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Houston, Here We Come

Posted By Matthew P. Martin, Tuesday, October 3, 2017

The 2017 Collaborative Family Healthcare Association (CFHA) Annual Conference will soon take place in Houston, a city in recovery from Hurricane Harvey’s record-smashing rainfall and floods. CFHA members are proud to be in Houston this year and continue to support all the recovery efforts for everyone affected by recent natural disasters.


The Annual Conference is known as the premier yearly meeting for medical providers, behavioral health professionals, foundations, payers and other health care professionals to meet and share the latest innovations in the integration of behavioral/mental health and medicine. Our participants work in primary care, specialty medical settings, hospitals and mental health centers. Our presenters are our renown expert members who bring a practical and passionate, real-world perspective.


So, what’s in store for you this year? The main conference will start with a look into the future of integrated care by CFHA’s new Executive Director, Neftali Serrano. On Friday, Len Nichols, Director of the Center for Health Policy Research and Ethics, will share his thoughts on future healthcare reform in the US. Be sure to grab a seat before all the policy wonks do! Finally, the very first episode of CFHA Shark Tank will take place Saturday morning. Clinician innovators will enter the tank to pitch ideas for integrated care in a variety of areas.


Beyond plenary talks, there are pre-conference sessions, numerous concurrent sessions, a job fair, poster sessions, task force groups, and speed mentoring. Perhaps best of all is the CFHA Debate which is back this year and promises to address some major questions in the field like “Is the Primary Care Behavioral Health model evidence-based?” Come see the light-hearted action that will certainly entertain and inform you at the same time.


To make the most of the conference, visit the CFHA conference webpage to begin selecting the sessions that most interest you. There are several tracks for sessions related to a particular topic like pediatrics, medically unexplained symptoms, ethics, research and evaluation, and Texas. Also, you can download the smartphone application sent to you via email following your registration. You can use the app to create your own conference schedule and receive real-time updates.


It’s a good time to meet in Houston. See you there! 

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What is Population Health?

Posted By MHA@GW Staff, Monday, September 11, 2017

This is the second of a two-part series on Population Health. This post is a reprint of a piece from the MHA@GW Blog. Click here for the original post. Reprinted with permission. MHA@GW is the online master of health administration from the Milken Institute School of Public Health at the George Washington University. 

“Population health.” It is a term that is widely used in the health care world, but not universally understood. Some definitions of population health emphasize outcomes. Others focus on measurement. Still others emphasize accountability. So what does population health truly mean? Who is responsible? What impact does it have on our current health care environment?

In recognition that there is no uniform definition of this important and emergent concept, we sought out to create a new dialogue featuring a variety of thought leaders in the field. We reached out to over 100 health care leaders and asked them to define the term “population health.” What follows are their responses.

What We Learned

The concept of population health first came about in 2003 when David Kindig and Greg Stoddart defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” While accurate, some complain this definition focuses strictly on the measurement of health outcomes without explaining or acknowledging the role that health care providers must take to impact those outcomes.

Population Health Graph_V3_2

Our survey reflected that notion. Of the 37 leaders who participated, only two people directly cited Kingdig and Stoddard’s original definition. While interpretation and understanding of the phrase “population health” differed greatly in the responses we received, many did view it as an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve. Two other key trends and questions we observed include:

  • A question of responsibility. Do the health outcomes of a specific population rely on the behaviors of the population? The actions of the provider? Or both?
  • A take on Triple Aim. Several participants referenced the Triple Aim Initiative, an approach developed by the Institute for Healthcare Improvement for optimizing health system performance.

What’s Next

While we may not have reached a universal consensus on what “population health” means, we discovered that now is the time to think differently — not only about the definition of population health — but also about the way health care is delivered. In our ever-evolving health care environment, perhaps the “traditional way” may not be the right answer.

Population Health Word Cloud_V2

We welcome discussion regarding the ideas we present here and look forward to creating an ongoing, open dialogue about the role population health plays in the health care industry today.


