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Mental Health vs. Behavioral Health

Posted By Peter Fifield, Monday, September 21, 2009
Updated: Wednesday, June 1, 2011

In a past CBC blog there was a brief discussion around the difference between "Collaborate and Integrate”. Although to some it may only appear to be an issue of semantics, to others there is a need to create consistent definitions in our profession. A reliable discourse within our profession could facilitate the relay of ideas concerning policy, process and practice.

As the concepts of Integrated Care become more and more familiar within the medical landscape, there is a potential need for a universal discourse. On occasion I interact within our local and state-wide communities here in New Hampshire spreading the word of integrated medicine and collaborative care. Naturally, two phrases that are often used during conversations are "Integrated Care” and "Behavioral Health”. Shortly after these words leave my mouth, a look of inquisitiveness often arrives on the faces of anyone lending an ear.

Dr. Ben Miller asked an important question in a prior blog: "Where is Mental Health”? As I read the blog, I thought that before we can identify where "it” is we actually need to know what "it” is. I have a request of you all. Please post your opinion related to the difference between Mental Health and Behavioral Health. I have my own operational definition but quite often I find myself attempting to discern between them and I’m sure my resultant answer is rarely the same. Questions I find myself asking are: "Is it more than just a way to euphemize a service being sold to an unwitting patient?”, "Is there a core practical difference between the two or is it merely a philosophical difference?”, "Does behavioral health only occur in a medical setting and mental health in a specialty clinic?” and "Does anyone really care about the difference aside from the Medicaid/Medicare billing departments?”. I hope that there are some Behaviorists, Gestaltists and Psychoanalysts out there, from a range of professions, ready to respond to this topic.

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Help Create the Collaborative Care Strategic Vision

Posted By Frank deGruy, Wednesday, September 16, 2009
Updated: Thursday, June 9, 2011

The Board of Directors met for a two-day Strategic Planning Retreat in San Diego on July 10 and 11, to clarify strategic priorities for CFHA, and to formulate a provisional action plan for the upcoming year. The external environmental context for this work is the extraordinary interest in health care reform, and specifically the interest in the Patient-Centered Medical Home and related initiatives that will most likely lead to the participation of new "health care teams” of clinicians rendering primary care.

While this is a promising opportunity, there has been little explicit attention to how mental health clinicians and primary care clinicians actually fit together and operate collaboratively. The internal context for this retreat was the need for CFHA to develop a clear focus on serving the needs of its members, on attracting new members who would benefit from collaborative resources, on finding and hiring an executive director, and on ensuring that our annual meeting and summits continue to serve our membership well. The following action plan was accepted by the board:

Hire an Executive Director, which is in process and should be concluded in the next few months. Add advocacy to the desirable skill set of this position, as detailed below.

Discuss and begin planning CFHA-sponsored programs for training physicians in systems, collaboration, team work, and integrated care.

Create a policy-relevant summary of the rationale and evidence for integrated care in terms of outcomes and cost effectiveness. Consider putting together a long paper and a one-page summary to use with stakeholders and policymakers, and develop an aggressive advocacy program while health care reform is still being debated.

Continue the annual conference with additions described above.

Creating community: develop local, state, or regional chapters within CFHA. Develop the blog section in the website. Have a booth at the conference to advertise CFHA, with its short-term goals and demonstrate the website to get participants involved and increase membership.

We are interested in vetting these ideas with our membership. Responses?

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I'm an Optomist

Posted By Gene "Rusty" Kallenberg, Wednesday, September 16, 2009
Updated: Thursday, June 9, 2011

It seems that I have been caught up in a totally new life of late. I have been hijacked by the Collaborative Care Movement! I have actually been a fan and practitioner of this movement for the past 10 years or more. But for the last few months the ride has become exponential. I have been a participant in the following activities that are part of this new accelerated movement to integrate mental/behavioral health into Primary Care:

1 – Planning the Feb, 2009 Annual Meeting of the Association of Departments of Family Medicine – during which a major plenary was devoted to incorporating mental health care into the Patient-Centered Medical Home with a great Canadian faculty, Nick Kates, who related his 14 year experience of embedding psychiatrists in general practice offices in Ontario.

