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Changing State Medicaid Policy: Five Questions with Cheri Rinehart

Posted By Randall Reitz, Thursday, September 20, 2018

Policy change can be hard, slow, and seem daunting. This is especially true at the federal level, but many of the important changes happen at the more accessible state and local levels.  For example, Pennsylvania leaders recently helped to change state Medicaid policy to allow licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) working as integrated clinicians in FQHCs to bill Medicaid.  In this blog post, Cheri Rinehart, President & CEO of the Pennsylvania Association of Community Health Centers (PACHC), answers 5 questions about why and how this policy was changed. 


1.        What is the history of this issue in Pennsylvania that prompted you and your collaborators to take it on?

As the number of health centers working to integrate behavioral health (BH) increased because HRSA made this a priority, PACHC received growing feedback about the challenges the FQHCs faced in recruiting eligible providers.  The need became even more evident and pressing when one of our partner organizations, the Health Federation of Philadelphia, negotiated managed care organization approval for a “warm handoff” initiative in health centers in Philadelphia. When discussion with the Department of Human Services (DHS) was initiated in the summer of 2012, our original goal was approval of licensed social workers (LSWs), LPCs and LMFTs as BH providers eligible to generate an FQHC reimbursable encounter.  It became clear very quickly that if we adopted an all or nothing attitude, we would get nothing, because DHS felt strongly that LSWs should not be included because they do not exercise independent judgment. We agreed on that compromise and DHS agreed to pursue a state plan amendment to initiate the change to add LPCs and LMFTs. And then nothing happened.  For a long time.  And then, in response to one of our regular inquiries on status of the issue, DHS asked for validation of need.  This was the pattern over many years:  We would reach what looked like agreement and then a new question would be raised, requiring new data, analysis and time.  Each time, after allowing ourselves to feel the disappointment, we regrouped, re-strategized and recommitted to the goal.


2.        What was your overall strategy in framing and advancing the case?

It is important to share that our relationship with our partners at DHS was established long before we started this advocacy journey and has strengthened along the way.  We both feel that our overarching goal is the same:  improve access to quality, affordable health care, especially for the most vulnerable individuals and families.  We recognize one another as important partners.  Key officials from both organizations meet every month.  Our initial discussions and exploration of DHS’ opinion on this issue were a more informal part of these regular meetings.  Our first goal was to listen so that when we moved to the more formal step of submitting what we refer to as Recommendations for Consideration, the document would reflect and address issues and concerns that DHS had raised. 


3.        Who were the key collaborators and stakeholders and why was their involvement important?

The health centers across Pennsylvania were our key stakeholders and they served as collaborators on the initiative by regularly sharing with us their frustrations in trying to recruit a workforce adequate to meet the needs of the individuals and communities they serve.  That meant that we could share with full honesty and integrity in our meetings that it was a rare week when we did not receive multiple calls and emails from health centers desperate to respond to the need and asking for an update on progress on the policy change to help them in doing so.


4.     Why do you think you were successful?

Many factors contributed to our success, but the key to successful advocacy on any issue is clearly identifying and staying focused on the end goal so you don’t get distracted by the barriers you are sure to encounter on the advocacy pathway.  Our end goal in this case was to expand the FQHC workforce to improve access to integrated BH services.  While we identified early in the advocacy process what we thought the best solution was, if we had solely focused on that solution rather than the end goal, it would have gotten in the way of success.  Success in advocacy requires development of relationships before you need them, being prepared for unexpected turns, extreme patience, a willingness to compromise, persistence, maintaining professionalism even when frustration levels rise, and seeking to understand as well as be understood.  Several times over the years we thought we were close to the finish line and then were confronted with a new obstacle, but we never gave up and remained gently persistent, always including the issue on meeting agendas with DHS. 


5.     What lessons learned would you share with CFHA members seeking policy changes at a grassroots level?"

You know what you want and why, but success also requires understanding, framing and responding to the issue from the viewpoint of those responsible for making the change you are advocating.  Because this issue for us was very FQHC-specific, we did not engage other advocacy partners, but that is not usually the case.  Identifying and engaging the stakeholders who might support or oppose your proposal is an important early step in advocacy on any issue.  Be prepared for success to take time and that you might have to change course multiple times.  In a world that generally moves quickly it is hard for those awaiting the change to understand why it is taking so long, so it is important from the beginning to set an expectation of preparing for a marathon, not a sprint, and for progress at “the speed of government.” A single person in a key role can be a barrier—it does not feel fair, but it is often reality. Feedback from our members anxious for the policy change was not an annoyance—it was essential to keeping our commitment to success high.  Never give up if it is truly something you believe is the right thing to do—reevaluate strategies and alternatives, but don’t relent.  When we were feeling most weary from the journey it was hard to believe, but true, that success was just around the corner.


Cheri Rinehart, RN, BSN, NHA, is President & CEO of the Pennsylvania Association of Community Health Centers (PACHC), the state association representing the more than 300 Community Health Centers and like-mission providers throughout Pennsylvania.  Ms. Rinehart is a registered nurse and licensed nursing home administrator.  She has held various administrative positions, including vice president and director of nursing, in health care organizations.  Her health policy expertise spans the health care continuum, from primary care to long term care and end of life care.  Ms. Rinehart was one of 20 nurses selected nationwide in 2004 for a Robert Wood Johnson Executive Nurse Fellowship, is a graduate of Penn State’s RULE Leadership Program, and is a summa cum laude graduate of Bloomsburg University.  She currently serves as Region 3 representative to the PCA Leadership Committee, serves on the national FQHC advisory boards of AmeriHealth Caritas and UnitedHealthcare, was named as a representative to the national Rural Primary Care Issue Group, and serves on the boards of several healthcare and other organizations.  She has served on numerous state committees and task forces and is the recipient of awards for her work in rural and emergency health care.   