  1. Wayne Brackin, Chief Operating Officer and Executive Vice President, Baptist Health South Florida
  2. Paul Brashnyk, MPH, Interim Director of Clinic Operations, UW Neighborhood Clinics
  3. Fred L. Brown, LFACHE, Chairman, Fred L. Brown & Associates, LLC
  4. Brian Churchill, Director of Clinical Content and Decision Support, PeaceHealth
  5. Todd M. Cohen, Director, AtSite Inc.
  6. Dr. Kenneth Cohn, CEO, Healthcare Collaboration
  7. Dr. Dennis R. Delisle, Director of Operations and Support, Thomas Jefferson University Hospitals
  8. Gigi DeSouki, MHA, Founder/CEO, Wellness On Wheels, Inc.
  9. Jack Friedman, CEO, Providence Health Plan
  10. Richard J. Gilfillan, MD, President and CEO, Trinity Health
  11. Jim Goes, Managing Partner, Cybernos LLC
  12. David Harlow, Principal (Attorney & Consultant), The Harlow Group LLC
  13. Jay Henry, Chairman & CEO, The James Marshall Group
  14. Dr. Patrick Herson, President, Fairview Medical Group
  15. Jay Higgins, Senior Director of Network Strategy and Surgical Program Development, Brigham and Women’s Hospital
  16. Ryan Jensen, CEO, The Memorial Hospital of Salem County
  17. Tammie Jones, Senior Health Policy Officer, US Army Office of The Surgeon General
  18. Dr. Christy Harris Lemak, Professor and Chair, the Health Services Administration Department at the University of Alabama at Birmingham
  19. Dr. Stephen Martin, Executive Director, Association for Community Health Improvement
  20. Dr. Larry Mullins, President and CEO, Samaritan Health Services
  21. Roy J. Orr, Director of Business Development and Supply Chain Services, Salem Health
  22. Joseph Paduda, Principal, Health Strategy Associates
  23. Bonnie Panlasigui, Chief Administrative Officer, Alameda Hospital
  24. David C. Pate, MD, JD, President and CEO, St. Luke’s Health System
  25. Janet Porter, Principal, Stroudwater Associates
  26. Barry Ronan, President & CEO, Western Maryland Health System
  27. David Rubenstein, FACHE, Clinical Associate Professor, Texas State University
  28. Kathryn Ruscitto, CEO, St. Joseph’s Hospital Health Center
  29. Marie Savard, MD, Managing Director of Health Care Practice, Diversified Search
  30. Dr. Nancy Seifert, Instructor, Oregon State University
  31. Dr. Peter Slavin, President, Massachusetts General Hospital
  32. Mari K. Stout, MHSA, Quality Improvement/Provider Engagement Specialist, ATRIO Health Plans
  33. Amy Stowers, CEO, OptimizeIT Consulting
  34. Quint Studer, Founder, Studer Group
  35. Bahaa Wanly, Administrator, UW Medicine
  36. Jennifer Weiss Wilkerson, Vice President, MedStar Health
  37. Dr. Stephanie Works, Senior Medical Director, Providence Medical Group


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Population Health and Big Data

Posted By Erin Sesemann, Monday, August 28, 2017

Population health takes on the challenge of looking at whole groups (i.e., populations) with the goal of improving the health and preventing sickness in entire populations.1 Upon learning the term, the idea of population health made sense to me; yet, I still questioned how I, as a medical family therapist, could help intervene on the population level when my work has focused so much on families, couples, and individuals.


Even from my training as a psychological researcher, the term “population” tended to be theoretical and captured through a representative sample; thus, making claims about populations usually led to problems with generalizability. Are my interventions valid and effective for people beyond this patient? Do the results of my study really apply to whole populations?


Needless to say, it was a little intimidating to begin thinking in terms of population health.


As I sought answers to how I could begin contributing to population health, I stumbled upon its many parts:1,2,3


·      Populations are defined by geographic regions

·      Populations are defined by characteristics (i.e., determinants) of health (e.g., race, class)

·      Populations are based on aggregates of individuals

·      Populations are based on neighborhood-and-community-level factors (e.g., access to care)

·      Population health discards individual identities for a broad understanding of health

·      Population health narrows down to individual characteristics (e.g., socioeconomic status, race) to identify specific risk factors

·      Population health addresses the absence of disease

·      Population health addresses overall well-being


All these parts of population health sometimes left me confused… What is the definition for population health and who is responsible for it? From my research, it seems there is agreement that there are multiple definitions for population health and that one profession is not solely responsible for it. Many professions are called upon to promote population health together to address its many integral areas:3


·      Health care

·      Public health (e.g., clean water)

·      Social environment (e.g., culture, income, education, employment, social support)

·      Built and physical environments (e.g., street layout, land-use)

·      Genetics

·      Individual behavior (e.g., smoking, physical activity)


When seeking information on health care tools specifically, I found that many suggestions surrounded using the electronic health record (EHR). The recommendations started by suggesting we choose an EHR with population health capabilities, such as:


·      Patient registries: an organized method used to collect and cluster information about a specific group (e.g., categorized by health condition or health determinant)

·      Care pathways (aka clinical pathways): a tool that tracks all providers’ treatment plans per patient, identifies the most common and best practice interventions from the aggregated population, and sends back prompts in the EHR throughout the patients’ treatment to suggest particular interventions or remind providers to check-in on patients’ results

·      Care analysis: tracking care and supplying pop-up messages for missed treatments or skipped standard-of-care protocol

·      Risk stratification: process of identifying which patients are high risk, medium risk, and low risk for particular problems (e.g., recurrent depression or readmission)

·      Coordinating care or referral tracking


A great deal of what I found, however, also stressed the importance of collaboration with big data analysts as our most important tool.4,5


Here in CFHA, we are well-acquainted with the term, collaboration, as we are physicians, patients, clinicians, educators, nurses, behavioral health professionals, family members, social workers, advocates and researchers all working together to promote quality and cost-effective models of healthcare delivery. Now, it seems, we are being called upon to invite new members to our team: big-data practitioners and data scientists.5


To answer questions/conduct research, big data analysis uses inductive research methodology to track patterns in data and then create models or find answers based on what the data are showing. Inductive methodology is in contrast with deductive methodology, which begins with an idea about what the patterns are (i.e., theory) and tests hypotheses based on that previous knowledge or assumptions to establish a model or find answers. While not often used in medical research, the inductive methodology of big data has the potential to help us piece together the vast amounts of information collected through EHRs. Big data is designed to deal with large quantities of data that have a variety of forms (i.e., text, integer, date) and that are being entered quickly yet possibly inconsistently due to human or machine error.5


To me, this sounds a lot like data being entered into EHRs.


