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Complex Patients: Positioning Teams for Best Outcomes

Posted By Matthew P. Martin, Monday, April 16, 2018


Patients living today with both complex medical and behavioral health problems are expected to die 25 years earlier than the general population.1 These patients have more medical problems than the general population and a disease burden that increases as behavioral health problems increase. Most patients with behavioral health problems are seen in non-psychiatric medical settings like primary care.2 Untreated behavioral health problems make it challenging for patients to improve their overall health.

Care management, a collaborative process of assisting and supporting patients, is a cost-effective approach for helping patients with complex health problems;3 however, most case management services focus solely on medical or behavioral health problems and do not always involve the primary care physician. The East Tennessee University Department of Family Medicine recently presented a regional conference on strategies for treating complex patients. Therese Narzikul, a gerontological nurse practitioner, was a co-presenter and helps answers some questions below about working with this patient population.

1. What are some of the challenges and barriers to treating complex patients?

Some of the challenges and barriers-or as I like to reframe these—the opportunities that we have in treating complex patients lie within the way the current system is designed. Structurally the system is set up for the average patient. The time allotted is generic and not geared for the complexity of the person. In fact the complexity/unique context of the person is rarely adequately explored or understood. We often do not ask the patient what matters to them and what are their life/health goals to ensure we create a plan that incorporates their perspective. The more complex a patient is-the more important the alignment and integration of the patients’ perspective with the plan.
The visit itself is problem-focused but often fails to appreciate the problem as an outcome of a complex system of interactions that are never fully explored or exposed—we treat the symptom. In science we break systems apart to make sense of them. With complex patients it is critical that we look at them as a whole in order to understand them. The dynamic nature of any complex system-biological/socio-cultural-makes their “problems” unpredictable and multidimensional. We have an opportunity to further develop care teams to explore and expose the relationships and connections and emerging outcomes for complex patients. This will provide the needed context to design interventions tailored for these dynamic, unpredictable and multi-dimensional complex patients and populations.

2. What are some prominent team-based practice models for assisting complex patients?

There are lots of super frameworks out there for assisting complex patients. The GRACE Model, Guided Care Model, The Transitional Care Model, etc…. The key to deploying any model is appreciating and designing it within the context of the organization and/or community as well as the population for which it is aimed to assist.
Taking time to understand the context provides key insights into model selection and implementation. In addition to the model selected and equally important is the underlying operating principles and appreciation of the role of shared vision, shared purpose, shared leadership, and shared understanding in enabling the team. In an environment that is focused on learning and improvement, the power of the individual and collective team perspectives can be shaped to design emerging solutions to the dynamic nature of complex patients and populations. Team members want to feel they are a part of things and want to have a hand in shaping the future. Leaders that create this environment for team-based practice models will be as successful as the teams.

3. What practice change targets can managers use to measure improvement in their practices?

It all backs up to what they want to accomplish? For whom? And Why? In healthcare practices we are trying to create value for our patients. Patients like practices value time, money and knowledge. They would like to get the best outcome without having to incur more time or money than necessary. The outcomes they want are to stay healthy, live with illness (if they have any) and get better (if they are sick). Change targets to measure improvements would be tied to the outcomes that help patients achieve these goals in the most efficient (least time, lowest cost) and effective (safe, equitable, patient-centered) manner. Do the patients at their practices get all the recommended care and services to keep them the case of complex (more vulnerable patients): provide these to prevent their chronic conditions from worsening or an acute condition from impacting them more seriously? Etc…

4. What financial models or strategies help to maintain sustainability with treating this patient population?

Financial models and strategies need to be developed within the context of the organization, region and market. If an organization looks to design interventions where you get 3 for one and one of the 3 generates new revenue that is the best design. A design where all stakeholders win. The payer gets something they need, the provider gets something they need, the patient gets something they need, the community gets something they need, the care team members get something they need… For complex patient, an intervention that accurately assesses and addressed the patient complexity, incorporates the perspective of the patient and pertinent team, captures and communicates the risk/complexity to the payers (on an claim) and to other providers in the extended care teams (with EMR) and creates short-term (new revenue) and long-term value (triple aim impact) for the organization.

1. Parks, J., Svendsen, D., Singer, P., Foti, M. E., & Mauer, B. (2006). Morbidity and mortality in people with serious mental illness. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, 25(4).
2. Kessler R., Stafford D. (2008) Primary Care Is the De Facto Mental Health System. In: Kessler R., Stafford D. (eds) Collaborative Medicine Case Studies. Springer, New York, NY.
3. Smith, S. M., Wallace, E., O'Dowd, T., & Fortin, M. (2016). Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. The Cochrane Library.


Therese DeVries Narzikul is Vice President of Practice Design & Care Coordination at Jefferson Health where she is largely focused on designing care delivery to improve health, experience of care and health outcomes, with a special focus on vulnerable patients and populations.  As Gerontological Nurse Practitioner with an MBA, Therese provides expertise in the areas of care delivery system transformation, population health and risk management, care coordination across the continuum and performance improvement.

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Financing the Primary Care Behavioral Health Model: Q&A with Dennis Freeman

Posted By Matthew P. Martin, Monday, March 26, 2018

It's no secret that the US health care system is expensive and under significant change these days. One part of the system that is receiving a lot of attention in primary care. The evidence suggests that primary care is an excellent investment for payers who want better health outcomes; however, recent data shows that payers are actually DECREASING their investments in primary care.

In the midst of this confusion, innovators are pushing forward to test new clinical and financial models in primary care. One clinical model you may already know is the Primary Care Behavioral Health (PCBH) model, a team-based primary care approach to managing behavioral health problems and biopsychosocially-influenced health conditions. But does this clinical model actually fit with the movement toward value-based payment models? If so, how and what should proponents of PCBH know to push for payment reform? 

