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Scaling Integration through Health Policy: North Carolina Policy Summit

Posted By Matthew P. Martin, Thursday, October 13, 2016



As conference attendees for the 2016 CFHA Annual Conference traveled to Charlotte, North Carolina, a group of policy wonks, clinicians, lawmakers, and administrators met just a mile away to share information and brainstorm new ways for addressing the fragmentation of the US and, specifically, the NC health care system. The group met in the beautiful Duke Endowment building, which is just a short walk away from the Westin hotel, site of this year’s CFHA conference.


As Ben Miller, Director of the Eugene S. Farley, Jr. Health Policy Center, put it during his opening remarks, "We are dealing with fragmentation and integration is the solution. How you do it, how you measure it, and how you train it: that’s up to you.” Dr. Miller made the case that states need to be adaptive when it comes to designing systems of integrated care because they have communities with unique resources and needs. "However” he concludes, "If we lose sight of why we are doing this, we will fail.”

The rest of the meeting included speakers representing various stakeholders in North Carolina: although, a few hailed from other states. Dave Richard, Deputy Secretary, Division of Medical Assistance, spoke next, giving an update on the state of integrated care from the perspective of the state department of health and human services as well as a plan for the future. "There are a lot of good things happening in North Carolina, just in pockets” he began. State officials and administrators have spent the last three years debating the NC Medicaid system and have come to a fairly strong consensus as to what it will look like.


The next steps, he argues, are deciding how Medicaid will work with other systems in the state as well as defining what integrated care looks like. "The needs of people in North Carolina will drive change” he argues. One interesting point he made is how the state defines good care as "person-centered community care". "If we just think about them as patients, then we miss a huge part of their lives.”

Courtney Cantrell, Former Senior Director of the NC Division of Mental Health, Developmental Disabilities, and Substance Abuse, spoke next on a vision of integration for North Carolina. She points out that a lot of work is happening on the ground, but providers are not getting paid the way they should be. She says the biggest barriers to progress are policy-related. "To move forward” she says, "we must get more data”. "You have to know your population and you need to measure care outcomes”. Ben interjected at this point saying "If you change the way you deliver care, you’ll need to change the way you measure it.”

The group broke for a working lunch at this point and listened to Alexander Blount from the University of Massachusetts and Lesley Manson from Arizona State University. Dr. Blount started by saying "I’m the humble guy coming from out of state with a few ideas that may work for you”. He recounted the history of integrated care in Massachusetts which included large Medicaid reform which made integrated care viable overnight. "My phone was ringing off the hook” he recalls.


Despite the successes, there were several problems. First, the integration did not work unless care systems had a large Medicaid population and received more training than just webinars and assembled meetings. "You need boots on the ground”. He argues that administrators who want long-term integration need to invest in workforce development. Systems need a core of highly-trained integration champions instead of an army of semi-trained staff members.


Lesley Manson from Arizona State University continued the working lunch by reviewing in detail the new federal MACRA legislation which moves reimbursement from volume-based to value-based, a significant shift in payments. Currently, many systems are already reforming through various programs like PQRS, VBM, and MU. The legislation gave birth to MIPS (merit based incentive payment system) which systems can elect to participate in or, alternatively, follow the APM (Alternative Payment Model) track. Overall, MACRA is a quality payment program and represents a long-term investment of the federal government in incentivizing care systems to reform their care models. Lesley concludes that integrated care is an essential component of this reform.

The final segment of the meeting was a group breakout session on three topics: 1) Envisioning Your Organizational Needs, 2) Workforce and Educational Needs, and 3) Policy and Payment Reform. Each group was tasked with discussing the topic and then identifying key action strategies. The first group concluded that organizational vision takes time and requires keeping a local focus and sharing stories of successful integration.


The second group determined that a large portion of the current workforce needs retraining and that one model for doing so is the ECHO telementoring model out of New Mexico. The group believes that state agencies should invest in statewide interprofessional training events and even design core competencies. The final group recognized that stakeholders need to align their efforts with payers (both private and public) and activate codes that support team-based, integrated care. Adam Zolotor, President of the North Carolina Institute of Medicine, facilitated the group discussion.

The state of integrated care in the Tar Heel state is vibrant and promising. The synergy of the group was palpable and produced a list of actionable items. The final word was by Cathy Hudgins, executive director for the Center of Excellence for Integrated Care, who invited all the group members to continue the conversation by attending the 2016 CFHA Conference where other like-minded people will be discussing how they can improve health care through collaborative, family-centered care.