After taking a class on databases, named Database Systems in Health Care, I can tell you, if you’re trained in traditional psychological statistics like I am, that it may not be easy to begin thinking in terms of big data and databases. It almost felt like learning a new language.


By the end of the class, however, I had gleaned enough to knowledge to know that finding a way to work through the language barrier is worthwhile because together we can harness the vast amounts of data in EHRs through the power of Big Data to help promote better health for entire populations.


As advocates for quality models of healthcare delivery, we can continue to petition to improve our ability to address population health through investing more time, money, and training in our information technology systems in order to:

1.     Improve training in data science

2.     Hire qualified big data practitioners

3.     Capture and analyze our own data (e.g., ability to track patient adherence, cost of services)

4.     Improve our ability to communicate/share information (e.g., with other healthcare providers, policy makers, media, institutional leaders1)


Technology has made astounding advances in the treatment of medical conditions within populations. Now, let us invest in our ability to manage, measure, and share that medical information for the sake of population health.


1Harris, D., Puskarz, K., & Golab, C. (2015). Population health: Curriculum framework for an emerging discipline. Population Health Management, 19, 39-45. doi:10.1089/pop.2015.0129

2Gourevitch, M. N., Cannell, T., Boufford, J. I. & Summer, C. (2012). The challenge of attribution: Responsibility for population health in the context of accountable care. American Journal of Public Health, 102, S322-S324.

3Kindig, D. & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93, 380-383.

4Krumholz, H. M. (2014). Big data and new knowledge in medicine: The thinking, training, and tools needed for a learn health system. Health Affairs, 33, 1163-1170. doi:10.1377/hlthaff.2014.0053

5Attride, K. (2015). Big data enables population health. In M. M. G., Mayzell, Population Health: An Implementation Guide to Improve Outcomes and Lower Costs (1st Ed.). Boca Raton, US: Productivity Press. Retrieved from


Erin Sesemann is a current Ph.D. student in Medical Family Therapy at East Carolina University. She has experience working in community mental health agencies, private practice, and integrated behavioral health care in primary care. She graduated with her M.S. in Marriage and Family Therapy from Oklahoma State University in Stillwater, OK.  

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News & Research

Posted By Matthew P. Martin, Tuesday, August 8, 2017


See what’s happening with integration in your neck of the woods:

New Jersey: Making Integration Happen

Integrated behavioral health is receiving quite a bit of attention in New Jersey. A recent opinion piece states the following: “Creating a more efficient and coordinated system that treats the whole person is the right move for New Jersey and especially for patients who will benefit from having their behavioral and physical needs met in the same hospital clinic or community health center.”

Gov. Chris Christie wants to transfer responsibility for New Jersey’s four state psychiatric hospitals, community-based mental health and addiction services, and other behavioral health programs from the Department of Human Services to the Department of Health later this summer. The governor’s plan is designed to improve government efficiency and coordination, and enable patients to receive more complete and effective care by better integrating behavioral and physical health services.

Moreover, the Nicholson Foundation is interested in funding integrated care in New Jersey.


Michigan: Integration Plan Considered Controversial

“What is going on at the Michigan health department about designing four pilot programs to test a controversial plan to combine physical and behavioral Medicaid services among mental health agencies, providers and HMOs?” says Jay Greene of Crain’s Detroit Business newspaper.

Read more using the links above.


California Looks to Support Behavioral Health Data Exchange

“The California Health & Human Services Agency’s Office of Health Information Integrity includes a litany of use cases in the recently published State Health Information Guidance to illustrate numerous instance where sharing protect health information is feasible legally and in the patient’s best interest…

Because patients with behavioral health conditions most likely receive treatment from a multitude of providers across disciplines, their mental health or substance abuse data must be part of an integrated care plan that gives members of the care team access to important information.”


Hawaii: Call for More Integrated Care

Washington State: Integration Saves Lives

Arizona: What is Integrated Care and Why Does it Matter



Here are some of the latest findings on integrated care:

Embrace, integrated primary care for older adults: Embrace slightly improved the perceived quality of care, particularly for elderly people with complex care needs for whom case management was organized. Caregivers judged implementation of integrated care to be greatly improved, though there was still room for further improvement. Further research should be carried out into the effectiveness of integrated primary care for the elderly on health, service-use and healthcare costs.


Community Health Workers Bring Cost Savings to Patient-Centered Medical Homes: The Integrated Primary Care and Community Support (I-PaCS) model, which integrates community health workers (CHWs) into primary care settings, functions beyond improved coordination of primary medical care to include management of the social determinants of health. The purpose of this study is to simulate the effects of the PCMH and I-PaCS models over a 3-year period to account for program initiation to maturity. The PCMH is expected to realize a 1.7% annual savings by year three while the I-PaCS program is expected to a 7.1% savings in the third year. The two models are complementary, the I-PaCS program enhancing the cost reduction capability of the PCMH.


