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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.

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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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Point / Counter-Point 3

Posted By Peter Fifield and Randall Reitz, Friday, March 16, 2012


A KISS to Make it Better: A Two Step Model of Behavior Change 


Peter Fifield



Why is it the more educated we become the more complicated we make things?

I was facilitating a Motivational Interviewing [MI] group the other day and during a discussion on the 5A's, the topic of Prochaska and DiClemente's Transtheoretical model [TTM] came up; specifically the stages of change. This got the entire group thinking about the complexities of behavior change and the most prolific model we use to describe it.

Since the 1980s when the TTM debuted, the stages of change have become the most widely used approach to explaining behavior change; thus it is the model most professionals [working on any sort of change process] have become familiar with. The substance abuse and medical worlds have been two sectors that have relied heavily on use of this model. Since its inception the TTM has been heralded as the kissing cousin of Motivational Interviewing [MI]. In all actuality, however, one of the originators of MI, William Miller, clarified in an article dubbed Ten Things that MI is Not [2009], that the stages of change where originally associated with MI only because, they provided a logical way of seeing how MI fits into the clinical process, but in the end, the stages of change model is not MI.

For substance abuse treatment, the TTM allowed for a fresh new look into addiction and allowed us to see how individuals made their way through phases regarding change behavior. One pivotal discovery birthed by this model was that patients needed motivational enhancement towards change more than they needed blame for their existing situation. Look at any substance abuse counseling program curriculum [and even some medical school curricula] and you are bound to find a class that mentions the TTM and its role in behavior modification. The insight that the TTM gave treatment professionals is absolutely extraordinary and subsequently the prevention world has coveted the TTM like a golden calf.

Leanardo Da Vinci has a famous quote that states "simplicity is the ultimate sophistication”. To me the TTM lacks this ultimate sophistication. Some may argue that you could not get a simpler model than one that has managed to reduce the complex nature of behavior change down to a mere five step process. However, I feel that the TTM is in need of one more round of distillation. According to the stages of change, people make their way from a precontemplative state, to contemplative, to preparation, then to action and after that they maintain: Then the cycle repeats [see below].

TTM

TTM Stages of Change Model


What this says to me is that what kind of Inaction the patient is in somehow matters more than the inaction itself. We are in constant flux and eternally making our way in and out of readiness regarding any behavior and quite simply it seems unnecessary to complicate the matter anymore than it needs to be. A simpler more therapeutically helpful perspective is that people are either in action or in ambivalence; nothing more.

Maybe it is we the therapist that is assisted most by the stages of change; not in that it teaches us more about the patient, but more about ourselves. Knowing that the patient is contemplative, in preparation or any other phase of the stage of change model may just be a way to help us feel better about the unknown nature of the situation. We resource the stages of change algorithm, place the patient in precontemplation and then [according to one manual] "encourage them to become more mindful of their decision making and more conscious of the multiple benefits of changing an unhealthy behavior”. This is stated like patient behavior is a forecastable action.


Ambivalence


What we typically find is that in action is not where we find most of our patients. I’d venture in saying that only about 10% of patients are in action mode; leaving 90% in ambivalence. For this 90% of the population we rely on motivational interviewing to work through the ambivalence, roll with the resistance and navigate a next step that derives from the patients wants and needs at that time. We don’t educate, advise or assist, we just sit there in the ambivalence with them, negotiating this unknown territory as if it were our own journey. We save the rest of the five A’s [Advice, Agree, Assist and Arrange] for the action phase: the other ten percent—a very small portion.

I once read, when people are in ambivalence it is like Linus without his blanket, we have nothing to hold on to. So we ourselves reach for something to grab hold of, to stabilize the spin. I think the complexity of the TTM merely gives providers a blanket to hold on to. It is an ameliorating agent for us; something to ground us as we flounder around looking for a way to help the patient out of their current predicament. What is a bit more difficult to master yet profoundly more therapeutic is to fully embrace that we are only accountable for the interaction with and not the outcome of the situation. In doing so we are able to commit to the patient without any expectation of an outcome and thus we can be more comfortable with their ambivalence. We then know that the best thing we can do is sit in the unknowness with the patient, experiencing the moment with them and not try to fix or right the situation.

The stages of change are very useful, but only if you use them cautiously. The problem that I have discovered is that they can facilitate an assumptive pattern, pigeonholing people into a mold that which we think they fit. This is done with such subtlety that we ourselves don’t even see it happening. Rechecking the manual I see that the patient is now contemplative so I must "encourage them to reduce their harmful behaviors and look for change within the next six months”. If this were true, my life would be quite boring, but a heck of a lot easier.

In the vein of Keeping It So Simple [KISS] I often think back to a childhood movie when Yoda explained to Luke one fateful day in the swamp. He said: "Do or do not, there is no try”. I think lil’ man Yoda may be on to something.





I Beg to Differ

Randall Reitz

 

Wow Pete, please take off your shoes when you address the Trans-Theoretical Model. It is a sacred calf and when you approach it you are standing on holy ground. Your heresy is that by dropping from 5 levels of readiness to 2, you are also dropping the model’s 2 greatest strengths: Hope and Change.

Hope. As astutely posited in your essay and supporting literature, MI is an evidence-based practice, but readiness assessment through the TTM is not. Fair enough, but how do you separate the 2 since they have been co-mingled since birth? How do you separate the science supporting MI from the science of TTM since most clinicians choose their MI interventions on how they gauge their client’s place on the TTM scale?

When you collapse the levels of TTM, you’re left with just 2 levels: abstinent or not. In the process you also take MI from a harm reduction model to an abstinence model. Yes, there is simplicity in this, but there is no hope. Once you carve out contemplation, preparation, and maintenance, clinicians will start turning Okham’s Razor on their own wrists in desperation. We need degrees of change to give us hope. We want morbidity and mortality. Imagine dropping all A1c values except a 7.0 for diabetes. Imagine dropping the quantitative PHQ9 and only keeping the binary PHQ2.

