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Talk About Situational Stress: Multigenerational Living is on the Rise

Posted By Peter Y. Fifield, Thursday, October 13, 2011

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.

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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What’s in a Name?

Posted By Lisa Zak-Hunter, Friday, September 30, 2011
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 most.

I 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 learning.

In 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.

As 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.

Enter 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.

Now 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!

Lisa 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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Why Integrate Behavioral Healthcare into Primary Care?: The Neglected Role of Systematic Quality Improvement

Posted By William O’Donohue, Ph.D, Thursday, September 22, 2011
In 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?

I 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.

Behavioral 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 quality parameters:
  • Safe—avoiding injuries to patients from the care that is intended to help them.
  • Effective—providing 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).
  • Patient-centered—providing 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.
  • Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

When 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 quality "care”?

We 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.

Our 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?

First 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.

Integrated 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 continually innovate.

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 ( He has published 70 books and over 150 journal articles.

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The Lone Ranger Rides No More

Posted By Brian Bonnyman, Thursday, September 15, 2011
I 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.

After 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.

If 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.

I 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 two examples.

Just 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!

As 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.

Overall, 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!

Brian 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 español, tambien.

Tags:  Cherokee Health  family medicine  Integrated Health  primary care 

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Labor Day Question: Does the American Workforce like or Understand American Healthcare?

Posted By Benjamin Miller, Monday, September 5, 2011

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:

"The 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:

"Despite 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?"

Description: 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:

"Most 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)."

So 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.

Is 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.

Game On Blog
Ben Miller is a daily blogger at and 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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The Collaborative Care Sorting Hat: Gryffindor or Slytherin?

Posted By Randall Reitz, Thursday, September 1, 2011
Updated: Tuesday, May 8, 2012

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.

The Sorting Hat

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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Who Says You Can’t Choose Your Family?!

Posted By Helen Royal , Thursday, August 25, 2011
So 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…

One 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 traditional lifestyle.

These 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...
Ask 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."

Ty 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?

The 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?

If 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.

This 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
Workforce Center
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

As 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 destination.

What a great symbol of paying forward that caring, compassionate connection that always seems to puzzle him from his "extended family".

Helen 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
Project leader for an integrated care grant working on integrated primary care. She is passionate about equine assisted psychotherapy!

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Finally, the Fruits of Our Labor! Bringing Integrated Care to Rural Communities in Southern Appalachia

Posted By Jodi Polaha, Ph.D., Thursday, August 11, 2011
Summer 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? Decisions, decisions!

The 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 our labor!

ETSU 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.

Integrated 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 care settings.

That 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.

One 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.

Another 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!

It 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 Administration, DHHS.”

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 surrounding mountains.

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Families are Messy, Complicated, and Silent Partners in Healthcare

Posted By Jennifer Hodgson, Thursday, August 4, 2011

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” ( 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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Salud 2.0 Part Two: Broadening the Collaborative Web in Healthcare and Emerging Technologies.

Posted By Gonzalo Bacigalupe, Thursday, July 28, 2011

The 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 Ochoa, a 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 film Robocop.

Imma Grau, 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 innovations.

Responding to the need for creating an instrument that facilitate continuous improvement in quality of chronic illness are in healthcare Andres 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. Juan 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.

Gonzalo 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:

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Contact Us

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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.