Posted By Juliette Cutts,
Tuesday, April 25, 2017
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This is a reprint of a post originally published in May 2015.
I have been asked by my esteemed colleagues at CFHA to submit a blog post explaining why I feel that being an extrovert is beneficial when working in integrated care. They have asked me to go first because they are still trying to convince my introverted counterpart to participate. I will do my best to represent my fellow extroverts, but if I get something wrong please let me know. I would love to talk about it!
(Side Note: How do you know if you are an extrovert? You have to ration how many exclamation marks you use in written communication!!)
As a behavioral health consultant, I am well aware of the need to initiate interactions in order to work as a team in primary care. It’s not that primary care providers don’t want to work together; they just don’t always have time to stop long enough to bring me in. Occasionally they forget I’m available unless I remind them. These dynamics of primary care have helped me to develop some of my potentially dysfunctional character traits in order to further the cause of integrated care.
In my opinion, the best personality type for integrated care is an extrovert who is mildly hypomanic, somewhat inattentive, and has a touch of OCD. My hope is to convince you to develop some of these traits in yourself in order to better work together as a team. In preparation for this blog entry I talked to everyone I know… not about what to write, but because I’m an extrovert and like to talk to people. Now it is getting late so I should probably start writing something.
Anyway, back to my formula. In order to establish a new integrated care function you have to be willing and able to talk to anyone and by that I mean, anyone! No shrinking violet when it comes to talking to the grumpy provider, the resistant patient, or the reluctant administrator. Sometimes you have to just keep talking to them until they agree with you, right? It also helps if you do not mind looking ridiculous from time to time. Communication can get a bit muddled sometimes and you may end up going into the wrong exam room – turn that into an introduction to the service and move on!
Because of the pace at which we work it’s helpful to keep your energy up. You can do that by developing a nasty caffeine habit or regularly raiding the candy drawer (admit it; we all have one – or 5 - somewhere in the clinic). I have found it is easier to just nurture my hypomanic tendencies. It keeps things light and really helps to burn off the extra calories from the coffee and candy. Just make sure you are not experiencing distress or impairment and you are free and clear. It’s not just the artists that can benefit from hypomania anymore!
The next component, inattentiveness, is a bit blurry in that it is a fine line between hypomania and hyperactivity but just humor me on this; a formula with only two components is not as interesting. Integrated care, especially in the early days of forming a new service requires a person to wear many hats. Because of this, you have to be able to switch sets at the drop of a hat. You think you are going to lunch but then you are doing a crisis intervention because a patient might be suicidal. Of course, the down side is that you can sometimes find yourself getting ready to go to lunch and trying to remember what you were going to do a couple hours ago…then you remember that you were headed to the bathroom.
I have found it is easier to just nurture my hypomanic tendencies
Lastly, it helps to have a little OCD. When you are going from patient to patient you need to be able to keep track of all those little details like what you saw them for the last time and what interventions you have already tried. Being able to find handouts on the fly is important (you need to move on to talk to more people!) so a good filing system comes in handy. Of course, at the end of the day when you are trying to remember what happened after you set your coffee down that morning, being a bit anal retentive about paperwork is really helpful. For those who need some help developing these tendencies I recommend putting tape outlines for everything on your desk…then just for fun put the objects outside of the lines and see who squirms! Another fun strategy is to start making super complex spreadsheets for everything. Once you have created a spreadsheet to manage your spreadsheets, you have made it!
Now I think it is time to stop as I may be drifting into more introverted pastimes. I certainly do not want my readers of the introverted variety to be uncomfortable…though I suppose it is too late for that at this point. You know the saying: "We’re here, we’re uncomfortable, we want to go home” but alas one of you must speak out. Do not panic! We are here to support you and if you will only speak up to the rest of the group…wait, that can’t be right. For all of my teasing, I will concede that an introvert can function in integrated care but I suspect it would require a lot of naps. We will all have to tune in to hear what the next post will be about…
|Juliette Cutts is a licensed clinical psychologist and Behavioral Health Consultant at Salud Medical Center in Woodburn, Oregon. She is a native Californian and got her PsyD from John F. Kennedy University in Pleasant Hill, California in 2010. After graduation she completed a post-doctoral fellowship in Health Psychology at the University of Wisconsin in Madison. After post-doc, she stayed on at Access Community Health Centers as a Behavioral Health Consultant to provide services to underserved patients in the Madison area. In 2012 she moved back to the West Coast to join Yakima Valley Farm Workers Clinic as the Behavioral Health Consultant at Salud Medical Center. At Salud she works with predominantly migrant workers who are not well served by traditional mental health.
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Posted By Matthew P. Martin,
Tuesday, March 14, 2017
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Welcome to the fifth edition of the CFHA News and Research
Column, a new series of posts that highlight recent developments in the field
of collaborative and integrated care. Check back for additional reports.
SAMHSA Webinar – Making the Most of your EHR
The SAMHSA-HRSA Center for Integrated Health Solutions is offering a webinar on March 28th, 2017 to help you make the most of the electronic health record (EHR) to support improved patient outcomes. Health technology experts and a behavioral health manager will show how to improve electronic health record workflows, data entry and reports for depression screening and follow-up interventions. They will also discuss practical strategies for sharing data with the team to improve benchmarking and quality.