This is especially true with the dreary art of behavior modification. It is often cited that it takes the average person 7 smoking cessation attempts to actually quit the habit for good. Then, you tack on to this the much larger percentage of patients that I see every day who are not ready to attempt smoking cessation. My guess is that, as a result, only about 2-3% of the smokers I see in counseling will actually quit smoking in a given year and that only about 10-15% I see for tobacco specifically will be fully successful. With those difficult odds, if I had a binary approach I would feel quite depressed. If I keep the 5 levels alive then I can at least take comfort in the fact that a smoker moved from precontemplation to contemplation. This allows me to believe that I am the Johnny Appleseed of a tobacco-free world—planting seeds that I won’t harvest. Don’t kill Johnny.

Change. Prochaska and Diclemente’s "Stages of Change” model has brought change to medicine. The model fundamentally change is how clinicians consider their patients. Before 1990 was there a field that hated their clients more than the addictions field? The lingua franca that joined clinicians and clients was all about "drunks, alkies, boozers, winos, and junkies”. In using TTM, we remove the focus from pathologizing a person to describing their desire and readiness. I’d much rather be labeled as a "contemplator” (it’s so zen!) than a drunk. Who wouldn’t prefer to be a "preparer” than a junkie?

And, this is more than mere semantics. This language can saturate a clinical setting and reverse patient hating. It adds a narrative sense to the way clinicians describe their substance using patients. It challenges simple stigma and replaces it with a story of resilience and everyday heroics. It provides an arc with a beginning point (addiction) and an endpoint (harm reduction). It prevents us from viewing patients and the change process in black/white terms. In a circular way, this change instills more hope in both patients and providers and keeps them engaged in the process.

In conclusion, I like Yoda. Compared to other wizened pond frogs, he is incredibly wise. However, one of his axioms seems especially glib: "Size matters not. Look at me. Judge me by my size, do you?” Size does matter. In basketball, bed, and behavior modification a "5” will always be better than a "2”.


 Don't Kill Johnny!

 


 

Peter Fifield
Randall Reitz
Peter and Randall have been close friends and collaborators since 2006 when Peter was "Data Dude" and Randall was "El Jefe" at the Summit Community Care Clinic in Frisco, CO.

With CFHA, Peter writes the Re:Activation Blog and Randall  writes the CollaboBlog.


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Point / Counter-Point 2

Posted By Elizabeth Horevitz and Randall Reitz, Thursday, March 8, 2012


Biopsychosocial Collaborative Care: Innocent Until Proven Guildy


Elizabeth Horevitz




Overheard conversation between two psychology post-doctoral fellows:

Psychologist 1: "I was so frustrated when I got to my community-based placement because I realized that all of my patients needed serious case management. I couldn’t do any of the psychological interventions I was trained to do!”

Psychologist 2: "I had the same thing happen to me! So, what did you do?”

Psychologist 1: "I sent them down the hall to the social worker for case management”.

Psychologist 2: "Yeah, so frustrating. I would’ve tried to do some of it myself, but I just feel like case management is too far below our pay grade”.

Psychologist 1: "Yeah. It’s not what we were trained to do.”

As a clinical social worker, it is not the first time I’ve heard an allied profession dismiss case management as "less than”. Case management is broad term with multiple definitions[i]. In the field of social work, case management has been defined as "a method of providing services whereby a professional social worker assesses the needs of the client and the client’s family, when appropriate, and arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client’s complex needs… social work case management addresses both the individual client’s biopsychosocial status as well as the state of the social system in which case management operates”[ii]

Integrated behavioral health in primary care is the new frontier for behavioral health practice. If you’ve been following the CFHA facebook debates, you’ll recall this request for people to weigh-in on who they would hire as a behavioral health consultant if they were starting a new integrated clinic. Many people gave their opinions, and the general theme was that focus should not be placed on "guild of origin” (psychologist, social worker, family therapist, etc.), but rather on assessing the individual’s attitude, openness, curiosity and flexibility to be able to effectively meet the demands of this new frontier of integrated behavioral health practice.

Importantly, a general consensus about collaborative care is that a good behavioral health consultant should approach health and well-being from a biopsychosocial perspective which allows us to understand how biological/physiological factors; psychological factors; and social factors converge and act on each other to affect health, and to intervene accordingly.

Unfortunately, my experience has been that the field, in actuality, tends to emphasize the biological (physical health) and psychological (mental health) aspects of assessment and intervention ("biopsycho”), and dismiss or altogether ignore the social components.

Full disclosure: when I first started out as an MSW student, the idea of case management didn’t exactly have me champing at the bit like my classes on motivational interviewing or cognitive behavioral therapy. The fact of the matter is this: case management isn’t sexy. But what I learned right out of the gate, my first day of internship is that case management is just as important (and to be done well, requires just as much skill) as any other behavioral or psychological intervention. It goes back to Maslow’s hierarchy of needs- if a client doesn’t have their basic needs met, even the fanciest most in-depth psychological intervention for, say, depression will simply not work (let alone the brief psychological interventions we tend to offer in primary care).

Social workers are trained in the biopsychosocial model and take a person-in-environment approach to assessment and intervention. Because we are committed to working with vulnerable and underserved populations, a good social worker recognizes that helping a client navigate our fractured systems of care and access needed resources is a matter of social justice. The ability to engage in good case management and client advocacy is just as important as delivering the latest evidence-based psychotherapeutic intervention. You can’t have one without the other.

Try working with a depressed client on "maladaptive thinking” (or behavioral activation, for that matter) when she is unemployed and was just served an eviction notice. And she has three children. And she is about to run out of her diabetes medication. And she doesn’t speak English. Anyone worth their salt as a clinician would say that doing anything other than assisting her with immediate concrete needs would be silly and, in some cases (I would argue) unethical.

It isn’t that the two psychologists didn’t recognize the importance of case management for their clients (on the contrary); it was their perception that this activity, although necessary, was beneath their professional scope of practice that seems so antiquated in this new era of integrated care.