The authors of a new publication identify new financing strategies are emerging which will further support the viability of PCBH integration. I reached out to Dennis Freeman, lead author and CEO of Cherokee Health Systems, to ask a few questions about their article. See the exchange below:


1). What unfavorable reimbursement policies currently exist for PCBH or behavioral health integration broadly?


The most problematic policy barriers are created when behavioral health is “carved out” from the general medical benefit in health plans. Even when health plans claim to “carve in” behavioral health they often do not modify their internal administrative structure and continue to maintain separate, isolated staff with the responsibilities for network development, contracting and providing oversight of the behavioral health services benefit. Carving out behavioral health perpetuates bureaucratic silos. When behavioral health is carved out who has responsibility of paying for integrated care-- the behavioral health division who manages the behavioral health benefit or the medical division with the responsibility of overseeing primary care? Whether both or neither claim the territory it is double trouble for the integrated provider organization.

Coding of the service is another potential barrier. Behavioral health providers of more traditional specialty behavioral health care use commonly accepted psychiatric CPT codes accompanied by a psychiatric diagnosis in order to garner reimbursement for their services. Behavioral health consultants (BHCs) working in primary care have a broader scope of practice. The usual CPT codes utilized by specialty behavioral providers will fit some, but not all, of the services BHCs provide. For example, a BHC might focus on prevention, risk reduction or general health behaviors. The patient might not present with a psychiatric disorder but an intervention to promote health behaviors or cope with a chronic medical conditions is still indicated. There are CPT codes to cover these services, the Health and Behavior Assessment and Intervention CPT codes 96150 through 96155. Payers are often unaware of these codes and the provider must negotiate with the payer to assure these codes are in their contracts.

A third common barrier is a prohibition against billing two healthcare visits on the same day. Sharing care during the patient visit is core to the PCBH model. Expecting the patient to return on another day is inefficient for the providers of care and illogical from the patient’s perspective. Frequently, the patient does not return for a behavioral health visit scheduled on a different day.

Some consultation components of typical PCBH practice are not covered in a fee-for-service environment. BHC time spent in daily team huddles, hallway consultations, treatment team meetings, care coordination activities or similar activities that do not involve face-to-face time with the patient do not generally translate to an available CPT code. However, we have been able to make the case to payers these activities have value in and of themselves and contribute to the effectiveness and efficiency of care. Often we have been able to negotiate a secondary revenue stream to cover these non-revenue generating activities. 


2. What does the field of PCBH need to do to leverage itself as a valued component of the future value-based healthcare payment system? 


This is an easy question to answer though, quite possibly, not so easy to achieve. BHCs working in the PCBH model need to prove--with data--the presence of the behavioral health provider on the primary care team improves clinical outcomes, enhances practice efficiency and reduces total healthcare costs for the panel of patients cared for by the practice. These are team outcomes not individual behavioral health provider outcomes.

The BHC needs to know and understand the value-based opportunities available in the organization’s contracts and bring a measurement mentality to help track and improve the measures (utilization, HEDIS, cost measures) upon which value-based payments are made.


3. What can clinicians do to increase their knowledge of financing models and payment reform? 


It is important for clinicians to understand why there is such an emphasis on health care reform in our country. While improving the outcomes of health services and enhancing the overall health status of US population would be sufficient reasons, the major driver of health care reform in this country is cost. The US healthcare system is the most expensive of any nation on earth, more than 50% more expensive than the next most expensive national system. Our outcomes don’t justify the cost. US healthcare expenditures are a drag on our economy and we are at a competitive disadvantage with other nations as a result. That is the “why” of healthcare reform.

Understanding the big picture helps clinicians appreciate the economic forces impacting their work.  Employed clinicians should take the initiative to gain a basic understanding of the revenue sources and the financing mechanisms that support and sustain their organization. Understanding the financing helps the clinician gain an appreciation of the efforts and decisions administration is making to secure the future of the organization.

Is my wish that clinicians promptly forget all they know about the financing mechanisms when they enter the room with the patient. At Cherokee we don’t ever want the financing mechanisms or the payer source to impact the care a patient receives. We want the uninsured patient to receive the same level of excellent care as the patient with the most generous health plan. Frankly, clinicians have enough to be concerned about just focusing on delivering quality care.    

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Cultural Considerations for Behavioral Health Providers in Primary Care

Posted By Matthew P. Martin, Monday, March 12, 2018

Healthy People 2020 is a multi-year, multi-stakeholder effort by the US government to address social determinants of health and disparities. This vision for a healthier country includes specific actions that the United States must take to achieve better health by the year 2020.

Some of the goals include:

  • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death.
  • Achieve health equity, eliminate disparities, and improve the health of all groups.
  • Create social and physical environments that promote good health for all.
  • Promote quality of life, healthy development, and healthy behaviors across all life stages.

To address disparities in health and healthcare, behavioral health providers must apply their knowledge and skill in ways that meet the high demands for care. Specifically, they must apply a cultural lens to utilize knowledge about patients’ cultural background, values, and experiences when delivering services.

One recent article on this very topic appeared in the recent issue of Journal of Clinical Psychology in Medical Settings. I reached out to the authors Jessica Jackson and Adeya Richmond for answers to some questions and received the following responses. 

1. How can a culture-centered paradigm help address health equity? 


Patient engagement and subsequent compliance with treatment are one pathway to improving health equity. A culture-centered paradigm is a more comprehensive way of assessing patient needs and addressing barriers to care. In order for patients to make health decisions that are in their best interest they need the opportunity to receive and interpret basic health information in a way that resonates with their cultural frame of reference.  Patients are more likely to engage in and successfully complete treatment when they believe that the intervention aligns with their values and beliefs. Culturally sensitive providers who provide culturally competent care have the potential to increase patients treatment engagement.