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Your Guide to the Latest Research in Integrated Care

Posted By Matthew P. Martin, Tuesday, September 11, 2018

There is so much good research coming out in the field of integrated care. Trying to keep up with all the new developments can feel like drinking from a fire hydrant. So, to save you time and keep you from overhydrating, your friendly neighborhood blog editor is here to separate the wheat from the chaff.


The studies you see below represent some of the best research coming out. I organized them into categories for easier reading and hope you find one that can make an immediate impact on your work. The categories are Implementation (evidence- and practice-based guidelines), Interventions (patient treatments), Specific Populations (integrated care for discrete patient groups), Attitudes and Perceptions (what people think of integrated care), Workforce Development (preparing the next generation of providers), and Outcome Research (end results of care delivery research).


Each category includes an abstract from the article that seems most impactful and then links to other research articles. If you found a recent article that is not listed here and want to right that wrong, please contact me and I will make sure we highlight it in a future blog post.



Sustaining integrated behavioral health practice without sacrificing the continuum of care


Abstract: This article describes how an innovative model of practice transformation, used by 4 integrated pediatric primary care practices over a 2 year grant period, promoted the practice of integrated primary care (IPC) behavioral health services. Practice transformation was possible through the implementation of an alternative billing strategy to enhance sustainability, effective utilization of clinical productivity to provide meaningful patient services, and the identification of strategies to further the practice of IPC. Specifically, we provide: (a) a description of the diversity of billing strategies typically used by pediatric practices utilizing integrated care and how those strategies are impacted by state health care policies; (b) a description of the grant, including the service delivery model, implementation phase, and data collection procedures; (c) results of implementation and billing/reimbursement data that were collected across the 4 practices; (d) an analysis of how billing strategies are critical in defining implementation strategies within pediatric integrated care; and (e) lessons learned about how billing strategies must be flexible and amenable to change over time to stay current with ever-changing health care policies and reimbursement models. (PsycINFO Database Record (c) 2018 APA, all rights reserved)


1.     Cost-savings analysis of primary care behavioral health in a pediatric setting: Implications for provider agencies and training programs.

2.     What are the effective elements in patient-centered and multimorbidity care? A scoping review

3.     The Core Dimensions of Integrated Care: A Literature Review to Support the Development of a Comprehensive Framework for Implementing Integrated Care



Adapting empirically supported treatments in the era of integrated care: A roadmap for success


Abstract: The emerging era of integrated care represents a major opportunity for clinical psychology to migrate empirically supported treatments (ESTs) into the mainstream of public health. To succeed will require us to modify current ESTs to make them brief, cost‐effective, patient‐centered and acceptable to and easily learned by both the mental health and health‐care professionals that will deliver them. Changes to the recently modified standards for designating ESTs are proposed that will facilitate adoption of a population health model of treatment development and testing, designed to promote rapid dissemination of empirically supported interventions that are a “good fit” for integrated settings. Defining characteristics of the “new look” for ESTs are examined.


Behavioral medicine interventions for adult primary care settings: A review.



Family Functioning in Pediatric Primary Care Patients


Abstract: Introduction. The purpose of this study was to pilot a brief measure of family functioning (Family Assessment Device–General Functioning [FAD_GF]) with caregivers of children aged 2 to 18 years, seen for routine pediatric primary care visits. Methods. This study evaluated the psychometric properties of the FAD_GF in a pediatric primary care sample of 400 families. Confirmatory factor analysis was used to validate the FAD_GF using R, and WLSMV was used to estimate missing variables. Results. The FAD_GF was found to be reliable with this sample, α = .90. The model fit was χ2(54) = 56.44, P = .38, with root mean square error of approximation = .01 and comparative fit index = .99. The 12 items were significantly predicted by family functioning, and family functioning explained more than 20% of the variance in the items, R2 > .25. Overall, 12.6% (n = 46) of families were identified as having clinically impaired family functioning. Discussion. The FAD_GF provides clinicians the ability to make evidence-informed decisions regarding referrals to family therapists.


Acceptability, feasibility and outcome of a screening programme for complicated grief in integrated primary and behavioural health care clinics

Integrated perinatal mental health care: a national model of perinatal primary care in vulnerable populations

Integrated care models for ADHD in children and adolescents: A systematic review.

Primary care integration in rural areas: A community-focused approach.



Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review




To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review.



A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal ( website) through to June 2017. The articles included in the review were summarized through a narrative synthesis.



After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient’s adherence to treatment.



Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.


Integrated primary care: patient perceptions and the role of mental health stigma

Providing Mental Health Services in the Primary Care Setting: the Experiences and Perceptions of General Practitioners at a New York City Clinic



Integrating Mental Health into Primary Care: Training Current and Future Providers


Abstract: In this chapter the authors will discuss an important aspect of the integration of behavioral health (specifically psychiatry) and primary care from a global perspective. The chapter examines this topic through the continuum of medical education, from medical student to psychiatry residency, and concludes with a discussion of post-residency continuing education opportunities. Current psychiatry residents share their experience in working in an integrated primary care clinic, highlighting the challenges and rewards. The need to fully integrate this concept into all aspects of medical training is the primary goal of the authors. This will require a change in culture from the existing specialty-driven approach to patient care. It will also help address the current crisis in limited access to mental health care around the world. There will never be an adequate number of psychiatrists given the current model of mental health-care delivery. This is not a new problem, but altering current training experiences has the potential to begin this necessary transition in mental health-care delivery. Achieving this goal will improve the overall quality of life for patients worldwide.