To be effective in behavioral health practice in integrated/collaborative care, case management must be part of every clinician’s toolbox, regardless of guild of origin. There are likely many reasons why case management and client advocacy have not been emphasized in the conversation in integrated/collaborative primary care; ranging from lack of reimbursement structures for case management to residual stigma about case management and the plight of behavioral health practitioners to be recognized as highly skilled professionals within a medically-dominated professional hierarchy.

With the passage of the Affordable Care Act, state and federal reimbursement will increasingly be linked to coordination of care and to "effective case management”[iii]. While it is likely that care teams will increasingly include specific positions for case managers, behavioral health consultants, regardless of guild, should have basic case management within their scope of practice. This is especially true given that we can expect to see an increase in patients with complex needs accessing the health care system in 2014 via the expansion of Medicaid coverage.

It is well known that health behaviors do not occur in a vacuum. Case management puts the "social” into the biopsychosocial model of practice and is a necessary component of improved patient outcomes. So, in addition to the list of requisite adaptations and skills for effective behavioral health practice in collaborative care settings (e.g., brief behavioral interventions, frequent interruptions during sessions, curbside consultation with medical providers), case management skills should be included on the list if we are going to be true to the biopsychosocial framework to which the we (proponents of collaborative care) lay claim. Otherwise, we risk reifying the very same professional ("that’s not my job”) and system-level silos that we have, and are, working so hard to overcome.



[i] For an excellent discussion of case management, its history and purpose, see Case Management: Uses, Critiques and Recommendations for Social Work Practice, Moore, M. (2010) unpublished manuscript available upon request meganmoore@berkeley.edu

[ii] National Association of Social Workers (1992). NASW Standards for Social Work Case

Management. http://www.socialworkers.org/practice/standards/sw_case_mgmt.asp

[iii] For a summary of the Affordable Care Act, see: http://www.govtrack.us/congress/bill.xpd?bill=h111-3590&tab=summary


 




I Beg to Differ

Randall Reitz

 

Elizabeth, while you make a very compelling and insightful case, I beg to differ.

I share your conviction that case management is a vital service in integrated settings, However, I don’t share your belief that clinicians and staff members of all stripes should embrace it equally. You see, this cantankerous collaborator is old-school beyond his years. I assert that the primary reason to integrate behavioral health and primary care is to expand access to different services in the same setting. The goal is not to have all clinicians and staff provide the same kinds of services.

Primary care is all about hierarchies of licensure and certifications: CNA, MA, LPN, RN, NP/PA, MD/DO. Each of these levels is qualified to do a different scope of medical/nursing care and is salaried based on the spectrum of what they are competent to do. While it is obvious that a CNA should not prescribe medications or order diagnostic tests, it should be equally obvious that it doesn’t make sense for an MD to do all the vitals on her patients. Yes, she is qualified to check vitals and should be willing to pitch-in and check-in a patient if things are backed up. But, in order for the clinic to run efficiently and economically, her principal concern needs to be doing things that only she is qualified to do.  She needs to "practice at the top of her license”.

The same is true for behavioral health services. Yes, I know a number of family physicians and pediatricians who are excellent counselors, but they should rarely, if ever, engage a patient in weekly 30-50 minute counseling sessions. As a behavioral health clinician, counseling sessions are at the top of my license.

I will grant to you that the behavioral health hierarchy is much more flat and fluid than the medical/nursing hierarchy (as are the income levels). But, the differences in training and credentialing are still important. Yes, a well-qualified case manager should engage in some motivational interventions, but should shy away from diagnostics and insight-based psychotherapy. Similarly, as I have worked in safety net settings my entire career, I am very well versed in community resources and governmental programs. I recommend them for patients all the time, and will often make a call to an agency myself to ensure the patient encounters "no wrong door”. With fragile patients I feel ethically bound to maintain the case management duties throughout because of the higher risk of things going awry.

However, the harsh reality is that a seasoned, licensed clinician of any behavioral health guild will command a salary that is 1.5 times what a case manager will make. At the doctoral level it is 2 times as high. As my clinic could hire 2 case managers for what they pay for me, if case management is the main job duty, then they should take away my badge, give me a cardboard box for my belongings, and hire 2 case managers.

This is especially true as it relates to "care management” (i.e. services to activate people with chronic illnesses through outreach and follow-up). Our doctors have really embraced the idea of sending care managers EMR "action items” to call a patient in 1 week to follow-up on a new medication, an exercise goal, or suicidal ideation. Our care managers spend hours on this every day, and have had amazing results. I will eagerly do it myself, but generally only if I already have a counseling relationship with the patient or if the physician judges that it is a sensitive situation.

And finally, even among licensed clinicians, we choose our specialty based on our passion and interests. Just as psychologists might not find case management "sexy”, I don’t find psychological testing sexy. (Nor is it relevant to primary care, but that is for a different blog post).

I have the fortune of working in a diversified setting that includes an LMFT, LCSW, addictions counselor, psychologist, and 2 case managers. In reality, all of us are generalist in scope and perspective. But, I would hope that if a patient requires sophisticated diagnostics, that the referring party would seek out the psychologist. If the patient needs family therapy, then all things being equal, they had better come find me. If the patient wants to break his wake and bake habit, then I hope they would seek out my addictions counselor colleague. If the case involves multiple agencies or is more socially-focused, then I'd hope they’d look for the LCSW. If the patient just needs a heads-up about how to apply for Medicaid or an outreach phone call, then the case manager should be the go-to person.

To do otherwise, would be lesser patient care, less financially wise, and wouldn’t promote the job satisfaction of the members of our team.


Elizabeth Horevitz
Randall Reitz
Elizabeth Horevitz MSW, is a doctoral candidate at the University of California, Berkeley.  Her research focuses on evidence-based primary care interventions for Latinos and other underserved populations.  In a previous CFHA blog post she cast aspersions at the "warm hand-off".

Randall Reitz PhD, is CFHA's Director of Social Media and the Director of Behavioral Science at the St Mary's Family Medicine Residency in Grand Junction, CO.  He does more case management than he cares to admit.

