of their primary care visit to be their back pain. It is difficult to focus this patient on their diabetes in the context of the medical visit, much less encourage them to leave our office and make meaningful lifestyle changes to improve their A1C.

Too often these patients become labeled "difficult patients,” as if something were inherently wrong with the patients. However, viewing ambivalence as a normal part of the chronic disease process allows us to treat ambivalence as a component of the disease. We must accept that we cannot force our patients to change. Rather, we must help our patients decide to engage in behavior change. Motivational Interviewing, a style of interacting with patients developed by Miller and Rollnick (1991), addresses this ambivalence by eliciting motivation to change from the patient through guided conversation.

At Cherokee Health Systems, a FQHC and CMHC with an integrated care model that blends behavioral health and primary care where I work as a Behavioral Health Consultant, we’ve learned that we must change our thinking about changing our patients. We serve a population of largely indigent patients with multifaceted behavioral health, primary care, and social needs who present across the continuum of readiness to change. Thus, we have instituted brief, basic trainings in Motivational Interviewing for our primary care providers. They are, in fact, the gateway to behavior change in an integrated model, either through direct conversation with patients or by "closing the sale” and facilitating a warm hand-off to a Behavioral Health Consultant. In implementing this training, we have learned that brief training can be effective in equipping providers with the skills to motivate patients’ behavior change and reducing provider frustration with "difficult patients.”

As we continue to address ambivalence as part of the chronic disease process and work to motivate behavior change, I am continually reminded that motivation truly is elicited and developed collaboratively in the context of the patient-provider relationship. I recently had a patient explain, "I don’t want to change, I just want to feel better.” There is perhaps no better foundation on which to begin a guided conversation about behavior change.

 

Suzanne Bailey, Psy.D. is a Licensed Clinical Psychologist and Behavioral Health Consultant at Cherokee Health Systems. She earned her doctorate in Clinical Psychology at Xavier University in Cincinnati, Ohio. Dr. Bailey practices in an integrated primary care clinic at Cherokee Health Systems’ Center City office in downtown Knoxville, TN, which serves a population of primarily indigent, homeless patients. She is the Director of Cherokee Health System’s Intensive Outpatient alcohol and drug Program and Supervisor for Case Management Services.

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Mother's Day Edition: The PHQ-9-Inch Circular Saw

Posted By Randall Reitz, Thursday, May 10, 2012

This Sunday marks my tenth Mother’s Day married to the dynamic Ana Reitz. Thus, it is also the tenth anniversary of when I gave her a 9-inch circular saw as a Mother’s Day gift. Now, please save your maternalistic eye rolls for another blog post. She asked for the saw and even picked out the model for purchase.

Unfortunately, as men and their tools go, I am a disorganized wuss. My ownings are scant and strewn amongst a number of broken-down cardboard boxes in the garage. I don’t value them enough to invest in them. I tend to buy them at garage sales and in bargain bins because my children break and lose them along with the rest of their playthings.

As a result, I am often required to make suboptimal usage of the tools I do have accessible at any one time. For example, during spring clean-up this year, I was forced to use my wife’s 9-inch saw to prune trees. As sap smeared the blade and sawdust sprayed my face, I reflected on the PHQ-9. A syllogism quickly formed in my mind:

     9-inch saw : Household cutting :: PHQ-9 : Clinical screening.

If you recently took the GRE, introduced yourself to an integrated care referral, or pruned a tree, I’m sure this logic is readily apparent to you. To the skilled craftsman or contractor, the 9-inch saw is of limited use. It is only helpful for shortening lumber with quick, imprecise cuts. A professional would cry inside to see me use it for pruning, ripping, demolishing, splitting, or chopping (all of which I have done with my wife’s saw).

Rather than investing in a table saw, chain saw, miter saw, hack saw, or ax, I grab the 9.

Such is the PHQ-9 in the integrated care setting. A clinician in a traditional private practice would maintain a fully-stocked tool box of clinical assessments: Becks, GAD-7s, Vanderbilts, Edinburghs, MDQs, OQ45s, Family Environment Scales, genograms, and an assortment of positive psychology screens. Each tool would be closely fit to a specific condition or patient. The tools would provide precise diagnosis and symptom management.

Despite the myriad advantages, I rarely use the other assessment tools. I grab the 9.

Don’t hate me because I’m undutiful.

The PHQ-9 presents numerous advantages in primary care and teaching settings:

  • It is unbeatably easy to take and score—especially when paired with the PHQ-2.
  • Many EMR systems have built-in smart forms that calculate the score, interpret the result, auto-populate the HPI, and track the levels across time like a lab value.
  • Health systems work most efficiently when the operations are kept simple. While I’d love to have nurses giving GAD-7s for patients with anxiety and MDQs for bipolar, that level of sophistication is a fantasy.
  • Integrated care charting is mostly a means of communicating with other members of the primary care team. I prefer to use tools that are familiar to my medical/nursing colleagues.