Utah Legislatures to Require Physicians to Complete SBIRT Training
On February 17, 2017 the Utah House passed a bill designed to deal with opioid misuse by requiring medical professionals to complete several hours of training in SBIRT which stands for Screening, Brief Intervention, and Referral to Treatment. SBIRT is designed to identify patients with problematic use of alcohol and drugs. Utah physicians would complete the training when renewing their medical license and would then receive reimbursement afterward. Before the current legislative session, Republican Representative Steve Eliason met with former directors of the National Institute on Drug Abuse and the National Institutes of Health. "I said, if there’s one thing we could do to address our opioid overdose problem, what would it be? And it’s this bill," Eliason said.
National Coalition on Health Care Forum: Panelists Discuss Integrated Behavioral Health
New payment models and dedicated efforts to coordinate care are changing the delivery of health care, but more progress needs to be made, panelists said March 6, 2017 at the National Coalition on Health Care Forum on health policy. "Primary care has been overlooked for too long in discussions about health care reform," said National Coalition on Health Care President and CEO John Rother, J.D. Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center at the University of Colorado in Aurora, spoke about the need for greater integration between primary care and mental health, noting that treatment of physical and mental needs is too often artificially segregated. The forum was the first in a three-part series co-hosted by the AAFP, National Coalition on Health Care, National Association of Community Health Centers, American College of Physicians and American Osteopathic Association. The next event is a March 28 forum on primary care's role in underserved communities.
Humana and Quartet Team Up to Deliver Integrated Mental Health Care to New Orleans Residents
Humana and Quartet, a technology company, are teaming up to improve access to care for New Orleans Medicare Advantage members living with anxiety, depression and addiction. Quartet technology allows primary care physicians to initiate their patients into a proven collaborative behavioral program. Resources include a highly curated group of local behavioral health providers, live psychiatry consults for providers, data driven insights through adaptive learning algorithms, and concierge support for patients. An estimated $48.3 billion could be cut from the total cost of health care in the United States each year by effectively integrating physical and mental health services, according to a 2014 study by leading actuarial firm, Milliman Inc. Quartet provides a scalable, evidence-based solution to integrate physical and mental health care that reduces costs and improves health outcomes.
Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care: The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy.
Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review: Integration of behavioral health into primary care settings has the potential to address barriers and improve outcomes for adolescents and young adults. In this paper, we review the current research literature for behavioral health integration in the adolescent and young adult population and make recommendations for needed research to move the field forward.
Experiencing integration: a qualitative pilot study of consumer and provider experiences: Existing frameworks for integration have been heavily influenced by the provider and organizational perspectives. They are useful for conceptualizing integration from a professional perspective, but are less relevant for consumers’ experiences. Consumers of integrated primary health care may be more focused on relational aspects of care and outcomes of care.
Integrated Psychological Services for Anxiety and Depression in a Safety Net Primary Care Clinic: Despite the recognized importance of integrated behavioral health, particularly in safety net primary care, its effectiveness in real world settings has not been extensively evaluated. This article presents 2 successive studies examining the effectiveness of integrated behavioral care in a safety net setting. These results support the short- and long-term treatment effects of brief primary care behavioral interventions, further strengthening the case for integrated behavioral healthcare in safety net settings.
Outcomes of Integrated Behavioral Health with Primary Care: Integrating behavioral health and primary care is beneficial to patients and health systems. However, for integration to be widely adopted, studies demonstrating its benefits in community practices are needed. The objective of this study was to evaluate effect of integrated care, adapted to local contexts, on depression severity and patients' experience of care. Results show that integrating behavioral health and primary care, when adapted to fit into community practices, reduced depression severity and enhanced patients' experience of care.
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Posted By Elizabeth Banks,
Wednesday, February 15, 2017
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There is a lot to be said for physical presence. As licensed
mental health care providers (LMFT in my case), we are taught to diagnose and
treat in person. Connecting with people
in a therapeutic, healing, and professionally intimate manner over a
telemonitor is difficult at best. It is possible to read body language and tone
through a monitor, but the amount of emotional energy it takes to convey
compassion, empathic presence, and sound clinical interventions through a
virtual space is harder than it sounds.
While tele-presence is better than no presence, and
comparable to in person care [1-2],
there are patients who distrust technology, who display emotions that
can be hard to help regulate in a virtual space, who have hearing deficits, who
speak a different language than the provider (more challenging over telehealth
than in person), and any number of other barriers. A thorough assessment of
functioning can be made more difficult without the benefit of having all senses
available. For example, if a patient is not bathing regularly, this could be a
sign of poor self care related to level of depression and impairment. Poor
hygiene can be difficult to assess in a virtual environment.
Advantages include the elimination of provider safety issues.
The two times that I can think of in the past 2 years that someone made
sexually inappropriate comments and/or gestures on the telemonitor, I didn’t
have to worry about a panic button or alerting someone to come help me. All I
had to do was give a warning to the patient, and when that warning was not
heeded, I let them know I was disconnecting due to their inappropriate
behavior, hung up, called the nurse on site to follow-up with the patient, and
voila! All bases covered.