Validating the Rainbow Model of Integrated Care Measurement Tool: This study aimed to validate The Rainbow Model of Integrated Care Measurement Tool (RMIC-MT) which assesses, using a self-administered questionnaire, micro level (clinical), meso level (professional and organisational), macro level (system) and enabling (functional and normative) aspects of integrated care. Preliminary results suggest that the RMIC-MT is both a reliable and valid tool for assessing integrated care in different integrated care settings. The results of the construct and reliability analysis across countries will be presented, interpreted and discussed.


Primary Care Physicians’ Ability to Detect PTSD: This investigation sought to determine whether the complex nature of PTSD, particularly the frequent presence of comorbid physical symptoms that may overshadow PTSD, makes the disorder difficult to detect in primary care settings. These results suggest that primary care physicians are fully capable of accurately identifying PTSD when it presents, regardless of whether the presentation is straightforward or complex. However, limitations must be taken into consideration when interpreting the results, including lack of variance in detection rates.


Ethical and legal issues in integrated care settings: Case examples from pediatric primary care: The purpose of this article is to examine salient ethical and legal dilemmas that may emerge in pediatric IPC practice. These issues are examined through the use of 4 case illustrations that collectively address issues related to consent for services among pediatric populations, confidentiality, scope of practice for the pediatric IPC psychologist, and multiple relationships. We apply an adapted ethical decision-making framework to highlight practice points drawn from each of these cases.


Family therapy as an integrated care model for pediatricians: Family therapy is an important therapeutic modality for children and adolescents with behavioral health problems and disorders. Research studies have consistently demonstrated the efficacy of family therapy for select pediatric patients and their families. Principles of family therapy are presented in this discussion. Examples based on actual cases illustrate what family therapists do and how they might integrate their expertise into cases, while working side-by-side with pediatricians.

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Hello CFHA. It's Me, Shared Care.

Posted By Jennifer Funderburk, Jodi Polaha, Nadiya Sunderji, Sunday, July 30, 2017

Greetings from Ottawa Canada, where we saw Parliament Hill, ate poutine, and made new friends! We’re writing to tell you about our experience with the Canadian Collaborative Mental Health Care Conference known as “Shared Care” where we (Jodi and Jen) attended as invited guests this June. 


Unlike CFHA, the Canadian event is an annual conference, not an organization, though it has some affiliation with the Canadian Psychiatric Association and the College of Family Physicians of Canada.  Another striking difference was the value placed on patient experience. Each year, a patient is invited to present his or her perspective as a keynote speaker. This year, a talented musician explained her preference for the term “patient” to describe her role within her healthcare, and helped the audience recognize the strengths and weaknesses within the current system in Canada using her own personal experiences. Her stories were deeply moving and we appreciated that Collaborative Care in Canada has incorporated this important perspective into their conference.


But Shared Care is more similar to CFHA than different. Importantly, its attendees have the same passion for integration and collaborative practice models. The conference instilled in us the same renewed enthusiasm for the value of integration. Like CFHA, it provided many creative ideas on how to improve our clinical research/practices.


Like CFHA, the Canadian conference is trying to grow capacity for research and evaluation, especially for clinician innovators in the “real world.” We (Jodi and Jen) were excited to hear what they were doing in this area, since we have led that effort within CFHA. Dr. Nadiya Sunderji, the Chair of the Scientific Committee for this year’s conference developed a “Works in Progress” or WIP format that has many similarities to our own Research and Evaluation Training Track.  I (Nadiya) was thrilled to have Jodi and Jen as coaches providing feedback to Canada clinicians wishing to evaluate their integrated care programs, and advising me regarding this type of capacity building within the conference. Thank you for playing in the WIPs sandbox with us! Like at CFHA, we (Jodi and Jen) loved hearing about the hard work of various clinician innovators who are striving to evaluate what they do in an effort to drive the literature and practice in integrated care.


We also co-presented a workshop together to introduce participants to evaluation based on Nadiya and colleagues’ new Quality Framework to Guide Measurement, Improvement, and Research. This work continues to challenge us to think about choices in evaluation in the service of local quality improvement versus generalizable knowledge, and we plan to explore that dilemma further next year.


Our experience in Ottawa left us hoping for more cross-pollination between CFHA and Shared Care.  We have much to learn from one another! Next year’s Canadian conference will be in Toronto in May or June 2018.  Apart from the conference, Toronto has much to offer visitors as Canada’s largest city, and the most ethnically diverse city in the world – food, nightlife, parks, museums and other attractions… and did we mention food? We hope you will consider attending! But, if not, stay tuned, we’ll have a Canadian presence at CFHA in 2018 as well. 


Jennifer Funderburk

Jodi Polaha

Nadiya Sunderji

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National Register Integrated Care Videos: Q&A with Morgan Sammons

Posted By Matthew P. Martin, Tuesday, July 11, 2017

Q & A with Morgan T. Sammons, PhD, ABPP, Executive Officer of the National Register of Health Service Psychologists

Earlier this year, the National Register of Health Service Psychologists released the Integrated Healthcare Training Series. This series features 41 videos averaging about 16 minutes each. The videos cover theory and models of integrated care, practice and implementation issues, and the medical, pharmacological and psychosocial management of specific conditions. I emailed Dr. Sammons to discuss the series. CFHA members can receive a 50% discount on the entire video series. Click here for more information.