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Point / Counter Point 1

Posted By Randall Reitz, Thursday, March 1, 2012
Updated: Thursday, March 1, 2012


Dejected Views
on Family-Hating


Barry J. Jacobs



The surreptitious eye-roll is bearable. The low groan is regrettable but not worth reproaching. But what irks me most about the occasional reactions of my family medicine residents to their patients’ relatives is the smug, dismissive, professionally rendered character assassination, complete with technical terminology. "The spouse is in denial,” they point out to their fellow inpatient team members when an overwhelmed and grieving husband or wife is unwilling to change a patient’s code status. "The daughters are being manipulative,” they observe about adult children who are urging their mother to resist physicians’ recommendations to undergo surgery or take a new medication. "They’re over-stepping boundaries,” they claim about family members who call them repeatedly or accost them with concerns in the hospital or office hallway.

It’s not that other healthcare professionals are substantively more family-friendly. For many of my mental health colleagues, hate of (or at least discomfort with) families is a many splendored thing. They focus on individual dynamics and prerogatives, invoking the delicateness of the therapeutic alliance or the sanctity of confidentiality as justifications for eschewing family contact. They cringe at the prospect of family meetings. They regard family systems thinking as a relic of the ‘60s, unsupported by current research or modern expediency.

I’m incredulous at these attitudes; I take them personally. From my teenage years caring for my father with brain cancer to my middle-aged years caring for my aging mother and demented step-father, I know in my gut how families affect patients’ clinical outcomes and how patients’ illnesses affect family caregivers. Others, clearly, don’t share the same visceral conviction. So what do I make of the widespread phenomenon of family-hating? Here are some over-the-top theories:

We operate in evidence-reinforced comfort zones: Much of healthcare practice and consequently research is focused on individual patients. In an era when clinicians are reminded at every turn to treat according to evidence-based principles, family-centered practices—lacking the same degree of empirical support—therefore seems the riskier clinical gamble. This is compounded by the fact that many healthcare professionals do not receive much training in the nuts-and-bolts of working with patients’ family members—e.g., running family meetings, addressing family conflicts. The seemingly prudent and comfortable treatment approach is centered on patients, leaving family members in the wings.

We are rats in templated, encoded mazes: Medical care, especially primary care, is being increasingly shaped by the clinical pathways that are the basis for the templates of our electronic medical records. By clicking through those templates, physicians not only have the assurance of following the so-called highest standards of care but are also working toward completing their progress notes for medical sessions as quickly as possible. It should come as no surprise that those EMR templates reflect bias toward individually-focused treatments. Family-centered healthcare is off-the-templates.

At the same time, clinicians are under enormous pressure to maximize reimbursement for healthcare services. The billing codes—aka CPT codes—they use have a powerful effect on practice. CPT codes for individually-oriented treatments are reimbursed by insurance companies. CPT codes for meeting with patients’ family members are generally not. We follow the money and avoid the family members.

Beaten and bedraggled, we cling to our authority: I don’t need to tell you that every year healthcare providers are worked harder, blamed more for rising healthcare costs, and disparaged more frequently by angry patients and aggressive lawyers. Evoking Rodney Dangerfield, all we want is a little respect. Now comes the dawning age of the patient-centered medical home with its emphasis on team-based care and who wants a place at the decision-making table as partners in care? Family caregivers do. (For example, see this recent AARP Public Policy Institute report). I think it’s tough for us to give up some of our remaining power to family members. When I hear professionals complain that patients’ family members somehow obstruct the treatment plans of the healthcare team, I infer that they don’t want their scant authority challenged any more than it already has been.

We are all adolescents at heart: Many of us give lip service to the importance of family members to patients’ care. But in our own lives, in our heart of hearts, we feel ambivalently about families. We want their support but don’t want them to encroach on the individual’s rights and independence. It reminds me a little of the sentiment captured in the title of the 2002 book on teenager psychology, Get Out of My Life, but First Could You Drive Me and Cheryl to the Mall. We want family members to drive our patients to our offices but then don’t make a fuss in the exam rooms. We want them to help our patients adhere to our treatment plans but not have input into those plans. That’s not family-centered care. That’s not even respectful of what family members know and have to offer. It marginalizes families. It’s reflexively oppositional and hateful.

For more on this general subject, check out the seminal article, "The Trouble with Families: Toward an Ethic of Accommodation” by Carol Levine and Connie Zuckerman in the Annals of Internal Medicine, 1999, vol. 130, pages 148-152.

Also please see "Interacting with Patients’ Family Members During the Office Visit” in the Oct. 1, 2011 issue of American Family Physician; it’s a tepid, timid approach to incorporating family members into primary care but at least represents some effort to do so.




I Beg to Differ

David B. Seaburn

I beg to differ with my good friend Barry Jacobs’ blog posting entitled, "Dejected View on Family-Hating.” Not only is he (uncharacteristically) off-base, but he may not even be on the playing field.

He notes that family-hating is rampant in the medical field as well as in most mental health disciplines. While I don’t espouse family-hatred, I doubt that any well-trained family-oriented mental health professional isn’t at least ambivalent about families from time to time. They are messy and confusing and inconsistent and wonderfully Resilient in their efforts to get us to respect their integrity. Non-family-oriented healthcare professionals are not the only ones to unfairly label families. In moments of frustration, I have considered whether "borderline” might be an apt relational diagnosis, especially when I don’t know what to do with a family.

Which brings me back to Jacobs’ criticism of residents. If as an experienced family therapist (35 years), I, at times, label and very nearly hate a family, what can be expected of residents. Remember---these are medical professionals who have been trained almost exclusively in a paradigm that focuses on the life and death of an individual patient; who have been acculturated to think reductionistically ("Let’s find the single cause of this patient’s symptoms”); who then enter a healthcare system that mitigates against inclusion of families due to time (see what it’s like to care for four or more patients per hour), diagnoses and healthcare reimbursement. If that were my professional background, my professional culture, I would run the other way when I saw a complex, demanding, needy family coming my way, as well.

