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Goodbye Old Friend, I've Known You Far Too Long

Posted By Peter Fifield, Thursday, May 12, 2011
Updated: Wednesday, May 25, 2011
We are all aware of the dangers of smoking. Yet the CDC reports that in the United States over 46 million people (20.6%) over the age of eighteen and 2.7 million (17%) of all high school students are current smokers. Out of the 46 million adult smokers, the CDC reports that over 40% of them tried to quit in the past year. The implication here is that to some degree they wanted to quit, but were unable to to actually stop smoking. It is hard, very hard, to separate oneself from the addictive nature of nicotine.

First hand exposure is not the only danger. Second hand and the newly implicated third hand smoke exposure endangers a much higher number of individuals; putting even the innocent at risk for many acute and chronic health conditions. The knowledge of these hazards is not new. We have been well aware of them for years yet about 21% of our adult population continues to puff away.

There is no doubt that everything we do, we do for a reason. Therapeutically as a Behavioral Health Consultant in a primary care office I see behavior as less of an issue regarding right or wrong but more so does it or does it not work. So with the known risks of smoking there must be a pretty good reason why people continue to smoke, right? Nicotine has psychoactive properties that are very addictive; most likely related to how it effects the brain’s pleasure/reward center---the mesolimbic dopamine system.

Smokers smoke because it works! Some say it "relieves stress”, even though it is a stimulant. Some admit they smoke for "something to do” when they are "bored”, Others report that they smoke when they are "feeling down” and depressed and even when they are "feeling great”--a reward system for feeling both crappy and wonderful. People smoke when they drive, they smoke when they sit at the computer, they smoke when they are having coffee, tea or a beer with a friend. Some even smoke because "as sad as it is, smoking is really the only thing in my life I enjoy doing”.

After many years assisting patients in the smoking cessation process, I have becoming more convinced that most individuals, even though they are not consciously aware of it, relate to cigarettes as a friend—an unconditional friend that is always there when they need them. What I find most interesting is the one sided, almost masochistic nature of this obliging yet very pernicious friendship.

Tobacco use is the single largest cause of morbidity and mortality in the United States; as touted by the CDC "the only legal product that when used as directed will kill one-third of users”. Each year smoking cigarettes accounts for 1 in 5 deaths--that is about 438,000 people. Just to give you a relative benchmark, deaths related to alcohol and illicit drug-use combined total 44,000 per year. This is surely a dubious friendship but it is one that comes with minimal conditions. It is a relationship that for most has no perceived incentive to change.

Below is a letter written by a client:

We've been friends and co-dependents for a very long time, 46 years to be exact. I remember the first time we met...I was five and boy did you get me in a lot of trouble. First I climbed high to reach you and then I gave you a try. I got yelled at and spanked because your partner burned my mummy's rug.

My mom knew you first and I wanted you to be my friend too. You seemed to be liked by my mom and almost all of her friends, but I was forbidden to associate with you...until 5 years later when I was 10, I snuck you away from my mom and we bonded in the basement. We lived in the projects. It made me cool with the other kids to be your buddy. You hung around until I couldn't get rid of you...but I didn't want to because you felt good, you calmed me and you made me look cool. Little did I know you were the controlling one in our sick relationship.

It took me years to realize that we were unhealthy together but I seemedto overlook it. Even when my mother cut her ties with you; when she begged me to do the same, I refused. I tried but you were stronger than me.

Today I want to tell you that..."you're killing me" and I don't want to have anything to do with you anymore. Very soon you can rest assure that I won't let you send me to my grave. I can't take the pain I've seen you cause so many other people.

In a nut shell I want to say "watch out" because you'll soon lose out in this friendship. I can't wait for the day I say...NICOTINE-I QUIT!!!


Your soon to be ex-friend.


Peter 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.

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Cacophony Healthcare

Posted By Ben Miller, Thursday, May 5, 2011
Updated: Wednesday, May 25, 2011
Think about it.

During the healthcare debate, after the healthcare debate and all in between, there have been voices whispering (or yelling) their opinion on healthcare.Nowhere is this more prevalent than in discussions around the integration of mental health and primary care. These are two worlds of healthcare delivery that are in desperate need to intersect.

There are many voices speaking up on what they believe needs to be done, but is the loudest voice getting the most attention? Is this an example of cacophony challenging our ability to hear healthcare innovation? When resources are scarce, does infighting and, in turn, wars start to trump the community’s needs?

While mental health integrationwas not a topic discussed openly during the reform debate, it is an underlying issue that, like the 400 pound purple gorilla in the room, cannot be ignored.
States, like Virginia, are not providing adequate mental healthservices for children. Iowa is reforming their $1.3 billiondollar mental health system because it is flawed. And it goes on and on and on and on.

It is time to harmonize. It is time to "clean out our ears” and start to listen to the needs of the community. There is a broken system out there that needs our attention. Mental health is in need of innovation. Healthcare might be willing (and dare we say able?) to take on this task of integrating mental health. What will this look like? How will we do it?

Innovate, but please don’t yell.