Our clinic’s experience with the Edinburgh Postnatal Depression Scale and the "PHQ-12” provide compelling reasons for the PHQ-9 hegemony in primary care. The Edinburgh is an excellent depression screen that is more reliable in the pre- and post-partum periods because it teases out the symptom overlap between pregnancy and depression. Before going live on our EMR it was our clinical standard to administer the Edinburgh to OB patients. However, our EMR isn’t hard-wired to easily track and communicate the Edinburgh, so we reverted to using the PHQ-9 instead.

Regarding the "PHQ-12”, I invented it about 10 years ago while at Marillac Clinic.  We were 1 of the first clinics to widely adopt the PHQ-9. Back in the day I noticed that the PHQ-9 and the GAD-7 had an overlap of 4 items and that by adding the extra 3 GAD-7 items to the PHQ-9 we could create a brief screen that gave scores for both depression and anxiety. Many other clinics have adopted it and loved it. I loved it, too, until we adopted the EMR. Because of the way we needed to move the items around on the PHQ-9 to have them line up with GAD-7, it made it much more difficult to enter the scores into the EMR’s PHQ-9 form. So, we reverted to the traditional PHQ-9.

Who knows, maybe in a few years (after we haven’t adopted a new EMR 2 times within 1 residency cycle) I’ll up the bar and re-institute the Edinburgh and PHQ-12 as first steps in reversing the trend of trading precision for convenience. But, for this Mother’s Day, I’m giving all my depressed (and anxious, grieving, and relationally conflicted) patients the PHQ-9-Inch Circular Saw.

Shhh…don’t tell Ana, but I’ve wrapped up a miter saw for Sunday.


9-inch saw 1

 

9-inch saw 2

 

9-inch saw 3

 

 

 

 

 

 

 

 

Randall Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of  Behavioral Science at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.  He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.

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Welcoming Patients

Posted By Margaret Peterson, Thursday, May 3, 2012

A month or two ago I was accompanied into a consult by a young woman who was training for a new job as a behavioral health consultant at a clinic elsewhere in the city of Philadelphia. The consult was an integrated care visit, which meant that we entered the exam room knowing nothing but the patient’s name and date of birth, and with the agenda being to explore behavioral and psychological factors that might be affecting the patient’s health: diet, exercise, substance use, depression, anxiety, trauma.

 

The patient was a middle-aged man who turned out to be a rather colorful character—flamboyantly gay, with a long history of polysubstance abuse and a range of other health issues including infection with HIV. He and I were quickly absorbed in conversation about his concerns and his goals for his health, some of which were more conventional (adherence to his medication routine) and some of which were less so (getting back in touch with a "hormone doctor” who had been helpful to him in the past).

 

Eventually the provider arrived and the consult was over. I left the room with the woman who had been observing me, whose presence I had more or less forgotten about in my focus on the patient. "Well, that was interesting,” I remarked. "It certainly was,” she agreed, fervently. Something in her tone of voice made me realize: she had been a little startled by this patient. Her reaction shed a sudden light upon my own: I had responded to this patient as if he were an old friend.

Margaret Peterson
Every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.
Where did this come from? It came, I realized, from my experiences at the Duke University Infectious Diseases Clinic in the early 1990s. My late husband was a patient there, and practically every other patient was a flamboyantly gay man. This was back in the day when there wasn’t much of a welcome mat anywhere for people who were gay or HIV-positive, and one of the things that distinguished the Duke ID clinic was the absolutely unconditional welcome extended to people who were either or both of these.

 

I was extraordinarily grateful for the care that my husband and I received at the ID clinic. At the same time, it was unnerving to find myself surrounded by the clinic’s other patients, many of whom were (like my recent patient) very colorful characters with complex psychosocial histories, and (superficially, at least) not at all like me. "What on earth am I doing here?” I would think. "How is it that I belong here, in this place, with these people?” It felt like I was normal and they weren’t, and I wanted out.

 

What I grasped only dimly at the time was that I was no more or less unique an individual than anyone else at the clinic, and the same unconditional welcome that was extended to everyone else was extended to me. There was no comment and no criticism; only curiosity and empathy and a desire to be of help. And it changed me; and one specific way it changed me was to create in me a deep sense of kinship with individuals who (like my recent patient) remind me of the clinic and its patients.

 

In a broader sense, I find that experience at the Duke ID clinic informing every aspect of my new work in behavioral health. Behavioral health is all about welcoming; it is about creating a safe space in which the patient feels confident that he or she is cared for, and thus feels free to explore issues that may feel overwhelming or scary, whether those have to do with symptoms ("I’m in pain all the time”) or risk factors ("I know I need to quit smoking”) or relationships ("I’ve had so many losses in my family recently”).

 

Sometimes creating this safe space seems to happen very easily. The other day I entered an exam room to find a woman in her 30s who a few weeks earlier had come in complaining of severe situational stress and anxiety. The doctor had prescribed an anxiolytic and invited her to come back for a followup visit in a month. She hadn’t taken much of the medication, she reported, but she was feeling much better. "That sounds like a big change,” I said. "How has that happened?”

 

She wasn’t sure. Externally, things were much the same: the job, the kids, the busyness of life. "But I’m not stressing about everything,” she said. "I just let it go. And I go out with a girlfriend from work, and we go shopping.” "It sounds like the beginning of the change might have been your decision to come to the doctor,” I said. "And then the doctor responded supportively, and that was enough to help you make some different decisions about how to handle your stress.”