I was a residency educator for almost twenty years. Early in my tenure I learned that I was a visitor in a different culture and, as such, I needed to enter that culture with respect and an eye to learning as much as I could to be of value. At first I thought I needed to convert the heathens to a family systems paradigm. If they could only become like me! Soon I realized that that wasn’t what was needed. More than anything else, residents needed help with their most difficult patients. As a family systems professional, my help with challenging patients often (but not always) included involvement of the family as a resource to the resident or as an important source for understanding the patient’s problems. Once residents saw that family could be integral to care and that involving family in challenging patient situations made their lives easier, residents often caught the family system’s bug. For me the lesson was---Don’t preach family-systems, just do it. Making it work in the exam room is the best evidenced-based example you can provide.

The challenge for family-oriented residency educators is to be comfortable and creative taking a one down position (yes, even after all these years!) in a system that is slow to accept differences, let alone change. That means wielding power and influence differently, if, at times, not equally. Becoming a recalcitrant adolescent ourselves is not the answer. Instead, we must recognize that as a maturing member of the medical education family, family-oriented healthcare educators must demonstrate the capacity to be systems-oriented in our clinical, research, educational, administrative and policy-making endeavors. We must leave "evidence” of who we are everywhere we go. I think that the better angels of Dr. Jacobs’ nature recognize this.


Barry Jacobs
Dave Seaburn
Barry Jacobs and Dave Seaburn are family medicine educators and long-term collaborators. Barry is the Director of Behavioral Sciences at the Crozer-Keystone Family Medicine Residency in Springfield, PA and the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent. Dave recently retired from a distinguished career as the behavioral science faculty in the University of Rochester Family Medicine Residency and has taken to writing novels, including Charlie No Face.

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Pain Spikes and Sugar Spikes--A Consumer's Perspective

Posted By Al Hackley, Thursday, February 23, 2012
My name is Al Hackley. I’ll be 70 years old in May, and I have type 2 diabetes that is mostly a little high. In the process of trying to control it I started to look at the high spikes and when they seemed to jump with any change in my eating habits. It quickly became quite apparent that when my wife's pain level went up my own sugar levels also went up.

Let me explain why this might be. In 2008 my wife was bleeding badly. We went to emergency room at the local hospital and were told she had been diagnosed with colon cancer. The mass was too large to take out at that time, so they had her take chemo and radiation. The doctors said they might not be able to put her colon back together, but fortunately they did. The doctor said he was amazed that he could put the colon back together. But there was very little they could do other than painkillers to help with pain due to scarring and nerve tissue damage.
We learned to live with it (most of the time). However, sometimes her colon gets blocked. When this happens she needs to flush herself out. During these times she is in really bad pain and even her morphine does very little to help. There is nothing I can do to help her but just to comfort her. The pain she has becomes my mental pain. Not that I physically hurt, but that I feel so bad for her and sometimes scared. Of course, I don't let her see my fear. Anyway, at these times my readings can jump as much as 100 to 120 points over my normal readings.  A better way of saying this is my reading would jump from 220 to 310 and there seems so little I can do to relieve my anxiety.

"The pain she has becomes my mental pain...at these times my readings can jump as much as 100 to 120 points"
It is so great to have a dedicated family doctor who is connected with all my records and an excellent team. When we go for check-ups they have our medical records right there, whether it be her chemo doctor, my diabetic meetings, a health class, a dietitian class, or from so many other services. I really like the integrated care model and being able to go to diabetes classes and see a marriage counselor right there at my doctor's office. If not for places like this, a lot of uninsured and low income people would be totally without medical care.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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Making Room for Behavioral Health

Posted By Margaret K. Peterson, Saturday, February 18, 2012

Fairmount Primary Care Center (FPCC) is not a big place. There’s a hallway for adult medicine with ten exam rooms, two apiece for each of five providers. There’s a hallway for pediatrics with four exam rooms for the two pediatricians. There are various support and administrative spaces—a waiting room, a front desk, an alcove full of medical records, a couple of triage rooms, a lab, a nurse’s station, a room full of computers where the providers sit to chart, storage closets for supplies and medications. And there is a behavioral health office, which until recently was a modestly-sized windowless room tucked in beside a back stairwell, next to the copy machine and a corridor leading to a bathroom that was usually out of order.

The behavioral health office was occupied by the director of behavioral health (my supervisor, Suzanne) and shared with the two behavioral health interns (me and my colleague Frank). It was furnished with a couple of computer work stations, a few chairs and a bookcase. We used it for consultations with patients who had been handed off to behavioral health by their providers, for scheduled followups with patients and family members, for charting and making phone calls, and for supervision. With all three of us using the room for all these purposes, it got a little crazy sometimes, like when more than one of us had a patient to see at the same time. Mostly, though, it was adequate.

Then the social worker quit. She was the latest in a string of social workers to quit after not very long on the job, and it fell to Suzanne to try and figure out why. Part of the problem, it appeared, was the location of the social worker’s office, which opened directly onto the waiting room and made the social worker vulnerable to limitless demands by both patients and staff. Suzanne hired a new social worker, and moved the new hire into the only other space available—the behavioral health office. It was a vast improvement for the social worker, who now had enough control over her time and space that it was possible for her to do her job.

It was not an improvement for behavioral health. Behavioral health couldn’t just move into the former social work office, since that office’s semi-public location would have made it impossible to safeguard patient privacy. But the office now shared between behavioral health and social work was now occupied by a rotating cast of patients consulting with the social worker. Suzanne and Frank and I couldn’t meet with patients there. We couldn’t make phone calls. We couldn’t talk with each other. We couldn’t even find places to put our coats. Right about the time this change happened, a consulting psychiatrist began coming to FPCC one morning a week. She, too, was supposed to work out of the behavioral health office. Guess how well that worked?

The space crunch highlighted a question that had been percolating along in the back of my mind for months: what exactly is the place of integrated behavioral health? Even at FPCC it’s not really clear how integral a part of the operation behavioral health is. Suzanne has been there for 17 years, and patients still occasionally report that when they return for followup visits with behavioral health, the front desk tells them that there is no such department. It strikes me that this may be less a problem with the front desk personnel than a realistic reflection of the medical care system as a whole. Everybody knows that medical offices are staffed with doctors and nurses. But behavioral health? What’s that?

