Posted By Peter Y. Fifield,
Thursday, October 13, 2011
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My two sons attend a daycare in the same building as a nursing home which has a multigenerational program integrating the wee tots with the geriatric populations. They pass the time singing songs, playing games and I’m sure, laughing at each other’s idiosyncrasies. My wife and I purposefully chose this daycare for this reason. We felt that there, both the young and the old had a lot to offer one another and that it would be a wonderful learning experience for our two young boys who unfortunately do not live near either set of their grandparents.
My personal story is a bit unusual. I am the youngest of seven biological children; added to the fray, I have a very sweet adopted Cambodian sister. This bit is actually not THAT unusual but you might find the rest is a bit odd. At the ripe old age of TEN I moved into a nursing home. Fortunately for me, it was not due to early onset dementia but to the fact that my mother inherited a rather quaint old colonial home from my grandmother, complete and equipped with 12 elderly persons. Out of necessity to "be closer” to the business my father built an apartment addition on the "Austin Nursing Home” and Shazam!, instantly l was engulfed in a multigenerational living situation.
Although it took some getting used to, I adapted and quickly decided that going with the flow was easier than trying to swim upstream. The first thing I had to adjust to was the olfactory delight of Pine-Sol, old mothballs, smoked tobacco and rose perfume. The second adjustment came with an increased pain threshold for my cheeks were constantly red and sore from being pinched by any given resident at any given time. The worst part though was that with every pinch of the cheek came the gooey grossness of "you’re so cute”...Bobby or Donny or Jimmy or even Beth or Dot seemed to follow. Due to their old age, dementia or Alzheimer related memory issues, I was sentenced to be identified by some non-gender specific "given name” other than my own. I quickly learned to pick my battles and decided that responding with, a simple "yes ma’am/sir” was easier than trying to explain that my name was actually Peter.
The days of living in the nursing home have long since passed. Although the land has been subdivided and the nursing home handed over to new owners the multigenerational living continues in the "Fifield compound”. On my parents "compound” [the use that term is somewhat accurate] there are three quaint yet well-kept homes. In total they are occupied by five, count them five generations: my grandmother (at age 102), my parents, two of my sisters, two of my nieces and three of their children. Why is this such a big deal you ask? It really isn't but it has me thinking about what I have witnessed a lot more of here at work.
I now am a Behavioral Health Consultant for an FQHC in the Seacoast region of New Hampshire. Approximately 80% of our patient population is either uninsured or under-insured. Due to our unique population, even before this current national financial crisis, a significant number of my patients were managing through their financial difficulties. In our therapeutic setting I have observed a correlation between our country’s current financial crisis and what seems to be a spike in reported multigenerational living. More and more patients report "having to” move in with another family member. Whether it is a single mother moving in with a son or daughter, a couple moving back home with the parents after losing a job or a son or daughter who is "not a fully functioning adult yet”, they all have a similar story. The consensus seems to be one of distress, desperation and despair.
According to an article in US News Money the downward trend of multigenerational living has happened since the end of World War II when, at that time, about 25 percent of families lived in multigenerational households. Due to many factors ranging from a growth-oriented capitalistic paradigm and the "Mobile society” to more recent influences such as the current mortgage crisis and collapse of home values, a decline in multigenerational households has happened ever since. Regardless, since the latter part of the 20th century we have become imprinted to fly the coop and make it on our own.
From so many of my patients suffering from any form of depression and/or anxiety, I have heard them voice the cause of their guilt as "I used to be responsible” or "I should be succeeding in the world”. My challenge to them is to rethink success. Our egocentric need for privacy and drive for success may have caused us to forget the gift of sharing in an extended household and thus isolated our dwellings to the nuclear family. Interestingly enough it was not long ago that our ancestors lived in "dwellings” that didn’t even have rooms, it was just one open area. For that matter, the majority of the world still lives that way. The challenge then as I see it is how do we Americans learn how to play in the sandbox again with others (in our family).
There are many websites (this one with extensive links) that openly offer ideas about the rejoining of multiple generations under one roof. According to one website the current percentage of multigenerational is on the rise: 16%--that is 50 million Americans. I wonder what the cultural break down is here. My personal observation has been that many more ethnic minorities still commonly practice multigenerational living here in the US and abroad compared to their Caucasian counterparts. I wonder if the observed local "surge” has anything to do with the fact that I live and practice in an area that is 90% Caucasian. Regardless, the core issues seem to be the same. We need to relearn how to share and this is not as easy as it sounds.
Sometimes living in a single family home is hard, never mind living in a multigenerational family, but what seems to be the trade-off is the richness gleaned from the old and the young living under the same roof. I will never forget the lessons I learned from all 12 of my beloved grandparents at the Austin Home. Sometimes it was hard, sometimes it was outright embarrassing but with learned patience, tolerance and dealing with a lot of "could you repeat that I can’t hear you sonny”, it always worked out. The other day my wife went to pick up our two sons at day care and the one-year old was upstairs. She found him up there with one of the daycare workers nearby "talking” with Gunther, an eighty year old resident. She said, "You should have seen the smiles on both of their faces. It was priceless”!
Pete Fifield is an integrated Behavioral Health Consultant 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.
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
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Posted By Lisa Zak-Hunter,
Friday, September 30, 2011
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Whats in a Name? I
found myself pondering this question as I walked away from a session in
which I introduced my current patient to her new therapist. As an
intern, I had a time-limited appointment as a behavioral healthcare
provider. My patients knew this, but that did not always make for a
smooth transition. Admittedly, I was less concerned about this transfer.
To the delight and dismay of her providers, the patient had made
remarkable progress and I assumed she would be discontinuing services
soon. I was unprepared for how concerned she was to be working with the
new therapist. I quickly suggested the three of us meet at our next
session, but she remained undecided. During the next session, I ran this
idea by her again, but she insisted the decision was mine and that she
was ‘fine’ either way. I opted to bring in the new therapist. When it
was just the two of us again, her once passive and seemingly nonchalant
attitude vanished and she thanked me exuberantly. She had indeed wanted
to have a transfer session to help establish trust with this provider.