Integrated Behavioral Health and Social Work: a Global Perspective

Developing a Computer Application to Prepare Social Workers for Integrated Health Care: Integrated Healthcare (Version 1.0)

Online CBT training for mental health providers in primary care



Community Mental Health Center Integrated Care Outcomes


Abstract: Despite the compelling logic for integrating care for people with serious mental illness, there is also need for quantitative evidence of results. This retrospective analysis used 2013–2015 data from seven community mental health centers to measure clinical processes and health outcomes for patients receiving integrated primary care (n = 18,505), as well as hospital use for the 3943 patients with hospitalizations during the study period. Bivariate and regression analyses tested associations between integrated care and preventive screening rates, hemoglobin A1c levels, and hospital use. Screening rates for body-mass index, blood pressure, smoking, and hemoglobin A1c all increased very substantially during integrated care. More than half of patients with baseline hypertension had this controlled within 90 days of beginning integrated care. Among patients hospitalized at any point during the study period, the probability of hospitalization in the first year of integrated care decreased by 18 percentage points, after controlling for other factors such as patient severity, insurance status, and demographics (p < .001). The average length of stay was also 32% shorter compared to the year prior to integrated care (p < .001). Savings due to reduced hospitalization frequency alone exceeded $1000 per patient. Data limitations restricted this study to a pre−/post-study design. However, the magnitude and consistency of findings across different outcomes suggest that for people with serious mental illness, integrated care can make a significant difference in rates of preventive care, health, and cost-related outcomes.

How Do Innovative Primary Care Practices Achieve the Quadruple Aim?

  Matt Martin, PhD, LMFT, is Clinical Assistant Professor and research faculty at the Doctor of Behavioral Health Program at Arizona State University where he teaches courses on health care research, quality improvement, and interprofessional consultation. Matt serves as the Director of the ASU Project ECHO hub for behavioral health integration. He is the CFHA blog editor.  

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When life hands you lemons… go fishing!?

Posted By Kevin Readdean, Tuesday, August 21, 2018

A prescriber-patient miscommunication causes an adverse drug interaction, the nurse administers the wrong immunization to the patient, or the EMR system goes down five times a day. When adverse events like these occur, it might feel like it’s time for a fishing vacation, but what these events really call for is a root cause analysis (RCA). One simple and effective tool for RCA is the Fishbone Diagram. The Fishbone Diagram is a quality improvement tool used to guide a structured investigation of what went wrong and why, and it helps generate solutions to prevent an event from reoccurring. Think of the fishbone RCA process as casting a wide net and fishing for solutions to problems. While fishing is often a solitary, quiet activity, the Fishbone Diagram process is a group effort. So, share this overview of the Fishbone Diagram and the following case example with your quality improvement team as a way to gear up for your next RCA.


The fishbone diagram is often called the Ishikawa Diagram, as it was created by engineering professor, Kaoru Ishikawa, a leading authority in quality control in the 1960s. Ishikawa created the fishbone diagram process as a technique for visualizing causal connections. The diagram resembles a fish skeleton with the head representing the problematic outcome and each of the bones branching off the fish spine denoting the causal factors that contributed to the problem. Taken together, the fish skeleton presents a visual representation of the causes (fish bones) that led to the effect (fish head). See figure below.


The first step in the fishbone exercise is to articulate the process as a collective, open brainstorming session that invites input from all members of the team. The goal is to find and resolve weaknesses in the system, not blame any one individual or subgroup. The old adage, often attributed to Deming, ‘every system is perfectly designed to get the results it gets,’ is a great way to set up the fishbone analysis. This openness also can be achieved through the use of poster board, on which to draw the fishbone, and sticky-notes, to allow brainstorming to occur both verbally and in writing.


Once the fishbone process is explained and the fish skeleton graphic is displayed on poster board, the second step is to, as a group, describe the problem. Spend as much time as needed to develop consensus around a clear, concise, factual description of the issue. Write down the problem statement at the head of the fish (e.g., medication error – improper dosing).


The third step is to label each bone branching off the fish spine with the categories of causes which contributed to the problem. The standard fishbone causal categories are Machine, Materials, Methods, People, and Environment. However, in a healthcare context, these six P’s offer more useful categories: Polices, Procedures, Programs (EMR), Patients (clients), Providers (staff), and Place (environment).


In the fourth step of the process, the group brainstorms the sub-causes that contributed to the problem under each of the six categories. This can be done in groups of six, with a report back to the larger group, or can be done one category at a time by the entire group. Here again, the idea is to use brainstorming techniques to break down a multidimensional problem into its elemental, root causes. It is a time to methodically look back and analyze causes, not suggest solutions. This step is often aided by the use of the 5 whys technique. In this iterative approach, the facilitator asks a series of 5 ‘why’ questions, each one building upon the previous answer to drill down into the fundamental issue. For example, in the category of Programs (EMR) the 5 whys technique might look like this:

Q: Why did the EMR system go down? A: The server crashed.

Q: Why did the server crash? A: There was not enough space in virtual memory.

Q: Why was there not enough memory? A: Scanned images are taking up too much memory.

Q: Why are image files too large? A: They are set at maximum resolution

Q Why do they need to be set at maximum resolution? A: They don’t, they are legible at half the resolution.