1. Tell us about the National Register Integrated Care Video Series. How did these get started?

The National Register has long recognized integrated care as an important and forward-looking practice area. We’ve published articles on integrated care going back to the mid-2000s but a few years ago the Board of Directors started discussing a more comprehensive training program. When I took over as Executive Officer in 2014, developing this series was one of my top priorities. In some ways, it was fortunate that this sort of visual, self-paced training in integrated care didn’t really exist at the time, and we generated a lot of enthusiasm in the community. Happily, we were able to line up fantastic presenters including Parinda Khatri, Kent Corso, Jeff Goodie, Jeff Reiter, Bob McGrath, Marlin Hoover, Neftali Serrano, and more.


2. The videos cover a lot of ground, from models and concepts to pharmacological management. What do you hope members will gain from these videos?

First, I hope our psychologists (and other professionals accessing the series) will get a basic understanding of practicing in an integrated care environment. Some of our newest members may have been exposed to these concepts during their graduate education and training, but many of our 10,000 psychologists have had no training or exposure in integrated care fundamentals. At the same time, our survey data show a sharp increase in the percentage of our psychologists working in organized healthcare delivery systems. With some uncertainty surrounding healthcare reform and the challenges of starting a private practice these days, we expect that percentage to continue to rise. Beyond the conceptual aspects of training, we also knew there was a need to expose psychologists to management of various conditions in integrated care — such as pain management, arthritis, insomnia, anxiety, depression, and substance abuse to name a few — and to present the care concepts from a psychosocial, medical, and pharmacological lens.  


3. Workforce development is a challenge for many clinics wanting to offer integrated care. What role do you think videos play in preparing individuals for integrated care?

We’ve been very pleased with the utilization by our members, and been successful in licensing the series to a number of healthcare organizations. So the first step — getting these videos in front of our target audience — is moving along nicely. We can always do better, but we are pleased so far. As noted above, these videos were designed to be easily digestible, self-paced learning. Think Ted Talks. We view this training as a first or second step for providers, not the final step. But the videos do provide a fundamental level of knowledge and should be a springboard to more comprehensive training and, of course, experience. 


4. Finally, who should consider accessing these videos?

The series was primarily developed for psychologists (and the presenters are primarily psychologists as well). However, we’ve had a great reaction from other professionals, specifically social workers and counselors. I think it fair to say the videos are universally applicable to mental healthcare professionals.


In terms of utilization, psychologists who are credentialed by the National Register have access to the entire series, free of charge. We also make the series available for free to the students participating in our Trainee Register. The videos are available at a cost to psychologists and other healthcare providers who are not credentialed by the National Register ($200 for access to the entire series which includes continuing education credits). Given our close relationship with CFHA, we’ve offered CFHA members a 50% discount on the series (go to and use coupon code CFHA50).


As noted above, we’ve also signed licensing agreements with healthcare organizations. Anyone interested in discussing licensing should contact Andrew Boucher (


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Integrated Care in India: Part 2

Posted By Matthew P. Martin, Friday, July 7, 2017


A year ago we highlighted the work of Dr. Manjunatha from the National Institute of Mental Health and Neurosciences in Bangalore, India, who had written a report for the Lancet describing an ambitious program to integrate mental health services into primary care systems. The program, called the Manochaitanya Programme, provides mental health services every Tuesday in taluk hospitals, community health centres, and primary health centres in Karnataka. The services are also available during the rest of the week at all primary health clinics.


This week Dr. Manjunatha reached out again to share his recently published critical analysis of the Manochaitanya Programme.  Click here for the publication


Here is an excerpt from the article:


"This is the first-of-its kind dedicated public mental health programme in India, launched by the State government with exclusive aim to integrate mental health at the level of primary care. It includes the treatment of psychiatric disorders by primary care physicians, and refer only the difficult-to-treat cases to specialized centres. Another highlight is making available psychiatric specialist care at every taluk hospital (TH) at least once a month for these referred cases. These benefits are available at about 2310 primary health centres (PHCs) and 180 community health centres (CHCs) and 146 THs covering more than 60 million population of Karnataka.


Training programmes and a manual for primary care doctors: The World Health Organization recommends effective training programmes to develop mental health skills of primary health care staff [3]. Traditional training programmes for primary care physicians in India are criticized as 'never properly trained'[25]. Providing continuing education for primary care physicians is more likely to improve the quality of mental health care than the recruitment of more psychiatrists.


The previous psychiatric training manuals were complex and could not be adapted properly for primary health care and caused difficulty for primary care physicians who had no or little previous exposure to psychiatry...  Hence, there is a need for a practical, concise manual which is adapted for primary care psychiatry."


The authors conclude that this is a major project and that next steps include workforce development, dedicated budget allocation, and clearer project outcomes. Read more to learn about integrated care on a large scale in another part of the world. 