Another great thing about Telehealth is that it is a
therapeutic modality that is evolving in terms of technology available and as a
billable service. When I first started in telehealth in the mid 2000s, telehealth
really meant talking on the phone…a land line at that! Imagine doing therapy
with a blind fold on and the client is the next town over! Now, we have
sophisticated HIPAA compliant, encrypted teleconferencing hardware and
software. At a teleconference conference in Maryland earlier this year, I saw
an actual telehealth robot that moved around the room seemingly independently.
In my current position I work with patients who live in
rural areas with no or limited access to specialty care. The teleconferencing
equipment is in their primary care physician’s offices, so they still have to
travel to receive care. As such, there are the typical no show rates and
transportation issues. There are connectivity issues, but there are also huge
pay offs and success stories.
I think about the woman with the 30 year old gunshot wound
who presented to telehealth for rising A1C, gastrointestinal distress, a
colostomy bag, and poor diet compliance. This woman had been seen for years in
her primary care clinic and there was no evidence in her chart that any
provider had ever asked her the origin of her gunshot wound or colostomy bag,
or the reason that her diet was so incompatible with her diabetic and
gastrointestinal status. A brief conversation about her social and emotional
environment revealed that she was in a long term abusive relationship, that she
was still living with the partner who shot her, and that the partner’s new form
of control of her was to prepare and monitor the patient’s food intake, with
violent consequences if she did not conform to his expectations.
By having access to a behavioral health provider with the
time and the skill set to assess for psychosocial stressors that could be
impacting her medical compliance, she was able to disclose the abuse, problem
solve around her options, and make strategies with regard to maintaining her
health as much as possible within an abusive environment. Knowing her home environment was directly
related to her inability to manage her A1C and gastrointestinal issues, it took
someone to ask her a direct question about her home environment for her to
With this information, I was able to work with her physician and a
nutritionist to tailor her treatment goals to her particular situation. This is an uncommon example, but I continue
to be amazed at what is revealed in telehealth sessions that are designed to be
about health behavior, but so frequently are tied in to relational and systemic
R. L., Shannon, G. W., Smith, B. R., & Woodward, M. A. (2015). The
empirical evidence for the telemedicine intervention in diabetes management.Telemedicine
R. E., Knudson, P. E., Meyer, S., Kearns, J., Ploutz-Snyder, R., &
Weinstock, R. S. (2003). A comparison of diabetes education administered
through telemedicine versus in person.Diabetes
|Dr. Banks is a clinical assistant professor at East Carolina University at the Family Medicine Center. She has a PhD in Marriage and Family Therapy and is a AAMFT Approved Supervisor. In her current role, she provides telebehavioral health services to people with diabetes and co-morbid behavioral health challenges. In addition to her clinical work, she teaches at both the undergraduate and graduate level. She serves on the CFHA Research and Evaluation Committee and is Continuing Education Chair for the North Carolina Association for Marital and Family Therapy. She is also a member of the American Telemedicine Association, She currently has 6 journal publications and has presented 24 times at local, state, and national levels. She is particularly passionate about keeping issues of social, human, and relational justice alive in our personal and professional roles.|
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Posted By Eboni Winford,
Thursday, January 5, 2017
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"Please don’t tell my parents.” These were the words spoken by
20-year-old "Gwenivere” upon learning that her routine pregnancy test to
determine which post-resettlement vaccinations she could receive was positive.
Gwenivere had just resettled to Knoxville, TN, after fleeing the war and
violence of Burundi, an East African country that borders Rwanda, Tanzania, and
the Democratic Republic of Congo. She and her family, including her parents and
younger sister, lived in a Tanzanian refugee camp for 12 years after fleeing
Burundi; eight of these years were spent undergoing the UN Refugee Agency’s
formal resettlement process.
Two weeks after arriving to Knoxville, and after being
oriented to their new home by the local resettlement agency, Gwenivere and her
family made their first visit to Cherokee Health Systems (CHS) where they
received routine vitals and had labs that were specific to their country of
origin or country of refuge performed.
At their second visit, which occurs 10
days after these initial labs are drawn, Gwenivere and her family met with a
medical provider who performed a medical screen designed by the CDC and Office
of Refugee Resettlement. She and her family also met with a behavioral health
consultant (BHC) who assessed Gwenivere and her family’s adjustment to
resettlement and screened for psychological symptoms including posttraumatic
stress disorder and depression. The results of Gwenivere’s labs 10 days prior
revealed a positive pregnancy test.
"Please don’t tell my parents,” Gwenivere said via an
in-person Kirundi interpreter. "If they find out that I’m pregnant and I’m not
married, they will kick me out of their home.” Because CHS has a
well-established model of integrated care and because continuity of care is key
as refugees settle into their new lives in the US, the care team collaborated
with Gwenivere to quickly implement a plan to accommodate her new healthcare
The BHC provided an overview of the available services at CHS including
but not limited to blended primary
care and BH services; obstetrical and gynecological care; care coordination
from community health coordinators; and specialty services including
psychiatry, cardiology, and nephrology, and worked to develop a culturally
appropriate and sensitive treatment plan that best suited Gwenivere’s needs. The
care team honored Gwenivere’s wishes to not disclose her health status to her
parents and utilized that opportunity to teach an important lesson regarding
protected health information and privacy, something with which Gwenivere was
The care team
coordinated an initial prenatal care visit on a day when Gwenivere was already
scheduled to return to the clinic to receive another vaccination. As such, this
additional medical visit did not appear unusual to her parents. She met with
the OB/GYN provider and a BHC who worked with Gwenivere to explore pros and
cons of informing her parents of her pregnancy. The BHC coordinated with a community
health coordinator who met with Gwenivere to discuss alternate housing
arrangements in the event that her parents did ask her to leave their home after
learning of her pregnancy.