Once all the potential root causes have been listed under each causal category, the final step is to have the team identify the themes that emerged in the process and begin to suggest solutions that can help prevent the problem from reoccurring. This could be any combination of changes to policy, procedures, modifications to the physical environment, training for providers, or different ways to engage with the patient’s family members. The fishbone process could also prompt the use of other quality improvement approaches such as a Plan, Do, Study, Act (PDSA) cycle to test out a potential solution. Alternatively, the process might create the need for further data collection, or a more in-depth quality improvement study, to validate subjective hypotheses that emerged during the fishbone process.


To summarize, the five main steps of the fishbone RCA process are: (1) establish an open brainstorming process about system level causes to an adverse event, (2) describe the problem, (3) categorize the potential causes, (4) pinpoint likely root causes in each category, and (5) identify solutions that will mitigate the root causes and prevent the problem from reoccurring.


I once had the opportunity to use the fishbone exercise with an integrated care team to address an issue where significant aspect of patient’s history was not fully shared across the team. The clinic received an ER report of an accidental prescription drug overdose. The report was reviewed in primary care and scanned to a patient’s EMR without being circulated to the specialty mental health providers involved in the patient’s treatment. The ER report was in the patient’s shared EMR for months, while treatment was ongoing, before it was discovered by a mental health provider. Fortunately, the lack of information access did not lead to an adverse outcome for the patient. Nevertheless, our quality improvement team felt the oversight needed to be addressed.


We employed the fishbone diagram process described above and came up with concrete resolutions to this communication issue. In brief, we changed our written policy and procedures on how external reports are processed upon receipt and instituted a new way to use the EMR to alert providers to newly scanned reports. While this was a positive resolution to the issue, we experienced additional secondary effects at the individual and team levels. The collective fishbone process served to strengthen a culture of whole health and interdisciplinary teamwork among the staff. For example, as a result of conducting the fishbone diagram exercise:


  • Individuals realized the importance of reviewing all aspects of the patient’s chart regularly.
  • Staff members were able to visualize how all different parts of the care team contributed to a single problematic outcome.
  • The interconnectedness of treatment planning was underscored.
  • We developed an appreciation of the EMR as an enabler of collaborative care.
  • The interdisciplinary team united around solving a system level issue.

These team level side-effects of the fishbone diagram root cause analysis process highlight the benefits of conducting this exercise with integrated care teams. Done well, this fishing expedition can, not only solve a problem, but also strengthen the provision of integrated, holistic care.

Adapted from University of North Carolina School of Medicine, Department of Pediatrics


Agency for Healthcare Research and Quality. Cause-and-Effect Diagram. (n.d.). Retrieved May 21, 2018, from

American Society for Quality. Cause analysis tools: fishbone diagram. (n.d.). Retrieved May 21, 2018, Available from:

Harel, Z., Silver, S. A., McQuillan, R. F., Weizman, A. V., Thomas, A., Chertow, G. M., … Bell, C. M. (2016). How to Diagnose Solutions to a Quality of Care Problem. Clinical Journal of the American Society of Nephrology : CJASN, 11(5), 901–907.

Phillips, J., & Simmonds, L. (2013). Using fishbone analysis to investigate problems. Nursing times, 109(15), 18-20.


Kevin Readdean, MSEd, LMHC, is Associate Director of the integrated student health and counseling services at Rensselaer Polytechnic Institute. He is also a PhD student at Rutgers University studying the organization and delivery of integrated primary care behavioral health.


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Quality improvement in primary care: A patient-centered strategy

Posted By Alex Young, Wednesday, August 8, 2018

This post is a two-part series on quality improvement. Check back later this month for the second part.

Quality Improvement in Primary Care

The use of quality improvement is not a new concept to the medical field as quality improvement teams are often routine in health system settings. Primary care, however, appears to have a lack of generalizable studies that support quality improvement (QI) efforts (Balasubramanian et al., 2018). Despite this lack of QI research in primary care, a recent study proposes a different type of approach that builds on the existing interactions in primary care.

QI research efforts can be strengthened using a relational-based approach that is high quality and conforms to the time parameters of primary care interactions (Bitton, 2018). This approach would help to ensure that patients’ specific needs are identified and addressed in a collaborative but efficient manner. Through this interaction a more patient-centered approach could be possible in future patient encounters (Bitton, 2018). This relationship affords practitioners and patients a rapport that is positioned to improve quality from a patient-centered perspective. The use of a patient-centered approach hopes to encourage positive and effective change throughout the system in which primary care is based. 


A Strategic Approach to Improvement

Approaches to quality improvement often use quantitative methods such as surveys or questionnaires to capture specific dimensions of improvement. These types of approaches can be helpful but often lead to a lack of voice from practitioners and patients. The current approach to patient-directed quality improvement could be guided by a mixed method approach using a sequential explanatory design or a concurrent triangulation design. This type of design would allow for quantitative data to be generalizable; while also supporting the development of meaning and voice from patients to identify what is working, and what improvements they would like to see for future visits. The qualitative component of this design could be comprised of brief semi-structured interviews using randomly assigned patients selected form the quantitative portion.


Brief Illustration of Intervention in Primary Care

In this patient-centered approach, every patient in a given time span could be given a brief survey about how they felt their visit went. This survey could be tailored to patients only receiving BHC services or every patient to encompass all services offered within the primary care setting. Once this quantitative process was completed and analyzed you could then randomly select from those who completed the survey. In this sample, you could invite them to think about a specific process in their experience. From this invitation you could ask them to focus on one of the many services offered in primary care such as nursing, BHC services, physician, or lab work and tailor your questions to that service.