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Ben Miller is a daily blogger at http://collaborativecare.tumblr.com/ 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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Questions of Collaboration at a Distance

Posted By Kenny Phelps, Thursday, April 28, 2011
Updated: Wednesday, May 25, 2011
Professionals in the collaborative field often speak of moving from silos to co-located and eventual integrated care, especially within the patient-centered medical home. I had the privilege to "come of age” as a therapist in integrated primary care settings. My clinical placements were alongside dieticians, health educators, nurses, physicians, and other health care providers. I found myself intrigued with intervening to control HbA1cs and BMIs through systemic interventions as much as assisting with couple and family discord.

An advantage of this training was to increase my awareness of systems of care and the full biopsychosocial picture. It also taught me about effective (and ineffective) collaboration. A disadvantage of this training was fewer instances of needing to collaborate at a distance. This would be understandable since colleagues were often in the room or down the hall, co-creating treatment plans. However, my acceptance of a position in an academic psychiatry context pulled me away from my primary care roots, as well as the easy access to these providers.

Certainly, my current role includes a great deal of multidisciplinary teamwork under the same roof, including psychiatrists, psychologists, family therapists, social workers, rehabilitation counselors, families, and patients. One could argue that mental health centers serve as the patient-centered medical home for many with chronic and persistent mental illness. This has been the impetus for integration of primary care providers into these environments. However, many individuals treated in our academic clinic present with acute clinical problems, such as adjustment disorders, major depression, panic disorder, or couple and family strife. In these circumstances, patients typically identify the primary care setting as their "home” for medical care. This fact has necessitated creative ways of linking care between primary and specialty care, as to not fall victim to the "out of sight, out of mind” problem.

On a systems level, we are integrating some of our providers into OBGYN, Family Medicine, and Pediatric settings to improve screening and treatment. We also have plans to use telepsychiatry to provide effective care at a distance. I have been involved with giving lectures on The Role of the Consultant Psychiatrist in Integrated Care, thereby increasing our residents’ exposure to the burgeoning efforts to meet patients were they are. While systems level changes are surely essential for improved healthcare, I believe that individual provider must take initiative to link with others while delivering care. Thus, I have developed a few questions that assist me in my clinical practice:

WHO needs to be talking to provide the best care possible?
This first question is the foundation for good collaboration in my opinion. The answer will likely be as divergent as patients’ presenting problems. For instance, a child with oppositional behaviors, asthma, and Asperger’s might warrant collaboration between a therapist, pediatrician, and school teacher; whereas, an adult with panic disorder, hypertension, diabetes, and significant suicidal ideation might warrant collaboration between a family physician, psychiatrist, therapist, and nutritionist. Thus, this is a question I ask myself and will also ask the patient during an encounter. The answer to "Who do you think needs to be talking to provide you the best care possible?” is often answered with "maybe you should talk to my husband, pastor, or friend.” I believe this reiterates the importance of including patients and their support systems on the health care team.

WHAT information should be shared with my collaborators?
The amount and type of information shared when collaborating at a distance often depends on the recipient. Considerations for this question include: What information is relevant to my collaborator? What can I share given limitations on confidentiality? What can I share given the amount of time to collaborate? Too much or irrelevant information may be met with frustration by collaborators, whereas relevant and pertinent information can improve treatment plans. Beyond shared information, the question "What information do I need from my collaborators?” is vital as well.

WHEN should collaboration occur? I typically try to contact collaborators when there has been a significant change to my treatment plan or I have the sense that there have been significant changes to their treatment plan. Beyond the frequency of collaboration, the specific time to collaborate can also be important. For example, I typically do not phone school teachers in the middle of their academic day, but either first thing in the morning or directly after school has been dismissed. If there are specific collaborators that I need to speak with regularly, I might ask "When would be the best time to reach you?” to avoid the familiar and frustrating game of phone tag.

WHERE are collaborators located? Since I prefer face to face collaboration, sometimes I like to ask where my collaborators are located. Collaborative care is a relational process and building these connections is an important piece of any practice. Thus, I will sometimes ask a family physician across town that shares 4-5 patients with me to meet for lunch or will ask a pediatrician if I can stop into their practice on a Monday morning to chat about our shared patients for a few minutes prior to starting our respective responsibilities for the day. While this is not always feasible, I am surprised that colleagues are often 5 minutes down the road.

WHY should I bother? This is probably my favorite question. Historically, I have worked with behavior change in my clinical work. This has involved talking at length with patients who may be precontemplative or contemplative about changing habits of smoking, overeating, or medication nonadherence. I am certainly not exempt from these stages of change either. There have been many instances where I was precontemplative about having to pick up the phone or write a summary letter to a colleague. Thus, asking oneself "Why is this important?” can be especially useful. Even utilizing strategies such as advantages/disadvantages analysis can spin us into preparation or action stages of change.