 

"Yes,” the patient said, thoughtfully. "I guess that’s exactly what happened.” As if on cue, the provider entered; I summarized our conversation and left the room. It had been a straightforward and enjoyable consult: the patient was resilient and had already reached out for and received some of what she needed and had made good use of it, she had been ready to relax into the opportunity to explore the sources of her increased well-being, and the connection between provider and patient had been enhanced.

 

Other times it’s not so easy. Later that same day I saw another patient, a man in his mid-twenties, at the doctor for a routine checkup. He was handsome, personable, and in apparently perfect health. He was also unemployed and uneducated beyond high school. Mostly, he just watched TV and went to the gym. "What would you identify as your primary goal for your life or health?” I asked. "Oh,” he said, "I want to have kids and grandkids, with some kind of check coming in—disability, whatever.”

 

"What???” I thought (but did not say). "You are smart and strong and 25 years old, and you actively aspire to be on disability? What is wrong with you?” In that moment, I was not feeling empathetic, or welcoming, either. Somehow I managed to stay with him. He wasn’t proud of his lack of ambition or accomplishment, he said; in fact, he was troubled by it. He hadn’t done anything bad with his life, but he hadn’t done anything good, either; years were going by, and he had nothing to show for them.

 

"If you did have an interest in something, what would it be?” I asked. His eyes lit up. "I love trains!” he said. "Not subway trains. Real trains, big ones.” And then he returned to the subject of his inertia in life. "I need a drill sergeant,” he said, fretfully. "Someone who will tell me what to do and make me do it. My mom made me work in high school, but since then I haven’t had anyone to make me do anything. I think things would be different if I had a drill sergeant.” He paused for a moment. "Or maybe if I had a father.”

 

All of a sudden I saw before me, not a 25-year-old man, but a six-year-old boy, a boy who loved trains, and who had no father to show him how to be a man. No wonder he had been unable to grow into adult achievements and responsibilities. No wonder he longed to be himself a father and a grandfather, yet had no idea how to integrate those roles with other aspects of an adult identity. What might help him develop into a fuller sense of himself and a greater ability to reach more of his potential?

 

"Have you ever had any outpatient psychotherapy?” I asked. "Do you know what psychotherapy is?” He hadn’t, and he didn’t. I offered a few words of explanation: "Children need certain things from their parents when they’re growing up, and if they don’t get those things, it can be very difficult for them to move into satisfying adult lives. Psychotherapists work with people who didn’t get what they needed when they were children, and help those individuals grow up and into more of what they want as adults. There are outpatient clinics where psychotherapy is available, and if you were ever interested in this, we would be happy to refer you.”

 

Before I was half done with this speech, the provider entered the room. She waited while I finished, and then I rose and took my leave. Of course I hope that this patient got some small piece of what he needed in our conversation, and that perhaps some day he will get more of what he needs in the context of some other relationship, perhaps even in therapy. What I got from our conversation, though, was a reminder: every patient needs and deserves welcome and safety, even—perhaps especially—the ones for whom empathy might not come automatically.

 

Margaret Kim Peterson, PhD, is a student in the master’s program in Marriage and Family Therapy at La Salle University in Philadelphia. She is doing an internship in integrated behavioral health at Fairmount Primary Care Center, under the supervision of Suzanne Daub, LCSW, Director of Behavioral Health for Delaware Valley Community Health.

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Collaborative Follies 4

Posted By Randall Reitz and Neil Korsen, Thursday, April 26, 2012

 

Randall Reitz


Narrative Means to Disastrous Ends


Randall Reitz, PhD, Family Therapist

St Mary's Family Medicine Residency

As a relative neophyte in family medicine education, I look back weeks, rather than years, to re-experience my foibles. A recent experience with my physician faculty colleagues is still poignant. My residency program director has tasked me with building a culture of introspection and feedback sharing among the faculty. Additionally, I have been introducing the physician faculty to the same therapy models that I teach residents. This led to a faculty development session during which I presented the basic concepts of narrative therapy to my colleagues.

 It was a complete disaster.

To demonstrate strength-based and problem-based narratives, I shared a perceived strength and weakness from my own residency teaching. I then requested that the others do the same in a small group discussion. My colleagues struggled to grasp the concepts, were uncomfortable with the requested disclosure about their teaching, and disliked sharing the problem-based narrative second (asserting that it negated the strength-based narrative). There was not an elegant way to close the discussion and the following day a dear colleague described it using an f-word combination that I was not previously aware existed.

Here are my take home lessons from the experience:

 

  • Behavioral science faculty are trained in environments rich in collegial feedback and self-disclosure. Because the same is not always true in medical training—tread very lightly.
  • Clearly distinguish between education and therapy, and always choose the former over the latter in collegial settings.
  • When introducing new curricular elements, test-drive it with a smaller group first.
  • Don’t give up: seek to understand what didn’t work, apologize for unintended consequences, and then recalibrate.