The CHC also provided resources for obtaining
necessary supplies for the baby upon its birth. With coaching and support from
the care team, Gwenivere made a plan to tell her parents of her pregnancy,
which went surprisingly well. Her parents expressed disappointment but did not
ask her to leave the home. Gwenivere continues to receive behaviorally-enhanced
prenatal care at CHS, which emphasizes wellness promotion during pregnancy as
well as ongoing monitoring for the development of trauma-related symptoms
secondary to her exposure to war in Burundi.
When CHS began
the integrated refugee resettlement program in October 2015, members of the
care team quickly learned that offering care via our health care home helped
eliminate barriers such as access to care, language difficulties, and a sense
of displacement that may linger after being uprooted from one’s home of origin.
We also learned that routine BH monitoring was essential for prevention, early
detection, and intervention of trauma-related symptoms, which may not appear
until several months after refugees have resettled in their new home countries.
Not only are BH providers able to implement interventions at the point of care
but they are also able to reduce stigma associated with receiving BH care by
being present at every clinical encounter refugees have during their initial
year following resettlement. Sharing an EHR allows for enhanced communication
of previous traumatic experiences to various care team members, which improves
the overall delivery of trauma-informed and culturally sensitive care. Accordingly,
whether Gwenivere would have had a positive pregnancy test or not, she and her
family would have been invited to make CHS their health care home where
they would then gain access to the range of services presented to Gwenivere.
refugee resettlement program is still in its infancy, but since its inception
one year ago, we have provided services to individuals from Iraq, Burundi,
Ukraine, Sudan, Colombia, Tanzania, Cuba, South Africa, and Burma. As we
continue to evaluate and improve the care we provide, we seek to do so in a
manner that is culturally sensitive and responsive to the needs of this unique
population while also remaining true to the spirit of integrated care. We are
honored to serve these families and to work as a bridge as they start their new
Eboni Winford, Ph.D.
is a Behavioral Health Consultant and licensed psychologist at Cherokee Health
Systems in Knoxville, TN. Dr. Winford is involved in workforce development and
is a member of the training committee of CHS’s APA-accredited clinical
psychology internship and the APPIC-approved postdoctoral fellowship program.
She supervises trainees at multiple levels including postdoctoral fellows,
clinical psychology interns, and graduate-level psychology practicum students.
Additionally, she consults with other primary care organizations as they seek
to integrate their practices. She is currently involved in multiple integrated
care initiatives including the refugee medical screening process and the
National Institute of Medicine’s All of Us: Precision Medicine Initiative. She
is the incoming Co-Chair and previous co-secretary to the Primary Care
Behavioral Health Special Interest Group, a member of the Early Career
Professionals Task Force, and the recipient of CFHA’s 2016 Founders’ Early
Career Professionals Award. Dr. Winford earned her degree in Clinical Health
Psychology from the University of North Carolina at Charlotte.
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Posted By Rick Ybarra,
Thursday, December 1, 2016
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A version of this piece was originally posted on the Hog
Foundation for Mental Health’s blog site "Rick on Reform.” Click here for the original
Reinventing. Rightsizing. Reorganizing. Restructuring. Turning around. You have
heard them before. Just a few of the terms used to symbolize "transformation.”
talk much of transformation. Actually, we talk about transformation all the
time. But I submit to you that in both the private and public sectors, many
transformation change management efforts to date have not been successful. We
continue to hear countless stories of well-intentioned change efforts that have
fallen short or completely come off the rails. "Our strategy? Well, it seemed
like a good idea at the time…” Most of these efforts end up somewhere in
between, likely skewed toward the lower end of the scale. Think of the bell
curve: outliers at each end; most folks fall somewhere in the middle, with the
majority tilting towards the lower end.
this was not the intention of those leading unsuccessful change efforts. So
what can we learn from this?
P. Kotter, renowned for his work on leading organizational change, shared the
results of his observations in a 1995 article (reprinted 2007) for the Harvard
Business Review titled "Leading Change: Why
Transformation Efforts Fail.” He highlighted the biggest errors
that can derail transformation efforts as well as basic lessons that can be
gleaned from successful organizational transformations.
the health care industry: listen up as Kotter's observations still hold true
many, many years later!
know where you are going, you have to know where you came from. In other words,
institutional culture and history.
a basic lesson from the more successful case examples is that the change
process goes through a series of phases. Check. It’s also important to
note that these phases usually require a considerable period of time and often
the right staging. Check again! Nothing comes easy or fast during the
implementation of change management.
second basic lesson is that critical mistakes during any of the phases can have
devastating consequences, either slowing momentum or worse (such as your change
process effort "coming off the rails”).
emphasized that the most unsuccessful transformation efforts almost always
occur during at least one of the following phases:
a greater sense of urgency.
a powerful enough guiding coalition.
a clear vision.