2 – Co-planning the Oct, 2009 Annual Meeting of the Collaborative Family Healthcare Association (CFHA) – which is wholly devoted to integrating mental/behavioral health into primary care.

3 – The above CFHA activity has also involved helping to organize the associated Statewide Summit on Integrating Primary Care and Mental Health/Substance Use Services for the State of California. There will likely be 60+ participants in this statewide Summit.

4 – In order to understand the content of the above Summit I became an advisory board participant to the Integration Policy Initiative – a collaborative effort of the California Institute for Mental Health, the California Primary Care Association and the Integrated Behavioral Health Project funded by The California Endowment. During this tutelage I learned so far is that there are over 50 pilot programs in collaborative care going on in California alone!

5 – At the 2008 CFHA meeting in Denver, I participated in early discussions about trying to establish the Collaborative Care Research Network (CCRN) – the brainchild of Rodger Kessler, Ben Miller and others – which will be used to assess the current state of the practice of collaborative care nationally and will be the vehicle by which the movement will generate the evidence for the benefits of collaborative care.

6 – The CCRN discussions ended up allowing me to – in a small way - participate in the planning for an AHRQ supported meeting to help flesh out and launch the CCRN scheduled for October.

7 – As a follow on to the ADFM meeting – and with much effort of key leaders in the US collaborative care movement – there has been a new interest in MH/BH + PC integration on the part of the Patient-Centered Primary Care Collaborative (PCPCC), which is the driving organization for the new emphasis on the Patient-Centered Medical Home in the health care reform effort. The PCPCC has led a series of 10+ national phone calls that have had as many as 40+ participants from as far away as England. This group of experts has greatly increased the PCPCC’s knowledge base and awareness of the importance of integrating MH/BH and Substance Use into the "whole person” fabric of the PCMH. This effort may ultimately have an impact on the NCQA designation of the critical elements needed for a PCMH.

Now, I am relating these personal experiences not to blow any horns - as my participation has been more of a student and learner than as a major conceptualizer of the future. But rather to indicate the veritable tsunami of effort, attention, participation, and beginning-growing influence on public policy that these efforts and others like them are having on health care dicsussions. The upcoming California Summit will be the 5th one in as many years in association with the CFHA Annual Meeting - Washington, Rhode Island, West Virginia and Colorado being the other four. The PCPCC and NCQA are certainly national organizations. And while mental or behavioral health does not feature prominently in the bills before Congress – the practice community who will carry out health care under the new policies is getting the message.

And in parallel with this very rewarding exposure to both state and national efforts, I have tried to bring home to our own local clinical setting what I see as the increasingly clear pathways to the future of collaborative care. These involve not only increasing the sophistication of our models of practice but also the new emphases on population management of mental/behavioral/substance issues in our patients and the practice-based research efforts that will serve to continuously improve the care we deliver and the outcomes we all seek. These efforts exactly parallel those we are now seeing applied to primary care and medicine in general, hence, we are in good conceptual company!

So I am optimistic about the futures – the future of collaborative care, the future of American medicine and the future of the health and wellbeing of our patients, clients, their families and communities…of our society. Life is getting ever more complex and stressful. If we can put the mind and the body back together again – we will be up for the challenge.

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Healthcare and Social Networking: The Case for Twitter

Posted By Gonzalo Bacigalupe, Monday, September 14, 2009
Updated: Wednesday, June 1, 2011

It's all the rage - you know or else you would likely not be looking at this blog right now. You see, social networking is one way to continue to ensure that our voices are heard. There has never, in my professional life, been an opportunity as timely as now, to take advantage of social networking and engage in the national dialogue on healthcare and health reform.

Harvard Business School posted a nice article outlining social networks. For the full article, CLICK HERE.

One of the points the author makes in this article is that online social networks are most useful when they address failures in the real world. Hmmm. Failure in the real world? You see the healthcare tie in now dontcha? As the IOM stated, "the health-care delivery system is incapable of meeting the present, let alone future needs of the American public". Ah, now you see where I am going.

We are all looking for solutions to the healthcare problem. We need more evidence, and we need an outlet. We need more stories, and we need an easy way to disseminate our information.