Dr. N. Manjunatha, MD, DPM, MBBS

Assistant Professor of Psychiatry, Department of Psychiatry

National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

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Steps Toward the Routine Implementation of Brief Tobacco and Alcohol Interventions in Primary Care

Posted By Jennifer Wray, Thursday, June 22, 2017

This post was written by the 2015 winner of the CFHA Research and Fellowship Award. 

For me, one of the most challenging aspects of transitioning from traditional training in specialty mental health to working in a Primary Care Behavioral Health (PCBH) setting was learning ways to deliver interventions in that can be effective in a short period of time. Coming from a tobacco research background, I knew there were evidence-based interventions for tobacco use that could be delivered in just three minutes or less.


Not long into my postdoctoral fellowship I also learned about the evidence base for brief interventions as few as five minutes in length for at-risk alcohol use. I felt encouraged by the evidence that brief interventions for these presenting concerns could be effective, especially at the population level. I regularly started implementing brief alcohol and tobacco interventions into my work with patients in primary care, but research data at the time told us that behavioral health providers in integrated primary care settings were not routinely incorporating brief interventions for tobacco and alcohol use into their clinical work with patients. I wanted to learn more about why these brief interventions aren’t regularly occurring in PCBH appointments. 


I was excited to receive the Research Fellowship from the CFHA Research and Evaluation Committee in 2015, which allowed me to begin research to help answer this question. For the fellowship, our study team conducted a national online survey of PCBH providers to better understand the barriers to implementing brief tobacco and alcohol interventions when working with patients using tobacco or drinking above low-risk drinking.  We also collected data on the facilitators that could promote the use of these interventions.  


We were excited that 265 behavioral health providers across the country volunteered to participate (we know these providers are busy!).  The majority of providers were psychologists (48%) and social workers (33%), but we also had representation from other professions including licensed mental health counselors, psychiatrists, nurse practitioners, RNs, and marriage and family therapists. Primary theoretical orientation varied, but the most common (51%) was cognitive-behavioral.


It was encouraging to learn that almost all providers (95%) reported previous training in brief alcohol interventions (when assessed broadly; we included class course, independent reading, online training, supervision, and training workshop). Fewer (but still most respondents; 77%) reported some type of past training in tobacco use interventions. As such, we felt it was unlikely that lack of training is preventing providers from implementing brief tobacco and alcohol interventions.


Participants reported that they are conducting at least a brief tobacco intervention with their patients who use tobacco products approximately a third (32%) of the time. This was somewhat encouraging, but left us feeling like there is a lot of room for growth! We presented participants with a list of potential barriers to conducting brief tobacco interventions and asked them to rate each of these factors on a scale from 0=Not a barrier to 4= A significant barrier. The highest rated factors (i.e., biggest barriers) were: 1) the perception that patients have more immediate needs to address than tobacco use, 2) the patient not being interested in quitting or cutting down, and 3) the patient not identifying tobacco cessation as a treatment goal.  


Things that participants said would help them conduct more brief tobacco interventions included 1) the patient identifying tobacco cessation or reduction as treatment goal, 2) having a good relationship with the patient, and 3) getting referrals directly from primary care providers (or other PC staff) specifically for tobacco cessation.   


Switching to at risk-drinking, participants reported that they are conducting at least a brief alcohol intervention with their patients who endorse at risk drinking 40% of the time. The same lists of barriers and facilitators were presented as in the tobacco section. Like with tobacco, participants said that the top barriers to incorporating brief alcohol interventions into their regular work were 1) the patient not being interested in quitting or cutting down and 2) the patient not identifying alcohol reduction or abstinence as a treatment goal. 


However, with alcohol, the providers said that patients not being motivated to cut down or quit was among the top three barriers.  Participants identified the same top three facilitators as they did with tobacco; they reported that the patient identifying alcohol reduction or cessation as a goal, having a good relationship with the patient, and getting referrals directly from primary care providers would increase the rate at which they delivered brief alcohol interventions. 


So where do we go from here?   We were encouraged to learn that lack of time to deliver brief tobacco and alcohol interventions and lack of training to do so were not among the top barriers identified (as these are often cited as a reason that primary care providers are unable to deliver these types of interventions). In addition, all barriers identified are able to be addressed (e.g., encouraging behavioral health providers to use motivational interview techniques to address concerns such as a lack of motivation or not being interested in modifying these behaviors), and the providers have given us great suggestions for things that would help them deliver more of these interventions.  


If you are reading this and working in an integrated primary care setting, hopefully this gave you some food for thought regarding how you might begin incorporating more brief interventions for tobacco use and at-risk drinking into your regular clinical practice! Feel free to check out the provider education tab located at this website for some resources related to conducting brief tobacco and alcohol interventions.



Jennifer Wray, PhD, is a clinical psychologist in the Primary Care-Mental Health Integration Clinic at the Ralph H. Johnson VA Medical Center, located in Charleston, SC.  She completed a postdoctoral fellowship at the VA Center for Integrated Healthcare in 2017.  Dr. Wray is interested in the process of integrating behavioral health and primary care services, and has specific interests in brief behavioral interventions able to be delivered in the unique setting of integrated primary care.