HOW should I collaborate? Once I am aware of the who, what, when, where, and why elements of collaboration, the final step often involves how I should collaborate. Commonly used strategies include phone consults, summary letters faxed or mailed, or creating a notebook for the patient or family to carry from appointment to appointment. In our setting, we have developed a simple form that includes the patient’s name, appointment date, DSM diagnoses, medication changes, vitals, and other comments (goals, strengths, follow-up) that can be easily completed and faxed to the primary care office after a first appointment. Formulating protocols or forms such as these can ease the process of collaboration at a distance.

While delivering clinical services in an integrated care system has clear advantages, elements of our health care system will always operate at some distance. Electronic health records could significantly diminish this dilemma. Until these technological advances take hold, individual providers can go a long way to improve communication and the overall cohesion of care. I leave you with one last question: "Why did you decide to do what you are doing?” For many of us, it was to provide patients and families with relief from their medical or psychological struggles. In order to do so, we need to collaborate no matter the distance…whether next to one another in an exam room or many miles away.


Kenneth W. Phelps, Ph.D. is an Assistant Clinical Professor in the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina. He was trained as a Medical Family Therapist at East Carolina University.  Dr. Phelps has been a member of CFHA for many years and currently chairs the Membership Committee.


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Beyond a Fad: How Integrated Care Can Swim to the Mainstream

Posted By Cassidy Smith, Thursday, April 21, 2011
Updated: Friday, June 10, 2011
The concept of "integrated care” seems to have joined the ranks of smartphones and iPads. Like those nifty devices, integrated care is innovative, effective and sought-after -- yet, not everyone can afford it.

In plain English, integrated care is a way of providing health care services that engages individuals and their caregivers in the full range of physical, psychological, social, preventive and therapeutic factors necessary for a healthy life. Within health circles, integrated care has become "all the rage” in Colorado. To illustrate the proliferation of integrated care, the Colorado Behavioral Healthcare Council mapped some of the numerous efforts underway to integrate physical health and behavioral health care services.

Supporting the delivery of integrated care has been a funding priority for the Colorado Health Foundation in recent years. Yet, while grantees rave about the positive impact integrated care services have on patient health and provider morale, they consistently report it is difficult to maintain these kind of services due to reimbursement limitations and the complex nature of billing health plans. National data tells a similar story. A 2010 article in Psychosomatic Medicine by Roger Kathol, MD, concluded that correcting disparate physical and behavioral health reimbursement practices is crucial for the survival of integrated care.

On April 8, the Colorado Health Foundation along with the Collaborative Family Healthcare Association, the Colorado Psychological Association and the Colorado Academy of Family Physicians convened a summit of nearly 100 Colorado primary care and behavioral health providers, health plan administrators, nonprofit leaders and policymakers to talk about the challenges associated with sustaining the delivery of integrated care services.

Here are some of the conclusions summit participants reached on how to make integrated care the expected standard of care for all Coloradans:

  1. Change culture of behavioral health -- Negative judgments of those with a mental health condition or substance-use disorder persist among the general public as well as health care and social service providers; despite knowing these conditions can be treated and prevented like any other health condition.
  2. Train providers to deliver integrated care -- Most physical and behavioral health providers have not been trained to work together in teams to provide integrated care services.
  3. Test new payment models – Current reimbursement practices hinder the ability of physical and behavioral health providers to work effectively as teams to deliver timely care to patients.
  4. Get support of the business community -- As employers, businesses are significant purchasers of health care services and can benefit the most from positive health outcomes and cost savings associated with integrated care.
  5. Encourage public to demand change – Many individuals have not had the opportunity to experience integrated care. Therefore, they do not know that it is the optimal way to deliver care.

The Colorado Health Foundation is partnering with the Collaborative Family Healthcare Association to take a closer look at the financial barriers impeding the delivery of integrated care services. Over the next year, Collaborative Family Healthcare Association will work with a broad group of Colorado stakeholders to summarize the financial barriers to integrated care delivery; identify potential policy fixes; and build a financial case for changing current reimbursement practices.

Hopefully, this new effort will help move integrated care from "the next cool thing” to the normal way of doing business.

Cassidy Smith is a public policy officer at the Colorado Health Foundation where she works with a broad group of stakeholders to advance public policies to improve access to quality, affordable health care services. Before joining the Foundation, she was special project coordinator in the Medicaid office at the Colorado Department of Health Care Policy and Financing. Cassidy earned her master's degree in Health Policy and Administration from the University of Illinois School of Public Health.

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It's Not Compulsive If it's Helpful, Right?

Posted By Randall Reitz, Thursday, April 14, 2011
Updated: Wednesday, May 25, 2011
OK, true confessions. When engaged to marry as an undergrad at Brigham Young University (at BYU you’re either married, engaged, or actively pursuing engagement) I took a course titled "preparation for marriage”. The class content was outstanding, and included a mixture of communication training, family-of-origin orienting, sexuality awareness raising, and expectation lowering.

Despite the bounty of helpful science that was shared, only one off-hand comment remains specifically lodged in my consciousness. The teacher, a slender woman in her 60’s, made the observation that if a person only puts on 1 pound per year after marriage, by mid-life he or she will be overweight, and before dying will be morbidly obese. I did not want to be morbidly obese.