(or under-communicating) the vision clearly and often.
obstacles to towards the new vision.
for and designing short-term wins.
declarations of victory.
or anchoring changes in the corporate culture.
real surprises here, right? That said, many transformation efforts continue to
fail or fall short by not paying attention to and not nurturing the
organization through these critical phases.
that even if you get seven of the eight phases right, misjudging or not
thoroughly planning for that one phase is enough to bring your entire change
management effort to a slow down or screeching halt! A valuable insight, I’d
realize this is an oversimplification as there are a multitude of complexities
that all organizations face during their transformation journey.
what can we learn from these important observations dating back to the mid-90s?
The big take-away is that all transformation efforts (yes, even successful
ones) are stressful, hectic and sometimes chaotic – and often combined with new
and exciting discoveries! Just as a clear vision is needed to guide an
organization through a major change process initiative, a vision of the actual
change process and phases, clarity on the endpoint for each of these phases,
anticipating some of the challenges to expect and ways to navigate these
challenges can certainly minimize the bumps to be expected. And fewer bumps can
be the difference between a successful transformation effort and failure.
which end of the bell curve do you want to find yourself on as you move through
your change management process?
Ybarra serves as program officer for the Hogg
Foundation for Mental Health
and leads the foundation’s Integrated Health Care Initiative. With over 25
years of clinical and administrative experience in both private and public
sector behavioral health, Ybarra’s policy and program experience extends to
county, state and national efforts promoting reforms, public policies and
clinical practice to improve effective service delivery and health equity for
racial/ethnic populations. Ybarra joined the foundation in 2007.
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Posted By Christine Runyan,
Thursday, November 17, 2016
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Dr. Tina Runyan is the CFHA President-Elect. She spoke at the recent 2016 CFHA Annual Conference in Charlotte, NC.
I’ve worn a lot of hats in my career – Air Force
psychologist, academic dean of a graduate school in psychology, behavioral
health clinician, post-doctoral fellowship director, and a psychologist in
academic medicine to name a few. Throughout this career tapestry, CFHA has been
a unifying thread for me. It is the organizational and professional home I can
count on for inspiration, information, collaboration, socialization, and
opportunities to advance and challenge myself.
Most recently, this opportunity
and challenge will be presenting itself as the Presidency baton is passed to me
in October, 2016. I am standing on the shoulders of giants in the field of
integrated care and honestly do not feel entirely worthy, but I do feel
empowered and ready to chaperon the organization for the next two years. When I
first joined CFHA and started going to conferences, I struggled a little bit
with its softer science and more applied philosophy as compared to other
professional conferences I attended and organizations where I sent my annual
However, I quickly realized that the practical focus on CFHA and the
collaborative – not competitive – spirit was exactly what kept me coming back
and actually fit my needs better. Within
CFHA, I have found both likely and unlikely collaborators, mentorship, mentees,
and an organization I am proud to introduce new professionals to and encourage
them to attend a conference or join the organization.
As I approach the
academic promotion process yet again, I undoubtedly owe some of my professional
success directly to CFHA. The organization is small enough to find a hook for
leadership opportunities and once I ran for the CFHA Board, I was catapulted
into what previously seemed like the "private back room” of the organization.
However, I was pleasantly surprised and delighted to learn that the engine of
the organization was hard at work trying to help CFHA survive and thrive,
volunteering copious amounts of time spawned from dedication to the mission in
general and the organization specifically.
The board strives for transparency
in managing the organization but at times has needed to be cautious to avoid inducing
fear or igniting panic when the organization was in financial jeopardy. Being willing to serve on the board (and it
is a volunteer, time intensive service role) allowed me the chance to work
alongside some of the brilliant leaders in the field, which always serves to elevate
my own thinking and contributions. This willingness eventually manifested as an
invitation for the presidency role (voted on by the nominations committee and
then by the board), which I am both nervous and excited about in relatively
equal measure. And I think these are the right emotions for the job actually.
Anytime I step to the edge of my comfort zone, I know I will be challenged and
that I will grow in ways I cannot fully predict but trust that whatever is on
the other side of this challenge, it will serve me well to face the next one.
And I suspect CFHA will be right by my side for that one too … and the one
after that … and the one after that. CFHA is the constant thread in the ever-changing
tapestry of my career, and truthfully one of my favorites.
|Tina Runyan is an associate clinical professor in the Department of Family and Community Medicine at the University of Massachusetts Medical School. She is the Director of an APA accredited, two year Post-doctoral fellowship in Clinical Health Psychology in Primary Care and the behavioral science director for the Worcester family medicine residency. . She recently joined the Board of CFHA and when not writing, practicing, training or talking about integrated care she enjoys being a mom, trail running, and practicing yoga.|
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Posted By Jodi Polaha, Tom Bishop, Reid Blackwelder, Beth Fox, Brian Cross, Diane Sloan, Leigh Johnson, and Di,
Tuesday, November 8, 2016
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At East Tennessee State University Department of Family Medicine, we are working hard on team care
transformation. Our Department has a long history of embedded pharmacy,
psychology, and social work services in each of its three primary care
residency training programs. Recently, however, our HRSA-funded project
"Collaborative Training in Team Based Care in Appalachian Primary Care
Practices” is providing us with the opportunity to develop a more progressive
We are four medical doctors, two psychologists, a
pharmacist, and our director of clinical services. We were excited to have the
CFHA annual conference come so close to home for us during our project
development. We returned from the meeting so energized we decided to share our
notes in a blog.