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It’s Not Enough to be LGBT “Friendly”

Posted By Ryan Cox, Wednesday, May 31, 2017


 As health providers, we like to help anyone that walks through our door, regardless of background or identity.  Sometimes, though, it’s not enough to simply be open-minded, or accepting.  With certain populations it is imperative to not only be “open,” but also competent.  All minority populations have their own unique needs, backgrounds, influences, and struggles.  LGBT individuals are no different.  This post is a brief overview, though it is important to keep in mind that each letter of that acronym is unique with its own needs, especially trans*gender individuals.


            LGBT individuals face a myriad of health disparities.  A recent study found that many gay men, for instance, exhibit psychological symptoms of severe PTSD, and display the concomitant health risks, even if they have never been in a life-threatening situation.  Over 70% of trans*gender individuals report at least one instance of overt discrimination in a healthcare setting, ranging from everything to deliberate misgendering to outright physical abuse.  Lesbian women have significantly higher rates of obesity, smoking, and are far less likely to receive preventative care, such as mammograms, than their heterosexual peers, but also tend to have better mental health outcomes and more stable relationships than gay men.  In order for any healthcare setting to be affirmative and competent, education, consultation, research, and ongoing awareness are necessary.  Following are a few steps to help facilitate more open discussion.


            Many individuals will not feel comfortable disclosing what may be one of the most important aspects of their identity to someone they don’t know and don’t yet trust, so providers should get in the habit of asking about identity and lifestyle characteristics of patients.  A great place to start is with new patient paperwork.  Having multiple options for relationship status and gender identity, and overtly asking about sexual orientation can go a long way to opening the door to conversations about identity and health risks and disparities.  What this conveys to your new client is that you are aware they exist (in a broad sense), it’s something you have thought about, and it is something that you are probably (hopefully) knowledgeable about.  For LGB individuals, even the assumption of heterosexuality by their provider can be alienating and invalidating.  For trans*gender individuals, a disclosure of trans*gender identity might be met with skepticism and invasive questions at best, or outright hostility or medical harm at worst.


            Next most important is simply asking.  It should not be incumbent upon the patient to disclose information to a new provider that could potentially be used against them.  We can help ease that anxiety by taking the first step and overtly offering a safe and supportive space for disclosure.  Because being LGB, and often T, is an invisible status, meaning it cannot be gleaned just by looking at someone, it is easy for the patient to stay quiet, let the clinician make assumptions, and move on.  But that isn’t good healthcare.  Understanding what is most relevant to our patients not only helps build rapport and trust, it provides us with a fuller picture of habits and behaviors, risks, disparities, and protective factors.


            Third most important is self-learning and continuing education.  Research in trans*gender health especially is moving at a rapid pace, and it is important to stay informed and updated.  Consulting with other professionals who have experience with these populations, attending continuing education workshops, and going to conferences are all excellent ways to keep abreast of the latest developments in the field, but also to network.  See if you can bring in specialists to your organization to conduct trainings and seminars.  Even seeking out clinical supervision while you begin working with this population might be helpful and a good idea.


            The key to all successful relationships is adequate communication, and it is no different with our patients.  The better we can learn to communicate, and the better we can learn to listen, the more likely clients and patients are to open up to us, confide in us, and let us give them the most competent and comprehensive care we can.  And we can only speak as experts if we have expert knowledge, which includes not only education, but experience.



Dr. Ryan Cox earned his Bachelor's in Psychology at St. Edward's University in Austin, Texas, his Master's in Counseling at Pacific University in Forest Grove, Oregon, and his PhD in Counseling Psychology at the University of Memphis in Tennessee.  His primary clinical interests are LGBT health, integrated healthcare, holistic health and wellness, HIV/AIDS, and masculinity and gender issues.  He currently works as an integrated psychologist in Oncology, Sleep Health, and Pain Management at Truman Medical Center in Kansas City, Missouri.  Dr. Cox also teaches graduate courses at Avila University, and sits on the board of the Good Samaritan Project, a non-profit dedicated to ending the impact of HIV in Kansas City. 

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The Highs and Lows of an Early Career Professional

Posted By Ruth Nutting, Thursday, May 11, 2017

I remember it like it was yesterday.  It was an afternoon in early April—like every good post-doctoral fellow I was sitting in my office working hard and pondering my future.  Or, maybe you could say I was catastrophizing my future. 


I had been blessed with a wonderful pre-doctoral internship and post-doctoral fellowship within a leading medical university—I was happy and I was comfortable.  To think about the familiar ending in just two and a half short months was overwhelming.  Don’t get me wrong, I was preparing for the transition from fellow to early career professional feverishly.  I spent hours scanning available positions, throughout the country, and was consistently sending letters of interest and my curriculum vitae. 


However, there were times, like this particular afternoon, when vivid visions of my fellowship ending, and a one-way ticket to New Hampshire being purchased to return to my parent’s home in order to reside in their unfinished basement plagued my mind.  Granted, my parents would have been thrilled to give me back my childhood bedroom, but the thought of the basement seemed much bleaker; it matched my mood.