"As much as I want there to be room for integrated behavioral health...it’s not clear how or whether that’s going to happen in any significant way."

On the mental health side of things, I don’t see much more evidence that integrated behavioral health is any closer to achieving mainstream status. It’s certainly not represented in the curricula of the majority of training programs in my field, marriage and family therapy. In the large and thriving master’s program in which I am enrolled, I have yet to hear the subjects of physical health and illness even mentioned, let alone explored. I got my internship at FPCC approved only with difficulty, and I have the sense that my faculty supervisors are less than enthusiastic about the work I’m doing there. After all, it’s not specialty mental health. And they’re right—it’s not. It’s primary care.

As much as I want there to be room for integrated behavioral health, both in the worlds of biomedicine and of mental health care, it’s not clear how or whether that’s going to happen in any significant way. It really seems like such a shame. Biomedicine is a fine thing, and so is specialty mental health care. But there is never going to be enough individual or family therapy to go around, and it’s more than lots of people need or want anyway. And part of the reason the medical care system is bankrupting us all is that we keep throwing more pills and procedures at problems that have at least as much to do with intrapersonal and interpersonal dynamics as they do with physical health or illness.

Just the other day I saw a patient for an integrated care visit. "What brings you in today?” I asked, as a prelude to my standard set of screening questions. She had pain in her shoulder, she said, radiating up her neck and down her arm and side; it had been this way for a couple of months. "What was happening a couple of months ago?” I asked. The patient couldn’t think of anything, but as we talked, more of the particulars of her life emerged: she was the single mother of two young children, going to school, negotiating details of child care with her mother, who was herself rearing two grandchildren close in age to the patient’s children.

It struck me that this patient’s pain might have a lot more to do with her mother than it did with her shoulder. "You know,” I said to the patient, "we don’t do ongoing therapy here, but we would be happy to meet with you on one or several occasions to discuss this further. You could bring your mother, if you liked, and we could all talk together.” "Really?” she said. "What would I say to my mother, to explain why I was bringing her in?” Later in the day I looked at the patient’s chart. The provider had found no organic basis for her pain, but noted that the patient had said she would like to follow up with behavioral health.

In ensuing days I found myself puzzling over that pain in the patient’s shoulder. If the pain was about her mother, why was it in her shoulder? A pain in the neck I could understand, but why a pain in the shoulder? An image came to mind of the patient and her mother, yoked together, rearing children of the same age, but being themselves of different generations, and one of them the parent of the other. No wonder they were having trouble pulling together. Behavioral health and biomedicine are having trouble pulling together, too. In the current culture of medicine, biomedicine is the established player and behavioral health the young upstart, and it is hard to learn to work together.

Will my patient come for a follow-up visit? Maybe she will. Maybe she’ll even bring her mother.If she does, we have a place to meet. After Suzanne and Frank and I and the social worker and the psychiatrist had spent a week falling all over each other in the behavioral-health-cum-social-work office, Suzanne said, "We have to do something about this!” The following week a corner of the office was partitioned off into a consult room. The office wasn’t big to begin with, and the new consult room is the size of a closet, and not a very roomy closet at that. But it has a door and a couple of chairs, and it’s definitely better than nothing. And in a sign that perhaps things are looking up, the bathroom down the corridor is even working.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

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CFHA Facebook Debate #1: Generalists versus Specialists

Posted By Administration, Thursday, February 9, 2012

CFHA has hosted a number of debates on our Facebook page ("like" CFHA today to participate!). This post is the first in what we hope will be a series of debates that went viral on facebook and were brought here for further commentary. Please add your perspective to today's debate.

You're starting an integrated team from the ground-up. Would you hire 3 mental health clinicians who view themselves as generalists (e.g. 3 LPC's or LCSW's) or would you prefer to have clinicians with some form of specialty focus (e.g. 1 MedFT, 1 psychologist, 1 addictions counselor)?

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The Pros and Cons of Patient Portals: Can Integrated Electronic Health Records Help Empower Patients?

Posted By Peter Y. Fifield, Friday, February 3, 2012
Providers spend a significant amount of time with patients problem solving effective ways to manage chronic health issues. Through the use of Motivational Interviewing for example, providers focus on increasing patient self efficacy; "how do I guide this patient in owning their own health?".

With the rapid grown of Health Information Technology (HIT) I'm optimistic that HIT, specifically the use of patient portals, will provide more tools for not only improving patient satisfaction and reducing costs, but also in addressing another real issue in healthcare: Increasing patient autonomy.


Patient portals become a window of opportunity for managing our own health. Metaphorically speaking it is like maintaining our car with the use of that dusty paperback in the glove compartment: The vehicle maintenance log. We resource the maintenance log to see what work has been done in the past and as importantly, what work needs to be done in the future. To compliment this log, we use the gauges on the instrument panel. We read the tachometer, the gas gauge, and the engine lights to understand what the vehicle needs. These data complete the feedback loop so we now know how to act: Get gas, inflate tires, flush your transmission.  You get the idea.

A patient portal could act in a similar way. Medications, appointment times and blood pressures could all be accessed via the encrypted portal and assist the patient in being a better manager of his or her own body. I can hear it now "there's an app for that"...imagine remote blood sugar sent from the glucose monitor to our medical record via the patient portal. Diet and exercise routines could be managed daily, calorie counts entered at each meal; all of this managed on your own medical portal (and possibly complimentary smart phone applications). Most important, it can all be updated and facilitated in real-time by patients or their HIT devices. There is a market here just waiting to explode.

With such potential, why is it then that so many providers have an issue with the use of patient portals? I heard one physician say: "not on my watch" and a BHC say: "I'm unsure of the benefits here" regarding initiating a patient portal access initiative at a local primary care clinic. In the spirit of investigating this enigma, I have listed a few key components of patient portals below that I think provide the most fodder for the cannon in terms of eliciting arguments from both camps. Just to clarify, in this blog I am referring to patient portal access to the patients own electronic medical record (EMR) not the "never-used" Electronic Health Record (EHR) that are typically little more than a hi-tech headache.