That being said, awareness of a potential problem is rarely sufficient for avoiding said problem, see: overweight doctors, stressed-out therapists, and bankrupt accountants. Ten years (and a divorce, remarriage, and child birth) later I found myself exactly 10 lbs heavier than when I sat in that fateful class.

While the premarital education hadn't had its intended effect, the moment of epiphany did. For the first time in my life I started jogging regularly. I began by running 2 to 3 miles around a local park a few times each week. In the process I found a partner who shared my running cadence and my interest in centrist politics, post-modern Mormonism, and raising children to be nerds. Six a.m. runs became the highlight of my week.

To keep track of my progress I started a simple spreadsheet for recording how often I ran, times in races, and occasionally a weight. Eventually I added graphs to the spreadsheet because I found the downward slopes motivating. Over time the spreadsheets became more sophisticated, including an automatically tallied point system for all forms of exercise, and monthly goals for points (100), days with at least 1 point (90%), and ratio of running vs other forms of exercise (1:1). I was in heaven (see: "raising children to be nerds” above).

Over the first few months I lost the 10 pounds and over the next 5 years my weight was homeostatic. As every first-year systems therapist learns, homeostasis is not stagnancy, but variation within limits. My limits were up or down about 2 pounds. When I moved to Frisco, Colorado my weight dropped another 5 pounds, I believe because of higher metabolism from living at 9,000’.

In the last months of my mountain years my work demands had become so consuming that I discontinued tracking my exercise and weights. Then, I moved back to Grand Junction and started my current job where I have unfettered access to free food in the hospital cafeteria. Within 6 months of stopping the spreadsheet, my weight was back up the 15 pounds that I had lost, and I was back on my way to the dreaded pound per year.

So, I brought back the spreadsheets, and for the first-time, I started weighing myself everyday. I was quickly able to re-gain my sporting lifestyle and re-lose the weight. With this close observation, the weekly average for my weights narrowed to a 1-pound range. Proof positive of the axiomatic, "that which is tracked moves in the desired direction”.

Admittedly, I do more than just track. I’m also 1.5 years into a habit of only drinking water and milk. When my weight gets 2 pounds over my goal weight I don’t eat sweets for the day and remind myself of this deprivation by writing "NST” (no sweets today) on my hand with a marker. This common medical acronym is cause for concern for my colleagues who are unaware of my habit and of laughter and reassurance for the previously initiated.

I had it all figured out.

And then, one day I was in the precepting room of my residency program—consulting with the young doctors regarding the behavioral issues of their parents. I felt a twinge of pain in my lower left flank. I quietly got up, did a lap around the clinic and returned to the precepting room massaging my side and walking with a slight hitch. One of the more brilliant faculty physicians looked up from her computer saw my gait, observed "you have a kidney stone”, and went back to her computing. Within 5 minutes I was writhing on the exam room floor, getting a rushed testicular exam from a colleague (evoking thoughts of how adolescent girls must feel in the back seat) and limping off to get a CAT scan while clutching a vomit-filled garbage can.

My wife still gets upset when women tell her that kidney stones are worse than labor pains.

Looking back, I make sense of this occurrence as the defining moment of when healthy, fastidious habits devolved into compulsive behavior. According to the DSM-4, repeated thoughts and behaviors aren't classified as obsessions and compulsions unless they cause distress or disruption in the person’s life. Or, more technically: "The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.”

Sometime in the previous 6 months, I had become so committed to maintaining the weight that I wanted, that I had taken up a bad habit. As my spreadsheet only included the lowest weight for the day, on days when I didn't like my morning weight I would put off eating and drinking in the morning and weigh myself again before lunch. Worse, on weekends my lowest weight was at the end of a long trail run. If I didn't like the weight before the run, I wouldn't drink much water during the run and then wouldn't re-hydrate until I got back on the scale.

In recounting, these steps are embarrassing, but worse, I’m convinced that they contributed to my developing kidney stones. This same family doctor who diagnosed me has helped with my on-going treatment. She informs me that one of the most important steps in preventing new kidney stones is to drink large amounts of water. Ugh!

One year later, I’m still as meticulous about tracking exercise and weights, but I've made an accommodation to ensure that my approach is more healthy. I now weigh myself only 1-time per day—first thing in the morning before breakfast or any exercise. This, then stimulates extra water drinking because I find that it helps fuel my exercise and temper my appetite.

What on earth does this have to do with collaborative care?

Well, as a therapist in an integrated family medicine residency, I’m constantly aware that it is a compulsive milieu:
  • We track all our warm introductions, joint appointments, and inter-disciplinary consults for grants;
  • The EMR and patient registry "tickles” us to pay attention to minute details of patient care;
  • Fear of a bad outcome or a litigious patient prompts extra tests and images;
  • We’re now sigma six and "lean” trained to practice healthcare using the same processes that pilots use to avoid crashes;
  • Meeting the accreditation requirements for graduate medical education requires that we document each aspect of our curriculum and our residents’ evolving competency.
Like my spreadsheets, this attention to detail is helpful. It helps to ensure efficiency, patient safety, and fidelity to our healthcare model. But, at some point the demands pile-up to an extent that one barely has time to look up from the computer screen to collaborate with a colleague or to motivate a behaviorally-challenged patient.