You see, I knew I was qualified.  I knew I had an impeccably comprehensive training in integrated healthcare and I knew my supervisors had spent endless hours investing in me and my future, but what I hadn’t found was that dream job.  I wanted to be a director of behavioral health, and the idea of any other position lacked satisfaction.  Perhaps this is why many letters of interest went unanswered and why some employers responded by saying my ambitions were beyond the scope of the posted position—readers could sense a strong desire for directorship regardless of the position being applied to. 


Then, they came, first one, then two, then three dream positions.  My letter of interest spoke to the current directors of these programs and I had interviews, fully funded interviews!  I have to admit that after being a graduate student for what seemed ages and spending a plethora of money to fly from interview to interview for different doctoral programs, pre-doctoral internships, and post-doctoral fellowships, I felt like a bit of a celebrity having all my interview trips arranged and paid for, as custom.  There was also a feeling of exuberance, as I met an array of dynamic professionals and could conceptualize my role in their programs and ways in which I could aid in enhancing these programs.  The idea of not knowing what part of the country I would end up in also energized me, testament to my adventurous personality!


As I was offered positions, and I chose the best position based on overall fit, negotiation came in to play.  Also a new feeling, as I had only experienced the thrill of acceptance prior.  Negotiation was an empowering experience as it continued to affirm my knowledge, skill base, and work related value.  In just days, negotiation was completed and contracts were signed. It was happening!


Like with every move and new position, there was a whirlwind of activities.  From apartment shopping and packing, to shot records and eye exams, it was all happening quickly.  Wrapping up my post-doctoral fellowship and training my successor proved challenging while I simultaneously planned for my position to come.  


Then the time came for me to embark in my professional career as director of behavioral health.  The first week was filled with orientations, meets and greets, and organization of my office, the second week work began.  I remember sitting in my office, staring at my computer screen, like every good director does, and it all of a sudden hit me…I was responsible for the maintenance and the development of this behavioral health program!  I could no longer walk across the hall to my supervisor’s office for her expert opinion anytime I needed, the responsibility was on me.  My immediate thought, “what were they thinking hiring me?”  Imposture syndrome had set in.  I somehow regrouped within the following minutes and began feverishly working on my first-hand initiatives.  I wanted to prove myself and prove myself quickly.


Over the next weeks, my feelings of imposture syndrome continued to dissipate.  My knowledge and hard work was allowing for my initiatives to align as I had hoped.  I was recruiting for four pre-master’s level medical family therapy interns from a local university’s marriage and family therapy program. Within just months of becoming director, we would have a fully integrated behavioral health program within our two clinics.  I was also in the process of piloting pre-clinic huddles, and anticipating another implementation victory.   However, implementation didn’t go quite as perfectly as my visions had.  On match day, I was incredibly fortunate to receive two marriage and family therapy interns, but this was not the sum of four I needed for full behavioral health coverage at each clinic.  I had failed, I had aimed for full coverage of an integrated behavioral health program and now I was not able to fulfill that.  To add to my dismay, not all faculty and residents were as excited about pre-clinic huddles as I was. Defeat! 


This time I stared at my computer screen thinking I had failed in my role as director, my thoughts simultaneously turned to my previous supervisor…I needed to e-mail her immediately to ask what she would do in this situation. I needed her immediate affirmation, or did I?  I took a minute, and then I took a couple more to breathe and reflect.  My thoughts shifted from what I hadn’t yet accomplished to everything I had accomplished.  In just a few short months, I had single handedly created a pre-master’s level behavioral health internship, was in the process of implementing pre-clinic huddles, and had increased my teaching responsibilities by nearly double; not to mention I had kept abreast of research efforts and fulfilled my clinical responsibilities. 


Why was I being so hard on myself?  Yes, my ideal plan and efforts had not been one-hundred percent fulfilled, but I had accomplished a lot.  This was not the time to succumb to defeat. This was the time to recognize my efforts and then strategize how to make this first internship year a success and to move forward developing a relationship with a nearby psychology program to expand recruitment for the following year, better ensuring a behavioral health intern cohort of four.  It was also the time to focus on providing further education to faculty as to why pre-clinic huddles would be invaluable.


I share these personally professional anecdotes to normalize and humanize the experience of being an early career professional.  Although different in nature, early career, mid-career, and maybe even late-career professionals alike face the highs and lows of leadership, sometimes winning and sometimes seemingly failing.  What I have learned and will continue to learn is that when challenges arise, as they will, we must allow ourselves to feel disheartened when things do not first go as plan, reflect on what still needs to be accomplished, and then re-strategize.  If you’re anything like me, cranking Sia’s “The Greatest” will cure any self-deprecation you may have and get you ready to conquer the world, or the workplace, all over again. 


Ruth Nutting, PhD, LCFMT, is the Director of Behavioral Health at the Via Christi Family Medicine Residency, and Clinical Instructor  at the University of Kansas School of Medicine.  She teaches a behavioral medicine curriculum to 54 family medicine residents, facilitates resident wellness initiatives, oversees the functioning and supervision of a pre-master's level medical family therapy internship, provides integrated and traditional therapeutic care to the underserved population, and continues her research on Chronic Illness and its Effects on Young Adult Populations. 

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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.