We lead with big praise for CFHA. The trip proved to be funding
well-spent. At least three affirmations
resonated with all of us. First, kudos
on bringing LBGTQ healthcare to the forefront across multiple
presentations. This content was an
impactful, albeit unexpected, aspect to our attendance. Drs. Heiman and Johnson have already initiated
changes to clinic practice to improve care for transgender patients and
building more training into our residency programming.
Second, we loved the innovative ideas for building team
care. We all agreed we had not seen this caliber of progressiveness in any
other professional meetings. We are
already looking at next year’s budget to see if there are others on our staff who
could have the advantage of learning about these ideas firsthand in Houston.
Finally, we definitely appreciated the spirit of
collegiality in the atmosphere including an openness to professional networking
and supportive engagement. We valued the validating audience response to our
presentation on an implementation strategy for building innovation into primary
care. We thoroughly enjoyed the engaging audience discussion with our panel on
Interprofessional Education. To sum, even though we were first-timers, we felt
like we fit right in.
Thinking critically about our
experiences, we wondered if CFHA can stretch to accommodate a wider range of health
professions such as pharmacists, nutritionists, and public health
professionals. We saw starting places for broader "team care” in multiple
presentations and, well, we wanted more!
Behavioral health has certainly been one of the leaders of primary care
integration and there is substantive content at CFHA that can be readily
generalized to another professional member of the team. Our pharmacist (Dr.
Cross) said several times how he was amazed at the parallels of so many issues
related to integration of clinical pharmacy services into primary care compared
to that of behavioral health, both victories and obstacles. We would love to
see CFHAs vision expand!
More connections to more diverse professions would add
significant value for us. While we
recognize that academic medicine accounts for a minority of attendees, there is
certainly a priority in university settings for broader interprofessional
practice and education. At CFHA, the
strong participation of a clinical audience from non-academic settings provides
an excellent sounding board for the pedagogical content we develop for our
student learners. In other words, we see
CFHA as having the potential of providing non-academic health care "ears” to
help us "keep it real” and in turn, we can develop training programs that
graduate professionals who are better prepared for their needs.
Thank you again, CFHA, for a quality learning experience
outside the office. We are looking
forward to next year!
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Posted By Corey Smith,
Friday, October 28, 2016
| Comments (2)
PCBH groups and music festivals couldn’t be more different
experiences, right? Well, sure, most
groups don’t suggest earplugs, don’t have food trucks and usually don’t include
intoxicated "20-somethings,” but there are a few lessons music festival
promoters have learned that are pertinent to PCBH groups. Namely, setting the date, getting useful
feedback and clear practical information for attendees.
The biggest limitation to setting a good lineup for a music
festival: the date. Once the date is set, 95% of bands have been
eliminated thanks to the world’s consistent refusal to revolve around me. ("But I really want to see Coldplay at Coachella!”) The task of coordinating the schedules of
multiple groups of people is too much work, better to set your date and send
out as many invites as possible. For
behavioral providers in primary care, the challenge is similar, starting a
group can be a long process and success is not guaranteed.
My typical strategy includes posting information about the
group to medical providers and compiling a list of as many patients as
possible. Once the date is set, I send
out letters with the expectation the date will whittle the list down
considerably. If 20-25 patients express
interest, I’m doing pretty well. The
process of securing "commitments,” scheduling and reminder calls may further
dwindle the list. Once we get to the
date of the opening visit, we may arrive to find 4-5 people waiting to begin
(one of whom needs to leave after 15 minutes).
Thing is, this is pretty successful.
Coordinating the schedules of more than two adults can be extremely
challenging, especially without any momentum off of which we can feed to inject
energy into the process. It’s much
easier to get someone to attend a meeting that has been taking place for months
or years; the risk it will not be what they are looking for is lower with a
known entity. Selling tickets to Bonnaroo is easy, try selling tickets to
the Maha Music Festival….
Any music festival worth its’ salt has a twitter handle and
at least one hashtag (@govballnyc,
#smile) to promote the experience via social media. Often, promoters project tweets and Instagram
posts onto screens near the stages. The
audience, those on the fence about paying for a last minute ticket, and
promoters get real time feedback on what is going well ("Gogol Bordello is melting faces in That Tent
#Bonnaroo2009”) or not so well, ("The Port-a-lets look like a war crime
#ACL2012”) and respond accordingly.
While PCBH groups may not rate high enough for a hashtag, feedback
measuring outcomes is important and can inform our practice going forward. Determinations of effects will depend upon
the type of group and the information the practice believes to be most
For example, outcomes for a group focused upon Acceptance
and Commitment Therapy for chronic pain may include patients’ subjective
reports of their pain levels, changes in narcotic medication dosages or number of
visits to the Emergency Department for treatment of out of control pain. Providers working on a mood management group
may simply choose the PHQ-9 and/or GAD-7 to determine efficacy; this is
certainly acceptable and may yield significant and actionable results. The word actionable is used intentionally in
Rather than simply serving
as formative and summative evaluation of the intervention, measurement may be
used to inform changes to the process, intervention or make up of the
group. Outcome measures are easiest to
track and disseminate within the electronic health record (If you find yourself
in a setting where this is possible, practice gratitude and enjoy!
#youredoinggreat). Without such tracking
capability my strategy has been to record data via my own excel file and,
although more time consuming, this works just fine.