For example, our new EMR is so time-demanding that laptops are now ubiquitous at our resident education days. At last week’s session 19 of the 20 participants were only nominally aware of the presentation because they were "working their boxes”.

Pursuit of best practices can result in worst practices.

A wise man once asked: "If a son shall ask bread of any of you that is a father, will he give him a stone? or if he ask a fish, will he for a fish give him a serpent?”

Obviously, people who choose to practice in primary care, do it to offer our patients bread and fishes: we aren't in it to offer stones or serpents to the unwell. But, neither did I start tracking my weights to give myself a stone.

When we find ourselves with a stone, we need to step back, re-calibrate, and return our focus to the pole-star. As we consider the excitement of each new healthcare innovation (PCBH! PCMH! ACO! EMR!) we do well to remind ourselves that the indelible center of healthcare is the relationship between the patient, the family, the community, and the clinicians who have the privilege of joining them in the pursuit of wellness.

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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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Why American Health Care Costs So Much

Posted By Lewis Mehl-Madrona, Thursday, April 7, 2011
Updated: Friday, June 10, 2011

We spend so much more time talking about how to pay for health care in the United States than we do wondering if what we get is worth what we pay or how to make health care more cost-effective. My fields are family medicine and psychiatry, and, to my chagrin, rarely do the two specialties communicate. Here’s an example that cost the health care system enormously. These kinds of situations arise commonly.

Recently a mother became concerned about her son who was feeling sad. She talked to him enough to learn that he was being bullied at school and that sometimes he wondered if it wouldn’t be better not to be here. She took him to their family doctor who said he didn’t do mental health and she would have to take her son to the emergency department at the hospital so he could get services.

At first this sounds crazy, but in our health care systems, the fastest way to get an appointment at the community mental health center is to go to the emergency department. Otherwise, one waits months for an appointment (at least where I work). It’s more questionable for the family doctor to say, "I don’t do mental health.” We have extensively training in handling mental health issues during our three year residency. In Canada, where residency training is only 2 years, family doctors are expected to manage all mental health issues with psychiatrists available only as consultants, and actually do so.

So, the mother took her son to the emergency department. They waited five hours to finally see a physician. He asked the son a few questions. The coup de grace came when he asked the boy if he ever felt as if it would be better if he were there. The boy agreed. Sometimes he thought that way. The physician left the room for an hour and returned to announce to the mother that he was transferring the boy to the regional psychiatric center by ambulance, because of his suicidal ideations. The mother objected. "I can take my son in our car to somewhere else to be evaluated, just like I brought him here.” The physician left the room and returned with a social worker and two security guards who told the mother that she would be arrested and detained if they interfered with the transfer of her son by ambulance and that Child Protective Services would be involved because of her failure to recognize the gravity of the situation and that her son needed immediate treatment. She acquiesced and followed the ambulance in her car. By now, her son was terrified.

At the Regional Psychiatric Center, they waited another 5 hours before they saw a social worker who took the history. Then a physician in training (called resident physician) came to talk to the boy and her. After a total of eight hours at the Regional Psychiatric Center, they were allowed to leave with a prescription for 5 mg of escitalopram, a selective serotonin reuptake inhibitor (Brand name, Lexapro) and some names of some private therapists to call in their home community. Imagine the charges stacking up. The family doctor billed for an office visit. The emergency department charged almost $2000 for their evaluation. The Regional Psychiatric Center charged $2500 for their evaluation. The ambulance transfer had cost $500. The prescription cost eighty dollars.

At the Regional Psychiatric Center, the social worker and the resident physician had managed to figure out that the child had no plan to kill himself, but only sometimes wondered if it would be better to cease to exist. In fact, until his encounter with the psychiatric system, the child had not actually considered that people really killed themselves. His concept had been more wistful and fanciful as he wondered if it would be better not to exist. Presumably others have wondered the same thing without benefit of Regional Psychiatric Care. The mother’s observation was that each time she was transferred her caregivers seemed younger and less experienced. At the same time, with each transfer her son was becoming more and more frightened.

In the end, after an extra $6000 in billing and probably the worst day of this mother’s and this child’s life, the end result could have happened in the family doctor’s office. He could have listened to the mother and the child and could have made a determination that these thoughts were not connected to a plan or to an intent to die, but rather an expression of how miserable the child felt. He could have written the same prescription since this drug is widely detailed to family doctors with instructions on its use. He could have given the mother names of psychotherapists in the community to call. In an enlightened office, he could have had a therapist on call for his office or visiting on a regular basis each week to handle these kinds of situations.

Why didn’t he? One explanation is fear of malpractice. That drives much of the insanity in American health care and is not so nearly a problem in other countries. These other countries have social networks to care for people who are injured in medical mishaps. We don’t. The only choice available to our injured patients is to sue. Another explanation is the silo model of American medicine. Each specialty keeps to its own domain somewhat exclusively. Internists don’t talk to psychiatrists and don’t treat psychiatric disorders. Similarly, psychiatrists don’t talk to internists and don’t treat medical disorders. However, the body is one. The arbitrary separations we create do not actually exist in nature.