On a much brighter note, last weekend was our annual residency retreat. While mountain biking in Moab (a perk of living where we do) one of the residents joked that he didn’t want to hear any medical talk or offer any medical treatments during their time-off: "If you break your arm, the only person who is going to help you is Randall”. And then a chorus of jokes gave me soothing reassurance regarding the positive impact I have had:

 

  • Resident A: "Think about a time when your broken arm wasn’t present, how was that day different?”
  • Resident B: "Suppose that I see you 6 months from now and your arm has healed itself, what will have happened to make that possible?”
  • Faculty Member C: "On a scale of 1 to 10 how much does that arm hurt? What change could make it 1 point better?”
  • Resident D: "Let’s suppose that when you wake up in camp tomorrow you discover that a miracle has happened and the broken arm doesn’t bother you anymore…”

Their solution-focused sarcasm was healing to my heart.


 

Neil Korsen

 

I'm a Doctor, Not a Business Expert

Neil Korsen, MD, Family Physician

Maine Medical Center

 

MaineHealth has had a Mental Health Integration program since 2006 and has done pilot work with several dozen practices. We have learned our share of lessons over the years by making mistakes and figuring out what doesn’t work.

One early mistake we made has to do with how we start a behavioral health clinician working in a practice. Our initial thinking was that starting with a small amount of time (1/2 day per week) minimized the financial risk and therefore should lead to the service working financially. We could then gradually grow the service as the clinician got busier.

 

The problem with this approach is that, if a clinician is not in the practice very often, it is hard for them to become part of the team. It is also hard for primary care providers and staff to remember when the clinician is in the practice, so they are less likely to think about referring a patient for integrated services. Given that many primary care providers work less than full time, it is possible that some will never even cross paths with the integrated clinician, making it even less likely that they will refer patients. We now believe that there is a minimum of about 16-20 hours per week needed for the integrated clinician to become a member of the team and for the primary care team to develop the new habits necessary for them to make good use of the clinician and to develop and build the integrated service.

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Collaborative Follies 3

Posted By Jennifer Hodgson and Norm Rasmussen, Thursday, April 19, 2012

 

Jennifer Hodgson

 

Jennifer Hodgson, PhD, Family Therapist

East Carolina University

 I was setting up an integrated care clinic in a family medicine residency setting in Florida. It took a while to earn the trust of the residents and faculty but even harder were the nurses. They were the gatekeepers...protectors of the providers and patients.

My students struggled getting exam room time to see patients. The providers wanted us to see their patients but the patients were processed so quickly. Then one day it hit me like a brick. We were hanging out in the precepting room joining with the providers but completely neglected joining with the nurses.

One day, a nurse was upset about something personal. We asked her if she way okay. She shared her struggle and we sat with her in her pain. The next week we had received a referral to see a patient. We were so excited. When the behavior health provider exited the room he saw a note stuck to the door, "Do not disturb. Therapy in Progress."The referrals started pouring in from that point forward. We were schooled. In our haste to join with the "physicians" we neglected the critical role of the nurses.

I cannot imagine integrated care now without them; except for now we prefer the note,
"Therapy in progress. Please disturb."

 

Norm Rasmussen

 

Norm Rasmussen, EdD, Psychologist

Mayo Clinic

 Recently I modified my integrated behavioral healthcare (IBH) approach for service delivery and teaching residents in my position as a Behavioral Healthcare Provider (BHP) in the family medicine department at Mayo Clinic. For 25 years, I used the co-located model of collaborative healthcare. My office was in the family medicine clinic, the collaboration was called the Psychology Preceptorship, and my office space was in general referred to affectionately as the "annex.” I was linked to and accepted by the family medicine staff and residents because they value collaborative care.

The recent change that I devised has been re-named as the Main Street Model of IBH. There are two important methodological differences between the prior approach and the new Main Street model. First, I now am physically in the office space where the resident physicians are located and I sit at the table where the medical preceptors reside – thus, I have migrated from the annex to main street! Second, I now have the potential to provide a significantly increased number of same day or virtually immediate IBH services such as curbstone consultation, resident physician-psychologist co-visits in the patient exam room, and "warm handoffs” from staff and resident physicians.

The first two weeks in implanting the Main Street model, I assumed the role of sitting at the medical preceptor table but remaining quiet and waiting for an invitation to be involved. Big mistake! I had assumed the resident physicians and medical preceptors would know how to involve me in this new model – all they had to do was ask! Indeed I was "invited” one or two times per a four hour block. This was not working as I had envisioned. Thus, I decided to move my chair into close physical proximity of the resident physician-medical preceptor discussion to form a triad. Immediately the requests tripled for either a curbstone consultation, warm handoff, or invitation to accompany the resident physician back to the exam room to either do a brief and focused IBH intervention for the resident to observe or to observe and train the resident doing an intervention that they were learning in the didactic work that I was doing with them. The message was clear: BHP proximity and visibility were critical but insufficient. In this new model, I needed to "move in closer” and reconfirm my role as the BHP on the healthcare team. Don’t expect family physicians to find you – rather find them and show your interest and enthusiasm in being a member of the collaborative healthcare team. As we all know, one can never be too experienced, not just early in one’s career, to make a mistake involving foresight or judgment.