2. What are the Five A’s Organizational Construct?


The Five A’s is an evidence-based assessment and intervention format for behavior change. (Hunter, Goodie, Oordt & Dobmeyer, 2009; Whitlock, Orleans, Pender, & Allan, 2002). It encompasses 5 phases that are patient-centered and collaborative: Assess, Advise, Agree, Assist & Arrange. This format equips providers with a tool to help thoroughly identify and address concerns that may be a barrier to optimal functioning and has been found to be especially effective in primary care settings.


3. What is the model of cultural competence you describe in your article and how can it help behavioral health providers?


The model of cultural competence described in our article is one put forth by Josepha Campinha-Bacote (2002): The Process of Cultural Competence in the Delivery of Healthcare Services. This model emphasizes cultural competence as a dynamic process that clinicians engage in as they work to understand and provide services within the cultural context of patients. This model encourages clinicians to develop (1) cultural awareness, (2) cultural knowledge, and (3) cultural skill which will influence their (4) cultural encounters and increase (5) cultural desire. This model can help behavioral health providers integrate their assessment of patient concerns with sociocultural factors that influence patient behaviors. Patients often understand and address their behavioral health and medical needs through the lens of their cultural beliefs (Andrulis & Brach, 2007) and providers need to be cognizant of how these beliefs are influencing behaviors and decision-making. Behavioral health providers who seek to understand these beliefs may be able to more accurately address patient needs and concerns.


4. How can behavioral health providers help other providers (physicians, nurses, and students) to develop a culture-centered paradigm?


Behavioral health providers often work in interdisciplinary settings and have the unique opportunity to help other providers understand how the cultures of multiple systems (medical culture, culture of the practice, the different personal cultures of the providers etc. interact and together and influence healthcare/behavioral health service delivery. Another way that behavioral health providers can help other providers develop a culture-centered paradigm is by assessing (formally or informally) the level of cultural sensitivity in the practice/clinic/classroom that they work in. This may include assessing for an understanding of the concerns of the specific community being served or ensuring that patients can receive health information in their native language or other community relevant concerns


  Matt Martin, PhD, LMFT is Clinical Assistant Professor at Arizona State University Doctor of Behavioral Health Program. He serves as CFHA blog editor. 

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4 Things Your Supervisee Wants to Hear from You

Posted By Kyler Shumway, Tuesday, February 13, 2018

For the tiny town of Cottonwood, Idaho – population 900 people and 1800 cattle – sports were something to rally around. 

My senior year in high school, we made it to the football state championships.  When we took to the field for the championship game, it was breathtaking to see half the town in the stands, ringing cowbells and bellowing themselves hoarse.  We knew they were counting on our ragtag band of teenagers to make everyone proud and bring home the win. 

We were losing the game at halftime, physically and emotionally defeated.  I remember being on the verge of tears, outraged and fearful of the possibility of a loss – of the town’s loss.

I was dumbfounded when my coach entered the locker room with a grin on his face. 

“C’mon boys, smile!” he said. “You’ve worked hard to be here!  I am so proud of you… you’ve made us all feel like champions.”

Those words meant the world to me. 

I played harder than I had in my entire athletic career.  A simple shift in perspective and affirmation dramatically altered my drive. This was the power of leadership. 

On the playing field of integrated care, supervisors have the opportunity to equally inspire and lead others.  Many of us recognize the vitality of supervision the future of primary care behavioral health; yet, supervision was only just recently recognized as a core competency by the American Psychological Association. 

As a supervisee, I hope to share four of the most meaningful things I have been taught in my training. 

#1 – “Keep Your Chin Up”

Many supervisees (including myself) tend to be excellent self-critics.  Push yourself harder than any coach can, and no coach can push you hard enough.  Although this mentality promotes motivation and careful analysis, the focus remains on failure rather than victory. 


In my first year of clinical training, I remember discussing my work with a patient with whom I was “failing at therapy.”  We had completed around four sessions, with little to no progress towards our goal.  My supervisor wisely pointed out three things: 1) that I was still in training, 2) that the patient’s condition was stable and not worsening, and 3) that the pressure I placed on myself might actually interfere with the therapeutic relationship.  “Keep your chin up, you’ll get there” she said.  


The role of a supervisor incongruously straddles that of the coach, the administrator, and the therapist.  Although supervisees need direction and motivation to grow, sometimes encouragement can do wonders for the self-critic.  

#2 – “Thank You”

This one is more of a friendly reminder.


The importance of expressing appreciation is not unbeknownst to supervisors.  Yet, a simple thank you can go a long way. 


My colleagues and I were together at a group supervision meeting after a particularly heavy week.  As we began to discuss ongoing issues with client work and external stressors (classwork, life transitions, etc.), our supervisor caught us off guard. 


“Thank you all, so much, for your hard work and dedication despite these challenges.  Our clinic couldn’t do this without you.”


Instantly, I experienced a refueled sense of clinical purpose.  The work of a mental health professional is just as challenging as it is meaningful, yet we often lose sight of the meaning.  A well-placed “thank you” can affirm, motivate, and provide perspective to even the most burned out supervisee. 

#3 – “These are Skis”

A supervisor once shared a story about the first time they went skiing. 


“As the class began, the ski instructor held some of the equipment up and said ‘everyone: this is a ski.’  That’s when I knew I was in the right class.”


Many of the fundamental elements of behavioral health become second nature for supervisors.

As a supervisee, I have felt challenged to ride the fine line between competent and coachable.  Asking for direction, particularly when the direction seems fundamental, can feel threatening to a supervisee.  Some of the most helpful instruction I have received in supervision has focused on the fundamentals – how to document, how to introduce myself, how to use the phone system, which drinking fountain tastes best. 