If we are going to actually afford an accessible health care system, we will need to address these questions of how care is delivered. Failure to do this will bankrupt our healthcare budget.

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Restorative Justice: A (Surprising) Example of Collaboration in the Justice System

Posted By Troy Sanders, Thursday, March 31, 2011
Updated: Friday, June 10, 2011

The idea of working collaboratively has obvious merits in the healthcare field; after all, the purpose of all healthcare providers is to improve the outcome of their patients. Patients or consumers should be seen as natural partners in their own care, especially in the realm of mental wellness as the efficacy of many treatments can depend entirely on what a consumer communicates to their friends, family and healthcare providers. Full and honest communication is essential in this context, as difficult as that can be at times.

Where the idea of collaboration tests our Western notions is the field of law. Our justice system (and this applies both in Canada and the United States) is predicated on two uniquely Western (i.e. owing their origin to the Greco-Roman concept of dualism) principles: 1. our rights system is centred on the individual and 2. our system is constructed in an adversarial fashion. In this light, medicine and law could scarcely be farther apart in their philosophical orientation.

However, when we examine judicial practices of other societies and traditions, we find another lens through which to aid our search for justice. These principles state the community, not the individual, is the centre of the social and legal structures. It then follows, if a community is composed of many people, that each person is not an insular individual but one of many community members. With this framework, one can use the medical analogy of a community being "the body” while the community members are the disparate parts of the body – organs, limbs, skeleton, neurological network, etc.

This organic understanding of community and people immediately challenges our current legal regime. The heart does not exist separate from the lungs, nor brain, nor mouth from the stomach. All are connected and work together, not in competition. These are the central themes of Restorative Justice (or RJ). Participants work together, communicating, each sharing their concerns and wisdom for the benefit of the larger whole. RJ does not say "A law is broken, thus comes punishment”. RJ states "someone has harmed another and by extension, the community”. A conversation then develops among the person(s) who have made a poor choice, those who have been harmed and other members of the community. It is essential to note the action (or choice) and not the individual is judged.

With honesty and compassion, the group examines what went wrong (regarding the incident itself but also within the person’s life) and what led to their poor choice. The person learns who has been harmed, how they have been impacted and through this process, learn how their actions affect others. The process reinforces the sense of community as well as allowing the person a chance at sober second thought and reflect on their mistakes. The talk then leads to ways the person can heal the harm. Again, this is not punitive. Sometimes, when a wrongdoer learns how they have hurt others, they proactively ask what they can do to make things right. Where one system would have crafted adversaries, RJ can, at its best, forge new alliances and strengthen everyone impacted in the end. RJ sees conflict not as something to eradicate, suppress or "deal with”, rather, it is a catalyst for personal growth.

We thus have a working model for collaboration in two critical fields in our society. This is an excellent start, but not without radical challenges. In a society structured around a competitive, "me first” mentality, "do your best” is often confused with "be the best”, while the ends too often justify the means (we will forgive winners for minor mistakes sooner than noble losers who failed to succeed). Frankly, in a society eager to infuse Sun Tzu’s The Art of War into new areas of public life, it is a wonder how any seeds of collaboration could grow in this hostile field of abject narcissism. It has taken far too long for science to see nature and nurture as anything but an either/or problem, an excellent example of the tendency to default to such dualistic thinking.

Any attempt in our society at working collaboratively runs against the grain. This is unfortunate but true. Yet this must always be kept in mind, especially by those of us who have fully embraced collaborative practices. It can be easy to give up when fighting layers of bureaucracy rooted in competitive assumptions. Privacy laws assume information will be used for the gain of one and at the expense of another. Never would we assume information would be shared among partners working collectively with one in need. Instead of building bridges to communication, we erect impenetrable silos as "protection”. We fail to see the void between silos as gaps too many fall into, never to recover.

Yet as difficult as it is to work together, there are thousands of years of wisdom which encourages us to do so. Many elements of RJ (and theories of collaborative practice in general) find roots in indigenous customs millennia old. These teaching models grew from resilient cultures who saw communities as central figures, yet valued each community member for the contributions they add to the whole. Working with one another came much easier to them – forging not only an enlightened environmental awareness, but also a social awareness in much the same way. We spend so much time proving the value of collaboration not because its value is questionable, but because we have forgotten we live in a social ecosystem, connected to everyone and everything else. When our first reaction is focused on the collective instead of the individual, everything will change.

When we ask "how can I help the community I am a part of” (whatever community means at that moment) instead of "what’s in it for me” our treasury of collective wisdom will explode exponentially and our ability to help one another will grow in equal measure.

Troy Sanders is a mental health consumer working with ADD, Depression and Social Anxiety. He holds both a B.A. and a L.L.B., degree; although he chooses not to practice law. He recently discovered a deep interest for Restorative Justice; a collaborative parallel to mainstream judicial processes and he has been an RJ practitioner for close to 5 years now. Writing is a passion of his.