Festival goers like to know what to expect, as most humans
do, and a festival’s smartphone application can facilitate or limit the flow
and organization of the event. People
need to know where to eat, how to find the bathrooms and on which stage their
bands are playing. PCBH groups, similar
to warm hand offs and initial visits with a BHC, should be described effectively
at the outset. For some clinics, group
therapy can be an effective adjunct for patients that would normally be
considered for referral to specialty mental health but lack the insurance
coverage for a successful referral. However, the expectation of many patients, as
we often see in the PCBH setting, may be reflective of their understanding of
traditional mental health. This
misunderstanding can be corrected with clear conversations regarding the nature
and duration of treatment prior to starting.
Over-all, the business case for group visits is clear and
the increased efficiency in primary care makes group visits a wonderful
addition to your practice. Behavioral
providers are well trained in running groups and can take the lead with the
recruitment, planning and execution of a traditional group, shared medical
appointment (SMA) or other innovative group process to meet the specific needs
of the practice. You won’t always get Desert Trip but you can certainly have fun,
make a difference and demonstrate again the value of behavioral health
providers in primary care. #smile
|Corey joined the faculty at the Maine Dartmouth FMR in 2015
after serving as the director of behavioral health at MidValley Family Practice
in Basalt, CO and the Lincoln Family Medicine Residency in Lincoln, NE. He
completed his doctoral training at Spalding University in Louisville, KY and
internship at the Wyoming State Hospital. Corey is enthusiastic about
integrated behavioral health care, primary care and education. In his spare
time he practices martial arts and enjoys cycling, reading, hiking, and spending
time with friends. Corey and his wife
Karen are anxiously awaiting the arrival of their first child in January of
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Posted By Matthew P. Martin,
Monday, October 17, 2016
| Comments (0)
The second plenary session of the 2016 Annual CFHA
Conference in Charlotte, NC was on Friday 14 October and included a panel of experts on
opioid dependence and treatment. The first speaker was Brooke who shared her
personal struggle with opioid dependence. Here is her story in her own words.
Brooke: "I first took opioids after gall bladder surgery. I
liked the way it made me feel. I felt like super girl. I could do anything.
Eventually though I started to spiral. I didn’t understand physical dependence
when I first started. Before I knew it though I was using just to feel normal.
Some people describe it like flu-like symptoms which makes me laugh because
it’s nothing like that. I was in and out of many, many rehabs. I had brief
moments of sobriety but it never stuck and I never got completely well. I heard
about methadone but I also heard about the stigma, how it was replacing one
drug for another. Even professionals along the way would say things like that.
I felt ashamed to go to a methadone clinic for a long time. Finally I decided I
had nothing to lose. There was a clinic one-hour away. I had immediate success.
I only failed one drug screen and haven’t failed one since then. After a year
of detoxing very slowly, I was diagnosed with post-acute withdrawal syndrome. I
was not right and needed a lot of help.
Fred Brason, President and CEO of Project Lazarus, then shared his
journey. He was hospice director and had no idea what was happening in the
community with drugs like opioids. "We had families from our clinic who were
using it, selling it, and sharing it. How did we get here?” he asked. He recounts
how the medical community had begun implementing asking all patients about
their pain level and then connecting patient satisfaction with pain outcomes.
He continues: "70% of diversion happens between friends and
family members. We realized we had to reach everybody in the community. Our
collaboration had to be person-focused.” They worked to educate prescribers in
outpatient and emergency settings. They started having success but realized
that it required a community-wide effort to solve this community-wide problem.
Don Teater, a physician with the Meridian Behavioral Health Services, then
described how he started treating opioid dependence. He believes that one of
the major problems in medicine is that we separate medical and mental health. He
recalls, "In 2004 I became certified to prescribe buprenorphine and it changed
my life to start helping people with opioid dependence.” His wife is a mental
health professional and worked alongside him to counsel the patients receiving
buprenorphine. He encourages all physicians to consider incorporating
medication-assisted treatment into their practice.
He says, "The number of opioid deaths is correlated to the
number of opioids we prescribe. Americans, constituting only 4.6% of the
world's population, have been consuming 80% of the global opioid supply.” He
points out that US physicians prescribe so many opioids today and yet pain
levels seem to be rising which suggests that medications may be leading to more
pain. The problem is that with the first dose, the human body decrease the
number of opioid receptors in response to the flood of medication in the system.
However, these opioid receptors help treat anxiety and depression which can
then lead to intense anxiety, depression, and even pain during the withdrawal
Donnie Varnell, Policing Coordinator, North Carolina Harm
Reduction Coalition, then stood up to talk about the law enforcement side of
the opioid epidemic. In a former life he jumped out of airplanes and
consequently dealt with a lot of pain and medication. "I’m very familiar with
opioids” Donnie says. He continues by saying law enforcement is trained very
well in many things but they are not trained in how to deal with substance
users. Incarceration does not work for these individuals. "In the past, we used
stigmatized language in their presence and so did family members. We were not
ready for when opioid epidemic hit our state. We did not know how to help.”