The evaluator-evaluated dynamic of supervision does not always foster an environment where basic questions can also be safe questions.  Sometimes, being able to ask what a ski is can make a mountain’s difference in supervision. 


 #4 – “I am Human, Too”

The power differential in supervision is an unavoidable necessity.    


Every supervisor has a different style, yet the general structure is designed for supervisee training and oversight of patient care.  As such, the role of the supervisee can feel less-than-thou, or at least needing to prove oneself. 


One of my supervisors arrived late to our meeting looking a bit spread thin – coffee in one hand, a stack of referrals in the other.  Despite this, they arrived with their usual warm and welcoming smile.  So, I asked how they were doing. 


They chuckled, and said “Ah, I have no excuse.  I was up late watching Netflix and I slept through my alarm.  I am human, too!”


The pressure to be on top of one’s game, it seems, is mutual in supervision.  Just like the supervisee, the supervisor may also feel the weight of performance. 


Acknowledgement of the supervisor’s humanness greatly enhanced our working alliance.  I noticed myself being more willing to share my shortcomings, which then increased my supervisor’s capacity to provide feedback. 


We ended up losing that state championship game. 


My teammates and I scrapped and fought until the final whistle blew, but it just was not enough.  And while the sting of defeat still pangs me today, I will never forget the impact of my coach’s leadership. 


As supervisors and supervisees in the world of integrated care, we have the chance to provide that kind of leadership.  Your words matter.  We stand at the forefront of a monumental movement in healthcare, one that will be shaped by the standards we set as leaders and followers. 


Have you shared a similar moment as a supervisor or supervisee?  Share them with the CFHA community in the comments below!

  Kyler T. Shumway, MA, is a doctoral student in George Fox University's department of clinical psychology. Kyler graduated from Duke University in 2014 and began pursuing a career in Primary Care behavioral health. Kyler's upbringing in rural Idaho spurred a passion for bringing behavioral health services to marginalized and underserved communities. To learn more about Kyler, check out his website at 

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The Warm Handoff: Turn up the research heat

Posted By Alan L. Schwartz, Tuesday, January 30, 2018

As I replay my experiences from the recent CFHA Conference in Houston, two primary themes emerged as key take-home messages.  The first, voiced by Executive Director Neftali Serrano in his eloquent plenary address, highlighted the central role of relationships and connections to the organization as exemplified by the mantra (paraphrasing) ‘don’t be afraid to gently accost people in the hallway for an introduction, question or conversation’.  The second message—crucial to the continued evolution of Integrated Care—was crystal clear:  as passionate advocates for Integrated Care, we as a community are tasked with providing the empirical evidence to support its continued development.  While the call was clearly heard at CFHA to unleash our members formidable research apparati and implementation science colleagues, we might be well served to not forget the humblest symbol of Integrated Care—the warm handoff (WHO). 


The WHO has long been a key element of Integrated Care and most notably of the Primary Care Behavioral Health (PCBH) Model.  Its simplicity and power in affording patients and providers instant access to behavioral health services is, as one primary care doctor expressed to me, “intoxicating”, particularly when compared to the Lord of the Rings-like travails required for a successful referral to outpatient treatment.  It is the rare provider that speaks ill of the WHO experience with the wealth of anecdotal evidence supporting its benefits.  It is typically a win all-around.  But do we have empirical evidence to support this important element of PCBH? 


Like the kids say, “Not so much.”


The concern about the empirical base for the WHO was raised in this very blog in a compelling post by Elizabeth Horevitz in 20111.  She noted at that time that “the warm hand-off has never been rigorously tested.  We have no proof of its effectiveness in enhancing follow-up to behavioral health treatment.”   She cited her own research which she later published2 suggesting that in her population of English speaking depressed Latinos, the WHO was associated with four times less likelihood of attending a follow-up session with the BHC.  The trust and rapport associated with the WHO3 was affected by factors including the patient’s primary language and the quality of the referral process and therapeutic relationship.  Clinicians responding to Horevitz’s post, themselves cited their own local data with either a small or no impact of the WHO on follow-up treatment.  


Since then, there have been few studies to further the research base of the WHO.  For one, Van Houten and Johnson4 reported an impressively high return rate—80%-- for the WHO as compared to 40% with less direct referrals, suggesting some impact on reinforcing patients’ connection with behavioral health services.  But aside from anecdotal reports, there is not much more in our literature.  Of course, as a part of collaborative care studies, the warm handoff is one of the elements that allows for facilitating the management of patients’ behavioral health concerns in primary care5.  


This came as a surprise to me as a psychologist who is relatively new to the integrated care world and someone who had transitioned from outpatient specialty care.  Everything about the WHO make sense, for the primary care providers, for the patients and for us.  While there are many variations on the WHO, the essence of the initial contact is the immediate connection between the provider, patient and behavioral health expert, connecting them as a treatment team at the most optimal moment to respond to their needs6 .  Considering that the term is borrowed from the customer service world, it is a fitting referent to the reaction often reflected in anecdotes of satisfied ‘customers’.  


But what should we expect of the WHO?  Certainly, the one-two punch of patient and provider satisfaction has helped many practices and organizations establish an initial foothold for the development of Integrated services.  In our organization, one internally grant-funded BHC position that introduced the WHO was the springboard for a systemwide transformation, based on compelling satisfaction data.  More than 90% of patents reported that they would not seek behavioral health care outside the practice as a result of this innovation. Beyond satisfaction, we also have seen the importance of using the WHO as a measure of utilization, engagement by Integrated Care teams.  Shelley Hosterman and Monika Parikh from Geisinger presented data in Houston on the functioning of their BHC team across multiple practices5.  They not only tracked the frequency of WHOs across clinicians and practices, but also the use of WHOs by hour during the day, day of the week and season of the year, allowing them to understand and adroitly address the changing demands. 