1. Patient portals can be thought of as a gateway to patient data, health record content, and web services associated with the hosting provider. Patients get secure, encrypted access via use of a patient ID and password; a similar process that allows clients access to other very sensitive information such as online banking. Unlike with online banking, medical information is often sensitive information and keeping unwanted eyes from seeing your portal could prove difficult. As this one article shows, the views on confidentiality are mixed.

2. Providers grant patients access via their username and password and through the patient portal, the patient may be able to perform the following tasks:
  • Check their appointment schedules and requests an appointment
  • View lab results and basic patient information such as BMI, BP, and weight
  • Examine medical and billing statements
  • Request prescription refills
  • Complete new patient intake forms and registration information
  • Complete ongoing assessment forms such as PHQ 9, GAD7, DUKE 17, etc.
  • Correspond with medical personal via encrypted email services
An interesting philosophical question here is that if the medical chart really belongs to the patient, why is it the provider that is granting access? Who is really driving the bus here? This may be a reflective residue of the slowly fading paternalistic role providers have played in the past. It could be argued that until the patriarchal paradigm is shifted to give power to the patient, they simply will not have it.

3. Through reviewing provider satisfaction research, one of the most often heard complaints is that the providers do not have enough time with patients. Period! In addition, providers spend significant time discussing symptoms and providing medical advice that they do not bill for. Simply stated, there are too many things to address aside from the Chief Complaint. Through the use of the portal providers and support staff can communicate back and forth with the patients and send messages such as appointment reminders, electronic statements, and lab results.

Historically, part of the provider-patient relationship included correspondence via phone. We could consider the patient portal a very high tech, and easy to facilitate version of that same information exchange, however; it would be more informative for the patient and much easier and less time-consuming for the provider.

4. The patient can complete much of the patient visit information and yearly paperwork prior to the visit. Existing patient intake and medical forms can be uploaded onto the website for the patient facilitating the process for not only the patient and provider, but for the support/office staff as well.

5. All of the interaction on the patient portal can be set to directly integrate into the chart. Although I disagree with this on a philosophical level [see above], pragmatically the medical practice is the ultimate authority regarding how much data is conveyed to the patient. Said otherwise, the patient does not have access to all of the doctor's records at any time. Patients only see what doctors want them to see and thus the physician note remains protected.

Portals could provide more patient access to a very valuable resource: Provider knowledge

Ideally, using a high quality patient portal allows the patient to upload their records to a central repository. The continuity of care between different doctors of different specialties, in different locations, becomes a reality for the self-efficacious consumer.

6. The portal is accessed through the practice’s web site. Educational material [including pdfs, photos videos etc] and links to other websites [i.e.patientslikeme.com, sermo.com, dailystrength.org] can be posted on the web site as well to provide adjunct services and supports. Many practices post educational information such as diabetes information, exercise options, support service information, times and dates of groups being held, diet/meal planning suggestions, and medication information, etc. on their practice web site as a service to their patients.

With the HITEC Act in place, it is reasonable to say that more and more providers will continue to venture into the world of high-tech charting. Patients could have far more access to their provider's vast knowledge by complementing the face-to-face visit with portal access and thus create a more interactive relationship with their medical record.

I see this as exchange of information via patient portal as a compliment to the face-to-face appointment; an extension of the office visit, if you would. Providers are the keepers of an infinite amount of medical knowledge and currently there are 2.7 physicians per 1000 people in the US. The informational bottlenecking lies in the finite space in time providers have to transfer that information to the patient. In a 15 minute visit we all know this is impossible. The patient portal could act as an expansion of this 15 minute window and would allow for more patient access to a very valuable resource: Provider knowledge.

Patient portals are obviously no panacea for the health care crisis. Ultimately nothing replaces patient accountability when it comes to overall health outcomes. However; the patient portal could function as an integral tool in increasing patients’ motivation for healthy living by giving patients access to their own information.

Inevitably technology will continue to play a role in patient care and most likely patient portals will be more widely used.

My question is, why not now? I'd be curious to hear other opinions out there regarding the pros and cons of using patient portals. Is there anyone out there in the CFHA audience already using them? How has it worked? What are your thoughts?


Pete Fifield is the Manager of Integration and  Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. In his off time he is the Managing Editor of CFHA Blog and makes all attempts to keep up with his wife and two sons.

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

Tags:  CFHA  health information technology  Integrated Health  patient portal 

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A Non-clinician's View - From Wingspread to...Where?

Posted By Bill Steger, Saturday, January 28, 2012

Thanks to Dave Seaburn for telling our story that began with Wingspread. We all need to be reminded of how this ball of energy started rolling. For me, what started as a part-time, strictly business, gig with the Collaborative Family Health Care Coalition (CFHCC) soon evolved into getting hooked on the passion and commitment of the people in the organization, especially the quiet but captivating nature of Don Bloch. Talk about ‘walking the talk', this group devoted countless hours meeting, writing, and pitching the organization to colleagues and students, collaborating with other organizations, and putting on bi-annual (initially) conferences with only volunteer time on a shoe-string budget, and one part-time staff guy. Truly amazing!

Today the Collaborative Family Healthcare Association (CFHA) is a membership driven organization but our coalition building has never stopped. Our conferences have grown as has our membership but, more importantly, the idea of collaborative/integrated care has caught on nationally and internationally. Many are now understanding that care delivery needs to be patient centered with considerations beyond just the medical or mental health aspects but the whole package, including the patient's living/support environment, or their ‘family' in an extended sense.

I guess that's where Family Systems Theory has played to our strength (here's where my non-clinical shows). In a role likened to Johnny Appleseed, we have been spreading the collaborative care model seeds, starting in Washington, DC and then on the road to Clearwater, FL, Chaska, MN, Seattle, WA, Newport, RI, Asheville, NC, Denver, CO, San Diego, CA, Louisville, KY, and Philadelphia, PA. As we move on to Austin, TX this October, the cycle then starts over with Denver in 2013, Washington, DC in 2014, and the process of harvesting hopefully begins.