 

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Collaborative Follies 2

Posted By JoEllen Patterson and David Clarke, Thursday, April 12, 2012

JoEllen Patterson

 

JoEllen Patterson PhD, Family Therapist

University of San Diego

Several years ago, I was working with an elderly cancer patient and her husband. They had been referred to me by a wonderful physician in my collaborative care setting. The wife had received grueling chemotherapy and radiation. Her prognosis was bleak.

I knew the physician to be conscientious, kind, and exceptionally thorough. The physician eventually told the couple that there were no further treatments available to treat the patient’s cancer. The couple was furious at the doctor "for giving up” and spent their next therapy session criticizing the physician’s heartless care. They hoped that I "would be more caring than the physician.” I was unsure how to respond. Eventually, they implied that "we” had failed them. They did not schedule another session with me.

I wrote a brief note in the chart but failed to discuss the session with the physician. I also realized later that I had not known how to respond quickly to being triangulated into the conflict between the physician and the couple. The physician eventually learned that the couple sought alternative treatments in Mexico, and the women died a painful death in a Tijuana clinic. When I eventually told the physician about the session, he said he had no idea that they were so angry with him. Why hadn’t I told him?

I thought about this case for a long time and what I might have done differently. Here are some of my regrets:

  • I wish I had viewed the doctor-couple relationship as my patient, at least briefly. I would have encouraged the couple to talk to the physician about their feelings of abandonment instead of simply ruminating about his "indifference”. I could have even offered to facilitate the discussion.

  • I was sometimes too concerned about interrupting the overwhelmed physicians to talk about an individual patient. So, I would write a note in the chart instead of taking their time. In some cases, I should have "interrupted” the busy physician to talk about a specific patient situation. This was one of those times.

  • I wish I had found more ways to gradually give the couple "hope” even when the clinic could not offer them a cure. I think I was too focused on the medical prognosis to move the conversation to an emotional/spiritual prognosis.

 

David Clarke

 

David Clarke MD, Gastroenterologist

Oregon Health and Science University

I met Catherine thirty years ago during my Gastroenterology Fellowship at Harbor/UCLA. We spent only an hour together, but the encounter completely changed my career. In her mid-thirties she developed severe constipation, largely unchanged even with simultaneous administration of four different laxatives at double the usual doses. Diagnostic evaluation over two years by her family doctor and two universities was unrevealing.

When I asked if she had been under a lot of stress recently, as other doctors had asked her, Catherine shrugged and replied, "Just the stress from being sick.”

My next question was: "Were you under any stress earlier?” I was wondering if she had experienced a specific stress when her illness began two years before. She interpreted the question to mean the more remote past.

"Yes,” she replied calmly and with little hesitation. "My father molested me.”

This was the first time anyone had made this revelation to me and I had no idea how to respond. Without any childhood stress of my own to recall, or any medical training about how to relate this information to her illness, I was at a loss for words.

She went on to say her earliest memory of her father molesting her was at age four. The molestation continued regularly for the next eight years. When she began menstruating, he stopped. There were no other incidents of abuse or personal trauma in her life.

I was aware of a psychiatrist on our faculty, Harriet Kaplan, MD, who was also an internist with expertise in mind-body medicine and requested a consultation. Four months later, I ran into Dr. Kaplan in an elevator and asked how Catherine was doing. "Well, I haven’t seen her in over a month, Dave,” she replied. "Her bowels are working just fine now.” She had even stopped taking the medicines I had recommended.

I was shocked at the concept of alleviating a serious physical condition solely by a few months of counseling. Over the next few years, I learned everything I could from Dr. Kaplan and during 25 years of practice treated over 7000 such patients myself.

Dr. Clarke invites you to find out more about psychophysiologic disorders and an upcoming conference at www.ppdassociation.org and www.stressillness.com.

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Collaborative Follies 1

Posted By Susan McDaniel and Andrew Pomerantz, Thursday, April 5, 2012

Susan McDaniel

 

Susan McDaniel PhD, Family Psychologist

University of Rochester

One of my first medical referrals was from an obstetrician on faculty in Family Medicine . He requested a "psychological evaluation" of a thirty-nine-year old single female patient who presented for donor insemination to have her first child. The obstetrician said he always asked any single OB patients to see a therapist, both for his own protection and for the patient and her family to have the opportunity to discuss the request and its likely consequences.

I thought this a fairly simple, straightforward request and scheduled a session with the patient, her mother, and her sister to discuss the procedure. I asked to see the patient only for the first half of the session. It quickly became clear that she was quite ambivalent about the procedure and more interested in proving to her family that she was an "adult” than she was in actually raising a child. In the second half of the session, the woman told her mother and sister that she did not want to proceed with the insemination and the family ended by agreeing to open more communication and contact among themselves. It seemed a good use of 50 minutes. However, when I reported this outcome back to the referring physician, he became angry, saying I "talked this woman out of her last chance to have a baby."

Like a bolt from the blue, I realized that I had not explored this physician's view of the problem when he made the referral. It was several years before I saw another patient of his. One of those lessons I had to learn again: to spend time early soliciting the physician's view and discussing the possible outcomes of a consultation.