She noted that although she knew and liked him from another clinical
setting that individual therapy was different. She pointed out a few
times that he had a rather strange last name and that frightened her the
thought about all the variables I had assumed were in place to make
this a smooth transition 1) the patient was familiar with the new
provider and had expressed liking him; 2) the patient had been making
such wonderful progress, I anticipated she would not need the same
degree of mental health services as before; 3) the patient would
continue at the same clinic with the same healthcare team; 4) the
patient would have a familiar and trusted translator, who also served as
a community leader. I had not assumed that the new provider’s name
would be the biggest sticking point. The new provider and I were both
dismayed by this. It reinforced the old adage that one never stops
the world of medical training institutions, transfers occur every few
years once the physician has completed residency. Patients have a
variety of reasons for choosing a residency as their primary care site-
referred by members of the community; grew up at that clinic; enjoy
working with residents whom they believe are more willing to spend time
understanding and investigating their condition; feel safer in an
institution that may be connected with a university wherein their
physician has access to the latest research and technology. For most,
this outweighs the downside of cycling through care providers- although
there are still a plethora of reactions to this cycle.
the time approaches, each physician has his/her own way of telling
patients about the upcoming transition. There may not be time to address
patient’s concerns about a new provider, the patient may not feel
comfortable voicing them, or there may be distractions. The patient may
leave wondering whether the new physician will address their needs in
the same way, will be able to handle their complicated health history,
is someone the patient can trust and feel comfortable discussing
treatment goals and plans. In the case of my patient, she may have left
feeling terrified of her new provider based on his last name. This is
likely not a concern she would have voiced with him. If the patient has
difficulty establishing trust and confidence in a new provider, it can
affect treatment compliance, no-show rates, and the patient’s
understanding of his/her conditions. Overall, the patient’s health may
be negatively affected and the new physician may wind up feeling
frustrated and helpless.
the importance of a team-based approach to healthcare. As we transition
into the patient-centered medical home, the impact of provider
changeover can be lessened. Other providers are available to discuss
these issues, increase communication, provide suggestions for a new
provider, and brief the new provider on the patient’s medical and social
history, thereby helping establish a provider-patient relationship
before the two even meet. Patients’ concerns can be addressed on a more
individualized level. Outside this model of care, each physician or
institution has more leverage in handling provider turnover, which may
not necessarily meet patient needs. Often a general letter is sent to
all patients indicating their physician is leaving and the name of the
new provider/s who are taking his/her patients. It is impractical to
conduct a hand-off to the new provider/s, especially when the
physician’s panel includes hundreds if not thousands of patients. A
collaborative model allows us to address both these issues: general
patient healthcare and individualized healthcare. Patients come from a
variety of backgrounds with different medical concerns. In a more
traditional medical setting, patients’ individual needs and social
contexts may not be consistently addressed.
there is a saying that one must not lose the forest for the trees. In
non-collaborative healthcare, this may be translated as the need to
follow what approach works best for the most patients. I would argue
that one must know what types of trees grow in the forest and how to
best care for them in order for the forest to flourish. For some
patients, the importance of easing provider transitions may be greater
than we realize or than patients communicate. This transitioning can be
handled in a more responsive manner in a collaborative setting. So,
what’s in a name? Quite a bit apparently.
A special thank you to Gregg Schacher for helping ease the transition for many patients!
Zak-Hunter, MS is a doctoral candidate specializing in marriage and
family therapy at the University of Georgia. She completed a behavioral
medicine internship through the University of Minnesota’s Department of
Family Medicine and Community Health. Her main clinical, teaching, and
research interests lie in the realms of collaborative health care and
increasing biopsychosocial understanding of mental and medical health
conditions. She has a particular interest in adult eating disorders.
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Posted By William O’Donohue, Ph.D,
Thursday, September 22, 2011
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the past decade there has been a notable increase in the amount of
interest of redesigning healthcare service delivery so that
"fractionated” care is changed into "integrated care”. The quotations
marks are meant to indicate that it is none to clear exactly what these
terms mean. How do we understand the reasoning behind this interest in
integrated care? Is it simply a fad—perhaps even a passing one? Is
the reason because some sort of change in an expensive, inefficient
healthcare system is needed and integrated care seems as good as any?
Is part of the reason rhetorical—"fractionated” sounds bad and
"integrated” sounds much better? Ought integrated care be pursued for
its own sake—is there something about it that is an unalloyed good—like
kindness or a goodwill?
propose that the fundamental reason for integrating care is that it—if
done correctly—is that it can improve the quality of healthcare
services. That is, integrated care needs to be understood in terms of
an overall context of quality improvement. If not understood in this
context, a much weakened, and perhaps even unsuccessful, integrated care
system will be instituted. An implication of this is that integrated
care is not good in and of itself—it is only as good as the QI process
it represents.The Neglected QI Agenda in Behavioral Health.
health has and has had a serious quality problem. This problem is
poorly recognized, harms patients and wastes money. Physical medicine
received its wake up call around a decade ago with the Institute of
Medicine’s 2001 Crossing the Quality Chasm
(which should be required reading for anyone in this area). This
report found that physical health care was dangerous, deadly,
inefficient, and did not have the needs of the consumer in mind. It
called for a radically new healthcare system around the following
- Safe—avoiding injuries to patients from the care that is intended to help them.
services based on scientific knowledge to all who could benefit and
refraining from providing services to those not likely to benefit
(avoiding underuse and overuse, respectively).
care that is respectful of and responsive to individual patient
preferences, needs, and values and ensuring that patient values guide
all clinical decisions.
- Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient—avoiding waste, including waste of equipment, supplies, ideas, and energy.
care that does not vary in quality because of personal characteristics
such as gender, ethnicity, geographic location, and socioeconomic
we examine standard contemporary behavioral healthcare, what evidence
exists that it meets the criteria above? How often do patients receive
care that is based on clinician’s irrational beliefs about
effectiveness instead of evidence based treatments? How often are
patients misdiagnosed? How often are patients given less safe and less
effective medication regimens instead of safer more effective
psychological treatments. How often do patients die because of the poor
quality of behavioral healthcare? How much money is wasted on poor
as a profession have been poor at recognizing the quality problem in
behavioral health and taking systematic responses to it. Integrated
care can be a step in the right direction, but if done without
sufficient attention to systematic QI, can suffer from most of the
quality problems found in specialty behavioral health care. The
integrated clinician can prescribe interventions that have no evidence
base. Diagnoses can be missed or false positives can be made. There
can be an over-reliance on medications, etc.
professional organizations are largely part of the problem—not part of
the solution. They have done little to lead on this issue, but instead
trumpeted guild issues such as increasing payment to practitioners for
the same old problematic services—instead of trying to raise salaries by
improving the value proposition we offer. There has been little to no
leadership on taking quality seriously. It is a good sign that
President Obama has appointed Donald Berwick as head of the Centers for
Medicare and Medicaid Services as Dr. Berwick has been one of the
leading thinkers on bringing systematic QI into healthcare. What Can be Done?
and foremost our profession needs to be educated in the philosophy and
technology of systematic quality improvement. QI is not a slogan and
most importantly it is not a rhetorical phrase meant to impress or
persuade. Rather it is a systematic approach to understanding what
consumers need, the extent to which data can be continuously collected
to see the extent to which these needs are being met; and continually
innovating to meet or exceed these needs all the while driving price
down. QI never ends. Honda has a saying "The reason why our customers
are satisfied is because we never are”. We can look at the innovations
in physical medicine and adopt some of these training programs and
innovations—they are ahead of us and making some excellent progress. We
need to get on board as soon as possible.
care can be an important step in QI. Many customers want one stop
shopping. By identifying the behavioral health pathways impacting
medical presentations, patients can become healthier and costs can go
down. Integrated care can increase diagnostic accuracy and the
treatments offered can be evidence based. Or integrated can be the same
sloppy, non-consumer oriented, set of services in a different setting.
We must make sure it is the former not the latter. We must learn
quality improvement, collect quality data, establish benchmarks, have a
deep understanding of the processes that produce key outcomes, and
William O'Donohue, Ph.D. received his doctorate in clinical psychology from the State University of New York at Stony Brook. He is currently Professor of Psychology at the University of Nevada, Reno and the CEO of OneCare Health Solutions, LLC (myonecare.com). He has published 70 books and over 150 journal articles.
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Posted By Brian Bonnyman,
Thursday, September 15, 2011
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finished my residency in family medicine in 1993, and returned to my
hometown to start work in private practice. My office was located in an
affluent suburb, and my patient population reflected that affluence.
The patients were generally well-educated, insured, and motivated, and I
thoroughly enjoyed caring for them. I had several excellent colleagues
in my practice, but we generally worked as solo practitioners under the
same roof, only consulting each other on occasional cases. I call this
the Lone Ranger model of providing primary care, which is typical for
most private practices, and represents the traditional and time-honored
way of doing things.
15 years of work in this setting, I left that practice and started
working across town, at a large urban community medicine clinic. The
zip code of my office location changed by one digit, from 37922 to
37921, but those sites are worlds apart. Now my practice includes many
homeless people, refugees, recent immigrants, and ex-convicts. The
psychosocial disease burden in this population is astonishing,
especially compared to my prior practice. As one person put it, the
main problem for patients at our clinic is not medical in nature, but
that their lives are broken. I have had to dramatically adjust my
expectations for patient compliance and outcomes, and change the way I
practice medicine. Among the many adaptations I have made in this
transition, one of the most pleasant is working as a member of a team
(rather than as a Lone Ranger), side-by-side with psychologists. In my
old practice, if I thought a patient would benefit from therapy, I would
have to give the patient a phone number of a good therapist. I call
this referral method sending a message in a bottle, given the low
likelihood that the patient would follow through on the recommendation.
I successfully convince the patient of the benefit of seeing a mental
health specialist (which is part of the art of medicine), I can now have
a therapist see the patient in the very same exam room after me. I can
get immediate feedback and additional history from the therapist. For
mental health diagnoses, we collaborate on reaching an assessment, with
appropriate treatment and follow-up plans. With this arrangement, we
estimate that 80% of behavioral cases can be managed without further
consultation. This is not too different than the 90% figure that I
always heard represents the percentage of cases seen in primary care
that can be managed without further consultation.
see a significant improvement in the quality of care that I now
provide, thanks to working in a team environment with behavioral health
specialists. Now, if I have a patient that is non-compliant with
diabetes, for example, I can enlist the help of the behavioralist to
help treat a medical condition. Patients that are ready to address
their substance abuse problems can enroll in a treatment program run by
the psychologists. Likewise, I can get patients easy access to
treatments that I have read for years are beneficial for a variety of
difficult-to-treat conditions, but I could never offer my affluent,
insured patients at my prior practice. Motivational interviewing for
substance abuse and cognitive behavioral therapy for fibromyalgia are
having another person get additional historical information from the
patient can improve quality of care, with little additional cost. Since
about 80% of the data I need to arrive at a diagnosis comes from the
patient’s history, every bit of information helps. For example, a
psychosocial condition unrecognized by me, but detected by the
psychologist, can be the key to getting the correct diagnosis of a
challenging case. The patient with hypertensive crisis who admitted his
cocaine use to the behavioralist (but not to me) comes to mind. Rather
than work him up for some obscure cause of malignant hypertension, we
could concentrate on his substance abuse. To paraphrase the old medical
saw, I have learned that when I hear hoofbeats in the hall, it is more
likely to be a horse with a behavioral problem, rather than a zebra!
a clinician experienced in the ways of the Lone Ranger model, working
in a team setting can be difficult in some ways. In a conservative
field like medicine that has a history of less-than-nurturing
educational methods, teaching an old dog (like me) new tricks can be
hard. At times, the learning process can be a challenge to one’s ego,
as when I find that my assessment of a psychiatric condition is off
base. Recognizing that the correct diagnosis is in everyone’s best
interest (especially the patient’s!), and seeing these moments as
opportunities for learning help minimize potential embarrassment.