After evaluating the responses to the qualitative portion of this design you could use both sets of data to develop an improvement strategy based on what is currently working for patients and what processes might need to be improved for a better patient experience. This experience has the potential to increase patient satisfaction with services and adherence to practitioner recommendations and interventions.

This emphasis on patient-centered improvement using a mixed method design is a slight shift from existing research. This shift in approach allows patients to be at the center of improvement with the hope that it improves the system and patient outcomes. This intervention would help to add patient voice to quality improvement strategies and expand the emphasis on quality improvement outside of the interprofessional system of primary care practitioners. Through this experience patients are afforded a form of systemic buy in, as their perspectives are being sought and used to improve the system that they belong to.


Alexander Young, M.A., LPC is a counseling doctoral candidate at Our Lady of the Lake University in San Antonio, Texas. He earned his master’s degree from the University of Texas at San Antonio in Counseling. He is currently completing his last practicum prior to internship at the Brady Green Clinic in San Antonio, Texas with Dr. Stacy Ogbeide.  

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The Cost Effectiveness of Embedding a Behavioral Health Clinician

Posted By Debra McQueeney, Thursday, July 19, 2018

When I first began working as a psychologist in primary care, I was embedded in a busy, 14-provider primary care practice in Kansas City with a 35,000 member panel. I developed a canned speech to explain to friends and family exactly what my new job entailed. My explanation was met with confusion, enthusiasm and doubt as people tried to wrap their heads around the idea of behavioral health care delivered inside the primary care exam room. I am reminded of these reactions by a quote shared with me by Peggy DeCarlis, former COO and CIO of New Directions Behavioral Health, when talking about integrated behavioral health:


“It’s the same each time with progress.

First they ignore you, then they say you’re mad, then dangerous,

then there’s a pause and then you can’t find anyone who disagrees with you.”

- Tony Benn, English politician


The results of our work from 2014-2016 were recently published in the article, The Cost Effectiveness of Embedding a Behavioral Health Clinician into an Existing Primary Care Practice to Facilitate the Integration of Care: A Prospective, Case-Control Program Evaluation (Journal of Clinical Psychology in Medical Settings, Kaile et al). In addition to improving health outcomes and reducing stigma, we found that embedding behavioral healthcare into primary care resulted in a significant cost savings: 10.8% when analyzed by Milliman in a comparison of medical, behavioral and drug claims relative to expected costs from Blue Cross Blue Shield analyses of cost trends for the same period.


 Now four years after the program began, I am compelled to reflect on the many things I learned from practicing in primary care.


I learned about the reality of stigma … and its consequences … by witnessing what is gained by reducing it. Seeing patients for behavioral health conditions in the context of their primary care setting helps them feel less ashamed. When their medical provider endorses this service and approaches mental health with an objective, matter-of-fact mindset, it has the effect of placing mental health issues in the same non-judgmental arena as medical conditions. As a psychologist coming from a thriving private practice, I was shocked to realize that had I not been in a primary care setting, the stigma attached to mental illness would have prevented a large population of people from meeting with me.


I learned that most chronic, serious medical conditions have co-morbid behavioral health components.


I learned it is incredibly rewarding to provide psychoeducation! Rather than needing weeks of therapy, a well-timed, accurate, scientifically-based brief intervention with a patient in the primary care setting provided immediate, effective symptom relief. And because people go to primary care at a high point of distress, they have the strongest motivation and readiness to change. As a result, my psychosocial intervention had a greater likelihood of long-term symptom relief.


I learned that reducing depression and anxiety is the bread-and-butter of integrated behavioral health; additionally, specialized services like weight management (with a definite therapeutic component) or substance use disorder treatment can move the needle on health outcomes. Empowerment of the patient, listening, and giving time to each person are central components to effective integrated behavioral health.


I learned that a physician champion is essential to getting any integrated program off the ground. This individual teaches and leads his or her colleagues into improved management of mental health conditions and chronic medical diseases with behavioral components. Once the concept was understood and utilized, primary care providers reported a high degree of satisfaction with it.


A recent poll published by the American Psychiatric Association reveals we are an anxious nation. In fact, almost 6 percent of people in the U.S. will be diagnosed with severe anxiety disorder at some point in their lifetime. We worry about finances, safety and our health. Even our children are developing anxiety and depression. In response to this trend, public and private initiatives are promoting behavioral health integration as an important priority. From my perspective, we are headed in the right direction. Behavioral health integration can make a difference to a country lying awake at night from worry and eating our way into a host of dangerous medical conditions. Primary care is an opportunity for behavioral health providers to be just the right person, at the right time, for the man or woman waiting for you in the exam room.


Debra McQueeney, PhD, is a psychologist who has partnered with New Directions Behavioral Health (New Directions) to promote the integration of behavioral health services in primary care.  She is currently a behavioral health consultant for Spira Care, an innovative approach to total person health care piloted by Blue Cross and Blue Shield of Kansas City and New Directions. Debra is committed to providing access to behavioral health care that promotes healthier lives and improved patient experience in the primary care setting.


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PCBH Part 3: Discussion of a Recent Study Involving the PCBH Model and Larger Implications

Posted By Meghan Fondow, Tuesday, July 3, 2018

 This is the third in a three-part series on PCBH research. Click here for part 1 and part 2

Research exploring the Primary Care Behavioral Health (PCBH) model has been increasing in the literature.  However, the body of work on this specific model of integrated care is still being built, and many unanswered questions remain.  There is consensus in the field that more study and research is needed to expand our understanding of the effectiveness, efficacy and systemic implications of PCBH work.  Gaining a more precise understanding of these issues will have policy implications on our health care system as well as on funding resources.  Research demonstrating effectiveness could assist in increasing implementation of this model of integrated care into the systems best suited for it, and expand funding resources to support the work.  Additionally, studies exploring the systemic implications for the PCBH model will increase our understanding of the complex, inter-related variables that impact access to behavioral health care and the effectiveness of this care.