So, at this moment in our Integrated Care evolution, we have developed some important elements that have guided our work on the WHO.  We have established that our customers—patients and providers are incredibly satisfied with this humble tool.  Once introduced, it is hard to imagine one’s practice without it.  We have also seen, as exemplified by our colleagues at Geisinger, how data about the WHO can improve efficiency and the process of care.  Elizabeth Horevitz’s research challenges us to look beyond (or behind) the shiny headlines, as not everyone seems to respond in the same fashion to the WHO.  We are still looking for the answers to many questions.  For example, while we are aware of the broad outlines to the WHO how might variations in their implementation—time spent, level of therapeutic communication/intervention, quality of the working alliance—impact outcomes?  Is care improved with more or less education provided or more or less intervention provided? Do WHOs which lead to internal versus external follow-ups impact show rates or outcomes differentially? And what patient factors, aside from those discussed above contribute to a successful WHO and improved care? With these questions, among others, we have our work ahead of us.

Alan L. Schwartz, PsyD

 Behavioral Health Consultant/Psychologist

Family Medicine Center-Foulk Road

Christiana Care Health System

Wilmington, DE


1Horevitz, E.  (2011, December 22). Integrate this: Evidence-based practice in integrated primary care. Retrieved from 

2Horevitz, E., Organista, K.C., Arean, P.A. (2015).  Depression treatment uptake in integrated primary care: How a “warm handoff” and other factors affect decision making by Latinos.  Psychiatric Services, 66(8), 824-830.

3Integrated Behavioral Health Partners. (n.d.). Accessing the behavioral health counselor.  Retrieved From

4Van Houten, P. and Johnson, M. (n.d.) Integrating behavioral health in primary care settings.   

5Serrano, N. and Monden, K. (2011).  The effect of behavioral health consultation on the care of depression by primary care clinicians. WMJ, 100(3), 113-118.

6Strosahl, K. (2001).  The integration of primary care and behavioral health: Type II changes in the era of managed care. In N. A. Cummings, W. O'Donohue, S. C. Hayes, & V. Follette (Eds.), Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice (pp. 45-69).

7Hosterman, S.J. and Parinkh, M. (2017, October). It’s all in the handshake:  Patterns and outcomes from warm handoffs in integrated pediatric clinics. Presentation at the 19th Annual CFHA Conference, Houston, TX.  



I’m so glad Dr. Schwartz has taken the time to reinvigorate the conversation about the efficacy of the warm handoff, and the need, in general, to expand our evidence base for such IBH-specific practices. Since I published my study, I’ve been asked to give many presentations about the effectiveness of the WHO as a patient engagement strategy to various health care organizations, and the response from practitioners has been extremely interesting. Specifically, in spite of mounting evidence showing that the WHO may not be an effective patient engagement strategy for Latinos (and may have the opposite of its intended effect among English-speaking Latinos), I inevitably get multiple comments from IBH practitioners about how wonderful it is, and how it just feels like the right thing to do.


However, we have yet to establish which components are effective for which intended outcome (is the goal provider satisfaction? Patient satisfaction? Engagement? Clinical intervention?). Like any clinical activity, a warm handoff is both an art & a science, and if we are to devote significant clinical time to it, it is imperative that we move beyond doing things that “seem” like the right thing to do when the published data shows them to be ineffective at best, and detrimental at worst. 


Until we understand the effective components better (who, what, when, where, why?), I am using the evidence we do have to inform my practice. For example, at my clinic, we save the warm handoff for crisis intervention, rather than prioritize it as an engagement strategy. When my clinicians have no-shows, we happily fill the slots with warm handoffs for purposes of initial assessment/intervention, but I have asked that our PCP colleagues not interrupt an active session simply as a means of patient engagement, given the lack of evidence to support such a practice.


For purposes of patient engagement, perhaps a better use of time would be to use the warm handoff address specific patient barriers to care—time, money, transportation, stigma… I urge all of us to move in the direction of implementing practices backed by effectiveness research. And, for those of us in the practice world, we can start by making use of our QI departments to help with the initial steps of testing some simple changes on-the-ground in a rigorous way to point us in new and improved directions. 

Elizabeth Horevitz, LCSW, PhD

 Director of Behavioral Health

Marin Community Clinics

UC Berkeley, School of Social Welfare



Thank you to Dr. Schwartz for his timely commentary highlighting the limited empirical evidence on outcomes from WHO activity.  It is crucial that CFHA members continue to lay down the “research gauntlet” in this way so we can continue to partner in advancing the evidence for integrated care models and key components.  The 2017 CFHA presentation was our Geisinger team’s first attempt to examine WHO data in a systematic way. I was surprised that even this first, very simple review of the data carried some clear operational and clinical implications for our team.  We consider WHO activity an important and powerful part of the model.  Although we believe this is the case and “feel” this is an important part of our model, our group has yet to generate evidence to support this assumption.  Our group has several projects in progress designed to answer some core questions posed by Dr. Schwartz.  Specifically, we are conducting a study of three years of clinical data that will examine access and utilization variables across integrated care clinics and the traditional outpatient therapy clinic within our system.  That study will examine influence of clinic type (integrated or traditional), wait time, WHO, and distance to services on outcome of first schedule visit.  We look forward to sharing those results with the broader community and to watching how other programs and investigators approach this research challenge.  Generating empirical evidence for WHO outcomes will be an important piece of the puzzle in our case for value-based payment models.  We are anxious to see how the story emerges from our data.

Shelley J Hosterman, PhD


Geisinger Bloomsburg


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Health care records on your iPhone?