Having supportive mental health colleagues is a big plus since their
communication and collaboration skills are miles ahead of many of my MD
friends, who aren’t used to working in teams. I now realize how much of
my medical education revolved around intellectual one-upmanship, and
appreciate the importance of creating a mutually supportive collegial
environment in the office.
though, giving up the Lone Ranger role to work as part of a team makes
sense, both for providers and for patients. Heck, even the Lone Ranger
had a Tonto!
Bonnyman works as a family physician with Cherokee Health Systems in
Knoxville, Tennessee. He enjoys treating patients of different
cultures, who cannot easily obtain care elsewhere. Habla un poquito de
Posted By Benjamin Miller,
Monday, September 5, 2011
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How satisfied are we with our current healthcare system? How satisfied should we be?
In a recent Deloitte report, the American public does not seem to believe the hype that the US has the best healthcare system. From the Hill's Healthcare Blog:
survey found negative attitudes at nearly every level. For example,
despite lawmakers' frequent claims that the U.S. has the best healthcare
system in the world, only 24 percent of Americans view it as even among
the world's best systems."
When you rank 37th in the world,
eventually someone might start paying attention, asking questions and
wondering why the US healthcare system "ain't doing so hot". Usually in
the political arena someone says - "but we have such a unique system,
international comparisons aren't helpful." From NEJM:
the claim by many in the U.S. health policy community that
international comparison is not useful because of the uniqueness of the
United States, the rankings have figured prominently in many arenas. It
is hard to ignore that in 2006, the United States was number 1 in terms
of health care spending per capita but ranked 39th for infant mortality,
43rd for adult female mortality, 42nd for adult male mortality, and
36th for life expectancy. These facts have fueled a question now being
discussed in academic circles, as well as by government and the public:
Why do we spend so much to get so little?"
some ways, it is good that the public is less and less inclined to
believe that our healthcare system is the best. While we do have some of
the best healthcare providers out there, the system in which they have
to operate is broken, expensive and consistently fragmented.
Another telling statistic from the report:
consumers do not have a strong understanding of how their health care
system works. Consistently across the 12 countries surveyed, with the
exception of Portugal (17 percent) and Luxembourg (16 percent), around
one in three consumers felt they understood the system well. Three in
four U.S. consumers (76 percent) feel they do not have a strong
understanding of how the health care system works; this perception has
not changed in recent years (77 percent in 2010, 74 percent in 2009)."
not only are we dissatisfied, we often don't understand how our
healthcare system works.
Will the community
rise up and begin to demand more from their healthcare system? Only time
will tell, but studies like this show that maybe the public is ready to question the healthcare "system".
Collaborative care is no exception when it comes to satisfaction.
the community demanding more "integrated care” from the system? Does
the community see the value and importance of better integrating mental
healthcare into the fabric of healthcare?
Based on the above information, I am beginning to wonder if I should trade in all my degrees for one in marketing.
|Ben Miller is a daily blogger at
his tweets can be followed at @miller7. He is an Assistant Professor
in the Department of Family Medicine at the University of Colorado
Denver School of Medicine. He is the President-Elect of CFHA.|
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Posted By Randall Reitz,
Thursday, September 1, 2011
Updated: Tuesday, May 8, 2012
| Comments (2)
A tangent to get us started. I'm one of the few people I know who is just getting started with Harry Potter. I read the first book about 7 years ago and loved it so much, that I knew that I would want to read the series with my, then, newborn daughter. We tried to start reading them during our bedtime reading when she turned 6, but even the more vanilla "Sorcerer Stone” proved too intense for her. About 7 months ago we tried again and it has since consumed much of our daddy/daughter time. We started out with her reading 1 paragraph per page and me picking up the rest. We're now starting Year 5 with a combination of shared and individual reading.
One of my favorite characters from the book is the Sorting Hat. As each new first year student arrives at Hogwarts School of Witchcraft and Wizardry she or he is assigned to 1 of the 4 houses of the school: fearless Gryffindor, devious Slytherin, friendly Hufflepuff, and analytical Ravensclaw. Click here to see which house fits your temperament.
This ritual occurs to great fanfare in front of the entire school at a ceremonial dinner. 1-by-1 the first years sit on a chair and has a floppy, snaggle-toothed witch's hat placed on his/her head. The hat has a mind and a mouth. The mind analyzes the student and intuits fit between the student and the typology of the 4 houses. The child wearing the hat can hear the reasoning of the mind. Then, the mouth announces the assignment to the breath-bated mass in the banquet hall. You can see Harry's experience with the Sorting Hat here.
Sorting through the hats. As a collaborative clinician employed as the Director of Behavioral Sciences in a family medicine residency, I have developed my own Sorting Hat technology. Unfortunately, my hat's intuition is still foggy, its mind confused, and its mouth glitchy. Hopefully putting pen to paper will help to work out some of the bugs.
In this professional role I wear numerous hats—sometimes consecutively, but usually concurrently:
- Educator—This is my primary role, either in didactic sessions or through staffing cases in the precepting room and exam rooms;
- Evaluator—After supervised appointments or behavioral science learning days I prepare formal evaluations of the learner's skills and professional development;
- Remediator—I serve on a committee that employs both carrots and sticks to assist residents struggling in identified areas (e.g. medical knowledge, professional behavior, curriculum completion, biopsychosocial health concerns);
- Supporter—Residents are scheduled with me on a 1-to-1 basis about every 2 months and many residents pull me aside to discuss personal issues;
- Colleague—I have the fortune of a psychologically-minded residency and my faculty colleagues will often seek me out to consult or to cathart;
- Clinician—I carry a small individual caseload, co-facilitate group medical appointments, and see numerous patients on-the-fly when invited out of the precepting room by medical providers;
- Supervisor—We have an integrated mental health team (therapists, case managers, doctoral interns) that I supervise clinically.
- Patient—My family receives our primary care at the residency clinic.
I love being a faculty member and usually wearing the multiple hats is a great job perk. For example, about 6 months ago (hopefully not as a result of Harry Potter), my oldest had a seizure. I found her lying on the floor at 6 a.m. already in the post-ictal phase with no idea as to the etiology of her altered mental status. I put on the patient hat, drove to the residency clinic, found a favorite resident, and got her seen without appointment. Within minutes the team narrowed in on a seizure diagnosis, and rushed us off to hospital. We benefitted from excellent technical care from the ER doctor and compassionate and patient-centered support from a resident and attending physician throughout our inpatient experience. As a bonus, this attending physician is my personal doctor and her partner is one of Grand Junction's few neurologists. To this day, when I put on the patient's hat in the clinic our family doctor answers my questions and offers quick phone consults with the neurologist.