 

 

Andrew Pomerantz

 

Andrew Pomerantz MD, Psychiatrist

Veterans Health Administration

My second attempt at integrated care took place at the White River Junction VA medical center in Vermont in 1989 (the first was in 1974 when I was still a Primary Care physician in the community). A psychologist and I opened an office in the primary care clinic and told everyone we were there to bring mental health care to primary care so we could reduce stigma. For a month or so, we sat there one afternoon every week reading journals (and probably some magazines as well).

Finally a patient with PTSD and alcohol dependence was deposited on our doorstep. We double-teamed him weekly for a month, after which time he asked us why he couldn’t just go see us in the mental health clinic where it was quieter. We said it was because we were trying out a new way to provide care. A month later he moved to Montana. By that time primary care needed the space back and we folded our tent and moved back upstairs. I did hear from him a few years later when he returned to Vermont with end stage lung cancer. We had a few visits – in the mental health clinic.

It’s often said that a plan without action is a daydream and an action without a plan is a nightmare. In this case, all I knew what that I wanted to provide mental health services in primary care, so I put out my shingle and waited for them to come. I had no plan, just a dream that ran afoul of the details. Though it did not turn out to be a nightmare, it taught lesson one: Integrated care is not just about co-location. It is a different paradigm. It also requires education of the customers (in the commercial world, that’s called marketing). In this case the main customers were the primary care staff.

Over the next 15 years, I tried many different approaches, each building on the experiences of the previous one. Finally, a concerted planning effort that involved primary care leadership and all of our mental health clinicians fulfilled the dream and the program unveiled in 2004 soon became the gold standard for co-located collaborative care in the Veterans Health Administration and, more recently, a core component of the Patient Aligned Care Team, the VA version of the Patient Centered Medical Home. 

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Point / Counter-point 5

Posted By Randall Reitz and Leslie Lieberman, Thursday, March 29, 2012


Trauma History:

ACE in the Hole

or Futile Fact?

 

Randall Reitz


 

At this point in my education I am not easily awed, much less shocked. Discovering the Adverse Childhood Experience research was a shock and awe campaign to my clinical sensibilities.

For the uninitiated, the ACE study was n=17,000 research sponsored by the CDC. It looks at the effects of childhood trauma on adult health and behavior. Each research participant completed a 10-item childhood trauma screen. They also provided a thorough health and behavior history. The participants were stratified by trauma history ("ACE Score”) to assess whether it was predictive of health outcomes. Their data proved statistically significant to a degree rarely seen in the human sciences.

In each of the graphs below the numbers on the X-axis are ACE Scores (i.e. how many of the 10 traumas the person endured as a child) and the Y-axis is the percentage of participants with a particular health outcome as an adult. I apologize for the low quality of the graphs.

 

 

 

 

 

 

2 Conclusions:

  1. Negative early childhood experiences, especially those involving family members and other caregivers, have a profoundly detrimental effect on adult health.
  2. People with low ACE scores are amazingly free of these problems.

Fine.

No, that's a poor word choice. It is not fine, it's horrible.

Let's try that again, inspired from a song my kids love, but I hate: "whatever, it doesn't matter, oh well”.

No, that's not right either. It does matter. It matters deeply. BUT, as it relates to my adult patients who are already demonstrating the health sequelae of childhood traumas, I haven't been able to identify anything I can do with these data.

Knowing the fact that horrible parenting or a chaotic childhood placed the patient on a nearly inexorable path toward health destruction is diagnostic, but not therapeutic.

How do I intervene?

How do I make it better?

How do I advise my medical and nursing colleagues?

I have attempted 3 (inadequate) responses so that at least I feel like I'm not being callous:

1. Normalize their Experience: I can say: "I'm sorry, you've been through horrible experiences in your life, and unfortunately, science and my own clinical practice has shown us that these experiences help to explain many of your health problems”. This might assist the patient in piecing together a different health narrative, and the empathy that it implies might fortify our therapeutic relationship. But, I've never seen it go very far.

2. Protect the Innocent: I haven't had occasion to do so, but I've often imagined that a reasonable MedFT intervention would be to go through the ACE research with an abusive parent. These data might be the missing piece to dissuading him from passing along this horrible family legacy to his children. After all, this is exactly what we do with pre-contemplative smokers (i.e. "Were you aware that 2nd-hand smoke can cause more frequent illness, asthma episodes, and perhaps even lung cancer in your children?"). So, yes, this might help the next generation, but it doesn't turn back the clock for the abusive parent in the room who is already addled with her own health problems from her parents' abuse.

3. Educate the Clinicians: Patients who were traumatized as children are some of the least rewarding for healthcare providers. They come to the room with intractable health problems and behavior which looks like an Axis 2 diagnosis. These are the patients who quickly get labeled and often get fired from a practice. Perhaps having the patient complete an ACE screen will assist the clinician in having more compassion and in passing less judgment to the patient. If so, that would be wonderful.