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A Taxonomy of CFHA Keynote Questioners

Posted By Randall Reitz, Monday, October 10, 2016


You're at this week's CFHA conference. You're glowing in the bucket list elation of a just-finished speech from a professional hero. And then, a flock of Questioners swoops to the microphone mid-way up the center aisle. Like the cicada, this noisy species only makes a brief appearance and then disappears for months or years. During their moment in the sun, they torment the speaker and audience with randomness.

Vox populi, vox diaboli.

And yet, after years of plenary sessions, this annual rite seems far less random. Over time, the Questioners and their statements gain familiarity and order. If you focus closely on the Questioners' gait, tone, dress, and breath, you can easily discern their genus and species.

Here is a first attempt at classifying the types of Questioners the astute observer might sight at next month's CFHA conference in Charlotte:

Niche Gadfly — This Questioner attends every plenary with the fervent expectation that all speakers explicitly frame their material around the Questioner's particular pet cause. If not afforded satisfaction, the Gadfly will counter with "I enjoyed your presentation, but you failed to address how your material relates to _____". Common subspecies of the Gadfly include Family Systems, RCT, Social Justice, ACEs/Trauma,and the never abiding Pan-Umbrage.

Sycophant — While gushing is his sine qua non, always specify if of the Brown Nosing(secondary gain)or Boot Licking (primary gain)genus.

Humble Braggart — Don't be fooled by this ostensibly lowly supplicant. Hubris belies her genuflection. Typical humble brags include "It's been a real struggle for me to grasp the full implications of your oeuvre, which I'm painstakingly deconstructing as part of my Harvard fellowship" or "Thank you for mentioning medical family therapy because I'm still licking my wounds from when I was put in my place by Susan McDaniel over dinner at Gramercy Tavern". Please specify Primarily Humble or Primarily Braggart.


Political Hack  Cherry-picks statements from the speaker to make overtly political commentary. While Blue Hacks typically far out-number Red Hacks in the CFHA populationNorth Carolina might provide a counter-veiling microcosm.

Early Career Idealist  Neophytes are classified as either Reverants (i.e. "Would you please autograph my copy of your CV?") or Comeuppants (i.e. "Never trust anyone over 40").

Solve My Intractable Dilemma — Easily identifiable by its "Yes but! Yes but!" chirp, this species presents an insolvably complex conundrum in hopes that stumping the presenter will justify his case for martyred sainthood. The genus declares itself according the urgency of the request, with varieties including: Here and Now, Immediately After the Plenary,or Through Escalating Email.

Long-Winders — All of this species have hypnotic powers, but not all speak in soothing tones. Drones are typified by their meandering fizzle while Warblers demonstrate characteristic bursts of imploding and rallying, imploding and rallying.

Long-Worders — Two sub-species: Sesquipedalian (uses lots of big words, like "sine qua non” and "sesquipedalian”) and Catachrestist (uses lots of big words inaccurately, like "irregardless”).

Confessor  This tormented soul finds secular Jesus amidst the cadence and crescendo of the keynote and approaches the pulpit seeking the presenter's public forgiveness. Please stratify according to the magnitude of the confessed sin: Myself, My Colleagues, My Privileged Class, or Western Medicine.


So, there you have the 24 known species and sub-species of Questioners. There are inevitably more that have been observed in the wild, but not reported in the scientific literature. If you're aware of any other species please describe them in the comments section below.

AND, for your conference-going pleasure, we have created Keynote Questioner Bingo cards, see linked document below. Simply print out the card, randomly fill in the squares with the species and sub-species, and bring the card to the major conference sessions. Each time you sight a new breed of Questioner mark the appropriate square until you have Bingo.


You might even be the first player to achieve Black-out! Obviously, there is considerable overlap among the species (notably SycophantsIdealists, and Long-Winders). As such, you will need to classify each Questioner within a single category for purposes of the game.

Good Luck!


Randall Reitz is the Director of Behavioral Sciences at the St Mary's Family Medicine Residency in Grand Junction, CO.  He runs a pre-/post-doc fellowship for medical family therapists With CFHA he is a current board member and the previous executive director.  His Questioner species is the unseemly product of a ménage à trois between a sycophant, a sesquipedalian, and a humble braggart.

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Zero Suicide

Posted By Michael Hogan, Tuesday, October 4, 2016

Mike Hogan is the Saturday Plenary Speaker for the 2016 CFHA Conference in Charlotte, NC.  



Increased deaths from suicide are in the news. The Centers for Disease Control recently reported that the increased suicide rate contributed to a rare rise in the overall death rate for Americans in 2015. What can be done to stem this tide? And, while "upstream” prevention efforts are needed, what should health care settings—especially integrated primary care—be doing about suicide?

One would think that detecting and caring for suicidal patients was not new. Unfortunately, this isn’t true. Health and even mental health providers have not been tuned in to suicide care, and the old but receding gap between health and behavioral health care makes things worse. While care for common mental health problems like depression is not adequate in traditional primary care settings, trying to detect and manage suicidality is even tougher.