My Mind and Mouth. Despite these benefits, it is not hard to predict that wearing multiple hats often troubles my mind with double and triple role conflicts. For example, when I see patients with residents the clinical, teaching, supportive, and evaluative roles overlap: If the resident is struggling with behavioral patient skills do I leave on the teaching hat and only observe the difficulty, or do I switch to the clinician hat and take over care? When debriefing after the appointment do I approach it with the supportive hat or the evaluative hat?
This is exacerbated when a resident is referred to the remediation committee. My participation during the tense interactions with referred residents can blunt a resident's willingness to confide in me during supportive 1-to-1 sessions. And conversely, it is not clear to me how information that was shared with me in semi-confidence while wearing the supportive hat should affect the proceedings of the remediation committee. Or worse, how would it affect our relationship if a new resident made a mistake in offering care to my family and it resulted in a bad outcome or a referral to the remediation committee?
My mouth is the behavioral manifestation of my mind's hat sorting quandaries. When an ethical or inter-personal dilemma arises from a multi-role relationship, the first response that is usually expected comes through my mouth. In faculty meeting when we discuss a situation with a resident, all eyes will often turn to me to provide insight into the resident's emotional constitution, cognitive faculties, or behavioral eccentricities. When I'm brought in to meet a new patient I feel heightened need to provide a pithy intervention so that my teaching opportunities later in the week will seem credible.
Toggling between mind and mouth while fumbling numerous hats requires 2 under-appreciated skills: delay and vagueness. Delay helps by slowing down the discussion to allow my mind to offer a reasonable solution to my mouth (i.e. "Let me think about this and talk with Resident X before I weigh-in”). Vagueness allows me to wear multiple hats simultaneously without violating their competing ethics. For example, I can respect confidentiality by making a broad statement such as "I think Resident Y might struggle with self-doubt stemming from a difficult experience during her first year”).
My Blog Colleague: My guess is that Sorting Hats are ubiquitous in collaborative settings, especially in collaborative teaching settings. Rather than my idiosyncratic head ornament, Sorters are endemic to our field. How does your Sorter fit?
- When is your Sorter comfortable? When does it provoke a rash?
- How do you balance the competing aspects of collaboration?
- Which aspects of your personal life do you bring to the professional setting, which aspects do you leave at home?
- Is there any video clip that depicts dual-role relationships better than this one?
Randall Reitz , PhD, LMFT is the executive director of CFHA and the behavioral science faculty at St Mary's Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.
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Posted By Helen Royal ,
Thursday, August 25, 2011
| Comments (2)
I’m running around, doing whatever it is that I do at a fast pace all
day long; seeing patients, supervising behavioral health providers,
consulting with medical providers, reviewing unanticipated outcomes,
trying to incorporate our behavioral health work into the new electronic
health record and uh-oh, my blog is due. As I start preparing to write
about the parallel process of change for patients and staff as we
transition to an electronic health record and an increasingly complex
world, I keep getting interrupted by some kind of patient need. I get
pulled away from writing about life in integrated care, to the reality
of patient care. That darn patient who relies on us for so many
unusual services keeps stopping by. He needs his pill boxes filled,
and can we check on his dental appointment time? He’s feeling stressed
and suicidal, can we talk to him? He’s got medication questions, and he
needs help in figuring out the letter he just got from unemployment.
Do we have anything to feed him because he missed breakfast in order to
catch the bus… and just in general, can we make time for him when
there often just isn’t time? It struck me that this is what you do with
family; shift your priorities and make time to focus on what’s
important. Of course we’ve got time. My blog theme just morphed…
of the values of the Collaborative Family Healthcare Association is
involving family members in patient healthcare. However, in many areas,
and in the life of many patients, their families aren't available, or
aren't even a great source of support if they are available. In the
rural resort region where my non-profit clinic for un/underinsured, low
income patients are served, we rarely see patients who've grown up here
or who really have any strong family ties. Often they "escape" to the
area due to unhealthy family situations or an inability to fit into a
patients, perhaps more than those with traditional families, need
providers to expand their definition of family to provide comprehensive
healthcare. Care providers need to challenge our notion of family. What
is family? People connected by duty, blood, history, values? Is there a
way to engage community members in this same manner? What does a
supportive family provide? Companionship, understanding, compassion,
honest opinions, help with life's day to day and big time struggles.
Communities can do that...
Ty! He is that darn needy patient who says: "I can't figure it out,
but everywhere I go people know me and say hello and are nice to me."
is a middle aged male who is currently involved in many services in our
community. He's suspected of having cognitive impairment his whole life
as evidenced by his employment history, law enforcement involvement and
overall poor decision making. Prior to his biological family's passing,
he had a "safety net" to help him redirect his actions, face the
consequences for the poor decisions and keep on track financially. After
his parents passed, the pattern of substance use escalated and he
suffered a series of medical complications. From that point on the road
got steeper. Have you ever tried to find a job, apply for food stamps,
keep stable housing, keep your beloved pet, stay sober, keep track of
medication and manage the daily stressors of life without transportation
and without family?
concept of medical home is, in a nutshell, a hub of compassionate,
comprehensive care. We are the core family. We are the ones who don't
give up, no matter how annoyed, busy, frustrated or confused we may
become. We may be charged with continuing to manage and encourage
patient engagement and access to services. Sometimes we too need
"family" help. Our colleagues and network of providers can fulfill that
for us if we remember to look for it; to challenge that notion of
"family". Can we bring others into the medical home web? Find out who
has your patient connected to? Maybe an employer or a child's daycare
provider. Food stamp administrator? Bring them into the web! Find who
can help you model those healthy connections?
we get stuck with the traditional view of "family" in collaborative
family healthcare we miss the rich opportunity to engage communities in
helping its members feel that sense of belonging and connectedness that
we strive for with our patients. We need to challenge ourselves to
engage with our patients and help them create families who can be active members in their healing process.
means really listening to what's important to them. Yes, Ty, you want
to live independently, yes you want to keep your dog, yes, you want to
have some power over how the little money you have is used/spent. No,
you don't want to live in assisted living with a bunch of people waiting
to die. You don't want to be pushed into decisions, you want to be
heard. And you want the darn sore on your arm to go away! Well OK then.