One recent study that has scratched the surface of the systemic implications of PCBH work was conducted in Madison, WI (Serrano et al, 2018).  This study utilized a data set that included primary care utilization data for an FQHC with 3 sites that utilized the PCBH model and for a primary care clinic that did not utilize PCBH.  Data was also collected on ED encounters for a subset of patients of the same four primary care clinic who were with a mental health diagnosis.  The study was pre-post in nature, exploring ED utilization before and after PCBH implementation at the FQHC clinics.  The primary care clinic (which did not utilize PCBH served as a control arm.  We found that one FQHC site did show a decrease (11.3%) in the ratio of ED visits to primary care encounters, and the other 2 FQHC sites did not.  We also discovered, not surprisingly, that research on health care systems is highly complicated, with many layers of intersecting variables that can make interpretation of data challenging.


One specific challenge was finding a control site that controls for all relevant variables.  There are several reasons for this.  Finding similar clinics with and without PCBH, that have the same demographics, geographic area, same insurance mix in the same time-period would be extremely challenging if not impossible.  These are simply too many variables to control in a “real-world” situation, particularly considering health care disparities that exist both nationally and regionally.  The lack of adequate controls can make it difficult to interpret cause and effect in data sets.


Ideally a controlled study could be conducted to help move the field forward and deepen our understanding of the model.  However, this would be extremely challenging to conduct.  For a formal randomized clinical trial, there would need separate clinics in the same geographic region with the same demographic mixes and insurance mixes in the same time period, one that has implemented PCBH and one that has not.  They would need to have similar services, provider types, access to care.  Of course, a formal randomized controlled trial, patients would need to be randomly assigned to treatment conditions (in this case clinics), taking away patient choice and likely not realistic.  Instead, it seems that more naturalistic studies will be more realistic, where clinics are compared but patients themselves are choosing the clinics.  It is recommended that as many factors as possible be controlled for in the analyses, including patient demographics, diagnoses, contextual factors, payor mix, geography and so on.  The more that is controlled for, the more specific the results can be, with less room for multiple interpretations. 



Meghan Fondow PhD is the Primary Care Behavioral Health Manager and Clinical Training Director at Access Community Health Centers in Madison, WI.  Meghan has worked as a BHC at Access for over 10 years, and also holds an adjunct clinical faculty appointment with the Department of Family Medicine and Community Health at the UW-Madison School of Medicine and Public Health.  

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PCBH Research Part 2: Does Primary Care Behavioral Health Improve Patient Outcomes?

Posted By Kyle Possemato, Monday, June 18, 2018

This piece is the second in a series of posts highlight research on the Primary Care Behavioral Health model. Click here for the first post.

Why and how did we do this review?

 My colleagues and I at the VA Center for Integrated Healthcare recently published a systematic review to assess the research evidence on how patients benefit from Primary Care Behavioral Health (PCBH) services.  As PCBH providers, we regularly see patients who benefit from our services, however, prior to this publication no study had systematically assessed the strength of the evidence for PCBH.  For this review we defined PCBH as services provided within primary care by licensed independent behavioral health providers with the goal of ongoing communication and collaboration between the behavioral health provider and other primary care members.  We focused our review on studies that investigated how PCBH is typically delivered in clinics, not on special interventions delivered for the purposes of research.   The review included 36 articles that reported on the patient outcomes of 1) access and utilization of care, 2) changes in symptoms or functioning, and 3) patient satisfaction.


What did we find?

The strongest evidence emerged for increased access and utilization of care.  Patients who received PCBH services get quicker access to care, attend more sessions, and are more likely to step-up their care to specialty mental health then patients who do not receive PCBH.  The studies that assessed changes in patient symptoms/ functioning and patient satisfaction tended to find positive results, however these studies were small and lacked comparison groups. In sum, we can be confident that PCBH improves access to care.  Also, there is early evidence that PCBH leads to decreased symptoms and improved functioning, but the methodological quality of this research is weak.


What does this mean for primary care behavioral health providers?

The implementation of PCBH is ahead of the research evidence and PCBH providers can help to close this gap.  Data from rigorously designed program evaluations can help the field to better understand how patients benefit from PCBH.  A recent article by Drs. Funderburk and Shepardson (2017) provide a practical guide on how PCBH providers can conduct feasible, yet rigorous program evaluation.  Also, more randomized clinical trials are desperately needed.  PCBH providers can partner with health services researchers at medical and academic institutions to get pragmatic clinical trials conducted within their clinics. Many of us are passionate proponents of the PCBH model because we see that it meets the needs of a wide variety of the patients in our clinics.  However, for PCBH services to continue to expand to new settings and new populations policy makers will need better evidence that these services benefit patients.



Possemato, K., Johnson, E.M.,  Beehler, G. P., Shepardson, R. L., King, P., Vair, C. L., Funderburk, J. S., Maisto, S. A.,  Wray, L. O. (in press). Patient Outcomes Associated with Primary Care Behavioral Health Services: A Systematic Review. General Hospital Psychiatry. doi: 10.1016/j.genhosppsych.2018.04.002

 Funderburk, J. S., & Shepardson, R. L. (2017). Real-world program evaluation of integrated behavioral health care: Improving scientific rigor. Families, Systems, & Health, 35(2), 114-124.