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For Patients' Sake... Let's Get on with Collaboration

Posted By Roger Bland, Thursday, March 24, 2011
Updated: Tuesday, April 12, 2011
Primary care, provided that it is accessible and available, improves population health. Primary care includes but is not limited to family physicians. In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder. Of that 35%, 93% were seen by a family physician and had a major diagnoses of an anxiety disorder, mood disorder, substance use disorder, schizophrenia and psychosis or cognitive impairment.  
 
The World Health Organization has nevertheless drawn attention to this "treatment gap"; the high proportion of people even in developed countries who have a treatable disorder but do not get treatment. The severity of cases and the diagnoses of those seen in primary care differ from those seen in specialist care yet the diagnostic systems and criteria are more oriented to specialist practice than to primary care. Family physicians in Canada have highlighted problems with the mental health system including lengthy delays for consultations, inaccessibility of psychiatrists and poor communication following referral.

The Canadian Psychiatric Association and the College of Family Physicians of Canada have worked together to improve care for patients with a mental health disorder and have strongly advocated for shared care or collaborative care where psychiatrists and mental health practitioners work closely with primary care physicians and services. There are several goals associated with this which include facilitating early treatment, achieving better outcomes, reducing stigma and ensuring that patients are receiving the most appropriate service in a timely fashion in a setting that is congenial and avoids stigma. Considerable effort has gone into ensuring that specialists services support primary care and primary care physicians rather than meeting the needs of specialist programs.

"In Alberta 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period 35% of the adult population of Alberta was seen for a mental health disorder."

Several different models have emerged.  One model uses a relocated consultation service.  Although it may perhaps be the simplest concept it has not necessarily proved to improve services or outcomes.  Another type of service includes placing mental health workers into primary care practices. Reports on this are variable depending on whether the services are designed to collaboratively support primary care or just be embedded in primary care but doing their own thing.
 
One of the better models seems to be where a psychiatrist and/or other mental health professionals are attached on a full or part-time basis to a primary care practice or practices and provide ongoing formal and informal consultation and support along with other aspects of psychiatric patient care. Integral to any of these services is that the individuals involved need to get to know each other and build trust and confidence. It is clear that when the various components are well coordinated it is reflected in how the patients feel about the service with greater satisfaction.
 
Research evidence is available but limited. Where a particular disorder, for example depression, is being treated with a standardized protocol and ample supports it is clear that patient outcomes are improved. Often the research project ends and those involved do not continue to follow the same protocol. Where there is close collaboration patient satisfaction studies tend to show positive results which is also often the case when additional service availability (for example counseling or housing services) are built in to primary care setting. Clearly role definitions are important.  Specialty mental health services will continue to play a significant role in the management of difficult cases--specifically those where patient needs are very high which are often associated with psychoses and dementias.

For cooperation to succeed there needs to be strong positive attitudes on the part of the practitioners involved and good administrative support including financial support from those bodies responsible for funding health care. The rapid growth of collaborative care arrangements in Canada suggests that there is a strong belief that this approach can help those with mental health problems.

Roger BlandDr. Bland is Professor Emeritus and former Chair of the Department of Psychiatry at the University of Alberta. His research interests have included epidemiological studies, long term outcomes and mental healthcare utilization including collaborative care.  He has served as a CPA member of the CWGSMHC for the last decade.

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Supported Self-Management of Depression and Anxiety

Posted By Dan Bilsker, Wednesday, March 16, 2011
Updated: Friday, June 10, 2011

After spending 25 years as the psychologist in an emergency psychiatric unit, as well as treating depressed individuals with Cognitive Behavioural Therapy, it has become clear to me that our North American health system does a poor job of sharing knowledge regarding effective methods for individuals to manage their own psychological difficulties. Our systems are heavily focused upon delivering treatments, generally pharmacological ones, and often leave patients in a passive role. If all we expect a depressed individuals to do is be adherent to prescribed medication, we are missing the boat in terms of the potential for collaboration between healthcare provider and recipient.

It is worth noting that antidepressant medication, the most widely applied treatment for depression, is not particularly effective for milder cases, although it does have the same worrisome level of side effects. Given the high rate of sexual dysfunction associated with antidepressant medication, one would like to be confident that the benefit outweighs the risks of reduced quality of life, impaired self-esteem and damaged relationships. At least within the Canadian system, the vast majority of depressed individuals have no practical access to evidence-based behavioural interventions. It is crucial that healthcare providers have training and support to deliver behavioural interventions. One such alternative is the intervention we refer to in our research unit asSupported Self Management (SSM).

In SSM, the health care provider (typically in the primary care system) serves as a facilitator and "coach” for the patient in learning and applying mood self-management skills. There is a significant amount of outcome research supporting this approach. Our research unit has conceptualized this as a form of collaborative knowledge exchange between policymakers, researchers, health care providers and care recipients—we have focused our investigative efforts upon methods for fostering this kind of knowledge/practice exchange among key stakeholders. We developed a depression self management tool (Antidepressant Skills Workbook) that is available for free download from our website as well as several variants for particular contexts and populations: depressed adolescents (Dealing With Depression), depression in the workplace (Antidepressant Skills at Work); and depression or anxiety difficulties associated with chronic illness (Positive Coping with Health Conditions). The basic adult workbook is available in several languages and as an e-book – all of these tools are free. Also available on this website is a relaxation training audiofile and self-help guides for dealing with suicidal thoughts.