When do you do well? When do you struggle? How can your "family" help
with this? Who do you consider part of your family around here? I
asked Ty that very question today and here's what he offered up:
Social Services caseworkers
Medical Clinic: MD, clinic assistants, front desk and Behavioral Health providers
Billing person at the hospital
Security Guard at the hospital
Peer Support at Mental Health Center
Therapist at Mental Health Center
Bus drivers on free bus
Regular bus riders
I was still letting the concept of extended "family" roll around in my
mind, I was driving around doing errands and saw Ty and a young child,
who I later learned was a neighbor child. They were walking down the
side of a busy road, Ty on the outside, so the kid stayed on the safe
sidewalk. I watched them walk together for quite a while and then Ty
took him into a store where his mom was working. Off to his next
a great symbol of paying forward that caring, compassionate connection
that always seems to puzzle him from his "extended family".
Royal is a Colorado State Licensed Professional Counselor and Director
of Behavioral Health at Summit Community Care Clinic in Frisco Colorado.
She has worked in community mental health for 20 years as a clinician
and quality improvement manager and is currently |
leader for an integrated care grant working on integrated primary care.
She is passionate about equine assisted psychotherapy!
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Posted By Jodi Polaha, Ph.D.,
Thursday, August 11, 2011
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gardens everywhere are kicking out crops at last. Just yesterday I
pulled six cucumbers from a vine and set three more tomatoes on the
kitchen windowsill. Hmmm… with balsamic and oil? Mozzarella and basil?
Psychology Department at East Tennessee State University (ETSU) is at a
similar point. About ten years ago, a grant from HRSA provided seed
funds to develop an idea: a doctoral program in Clinical Psychology with
a special emphasis on rural, integrated care. About five years ago,
the program accepted its first cohort. This fall, the program will have
a full complement of students including three attending internship.
It’s been a long growing season and we are excited to see the fruits of
is nestled in the foothills of the Appalachians. We’re a gorgeous
one-hour drive through the mountains to Asheville, NC or to dozens of
other communities nowhere near as populous, gentrified, or well-served.
The University has established a niche in serving rural communities
across multiple disciplines with, for example, an award-winning program
in Rural Family Medicine. That our new doctoral program would serve
rural communities was a given.
care boasts particular advantages in rural communities where travel and
stigma are top barriers to behavioral health care. So, it made sense
to our program’s forward-thinking founders*, that the integrated model
should be a strong component and we developed a program with graduated
didactic and experiential rural and integrated
training elements. This includes interdisciplinary courses with other
health professionals, courses in our department exclusively focused on
integrated practice, and out-in-the-field experiences in integrated care
at the observer, externship, and, if chosen, internship levels. This
year, two of our three students will complete internships in integrated
said, the shortage of behavioral health providers is perhaps the most
significant barrier to care in rural areas and simply training our
students to provide integrated care is not enough to address it. In
developing a program with a rural focus, we have had to grapple with how
to use the integrated model in innovative ways to get services to
remote places and
to recruit students to locate to rural communities, particularly in our
underserved region. This is where working in the garden gets really
fun. To extend the metaphor, it is a little bit like moving beyond
simple plant-and-pick gardening to learning how to preserve seeds, use
cuttings to start new plants, or can crops.
example includes the development of the Southern Appalachian Children’s
Telebehavioral Health Clinic. Funded by HRSA (Office for the
Advancement of Telehealth**), this Clinic is staffed full-time to
provide behavioral health consultation to patients in five pediatric
clinics in rural Tennessee and one school-based health network in rural
North Carolina. Equipment is located in primary care clinics and "open
access hours” allow physicians on-the-spot consultation and the capacity
for warm hand-offs which, sometimes occur at a rate of 5 to 8 in a day!
We are experimenting with all kinds of interesting seeds and it is
thrilling to see some of them sprout and grow.
example is the initiation of the East Tennessee/Southwest Virginia
Predoctoral Psychology Internship. Few local internship opportunities
for our students meant that some of them would have to move away from
the region for a year and the possibility that they might not return to
grow the local workforce. Recently, Dr. Kay Matlock of Stone Mountain
(an FQHC based in rural Southwest Virginia about one hour northwest of
ETSU) was awarded HRSA, Office for Workforce Development funding to
develop behavioral health professions training at their site, using a
truly integrated model. Co-directed by Dr. Jodi Polaha (ETSU) and Dr.
Jim Werth (Radford University), this predoctoral internship will see its
first trainees begin on August 15th.
This reminds me of our strawberry plants, whose runners leap from
garden boundaries about this time of year. We cut them and plant in
another bed, providing a whole new crop in the Spring!
has been a pleasure to write this blog entry, to take the time to
appreciate all we’ve grown, and to anticipate our "fall garden” which
will be very full indeed! Now, out to the garden with all you readers!
You can never put enough water down in August, and, for a readership of
forerunners in integrated care, I’m guessing you’ve got a few baskets
of your own veggies to harvest!*Dr.
Peggy Cantrell, Director of Clinical Training; Dr. Wallace Dixon, Jr.,
Department Chair; Dr. Bruce Beringer, Office of Rural Health **
The project described was supported by grant number H2AIT16623 from the
Office for the Advancement of Telehealth, Health Resources and Services
|Jodi Polaha, Ph.D.