  Kyle Possemato, Ph.D. is the Associate Director for Research at the VA Center for Integrated Healthcare 

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PCBH Research Part 1: A Pilot Study Across the U.S. Air Force

Posted By Ryan Landoll, Monday, June 11, 2018

The Department of Defense (DoD) was one of the original adopters of the Primary Care Behavioral Health (PCBH) model. Over 20 years ago, the United States Air Force (USAF) piloted its “Behavioral Health Optimization Program” or BHOP at a single Air Force Base. Since 1997, the program has expanded across 72 Air Force facilities and since 2013 has been incorporated into medical care across all DoD services. While there are many unique features of the Military Health System (MHS), its beneficiaries, which include not only Active Duty service members, but also retirees and their families, represent a diverse cross-section of America. DoD facilities are scattered throughout the United States, in populous cities and rural towns. As such, the USAF provides an ideal setting to study aspects of integrated care that apply across the diverse healthcare landscape.


A recent study published in Translational Behavioral Medicine describes the results of a quality improvement project undertaken by the USAF using PCBH within a stepped care framework. Three treatment facilities, chosen across the country to represent both rural and urban care facilities (ranging from 13,000 beneficiaries up to over 54,000), participated in this pilot. Without any additional resources (e.g., no hired staff), these clinics reallocated a behavioral health provider and behavioral health technician (equivalent to a medical assistant with exclusive behavioral health training) from specialty mental health to primary care. They also ran an aggressive marketing campaign to funnel new patients into primary care as opposed to specialty mental health. In one year, these sites doubled the number of behavioral health encounters, reached 150% more of the beneficiary population, and saved community mental health costs by over $100,000. These results far outpaced their peer institutions while maintaining high levels of patient satisfaction.


 Read the study here to learn more about this innovation.



Ryan R. Landoll, Ph.D., ABPP, is the Assistant Dean for Preclinical Sciences at the Uniformed Services University. His research broadly focuses on two main topic areas: primary care behavioral health, and adolescent peer relationships (i.e., romantic relationships, friendships, and peer victimization, including cyber victimization) and internalizing disorders (i.e., social anxiety, depression). Dr. Landoll currently heads the Military and Sexual/Reproductive Health (MARSH) Research Program at the Uniformed Services University.


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Taking the Hamster off the Wheel: How My BFEF Experience Helped Me Get My Feet Back on the Ground

Posted By Max Zubatsky, Monday, May 14, 2018

At the beginning of my year in the Behavioral Science/Family Systems’ Educator Fellowship (BFEF), I had  a gut feeling that I was “hitting the wall.”  The burnout week had arrived. This occurred both in my personal and professional life.  When I started my job 4 years ago, I hit the ground running and tried to offset my burnout by working even harder.  I quickly learned that this was not a successful coping skill.  As my second year of work progressed, I got back into my past hobbies of running and art. These were both therapeutic and a way to escape from being fully consumed by my job.  I still felt that as a new faculty member, I needed to keep reaching a higher bar to meet the constant expectations of the university.  I not only ramped up my workload, but my hobbies as well.  Now, my coping activities had turned into stressors themselves! I was doing too many things on hyper drive, while continuing to plan for upcoming things in my career. The hamster was pedaling so hard, that the wheel was now starting to break.   

During fellowship year, I decided to change my mindset around any potential onset of burnout.  I found the support of my small group and mentors was instrumental in that.  Here we all were just trying to do the best that we could and all having moments of insecurity.  We slowly could bolster each other up and help each other find small meaningful things in each work day.  I found myself trying to act quicker in the moment when any difficult work and personal issues arose.  Heck, if I emphasize these skills to my patients, then why was I not “practicing what I preached?” I often looked to comedy, inspirational quotes or human interest stories to put my life in context. 

I have to keep being mindful of my privilege as a white male professional.  Some of my hardest days would still be embraced by some of my patients and families that I treat in my practice and in the community.  These patients would be grateful for those days that challenged me but perhaps were just an everyday occurrence to others who did not have as much as I did.  It’s a constant reminder to myself of, “Max, these are issues that you are sweating way too much about.” Putting my life in perspective forces me to lessen my strict expectations that I often set for myself. Even if I can make 1-2 small breakthroughs during a tough week, these are moments that are meaningful and that I can pay forward to my students and residents.  The guidance from my mentors definitely made a difference in this new perspective towards my work.  Not looking over small breakthroughs or successes has now made me become more present-centered as a person and professional.  Whereas in the initial months of my job I was doing nothing but planning and coordinating future tasks, I now embrace more of the virtues that each day brings. 

I learned so much from my small group colleagues and mentors this year around momentum and self-motivation in our lives. A number of Ted Talks that we discussed as a group covered the need for self-balance and recognizing successes in life from different perspectives. Many in the group explained the ways that we can push through challenges or barriers at work, whether it be difficult leadership, team dynamics, resistant residents or overwhelming projects as a new faculty member. Before the fellowship experience, I was doing more self-guided learning and not enough team building, sharing, collaborating and group thinking.  Now, I make it a priority to run creative ideas past other faculty, create brainstorming sessions with residents and students, and facilitate reflection and observation activities with multiple learners. One thing that really stuck with me was that much of our expectations for our job and others at work can be largely determined by our own mindset. When I now face challenges or problems, I embrace them as an opportunity to learn more as both a person and professional. 