Let's start with Twitter. Twitter is like texting, but online - and (almost) anyone can see what you have said. In 140-character messages, Twitter allows users to get their message out there as often as they would like. Being a Twitter neophyte, I am new to much of the "Twitterease", but can tell you that tweeting can have great benefit to healthcare engagement. My Twitter name is not original or witty, but I knew once I heard about Twitter I had to at least check it out.

At first, Twitter was like an old college roommate you had not seen in some time. You were comfortable (read texting), but you weren't sure how your new life would interact with their new life (read everyone reading your "tweets"). You exchange anecdotes ("Del Mar is not a bad place for lunch"), but there is something dramatically unsatisfying about this. You want to go deeper, but you're not quite sure how or what to say.

Then it dawns on you, I am passionate about healthcare, I work in healthcare, I need to know what's happening in healthcare at all times, maybe I should tweet about healthcare (WARNING - actual tweets: "In all the #healthcare debate, we cannot forget about the inclusion of mental health in the patient centered medical home"). You learn the lingo (placing # before any word means that anyone searching for the word following # will see your tweet - try it by clicking on #healthcare above). You learn how to shorten lengthy links with great websites like THIS ONE so that your long website now fits within the 140 character limit. You learn who else is out there sharing information (you follow them). You learn about software that let's you keep track of who is saying what. Once you grasp the subtle concepts of Twitter, your posts evolve (What the public thinks of evidence-based #healthcare? & one answer to provide more #evidence:

So, how does this all tie in to natioanl reform efforts? Well, I know that on Twitter, there are a ton of people, and very few of them are talking about collaborative care! I know that while not many people follow me, many people follow some of the people who follow me (you see the systems connectivity here?). I want to disseminate information on healthcare the fastest way possible. I see Twitter as one avenue for doing this.

#Intrigued? So am I!

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Time to Unite

Posted By Ben Miller, Friday, September 11, 2009
Updated: Wednesday, June 1, 2011

It appears that the infamous "Gang of Six" are emerging with a health reform bill sometime early next week (Senate Finance Committee). Will this Bill from the Senate side be more comprehensive? Offer a public option? Many speculate that this Bill may be the one that is most likely considered as a contender in the race for health reform. The Gang of Six is an anomaly of sorts. First, they are bipartisan, and have been from the beginning. Second, they are the Finance Committee. Let's construct these two points for a moment and consider their implications:

1) Collaboration and compromise: There is no doubt that this group had to simultaneously collaborate and compromise to get anything out the door let alone a complex Bill for health reform. Think of who is in this group (Enzi, Grassley, Snowe, Baucus, Bingamen, Conrad), there are some real political difference here. The take away is that there had to be some level of collaboration to get anything done. President Obama has tried to have bipartisan support for health reform, but this has not worked as well as he would like; however, this group may be the lone exception. Now there will be significant compromises here, but it is a product isn't it?

2) Finance Committee: Some of the most significant arguments for and against health reform have come down to money. As we all know, healthcare is expensive. As we all don't know, if we don't change healthcare (and fast) no one will be able to afford it (see HERE and HERE for examples). Oh, and most of us have read and seen Gawande's New Yorker article on cost by now (but if you haven't HERE). So cost (read financing) has everything to do with health reform hence the reason this coming from the people who talk about financing in government is important.

So, if a group of six individuals, representing different states, political ideologies, and interests can come together and deliver a product on health reform, why can't we? Why can't different professional associations sit at the same table and talk about reform? Why can't different disciplines collaborate around a united cause? Not to say this doesn't happen (CFHA as an outlier), but it should happen more!

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Mental Health: Come Out, Come Out Wherever You Are!

Posted By Ben Miller, Friday, September 11, 2009
Updated: Wednesday, June 1, 2011

As the health reform debate rages, so many numbers, names, and "theories" are thrown around, we have to ask ourselves the question: "where is mental health"? You see, being a mental health professional committed to seeing the divide between mental health and physical health erased, I want to know that the next version of health "care" comprehensively addresses the needs of the whole person. So, I always make sure to try and see where mental health sits within any discussion on healthcare. To this end, I follow blogs, check certain websites, read bills, etc. to get a better sense if the artificial divide between systems will be erased.

My findings: mental health is not part of the larger health reform discussion (that I can see) - if we are talking HEALTH REFORM, shouldn't we include all aspects of health?