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. In addition to her work, she spends lots of time with her
husband and two young boys swimming, biking, and hiking in the
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Posted By Jennifer Hodgson,
Thursday, August 4, 2011
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Primary care settings are rich with all types of patients, diseases, diagnoses, celebrations, and providers. As defined by the Patient-Centered Primary Care Collaborative (PCPCC), "The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth, and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family” (http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home). The key question that I want to pose in this blog is "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”
I can think of countless times when the family (defined by the patient) has been the missing piece of the healthcare puzzle. The family was the one thing not accessed that helped put things into motion or helped providers realize why there was no motion. Family boundaries can be either enmeshed (no new members in or out), disengaged (no connection to one another), or permeable (new members allowed in and current members allowed out). This information is critical to providers because it may help make sense on why patients are not showing up for appointments, nor following treatment plans, or why some patients, conversely are model healthcare citizens. Of course, attending to the family and their unique dynamics is not the holy grail of medicine but neglecting the family may be another chasm interfering with the quality of care.
For example, a patient presented to his PCP with homicidal ideations. He was in constant pain, clinically depressed, and was waiting to hear whether his final appeal for social security disability was going to be accepted or denied. He scared his PCP with his voiced ideations, plan, and intent. At this point the PCP called in the Behavioral Health Provider (BHP) to collaborate. Both providers were quite convinced of the patient’s intent when he said that if he lost his appeal he was going to follow through with his suicidal plan. Taking necessary precautions the PCP and BHP collaborated and had the patient hospitalized. Surprisingly, the patient was voluntarily committed. Continuing their collaboration the PCP and BHP corresponded with the inpatient psychiatric unit attending to ensure that he had all the information needed and that duty to warn was enacted. The PCP and BHP knew that the patient would eventually be discharged and return to primary care for follow up.
One week later, he was back in their outpatient clinic and one week after that he was having ideations again. Quickly the integrated care team, with the BHP at the lead, contacted the patient’s spouse and brother. The PCP and BHP encouraged the patient to bring them into his therapy sessions. He complied and together they developed a plan for how the patient would be monitored for escalation of ideations. They were educated about his pain, diagnoses, pharmaceuticals, and psychotherapy plan. The family had been scared for years, watching his mental health decline, and did not know what to do. He had seen several psychiatrists and mental health providers, but he never attended more than a few sessions at each. This was the first time since he was injured 5 years ago that he continued with care and that anyone invited his family to be a part of his care. Without the family, the work of the integrated care team would not have resulted in successful management and care for this patient’s medical and mental health needs. Thankfully the patient is continuing to do well, as it has been over a year. Note: His social security disability was declined.
Researchers back the importance of the family role played in patient care and numerous therapeutic models exist for working with families. What we lack is strong policy and insurance incentives to make families a greater part of a patient’s care. We have more barriers than pathways (e.g., privacy laws, exam room size, appointment times, and lack of training). Families can be messy and very complicated but notwithstanding they are silent partners to any PCP/BHP team. They are there in the room with us whether we choose to see or talk to them. Most of the time, unbeknownst to us, they are either reinforcing or discouraging treatment plans. Most importantly, family members often feel like they have important information to share with us but have been told that we cannot hear it nor respond to it. While some may abuse this privilege, most just want to help and be helped.
Again I present to you the following question, "When is it appropriate and when it is not appropriate to collaborate with a patient’s family?”
Jennifer Hodgson, PhD, is a licensed Marriage and Family Therapist, Associate Professor in the Departments of Child Development and Family Relations and Family Medicine at East Carolina University, and President of CFHA. She has over 18 years clinical experience and has served on numerous boards and committees related to healthcare and mental health care issues. She is co-author to the first doctoral program in medical family therapy in the nation.
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Posted By Gonzalo Bacigalupe,
Thursday, July 28, 2011
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second day at the Salud 2.0 Euskadi in Bilbao
was as rich in content and participation as the first. Manuel
Armayones, lecturer and researcher at Universitat
Oberta de Catalunya and president of a rare disorder association, and Carlos
Luis Sanchez Bocanegra, e-health and system
administrator with the government of Andalucía, spoke about research and
development from the perspective of rare disorders. Like the e-patients during the first day,
Manuel and Carlos also transformed their personal plight into actively
contributing to communities of patients.
They are the paradigmatic situations in which professional-patient
boundaries are tested, Manuel told us. A
core dimension of these connected communities is the ability of patients to
shape research and development. We know
that social networks and the easy access to health research information makes
the lives of families, with a member diagnosed with a rare disorder, less
unbearable. Being able to overcome
geographical barriers to reach for emotional support, medical expertise, and
tailored research are central. Most
important, however, is the potential for unifying across the same barriers
towards eliciting clinical trials, developing new collaborations in research,
and venturing into the development of innovative treatments. Several social media examples were given and
the dilemmas of social participation, the role of the professional, and the
funding difficulties were outlined in this presentation. Two must read books were mentioned by Carlos: e-Patients: How They can Help us Heal Healthcare by Tom Fergurson and Unlearning: Incomplete Musings
on the Game of Life and the Illusions That Keep Us Playing by Alejandro Jadad.
Miguel Angel Manez financial vice-director of the Alicante-Sant Joan
Health Department, reported on the efforts related to creating a social network
for the professionals in the system and to coordinate all the web efforts of
the health department. The challenges of moving from a 1.0 scenario to a 2.0
dynamic are not about the technological tools, but about organizational
cultures. We have to be clear about what
we want to achieve. Leading the transition should not be left to the
information technology employees, but those in tune with the strategic goals of
the organization. He utilized the songs
of Coldplay to challenge us not to be afraid of the new media and to help us
move a government department into a 2.0 environment. Some of the advice included: motivating people
to do new and different thing, not to interfere with the free flow of
information, find the natural leaders who can motivate others, and do not rely
on the myth that the internet will resolve everything. He also suggested that the tools are about
finding solutions collaboratively utilizing the cloud with some
incentives. Miguel Angel suggested that fear of imposition, suspicion,
and lack of skills are intrinsic in organizations, but this should not stop us
from innovating. Finally, he reminds us
that health is communication.
The Basque Country health system has been a leader at
implementing a strategic plan that acknowledges chronic illness prevention and
treatment as a central undertaking for the healthcare system. Economist Carolina
Rubio, program director at Innobasque,
acknowledging her own chronic illness has been leading the implementation of a
social network for chronic illness patients to share information and support.