OK, there might be some clinical advantage to screening for childhood traumas. However, I remain unconvinced that it is a clinically relevant tool. The ACE score should NOT be the 6th vital sign (or the 7th or 8th, or however many there are now that we therapists keep adding our soft scales to the hard science of checking patients-in). Perhaps I will continue to bust out an ACE 1-2 times per year, but it's not about to join the PHQ9, GAD7, and Vanderbilt in the pantheon of primary care screens.

 





Embracing the ACES and Trauma Informed Care: The Time is Now

Leslie Lieberman

Randall, I am very pleased that you raise awareness of the importance of the Adverse Childhood Experiences (ACES) research. However, I beg to differ with your conclusion that there is no place for translating the significance of the ACES findings into the design and provision of collaborative healthcare practice.

To recap, the ACE study surveyed more than 17,000 mid-life adults about 10 categories of adverse childhood experiences (all forms of abuse, witnessing violence, parental absence, incarceration, mental illness and substance abuse) then linked their responses and health histories. Key findings included: 1) a high prevalence of ACES – only 1/3 of those surveyed reported NO ACES - and 16% reported 4 or more ACES; 2) a very strong correlation between ACES and numerous health and behavioral health diagnoses, as well as high risk behaviors associated with poor health outcomes; and 3) a cumulative effect, four or more ACES translated into significantly higher rates of morbidity and mortality.

Results of the ACE study were first published in 1998 and there have been numerous replications since then. Additionally over the last 20 years there has been a plethora of neuro-scientific studies demonstrating the negative impact of toxic stress, trauma and adversity on health and development. In spite of this, few health and human services organizations, CFHA among them, actively advocate to integrate this research into practice. Trauma informed care (TIC) is an approach which both acknowledges the importance of the ACES and provides a framework for how organizations and systems must change in light of this knowledge. Fourteen years is long enough - it is imperative that all health and human services systems, including collaborative care models, become trauma informed now.

The concept of trauma informed care, first introduced by Fallot and Harris in 2001, requires that all services designed to assist vulnerable populations (health, behavioral health, education, housing, welfare etc…) acknowledge the prevalence of and pervasive impact that violence and victimization play in the lives of many consumers and recognize the presence of behaviors and symptoms associated with trauma. This understanding must then drive the design of services to validate trauma survivors, promote their resiliency and recovery, and reduce and eliminate policies and practices that may be traumatizing or re-traumatizing.

To promote trauma informed care, a number of individuals and organizations have defined core principles and developed models of TIC (Sandra Bloom, Sanctuary Model, Community Connections, The National Child Traumatic Stress Network to name a few) All have at their core safety first and safety for all (consumers, family members, employees). Additionally most advocate the importance of establishing cultures where collaboration, democracy, consumer choice and control, and establishing positive relationships are paramount.

CFHA is in an excellent position to be a strong advocate for trauma informed care. The core principles of TIC are embedded in the organization's self description which states: collaboration isn’t just a word in our name; it defines who we are, how we interact with each other and other organizations. We believe deeply that collaboration is an essential element necessary for re-visioning healthcare, specifically, and society, generally. And echoed in its mission to promote comprehensive, cost-effective integrated health care and achieves this mission through education,training,partnering, consultation,research and advocacy.

Randall your "shock and awe" in response to learning about the ACE research is noteworthy, yet your follow-up statement that you don’t know how to use the information is dismaying. You suggest that perhaps the ACES can be used to: 1) to normalize the trauma experience, 2) protect the innocent (prevent the transmission of trauma to the next generation), and 3) educate providers. These ideas are a good start toward becoming trauma informed, but much more needs to happen and CFHA can take a leadership role in ensuring that it does.

With CFHA's urging, ALL collaborative care providers and organizations can be sensitized to the prevalence and impact of violence and trauma, not only in consumers/patients but among providers/staff; they can learn to address secondary traumatic stress (the impact of exposure to traumatic material from consumers/patients); they can provide psycho-educational materials about trauma and toxic stress; they can integrate routine screening for trauma exposure and trauma symptoms; they can identify, refer to, and integrate evidence based trauma-focused treatment; they can closely and deeply examine and change their policies, protocols, standards and practices to ensure that they do not re-traumatize, and they can involve trauma survivors in the process of transforming services. Above all, each CFHA member can use his or her sphere of influence to be a champion for trauma informed care. Together we can shift the fundamental question that still permeates far too much of the health/behavioral health care services system from: What's wrong with you?" to "What has happened to you?" – the ACE study data make it clear why we must do this now.


Randall Reitz
Leslie Lieberman

Leslie Lieberman, MSW directs the Multiplying Connections Initiative in Philadelphia. This program's mission is to build and sustain a trauma informed system for young children using relationships and connections as the vehicles for change.  For more information visit their website at www.multiplyingconnections.org or contact Leslie at llieberman@healthfederation.org


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Point / Counter-Point 4

Posted By James B. Anderson and Jodi Polaha, Thursday, March 22, 2012


Empathy

       =

Non-Essential 

James B. Anderson


 

Em.pa.thy (\ˈem-pə-thē\)

1:the imaginative projection of a subjective state into an object so that the object appears to be infused with it.

2:the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;also: the capacity for this.