Now, here me on this one, I know the mental health community is actively engaged in advocacy around parity, but is this sufficient?

Watching the President's speech to Congress two nights ago, I kept wanting to hear something about mental health - that is too much to hope for. I follow Twitter to see what other thought leaders (yes, they are on Twitter) have to say on #healthreform (a Twitter technique), etc. I see brilliant articles, discussions, ideas, but none include mental health. Being a Twitter amateur, I try to push for integrating mental health into the discussion as often as possible, but this is not going to get the message that now is the time to end the separate histories of mental and physical health and defragment healthcare. Still, I try and use any and all any means necessary to bring attention to this issue. If you are feeling adventurous, you can follow me on Twitter - miller7

Am I off base here?

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Thank You Mentor, Thank You Collaborator

Posted By Randall Reitz, Wednesday, September 9, 2009
Updated: Thursday, May 26, 2011

Some names in our field naturally go together: Mac Baird and Bill Doherty, Donald Bloch and Nathan Ackerman, Susan McDaniel and Thomas Campbell. By its name and nature, collaborative care is a team sport. Without our collaborators, integrated care services are as effective as one hand clapping.

Similarly, wherever we are in our careers, we owe much of our success to the assistance of mentors who have helped us along the way. Mentors are our key advocates and personal champions. They point us in the right direction and stick with us along our professional path. They have sufficient hope to bring out our best and sufficient compassion to help us overcome our worst.

I would like to thank two treasured mentors.

Larry Mauksch took me under his wing back in 2000. I was fortunate to complete my PhD internship at Marillac Clinic shortly after Larry had completed a year-long sabbatical during which he established Marillac’s collaborative care program. My internship was funded through a 5-year RWJ grant Larry had co-authored. During my years there, Larry returned to Grand Junction yearly to offer training and conduct research. My first published research was with him as a first author, and my early professional presentations included him as co-presenter. On multiple occasions I’ve slept in his home and eaten at his table. I’ve called him for advice before each major decision of my career. He personally nominated me when I was invited to join CFHA’s board. Thank you, Larry, for your loving wisdom and prescient vision.

Steve Hurd was my 2nd supervisor at Marillac Clinic. I’m pleased to have played a role in his conversion to the collaborative care model. He was a dream supervisor who provided direction, required accountability, and advocated for my promotion. Steve was always very tolerant of my pet projects and clinical distractions. When I became the Executive Director of a Marillac-like clinic in Frisco, CO his phone number was #1 on my speed-dial and he never lacked time to work me through issues. He consoled me in South Bend when Notre Dame beat BYU and I consoled him in Provo when BYU returned the favor the following year. He is the godfather of my eldest daughter. Thank you, Steve, for your warmth, caring, and abiding support.

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Coyote Medicine

Posted By Peter Fifield, Monday, September 7, 2009
Updated: Thursday, June 9, 2011

Although I have owned the book for years, I most recently rediscovered and read Coyote Medicine a book by Lewis Mehl-Madrona, M.D., Ph.D. What a fantastic read. To my pleasant surprise, just yesterday, I found out that the author will be presenting at the CFHA conference in San Diego CA this October 2009.

The following link provides a description of Dr. Mehl-Madrona’s book as follows:

A Stanford-trained physician, who gave up the promise of a lucrative private practice to embrace the Native American healing arts of his ancestors, describes his continuing efforts to integrate both ancient and modern medicine.

Dr. Mehl-Madrona’s attempts to shake things up in the medical world are similar to the concept of Integrated Care; shifting a medical paradigm from traditional approaches to something new. Providing integrated care is partially about addressing the mind body connection in order to provide comprehensive care to our patients. A unique characteristic of Lewis Mehl-Madrona’s approaches is that he practices a combination of modern technology based medicine coupled with spiritual precepts from his Native American heritage.

Mehl-Madrona’s approach not only addresses the mind/body connection he also adds a spiritual component to his medicine. Cultural sensitivity and relativity are very important concepts when treating patients. Spiritual healers range from Curanderos and Houngans, to Priests and Rabbis. These practitioners use the person’s faith and belief systems to address the presenting medical issue. Preparing for a Native American "sweat lodge” can take a significant amount of effort but there are more subtle, realistic and practical approaches that could be attempted even in our offices.