Little did I know that one of my most valuable fellowship lessons would be to slow down and take time to appreciation small things in life.  As early career faculty, we often think we need to speed up and do more in order to constantly make our mark.  My small group mentors continually reminded us that we need to set achievable work goals that are attainable and manageable. They encouraged us to be open to making mistakes and being vulnerable to learn from these teachable moments.  It’s important to grow from the challenges and the mistakes, but equally important to celebrate the successes, both large and small.  As Ralph Waldo Emerson puts it, “Bad times still have a scientific value. These are occasions a good learner would not miss.”  The hamster now gets on the wheel at his own pace, realizing that this journey is a marathon and not a sprint.

  Max Zubatsky, PhD, LMFT is Assistant Professor in the Medical Family Therapy Program at the St. Louis University School of Medicine.  

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The Pre-Rehab Checklist: How to Get the Most Out of Your Recovery

Posted By Caleb Anderson, Tuesday, May 1, 2018

In the United States right now, there are over 14,500 rehabilitation centers for people recovering from drugs and alcohol. These centers offer a range of treatment options, including detox and inpatient or outpatient rehab. With outpatient rehab, addiction specialists and nurse practitioners visit people in their homes, allowing them to continue with their normal routine outside of treatment. Usually, outpatient is recommended for patients with mild addictions. Inpatient programs, on the other hand, are designed to help people who suffer from severe addictions. These generally begin with some form of medically-managed detoxification – in layman’s terms, “withdrawal.”


Withdrawal syndrome is essentially your body restoring its chemical balance after the cessation or decrease of your regular intake of drugs or alcohol. The symptoms differ according to each substance, ranging from discomforting to excruciating, to possibly fatal. Alcohol withdrawal, for one, may begin 12 hours to a few days after you stop drinking. Mild symptoms include nausea, sweating, shaking, and high blood pressure. Intense trembling and hallucinations are just a few of the severe symptoms. Delirium tremens (“DTs”), meanwhile, comprise all the signs above, and cause seizures. If untreated, DTs can lead to death. Symptoms of withdrawal from illicit drugs are chillingly similar – drenching sweats, hallucinations, seizures, and death.


Keep in mind, those are the dire results if an especially bad withdrawal goes untreated by professionals. But with the stakes so high, it’s important for anyone with an addiction to go to rehab, and to be prepared before you check in. Following the steps below will assist you in focusing on your recovery.


Planning Your Absence

Before you sign into rehab, it’s important to determine your schedule. Some facilities offer programs that last just a few days – long enough for a patient to detox, but not fully recover. Thirty-day programs are usually considered “short-term”: sufficient for an addict to dry out and feel stable. The National Institute on Drug Abuse, however, recommends a 90-day timetable for individuals to combat their habit. That said, few people can clear their calendars for three months. So you’ll need to decide if rehab is worth quitting your job or significantly disrupting your employment.


Money is another consideration. Medicare covers certain aspects of rehab, and some nonprofit facilities offer low-cost admission, but most treatment centers are thousands of dollars a month. Outpatient stays can cost $3,000-$10,000 (90 days), while inpatient is $5,000-$20,000 (30 days). Per day, the price-tag of detox can run to $250-$500. Make sure that you – or someone you know and trust – can afford the treatment center before you sign up for it, and that your bills are covered in your absence. You’ll want the least amount of stress possible during your recovery, including financial stress, so that you stay at rehab can be an oasis of calm and self-reflection.


Finally, let your friends, loved ones, and coworkers know where you’re going, so that no one is worried about you. One of the most destructive features of addiction is that few addicts admit to themselves they have a problem. That’s why rehabilitation is a physical ordeal, but also requires tremendous honesty and self-confrontation. That you’re willing to ask for help is itself an accomplishment, which other people will recognize. Relieved that you’re addressing the core dysfunction in your life, they’ll probably send you letters or visit you or call, just at the time you need support the most.


Figuring Out Pet Care

One final call to make before leaving is what to do with your pets. If you’re living with or near family, a spouse, or roommates, they might be able to feed your dog or change your cat’s litter box. Expect to pay about $14-19 per hour for a pet sitter to look after even animals that require minimal care, like a turtle or a goldfish. And if you have a dog, you’re in luck. Nowadays the internet is rife with dog service apps that connect you with dog therapists, dog groomers, dog walkers, and more.


Usually, you’ll need to shell out $20-$25 to pay someone to walk your dog for 30 minutes. Twice a day, for the 30-90 days that you’re gone, that can add up, as can the many dog-boarding options out there. Kenneling your dog is usually priced at $25-$45 a night, while more “ritzy” dog hotels ask $50 per night. A pet sitter is about the same. The most reasonable choice is in-house boarding, where people who are usually dog-lovers themselves charge $15/night to hang out with your dog.


More and more, treatment centers are starting to let people check in with their dogs, since pets have been shown to provide a range of benefits to their owners. Some of these perks include assuaging your sense of loneliness, nudging you into a more active lifestyle, and even elevating your serotonin and dopamine levels. (Code for making you a lot happier.) Considering the joy and gentleness that pets introduces in our lives, it makes sense that rehabilitation centers allow them to join their owners to help allay a sense of fear and isolation.


Sometimes an addiction is so severe that you’re forced to face it, the same way you don’t have time to balance your checkbook before rushing to the ER. But for the best experience in rehabilitation, make sure that you’re truly ready for it. That means caring for your pets, arranging your finances, and letting your friends and family know where you are. That you have peace to face your addictions within a refuge from the volatility that drugs introduced into your life is vital to your stay, and to your long-term recovery.

  Caleb Anderson developed an opiate addiction after being in a car accident. He’s in recovery today and wants to inspire others to overcome their addictions. 

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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.