-------------------------------------------------------------------------------------------------------

The importance of the relationship between therapist and client has long been recognized as a key to successful intervention. In his landmark work in developing his style of psychotherapy, Carl Rogers advocated a humanistic, client-centered approach to therapy. Central to Rogers' approach was the creation of the relationship between therapist and client. According to Rogers (1946):

If the counselor can create a relationship permeated by warmth, understanding, safety from any type of attack, no matter how trivial, and basic acceptance of the person as he is, then the client will drop his natural defensiveness and use the situation (p. 419).

Since Rogers' work, a strong therapeutic alliance has been reliably demonstrated to be associated with positive therapeutic outcome, regardless of type of therapy. Recognizing the importance of such a relationship, many clinicians have made the assumption that empathy is an essential component of effective therapy. Explicitly or implicitly, it seems that many assume that empathy serves as a mediating variable to achieve the coveted alliance so valuable to positive therapeutic outcome.

A prime example of this assumption can be found within Motivational Interviewing (MI). MI is a contemporary therapeutic approach that has been demonstrated to be efficacious when used to help patients make behavioral changes for a variety of health concerns (smoking, weight loss, diabetes, etc.). While certainly not a magic bullet approach (it's not a "panacea,” as founders William Miller and Stephen Rollnick repeatedly remind us), it is very clearly a very important approach to clinical care that has the potential to make primary care interventions more effective. Listed first amongst principles for an MI approach to talking with patients is the expression of empathy from the therapist towards the patient. While it is clear that therapeutic alliance is important to therapeutic outcome generally, and that expression of empathy may be an important path to such an alliance, I argue that it is the former component ("expression”) that is more vital than the latter ("empathy”).

What is vital to what happens in therapy is a result of what happens in therapy—that is, outcome is related to actions, not a hypothetical construct felt inside of the therapist. Certainly the relationship between the patient and the provider is important, as has been repeatedly demonstrated, but that relationship is an interaction of behaviors that have symbiotic influence on one another. When the construct of therapeutic alliance has been evaluated empirically, a number of variables that influence outcome and treatment retention have been identified, ranging from agreement between patient and clinician about treatment tasks, to level of patient arousal (energy and alertness) to the bond between clinician and patient as characterized by expressions of acceptance and confidence.

While one could argue that it is helpful for a therapist to truly have a subjective sense of what life feels like in his or her patient's shoes in order to exude behaviors typically interpreted by patients (or observers) as representative of clinician empathy, it is not necessary. In fact, a clinician might be able to effectively articulate his or her difficulty understanding a patient's motivations or circumstance to help the patient clarify values, recognize possible dissonance between actions and values, and assert and strengthen autonomy to make decisions even if they are not completely understood by another. The bottom line is that while a good working relationship is important (and perhaps vital) to successful treatment, the way that the therapist feels is not essential to creating such a relationship. It is the interplay of behaviors between individuals involved in this complex interaction is important, and ultimately the way that the patient thinks and feels as a result of the interaction is much more important to therapeutic outcome than the feelings of the therapist.





Empathy Shmempathy?

Jodi Polaha

Empathy Shmempathy?

Does the therapeutic alliance (with or without empathy included) predict positive outcomes in therapy? I called my good friend Trent Codd, III, Cognitive Behavior Therapist Extraordinaire, about the empathy issue. He pointed me to studies by DeRubeis and Feeley (1990) and Feeley, DeRubeis, & Gelfand (1999), examining early and late measurement of process variables, including factors specific to CBT as well as therapeutic alliance/facilitative conditions. The findings of these studies showed that "common factors” including alliance did not affect depression early in treatment (CBT factors did), but were, instead, the consequence of change. Since these common factors were traditionally evaluated at a point when a great deal of symptom change had already occurred they could not be considered causal. These results suggest the field needs to go back and redesign its studies, taking temporal factors into account. In the process, researchers could examine the definition of "alliance,” better operationalize "empathy,” and try to unbundle these to identify which elements have greatest impact (or, the MINC, Minimum Intervention Needed for Change) just like we are doing with multi-component evidence based interventions.

Is empathy relevant? It is an empirical question, which is the easy "out” for any academic with a full in-box. Therapists' assumption that empathy is effective or necessary might be driven by a history of real-world observations; the stuff upon which relevant science is based.

Still, when placing this question in the context of a field working to implement and disseminate our science in new and changing paradigms driven by a new group of consumers, I'm having a hard time empathizing with the issue as a whole. What is the place of empathy or even therapeutic alliance in integrated care? What about in mHealth or eHealth interventions, which are gaining popularity and an evidence base? Treatment in these contexts bears little resemblance to the kind of therapy upon which these concepts of empathy and alliance were originally conceived. Perhaps, for the readers engaged here, it's time to exnovate some of the research targets that made sense in days gone by and consider innovating fresh and relevant targets.


 

 


 

James Anderson PhD
Jodi Polaha PhD

James is a second-year UMass Fellow of Clinical Health Psychology in Primary Care. He received his BA from the University of Wisconsin- Eau Claire, research training from the Neuropsychiatric Institute of UCLA, and his PhD in Clinical Psychology at Western Michigan University.

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


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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.