In a role likened to Johnny Appleseed, we have been spreading the collaborative care model seeds...

What has changed since we started as CFHCC is the healthcare environment with pressing issues of affordability and access and a sense of urgency to deal with coverage issues at the federal level. There are also now a growing number of diverse organizations acknowledging that integrated care promises less overall cost and better outcomes. The collaborative/integrated ‘market' is getting crowded but we can take satisfaction in that this is probably because we have been true to our mission.

The challenge now is planning for what we should probably consider as the next phase in our growth. We are at the point of a typical business life cycle where the growth curve becomes steeper in a shorter period of time. We have an increasing base on the membership side and we are evaluating an increasing number of collaboration opportunities with other diverse organizations on the coalition side. Another aspect of our growth is our expanding ‘staff' including Steffani Blackstock, another part-timer managing our conferences, and the addition of a part-time Executive Director, starting with Steve Snow, to Randall Reitz who significantly increased our productivity, to our newest and almost full-time ED, Polly Kurtz who will be the enabler of our next phase of growth.

So, what is our future? That will be determined by our membership and the wisdom of our leadership. The opportunities appear to be many, the need is certainly there, and there is the desire to be relevant. Volunteerism still is the linchpin of CFHA and as we head down this road to the future, there are still some seats up front. Become involved if the spirit moves you!



Bill Steger, MBA has been the Business Manager for CFHA since 1998 with past relevant positions as Director of Marketing and Oncology Department Manager for Highland Hospital of Rochester, NY and Operations Manager for Highland Family Medicine. He is a principal in Quality Services & Products, LLC, a business management consulting company.




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Eight Steps for Creating Successful Behavioral Health and Primary Care Partnerships

Posted By Cheryl Holt, Thursday, January 26, 2012
There are numerous initiatives underway that address the primary care needs of people with behavioral health disorders. It is heartwarming to see the silos begin to develop cracks, allowing the primary care folks and the behavioral health folks to engage in serious conversation about how they can work TOGETHER to serve this vulnerable population.

It isn’t easy for two disparate groups to work together. It takes considerable planning, patience, and commitment. Despite the fact that both primary care and behavioral health are healthcare fields, they have vast differences. Their cultures, funding streams, philosophies, and overall approaches to treatment vary greatly. Therefore, it is not an easy task for these two groups to collaborate together to serve individuals with behavioral health disorders….yet they are doing just that! The mission is far greater than are the differences! It is worthwhile to devote the necessary time, energy, resources, and focus to develop strategies for streamlining the integration process. Whether the services are provided in the primary care clinic or in the behavioral health clinic, working collaboratively provides enhanced results.

For a successful behavioral health – primary care partnership, these eight steps that were adapted from "Strategies to Preserve Public-Private Partnership ‘Best Practices’: Keys to Genuine Collaboration” by Greg Schmieg and Bob Climko, will provide the foundation for success:

· ESTABLISH THE MISSION OF THE PARTNERSHIP
It is vital for both organizations to sit down together and create a shared vision. This will likely require a merging of goals into a partnership mission statement. This mission statement must be communicated with everyone involved in the partnership. The success of the partnership will depend on frontline champions. They need to be identified and empowered from the onset. They will provide the energy to motivate other team members.

· IDENTIFY A COMMON LANGUAGE
Primary Care and Behavioral Health speak different languages; therefore, a common language must be identified. Clarity of communication enhances mutual understanding of cultures, roles, and expectations. While these differences might not seem important at the onset, it will become increasingly important as the partnership progresses. Most likely, each partner has a different language for many things. There are notable differences between contract deliverables, medical records, coding, management structure, procedures, and even the language used in describing the clients/patients/consumers/members/individuals served.

· MAINTAIN PACING, FLEXIBILITY, AND CAPACITY
It is very important to temper expectations within the partnership. Establishing regular meetings will help to promote ongoing communication. Mutual goals and disappointments should be continually communicated so that they can be addressed immediately. The partners must remain flexible in order to sustain a healthy partnership.

· DEVELOP SHARED SOLUTIONS
The decision makers must be open to new ideas and problem solving. Developing shared solutions maximizes organizational efficiency and capacity. Everyone must have skin in the game! Compromise is important for success.

· DETERMINE EXPECTATIONS
The project should first be piloted to allow for evaluation and for adjusting expectations to ensure that both partners are on the same page. Internal conflicts are inevitable and should be discussed openly. The partners must address differences of opinions on an ongoing basis. Partnerships create an opportunity for enhanced outcomes through blending of resources to maximize the capacity of each organization.

· DELEGATE TRUST
Face-to-face meetings are essential for establishing and maintaining trust among partners. Be sure to focus on building trust at all levels. Face-to-face time creates a forum for maintaining checks and balances to ensure fidelity to the mission. Constantly solicit feedback from partners at all levels.

· CREATE EMPOWERMENT
Success is dependent on the involvement of everyone. This requires empowering champions at all levels to move the mission forward. This empowerment develops buy-in among staff. Communicating with everyone and soliciting feedback ensures ongoing focus on the mission. Be sure to create a forum that allows both positive and negative feedback.

· MEASURE OUTCOMES
Establish the outcomes to be measured early in the project. Be prepared to modify outcomes as needed. Don’t overlook the benefits of partnership that include more efficient allocation of resources, less duplication of services, increased choice among clients, and the synergistic effect of the partnership resulting in enhancing the lives of those we serve.
Following these eight steps will assist in bridging the innate differences between behavioral health and primary care to ensure a successful partnership. Far too many promising partnerships have been derailed due to poor communication and lack of planning. Careful preparation at the onset will ensure a productive partnership that will ensure a focused mission aimed at addressing health disparities among people with behavioral health issues.


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


Blog Disclaimer: 

The view expressed in the blogs and comments should be understood as the personal opinions of the author and do not necessarily reflect the opinions and views of the Collaborative Family Healthcare Association (CFHA). No information on this blog will be understood as official. CFHA offers this blog site for individuals to express their personal and professional opinions regarding their own independent activities and interests.

Tags:  family medicine  health policy  Integrated Health 

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What We Do

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