What sort of faith, spiritual or cultural based approaches have you seen used, have you used in your practice or heard of in other practices regarding behavioral health. Please share your thoughts on what you think constitutes "hokey” and why. When does a certain faith/religious or cultural approach violate your office policy?

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Using Direct Observation for Team Development and Collaborative Training

Posted By Larry Mauksch, Sunday, September 6, 2009
Updated: Thursday, June 9, 2011

A great way to flounder or fail in system change is to avoid relationship development between team members. When we examine efforts to integrate collaborative designs, relationship development is often given short shrift or completely overlooked. For example, the recently published initial evaluation results from the medical home National Demonstration Project found team function suffered (Nutting et al, Ann Fam Med 2009;7:254-260). One way to build teamwork is to use direct observation of day-to-day practice. I have been experimenting with this strategy for 15 years and below I will share some experiences.

Since we began the mental health internship in collaborative care within our Family Medicine Residency in 1996, the first month for the new intern is spent shadowing residents and faculty. Observing helps the intern learn about the challenges of family practice and it spawns many new relationships. Our residents and medical students observe one another regularly as well.

In 1998 I was invited to spend a year training providers, serving patients and designing a system of care in an indigent primary care clinic. During the first half of the year I regularly observed the primary care providers, teaching them interview and primary care psychotherapy skills and forming relationships. My behavioral health practice grew rapidly. A few years before I arrived a local agency had placed a counselor in the clinic. Six months later the counselor was withdrawn due to lack of referrals despite being in a clinic where 50% of the patients had one or more mental disorders. Looking back, it appears that little was done to create relationships with this new team member.

In my work with health care organizations to train primary care teams to be more efficient and effective in communication with patients, a standard portion of training is peer observation. When the lack of team coordination between medical assistants and physicians became a common theme, I began asking physicians how often they had observed their medical assistants or if medical assistants had observed them. The answer was almost always the same—team observation had never occurred. I began having these dyads observe one another and discuss how to increase the quality and efficiency of patient flow. These primary care dyads or "teamlets” (see Bodenheimer, Ann Fam Med, 2007, 5:547-461) immediately began dissecting day-to-day processes to improve systems of care.

Collaboration is hard won without adequate relationship development. One way of forming relationships is to curiously watch each other provide patient care. It takes time. Trainees need to be sensitive to how feedback is delivered and remember that watching someone else promotes observation of one’s self.

Many of you have other strategies to promote team development or perhaps use similar approaches. What experiences have you had where team development went really well or stumbled?

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Advancing the Evidence for Collaborative Care

Posted By Ben Miller, Saturday, September 5, 2009
Updated: Wednesday, June 1, 2011

The case for integrating mental health services into primary care has been made. We know that primary care, the largest platform for healthcare delivery in the United States, remains the de facto mental health system. There is evidence to support combining mental health and primary care services to more comprehensively address the construct of health (mental and physical), but when making a business/policy case for such integration there is less evidence for what works and what models or elements of models should be incorporated to reach the desired health outcomes.

A recent systematic review (Butler, et al., 2008) pointed out that it is often difficult to tease apart the success of integrating mental health into primary care from the attention that a specific disease is receiving. Of the 33 studies examined, 26 focused primarily on depression. If depression were the only mental health condition we treated in primary care, we may have more answers, but it is not as patients bring complexity co-mingled with co-morbidity.

To this end, the Collaborative Care Research Network (CCRN) was created to expand the evidentiary support for mental health in primary care and to enhance the understanding of what works using a practice-based research network (PBRN) structure. To date, 40 practices have enrolled. The team developed a position paper arguing for a collaborative care PBRN and sent it to the Agency for Healthcare Research and Quality (AHRQ), after which we were advised to immediately submit a grant application as they had certain dollars that needed to be spent this fiscal year. We were also advised to keep an eye on the AHRQ website if the President's stimulus package was approved as there would be initiatives of interest.

Dr. CJ Peeks reminds us of the famous Peter Drucker quote: "In business and elsewhere, nothing ever happens except when created by a monomaniac on a mission." And monomaniacs we (CCRN) are. Even so, we are systems folks who are observing what Harry Goolishian said was the first rule of working in systems--keep the conversation going; hence this communication and blog. For more information on the CCRN, please visit

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

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