When Donnie took over the prescription drug abuse unit, he
knew that traditional methods would not work. So, first he started training
police officers in how to correctly investigate these cases and then how to
respectfully address people. He collaborated with Fred Brason at Project
Lazarus and Robert Childs at the North Carolina Harm Reduction Coalition. "Instead
of arresting people, we are trying to get them into the systems they need.” For
example, he says that police officers in Fayetteville, NC are implementing a
drug diversion program called LEAD which is a pre-booking program for substance
users. There are four other agencies in NC starting LEAD programs.
Robert Childs, Executive Director, North Carolina Harm
Reduction Coalition, the final speaker, made a strong case for making naloxone,
an opioid overdose reversal drug, available to as many people as possible. "We
can’t get rid of cars and highways to reduce traffic deaths, can we? No, that’s
ridiculous. Instead we make cars as safe as possible.” In the same way, he
argues, we can’t completely get rid of harmful drugs so we have to reduce their harm as much as possible. "We handed out 35,000
naloxone kits which lead to over 4,000 overdose reversals in North Carolina”. Naloxone
kits work, he argues. For clinicians who want to get involved, he recommends first
reducing stigma about opioid dependence treatment and prevention.
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Posted By Matthew P. Martin,
Friday, October 14, 2016
| Comments (0)
Welcome to the 2016 CFHA Annual Conference! The opening
plenary session included remarks by current president Natalie Levkovich and
incoming president Tina Runyan. The Don Bloch award was presented by John
Rolland and given to Barry Jacobs, a worthy recipient. Check here for a video
of the presentation.
The actual plenary session was an incredible, multimodal
presentation of video, music, and live speakers. Directed by Randall Reitz and
moderated by Jodi Polaha, the theme was "LGBT at CFHA” and included a panel with Beth
Evelyn Barber, Michelle Evers, Steven Migalski, and Stacey Williams.
The first video introduced the audience to several LGBT
advocates: a University of Chicago student, a state department worker in Brazil,
and a Mormon couple in Seattle. Jodi started with a question: what does an
organization do when they’re locked into a conference site in a state that
passed controversial legislation affecting the LGBT community? Here is our
response: we will hold up the LGBT community!
During the first video, the Seattle couple shared their
experience of raising a 10 year old transgendered boy. When he was younger, he
hated his hair and insisted on wearing hats to hide his hair. One day, when the
boy was three years old, the mother found him in bed crying and asked him what
was wrong. He said, "Why would Heavenly Father make me a girl when I’m a boy”.
The mother responded, "I love you no matter what”. Years later, the boy was
teased at a Sam’s Club store which upset the entire family. The mother pleaded
with the father "Get us out of this state. We can’t raise our child here”.
Stacey Williams then took the stage to explain the terrible
health disparities that LGBT patients face. She attributes these disparities to
minority stress at the individual and structural levels. "Even if they don’t
experience it firsthand” Stacey says, "they can experience it through
anticipation, constantly monitoring the environment to see if it’s safe”. She
quoted one study that demonstrated the higher rates of mortality that LGBT face
compared to the general population.
Beth Barber then identified the barriers to affirmative
healthcare. "One of the easiest ways to demonstrate your acceptance of LGBT as
a clinic” Beth says, "is to place a rainbow sticker or sign on your building”.
Other strategies include developing non-discrimination policy, labeling
bathrooms as gender neutral, placing LGBT-friendly reading materials in the
waiting room, and being willing to open the conversation about LGBT
health-related issues. She cited the Fenway Institute
Guidelines as an excellent resource for talking to patients about gender,
assigned sex, and preferred names.
The panel then discussed together the need for addressing
LGBT health in every health setting and how clinicians can assess if minority
stress is contributing to the presenting problem at a medical visit.
Steven Migalski continued the plenary by recounting his
story of coming out as a gay man. After growing up in Chicago, he completed
graduate studies at Auburn University where he came out and then became involved
in LGBT advocacy efforts. At one point he was interviewed on CNN which is how
his family learned about his orientation. "We have come a long way since I
started at Auburn” Steven says. "The fact that I can speak to you this openly
is a sign of that. Please, let’s keep it moving forward.”
The next video included the student, the state department
worker, and the couple all suggesting ways in which clinicians be
person-centered and address LGBT health issues.
Steven then took the stage again to deliver ten guiding
principles for compassionate care:
Use sex and gender accurately
A binary for gender and sex does not reflect
Differentiate between gender role, expression,
Know and use gender queer appropriately
Use transgender and cisgender
Appropriately use transman and transwoman
Distinguish between social, emotional, and
Understand intersectionality of sexual and
Mange pronouns sensitively
assume homogeneity of identity and experience
Steven also identified several common missteps to avoid: education
burdening, gender inflation, gender narrowing, gender avoidance, gender generalizing,
gender repairing, gender pathologizing, and rigid gate-keeping. He encouraged
clinicians to show their humanity to patients because then that gives
permission to patients to do so as well.
The final story was given by Michelle Evers who shared her
experience of growing up in a loving family in Ohio and then slowly discovering
her identity as a lesbian woman over time. This discovery included periods of
uneasiness, recognizing she did not fit in with the normative. She considers
herself to be on a continuum of sexual orientation rather than a concrete
binary. She then shares how her story has affected her work as a nurse
practitioner with LGBT patients.
The audience left feeling inspired and informed. The
presentation ended with a quote by Mia Kirshner: "I think one’s sexuality can
be the center of life, and coming out and discovering your sexuality is
something that really can define your existence”.
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