Posted By Matthew P. Martin, Friday, January 26, 2018

Yup, Apple is making the foray into health care.

One of the biggest companies on the planet wants to give you access to your medical records using the popular iPhone. This feature will be available once the iOS 11.3 update rolls out later this year. 

Check out the article link above for details on how it works (basically using a phone app that links with care systems that have opted into an agreement to share records; patients have to opt in as well).

The implications for this development are enormous. Patient portals via web browser have been around for several years but many of these portals are limited in stability and scope. Moreover, clinical researchers have been challenged for years in gathering more patient-reported data to evaluate health interventions. A new phone app like this one may be the break they need.

Maybe the biggest implication is that electronic health records may now finally be streamlined into an easily accessible platform for both patients and physicians. Imagine interacting with patients more often outside of a medical or behavioral health visit. Imagine collecting additional health outcome data from them or family members. 

The rollout for this new app is quite small but hopefully will gain momentum in the near future. Stay tuned listeners ...

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Addressing Fidelity in Primary Care Behavioral Health with the PPAQ: Measurement Matters

Posted By Greg Beehler, Thursday, January 11, 2018

(Brief History)

My colleagues and I at the VA Center for Integrated Healthcare (CIH) first developed the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to address a fundamental question: What do PCBH providers do every day?  We all know that variation in clinical practice is common.  In short, clinicians don’t perfectly follow conceptual models or detailed protocols in their usual practices for any number of reasons. Thus, we developed the PPAQ with the goal of creating a self-report measure of PCBH provider fidelity. 

Fidelity typically refers to the degree to which a model of care (or a specific treatment) is implemented as intended. To craft our measure, we started with an expert consensus study to help identify the essential components of the PCBH model that could be measures by self-report. This expert consensus study (1) ensured that we included the right survey items in our measure. A subsequent study ensured that the measure had adequate technical quality in terms of reliability and validity (2). Additional research showed that the PPAQ was effective at classifying PCBH providers as engaging in high or low fidelity practices (3). 



The PPAQ is a 48−item self-report measures that uses a 5−point, Likert-type response scale ranging from “never” to “always.” It sounds long, but don’t worry! It only takes about five minutes to complete. The PPAQ includes essential items, which measure behaviors that are highly consistent with the PCBH model, and prohibited items, which measure behaviors that are inconsistent with the PCBH model. The items are organized into four content domains:

1.     Clinical Scope and Interventions

2.     Practice and Session Management

3.     Referral Management and Care Continuity

4.     Consultation, Collaboration, and Interprofessional Communication

The PPAQ can be used for research and evaluation, but to make it easy to use as a quality improvement tool, we also converted it into a toolkit that was found to be highly acceptable as a self-assessment to frontline PCBH providers (4). 

The best way to get to know the PPAQ is to visit our webpage to download the PPAQ Self-Report Form and various versions of the toolkit to take a look for yourself:



So why should you care about fidelity and the PPAQ?  I think the answer to this question is quite simple: fidelity is an indicator of care quality. Consider the following:

       Monitoring fidelity means you are keeping an eye on quality of services

      Areas of low fidelity can indicate targets for quality improvement initiatives which are key to improving service delivery

       We can advance the knowledge base in PCBH by addressing fidelity in our research and evaluation

      Formally linking provider behaviors to patient and system outcomes will help us determine what aspects of care provided by PCBH providers matter most

       Fidelity assessment can enhance training and implementation efforts

      PCBH is a challenging and complex model. Using a measure like the PPAQ can assist providers with understanding what behaviors constitute high quality practice

It also should be noted that high fidelity practice doesn’t mean providing the same service to all patients every single time in a mindless, if technically correct fashion. Purposeful modifications to high fidelity practice can ensure high quality, patient-centered care.


(Future steps)

Currently, the VA has undertaken a huge step in addressing competencies among integrated primary care providers.  In summer of 2017, experts at CIH have developed a comprehensive competency training program that will be completed nationally by all VA Primary Care Mental Health Integration providers. The PPAQ is being used as part of an evaluation plan to assess changes in provider behavior as a result of the training program (…and early results are encouraging.) Initial competency training will be conducted at all VA healthcare systems through December 2018 with ongoing training occurring for new providers thereafter.

Also in 2018, the PPAQ-2 will be made available. Since integrated primary care comes in many shapes and sizes, the PPAQ-2 has been expanded and re-validated to include new subscales to address essential components of collaborative care management.  The PPAQ-2 will now be useful for both PCBH providers and care managers.

I hope you will consider embracing fidelity measurement in PCBH. It’s a chance to make care quality better.


1. Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8, 19. (Link to PubMed Abstract)

2. Beehler, G. P., Funderburk, J. S., Possemato, K., & Dollar, K. (2013). Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Translational Behavioral Medicine, 3, 379-391. (Link to PubMed Abstract)

3. Beehler, G. P., Funderburk, J. S., King, P., Wade, M., & Possemato, K. (2015). Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns. Translational Behavioral Medicine, 5, 384-392. (Link to PubMed Abstract)

4. Beehler, G. P., & Lilienthal, K. R. (2017). Provider perceptions of an integrated primary care quality improvement strategy: The PPAQ Toolkit. Psychological Services, 14, 50-56. (Link to PubMed Abstract)


Gregory P. Beehler, PhD, MA is the Associate Director for Research and a Clinical Research Psychologist at the VA Center for Integrated Healthcare in Buffalo, NY. He is an adjunct assistant professor in the Department of Community Health and Health Behavior and the School of Nursing at the University at Buffalo. Dr. Beehler is a licensed psychologist and medical anthropologist currently conducting research in the following areas: improving the implementation of primary care-mental health integration, fidelity assessment, measurement-based care, developing and implementing brief interventions for chronic pain, and promoting wellness among cancer survivors.