Kronikoak Sorea relies on the notion that caring for others
is also healing. Carolina
mentioned that to accompany, to be flexible, to learn, and to build
are key in the planning of a social network platform for chronic patients. One of the most innovative aspects of this
project is the special focus on the emotional state of patients instead of the
illness per se in designing the social platform to ensure participation.
Two primary care physicians, Ignacio Basagoiti at the Polytechnic University of Valencia, and Salvador Casado, assessed the adoption of technology by doctors and
patients. Ignacio spoke about how
doctors have to adapt to new technologies amplifying traditional social
networks. If I am not an excellent
physician to begin with, the social media tools will not make me an
excellent one in the end. But
can these tools make us better professionals? According to Ignacio, the answer is
affirmative. He explored each of the tools that are freely available. He described Fernando Casado (not related to Salvador
and also a primary care physician, the presenter in this panel) use of twitter
to inform patients about appointment delays or useful health tips. Ignacio emphasized the amplifier role of
social media to communicate, a means to relay specific goals.
Salvador Casado, after taking his shoes off, talked
in a very personal way about humility. Patients want someone who cares and will
help them find solutions. What do the physicians want? The same, a shoeless Ignacio told us. Patients
want to wait less and to suffer less. He
mentioned the usual challenges and villains in the healthcare system with the
obvious consequence: burn out. Communication seems to be the solution and the
social networks could be helpful. However,
face-to-face communication really makes a difference. The magic of being
together, like the participants in the conference who knew each other
virtually, but for the first part can be together in the same room. Salvador challenged us to
think of change from bottom up and to use the web 2.0 tools to address this via
seven proposals: take care of yourself, humor, talk with your peers, innovate,
slow medicine, eliminate the bureaucracy from your office, and flow. Casado’s talk was probably the most applauded
of all and he deserved them. His call for personal accountability was clear.
The last part of the course addressed the perspective
of journalists as well as how health care communications and public relations
can be managed with the new media. Alain
journalist at Diario Medico used a photo of a sinking Titanic to demonstrate
where journalism is. He called for no
excuses to figure out how to move forward. The cartoon by Jesús Martínez del Vas, where two kinds of
journalists look at each other, the techno savvy and the ones still caught in
the traditional print outlet, synthesizes well the central point in Alain’s
talk. The techno savvy see the others as
dinosaurs and the traditional reporters see the others as
extraterrestrials. Alain framed the new
scenario not as an excuse to go back to a nostalgic form of journalism, but to
embrace the digital form as a way of reaching readers. However, the implementation of any new
technology could backfire and for that Alain made an analogy based on the
researcher at the Hospital Clinic of Barcelona, described the forumclinic experience as a form of handling communication by a
large hospital. The approach is based on
the notion that satisfied patients will handle their chronic illness better. Imma reaffirmed the power of patient
communities and their role in making healthcare collaboration a reality. Her work reminded us of how much we need
systematic research related to the impact of healthcare social media
tools. The health system needs to use
research evidence in making decisions about how to utilize resources. Imma shared the story of patients who propose
themes to deal with. Patients organized
around specific illness make sense because it focuses the discussion on a
common interest. What really matters to
the patient emerges through the social network medium and not necessarily via
the physician-patient relationship. In
analyzing the data, one of the main findings is for the institution to adapt
based on the patients’ conversations.
Journalist Elena Escala, from Diario
Medico and TEDxSol, outlined
the ways in which communication is not unidirectional and how the dialogue with
readers can be uncomfortable and difficult. To witness or to be around is
different from true participation. For Elena, joint collaboration and creation
are the focus of the new way of doing journalism in the 2.0 era. As an
example, she announced the publication of a free book in Spain: The New Health and New Patients in the Web 2.0, a
joint effort that did cut through disciplines and professional silos. She
challenged the audience to move the innovation out of the garage to
make change sustainable. Innovation is
occurring at the margins of organizations; we need to include it in the
organization and with its support. 2.0 need to be more than the result of a
small group of people in each healthcare institution. Incentives are needed to mainstream these
Responding to the need for creating an instrument
that facilitate continuous improvement in quality of chronic illness are in
Cabrera, a mathematician at the Government of
Andalucía and lead person at OPIMEC, the Spanish Observatory of Innovative Practices for
Complex Chronic Disease Management, presented the project that utilizes many of
the most innovative 2.0 technologies. The
initiative born in 2008, intends to bring together communities of knowledge and
practice. The pharmaceutical industry was also represented at the course.
Carlos Esteban, communications director at Amgen,
acknowledged the difficulty that some may have at viewing a positive role for
pharma in social media. According to
Juan Carlos, there are obvious advantages in participating in social media, for
instance with adherence to treatment (medication) in which there are applications
being developed and tested. The social
networks are an opportunity to educate patients and he reiterated some of the
same ideas shared by others during the course. According to him, however, the
fear towards entering the social media sphere varies, with institutions being
very interested in implementing initiatives. The pharmaceutical industry in Spain has been
much more cautious than other industrialized countries in joining social
networks like Facebook or building virtual games.
The last interventions attempted to predict the
future (always a difficult task, but the organizers tried) with an audience
that was still fully engaged in conversation.
Javier Bikandi, one of the host organizers proved that it is not only
necessary, but feasible to work on innovation with the government. Mapping the
social media players, Javier invited participants to review the Basque
blogosphere map. Javier mapped the Basque
social media landscape and the use of LinkedIn and Facebook by the
government health care institutions. A
community of knowledge that includes all the professionals in Osakidetza is being implemented as well as other simple web 2.0
tools like wikis. Javier pointed out to
what I believe was a consensus in the meeting: the most significant
challenges that innovation faces are not in the technological front, but
the cultural. We have the tools; the
question is how to mainstream their adoption to improve health outcomes and
better the systems of care.
Bacigalupe, EdD, MPH (standing third from right in the front row) is an
Ikerbasque Research Professor with the Vulnerability to Stress and
Resilience Research Team at the College of Psychology and Education,
University of Deusto Bilbao; Associate Professor, Department of
Counseling Psychology, College of Education and Human Development,
University of Massachusetts Boston. Gonzalo is co-senior editor of
Family, Systems, & Health. His webpage is at: www.gonzalobacigalupe.com|
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