Approximately 100,000 copies of these various workbooks have been downloaded from the website over the past six years. With support from healthcare agencies, we have trained over 500 family physicians to deliver SSM to their depressed patients. We carried out an implementation study to determine the degree of update one could attain using sophisticated knowledge exchange strategies: we studied 85 family physicians who each received a one-hour training session and access to the workbook for enrolled patients (an envelope the patient could return for a copy of the workbook). These physicians distributed the request envelopes to 1300 patients over a six-month period, and 55% of these patients sent back the envelope to request the workbook. This degree of adherence to a prescribed therapeutic action is comparable to the adherence to prescription of antidepressant medication. Given the minimal cost in time and financial resources of this system intervention, we consider this to be an impressive outcome. The bottom line is that dissemination and support for psychological self-management should be a core component of all mental health systems. Collaboration in mental health care should include not only primary and specialist care providers, but also care recipients.

References

Bilsker, D., Anderson, J., Samra, J., Goldner, E.M., & Streiner, D. (2008). Behavioural interventions in primary care. Canadian Journal of Community Mental Health, 27, 179-189.

Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S & Lovell, K. (2007). What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychological Medicine, 37, 1217-1228.

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Canadian Mental Health Shared Care: A Beginning

Posted By Gary Mazowita, Thursday, March 10, 2011
Updated: Friday, June 10, 2011

The upcoming Halifax Collaborative Mental Health Conference both exemplifies and showcases the kinds of changes that are currently taking place in the Canadian healthcare system related to mental health. After a decade of "talking about” the changes necessary to ensure ongoing sustainability in the face of an ageing population and evermore expensive and sophisticated tests and treatments, things are finally happening in visible fashion, in virtually all areas of the country.

A cornerstone of change in all locales is "collaboration”. Such collaboration is not narrow, but rather attempts to engage a broad swath of society at large: family doctors, specialists, other healthcare providers such as nurses, nurse practitioners, psychologists, pharmacists, social workers, and perhaps most importantly, families and patients.

In many ways, mental healthcare has been the "crucible” of change…..perhaps largely because the need was so pressing, and the existing delivery models so stretched, and even dysfunctional.

Fascinating to me has been the apparent willingness of the mental health consumer population to accept, and even endorse, certain aspects of the "medical model of care”. Historically, the term "medical model” has conjured up values of paternalism, dogma, and elitism. Now, it seems, there is exciting openness to some of the "good” things possible from certain aspects of this model, particularly in the domain of "chronic disease management”. Elements include active patient engagement, self-management, goal-directed choice, recall systems, planned proactive management, attention to routine primary care, and a range of collaboratively-oriented providers.

It is fair to say that there is now more interest in mental health, and in collaborative mental health models of care specifically, than has ever been the case in Canada.

If this "cultural change” continues (and it surely will, if we expect to enjoy the benefits of our publicly funded healthcare system) then the next decade will likely witness a transformative change in mental health service delivery, and in stigma reduction as well.

In my province alone (British Columbia), some noteworthy developments have been:

  • Tools and supported office change for family doctors and their Medical Office Assistants (MOA). These have been extremely well received, and are available under "Practice Support Program’ at www.gpscbc.ca. One particularly exciting element of the "Adult Mental Health Module” is the provision for MOAs to take the "Mental Health First Aid Course”. This course helps to educate and sensitize MOAs with respect to prioritizing appointment-making, waiting room environment, signage, conflict resolution, etc. This truly brings MOAs into the "collaborative team”.
  • Building on the above, more and more shared care models between family doctors and psychiatrists, and more recently psychologists, pharmacists, and nurses, are being discussed, or being planned, or exist. There is an expectation that this direction will continue, and will expand.
  • The "Bounceback” program of peer cousellors, who connect to patients by phone, has been well-received, and is expanding.(www.cmha.bc.ca/bounceback).
  • A "Child and Adolescent Mental Health Module” is nearly complete, and will complement the adult module, and likewise encourage collaboration. It should eventually be available on the gpsc website.
  • Payments to family doctors and psychiatrists are increasingly being aligned to support collaboration. We believe this will not only ensure sustainability of our publicly funded system, but improve the patient journey, and provider work-life. Still largely outside the publicly-funded umbrella are psychologists and others, although creative solutions are beginning to appear.

Similar initiatives are ongoing in other parts of Canada, and venues such as the Halifax Conference allow us to learn from each other, and both drive and spread change. On behalf of the Shared Care Mental Health Committee (College of Family Physicians of Canada, and Canadian Psychiatric Association) we are happy to engage in dialogue with our American colleagues.

To quote an old American proverb: If you don’t believe in cooperation, watch what happens to a wagon when one wheel comes off.

Together, we are stronger.

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