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Current State of Integrated Care: Collaborative Care in Kentucky

Posted By Xiaodi Chen, Thursday, January 4, 2018

Kentucky has a long history of healthcare innovation. In May of 1993, it submitted its first 1115 waiver (under section 1115 of the Social Security Act, the federal government may grant the state flexibility to experiment with projects that are likely to promote the same objectives as the federal program – for more information, see this key fact sheet), called the Health Care Partnership Program.


In 1997, implementation of the project began. The demonstration project was set to create eight partnerships of public and private providers, one for each identified geographic region, to deliver Medicaid acute services through managed care arrangements. One of the hopes was that by developing a capitated payment system, under which the fee is based on enrollment rather a fee-for-service scheme, and improving coordination of care, the rate of Medicaid expenditure growth would decrease.


Ultimately, only two of the eight partnerships were fully implemented. In 2000, one of those two terminated its contract, leaving only the partnership in charge of the Medicaid delivery system for Louisville and surrounding counties. The commonwealth of Kentucky filed for extensions several times, and the waiver eventually expired December 31, 2012. A report by the CMS hypothesized that low population density meant many regions simply did not have the membership base to be financially viable. In addition, setting feasible capitation rates was an important strategic choice that determined the fate of the two established partnerships.


Although that particular demonstration did not go completely as planned, Kentucky seemed to continue to move in the direction of improved care coordination. According to a report by the state government, by September 2014, Kentucky had over 200 National Committee for Quality Assurance (NCAQ) recognized Patient Centered Medical Home (PCMH) clinicians, as well as 21 – 61 PCMHs.


Furthermore, Kentucky participated in the CMS’ Comprehensive Primary Care Initiative (CPCI) from 2012 to December, 2016. This is a multi-payer initiative that fosters collaboration between public and private health care payers to strengthen primary care, which, historically, has been underfunded. Under this model, participating primary care practices receive a monthly non-visit-based care management fee and have the opportunity to share in any net savings.


In addition, Kentucky was part of the project lead by TransforMED that won the Health Care Innovation Award in 2012. This was a three-year initiative to create “medical neighborhoods” to promote care coordination among PCMH, specialty practices, and hospitals. This project used a sophisticated analytical engine to identify high-risk patients and coordinate care across the medical neighborhood to provide comprehensive care while reducing costs. Outcome research conducted by the CMS suggests that, overall, the project had statistically significant favorable effects in terms of service use, while having no substantive effect on quality-of-care processes or spending.


In 2015, as winner of the State Innovation Model Initiative Model Design Awards Round Two, Kentucky received 2 million dollars from the CMS to improve statewide health care quality and access while reducing costs. Kentucky planned to enhance delivery system for behavioral health, long term services and support, and end-of-life care. Innovation projects include the introduction of Complex Chronic Condition Health Homes, the Episode of Care (EOC) payment model, telehealth to connect primary care providers and patients in rural areas with specialists, and “Citizen Portal” for consumer direct access of personal health records as part of the Health Information Exchanges (HIE) expansion. The projected saving from the project is $104.1 million to $270.5 million. The state proposed a two-year implementation timeline. (For more information on this initiative, you can read the state’s grant application.) [In my research, I found that the CMS website has a very interesting interactive map, where you can select a state and see all the innovation models run at the state level.]


In 2015, Kentucky also won an award of nearly a million dollars from the Substance Abuse and Mental Health Services Administration (SAMHSA) to, as part of the initiative to integrate behavioral health with physical health, promote evidence-based practices and increase access to high quality care.


One challenge facing the commonwealth of Kentucky is the cost of operation, especially after their recent expansion of Medicaid eligibility. In 2014, Kentucky expanded its Medicaid program to cover all newly eligible adults with income below 138% of the federal poverty level (FPL), as part of the Affordable Care Act (ACA). The number of insured people in Medicaid/CHIP increased 107.65% percent from 606,805 in 2013 to 1,260,001 in 2017.


This cost challenge was one of the driving forces behind Kentucky’s second application for a 1115 waiver. Under the new proposal, adults with income below 138% of the FPL would generally no longer be automatically insured through the Medicaid program. Instead, enrollment would be provided through their employment, with the state offering employers a premium assistance program. To make it a consumer-driven health plan, each person would have a deductible account and a reward account. The state would contribute $1000 a year toward the deductible account to help consumers afford the deductible required by various plans. In the reward account, individuals could receive enhanced healthcare benefits such as vision, dental, over-the-counter medications, and gym memberships by completing specified health-related or community engagement activities. A decision on the application will come soon, and should significantly impact the healthcare landscape in Kentucky!


From this overview of Kentucky’s recent healthcare initiatives, it is clear that the commonwealth has been actively exploring alternatives to improve the efficiency and quality of its healthcare system.  At this stage, it is difficult to know the outcome of Kentucky’s newest proposal. If the most recent 1115 waiver is accepted, we will be watching closely to see how it works out!


As always, it is important for clinicians to understand the changing landscape and advocate from their perspective, so policy-makers and administrators can better plan and implement relevant proposals.  Please leave us a comment if you would like to share more about what is going on in Kentucky or another state regarding Collaborative Care!


Note: Special thanks to Jessica Beal, who has provided valuable insights and support in writing of this blog.


Xiaodi Chen, MSMFT, is a recent graduate of Northwestern University's program in Marriage and Family Therapy, where she had extensive clinical training at The Family Institute's Bette D. Harris Family and Child Clinic.  She previously received a Bachelor of Arts in Economics from Cambridge University and a Master of Education focusing on Human Development and Psychology from Harvard University's Graduate School of Education.  Ms. Chen is particularly interested in interdisciplinary work to promote patient-centered healthcare.


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Current state of integrated care: An opportunity in England

Posted By David Humphreys, Monday, December 4, 2017

A recent article in Context, the house magazine of the Association of Family Therapy (AFT), raises questions about the future of family therapy as an accredited profession in the UK. A variety of threats to the profession are described, which include a lack of clarity about what the family therapists do and with which client groups. The recognition and accreditation by AFT of the systemic practitioner role. This can be achieved with the completion of the first two years i.e. intermediate level, of the four-year family therapy training.


AFT argue that they are responding to an increase in intermediate level training being provided by private, voluntary and NHS providers. This is attractive to organizations because training can be delivered in house to existing staff, who can be skilled up for specific projects. Further the nature of the requirements permit the two years to be delivered in one.  


 There has been a reduction in the numbers on qualifying training courses and several courses have moved to bi-annual intakes. In recent years one private training provider, Kensington Consultation Centre (KCC) closed because of financial issues. There is also some suggestion that universities providing qualifying level training are losing money on these courses. This in a climate where those same organizations have closed other courses because of insufficient numbers.


There would seem to be many reasons for the changes, including the ways that the NHS and Social Services departments have responded to several years of having to make efficiency savings. They are the major employers of family therapists in the UK, the majority of whom are employed in children’s services. In a bid to buy more, with less, many of them have adopted a re-banding strategy. An example of how this works can be seen in a large mental health trust of 3000+ staff close to London.  A layer of middle managers was removed, and their tasks were given to senior clinicians below them, requiring them in turn to reduce their clinical caseload by passing it down and so on. At the same time a new grade of clinician was created, with a lower level of training, using manualised approaches to work with less complex clients, and being supervised by the senior clinicians.  The economics are straightforward depending on grading you can buy 2.5 -3 junior clinicians for one middle manager.


It could be argued that one of the effects of these strategies might be to increase the demand for qualified family therapists as supervisors. This might be the case, but to ensure compliance that would require a binding agreement that systemic practitioners could only be supervised by qualified family therapists.  That doesn’t exist; and already that role is often fulfilled by other clinicians such as clinical or counseling psychologists, who may have completed a systemic element in their training. All of this would support the argument that the profession may be facing a serious reduction in numbers of qualified practitioners and an associated reduction in dedicated posts.


Into this bleak description of the future, maybe consideration needs to be given to current developments in the NHS, and where most of the resources are being allocated. One of these is primary care; the launch in 2015 by NHS England of the Vanguard project; initially establishing 23 trial sites. These are Multi-Speciality Community Providers and Primary and Acute Care systems, trialling integrated care structures. They are bringing together physical and mental health treatment in a variety of structures including within GP practices.  These are large sites serving big populations providing primary physical and mental health care, and outreach secondary services. They are looking to collaborative integrated primary care models in the US, such Intermountain Healthcare and Southcentral Foundation for ideas and inspiration. In 2017 there are over 50 trial sites with a variety of models and configurations across the country. Recent feedback is very interesting.


These developments would seem to offer a potential demand for mental health clinicians skilled in relational working, trained to think about and engage with the network and system at an organisational, team, familial and individual level, aiming to build collaborative working across disciplines. Family therapists would seem to be well placed to meet these demands.


Primary care has not historically been a place of employment for family therapists, there are a number of reasons for this. The first is that the majority of family therapists were, as previously mentioned employed in secondary children’s services in dedicated posts. Until 10 years ago mental health provision in primary care was inconsistent and of variable quality. There was little guidance offered to GPs about the variety of therapeutic modalities and the most effective evidence based treatments. At the same time secondary services especially for people with mild to moderate depression and anxiety disorders were very sparse and often non-existent. The combined effect was an increasing untreated population of adults, with many GP’s trying to treat people with medication and informal supportive counseling.


This changed 10 years ago, when following the publication of the Depression report,  teams of CBT therapists were established across England contracting with GP practices to provide time limited evidence based treatments. Although they are based in secondary care, they see some people in the primary care setting.   Interestingly in the original report family therapists had been identified as one of the professions to be trained to work in primary care, regrettably it didn’t happen.  One of the reasons may be that when in the 1990’s, Susan McDaniel and others in the US, described a Medical Family Therapy role working in primary care. It was dismissed by some in the UK family therapy establishment, on the basis that they were already using that approach in secondary care had been for 40 years.  


Whilst acknowledging that it wasn’t used in primary care, maybe the time has come to take another look at MFT and consider the possibilities that might be created in the Vanguard sites, it is not too late. The Vanguard sites provide the opportunity to implement change, MFT provides a model to learn from and Family Therapists have the professionalism and the motivation to drive the change to integrated care.


David Humphreys, MSc., is a registered family therapist working in a primary care practice in Hertfordshire in the UK. He is a 2016 Winston Churchill Fellow and visiting lecturer at the University of Hertfordshire. 

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New Editors at Families, Systems, & Health

Posted By Matthew P. Martin, Friday, November 24, 2017

Congratulations to the new incoming editors at Families, Systems, and Health: Drs. Jodi Polaha and Nadiya Sunderji. We are looking forward to some great work!

This signals an end to the productive and expansive era of the former editors, Colleen T. Fogarty and Larry Mauksch. CFHA would like to thank Colleen and Larry for their visionary leadership. Under their watch, the journal published significant research including a recent special issue "Strategies for Evaluating Integrated Care in the Real World" that featured Jodi Polaha as a guest editor.

For information about the history of the journal, click here. If you're interested in submitting a manuscript click here

FSH publishes research, literature reviews, health policy briefs, conceptual explorations, educational and clinical models, narrative essays and poetry at the intersection of family functioning, systems thinking and health and health care.

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Contact Us

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What We Do

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