In multiple studies, up to 45 per cent of all patients and a shocking 78 per cent of older people who die by suicide, saw a medical doctor in the month before they died. But something was missing. In all probability, they were not asked about self-harm or suicide. When it comes to most of health care, a kind of "don’t ask, don’t tell” approach to suicide has been typical.

Suicidal people generally do not want to die but can think of no other way to end their pain. They slip through other cracks in health care as well. In a 2006 study in South Carolina, 10 per cent of all suicide deaths were among people recently seen in emergency departments. They may have been asked about self-harm, if suicidal impulses brought them to the hospital.


But new and effective interventions (such as developing a one page Safety Plan that provides practical alternatives that the patient and family can take, or medical personnel making supportive follow-up phone calls in the days and weeks following the visit) were probably not used.

Another surprising gap is the poor training of most mental health professionals such as therapists, psychologists and psychiatrists in treating suicidal patients. Good training in caring for these patients should be expected, since suicidal patients are usually sent for care to mental health settings. However, these skills are rarely provided in the graduate training of licensed mental health professionals.


A few states, such as Washington and Kentucky, have recognized this gap and passed laws to require continuing education in suicide care. But the gap persists. It means that a referral to specialty mental health care, long thought of as the best way to care for suicidal patients, may not be adequate.


It does not have to be this way. The good news is that effective screening tools and treatments now exist. The bad news is that since these tools are new, they not used yet in most health care settings. We also have evidence that systematic suicide care can be effective. At the Henry Ford Health System in Detroit, the "Perfect Depression Care” effort—a systematic quality improvement program within the behavioral health division—reduced suicide deaths among people receiving care by over 75 per cent.

The new tools for suicide care have been bundled together in an approach we call "Zero Suicide in Health Care,” and implemented successfully in real world clinics and health systems. One of the innovator organizations demonstrating that suicide safe care is feasible in integrated primary care settings is the Institute for Family Health in New York, where suicide care protocols have been successfully embedded in the clinical workflow and EMR. The tools involved in suicide safe care are demonstrated and available at

The approach involves hard work, but it is feasible. Over 200 health care organizations in the United States, with others in the Netherlands and United Kingdom, are now putting it in place. But this is only a beginning. Most health care today cannot be labelled as "suicide safe,” and taking on the mission of suicide prevention is a new challenge for health care organizations. It is especially difficult in health care settings that have not integrated care for mind and body.


The Joint Commission has issued a "Sentinel Event Alert” that puts health care organizations on notice that detecting suicidality among patients should be expected. We hope that these developments, and new leadership among health care professionals to prevent suicide, can make a difference. Suicide is preventable—if we work at it.

Michael Hogan, Ph.D., is a clinical professor in the psychiatry department at Case Western Reserve University School of Medicine in Cleveland.

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Welcome to Charlotte!

Posted By Cathy Hudgins, Eric Christian, Tuesday, September 27, 2016

This post is by the 2016 CFHA Conference Co-Chairs. 


Come See for Yourself!

A psychiatrist, a primary care doc, and a therapist walk into a bar…So, you think I am joking, right? Actually, this type of meet-up is not uncommon at CFHAs annual conference. Come to Charlotte, NC in October and see for yourself!


One thing was clear during the initial planning meeting for this year’s CFHA conference – we wanted the theme to be inclusive. It needed to welcome all types of providers, practices, policy makers, and others who are working together to make integrated care (IC) a standard of care. We may come from different states, backgrounds, perspectives, and job roles, but we are united and working toward the same goals. I can think of no other organization like it for this reason.

There are always sessions that challenge the way I think about some aspect of IC (over 80 to choose from!). Every year I walk away with new tools and implementation strategies that put a new spin on the foundations built by many of our CFHA members. This year you will have the opportunity to dive deep into the IC models or learn more about how to negotiate health information technology during the precons. You can choose from 2 Master Lectures: The Intersection Between Physical and Mental Health Disorders in Older Adults or the Ethical Challenges of Working with Diverse Couples in Primary Care.


We are also excited to offer timely plenaries on the healthcare needs of LGBTQ and Ally community, community-based solutions to the opioid epidemic, and provider strategies to reduce suicides. All of these special events punctuate 6 specialized tracks to choose from – topics that span from finance and cost control, training and research, patient and family-centered approaches, team-based clinical skills and innovations, workforce and inter-professional education, and population and public health.


If all of that is enough, you also have the opportunity to swap lessons learned and best practices with experts from across the nation -- the "rock stars” who share their expertise via publications, the listserv, monthly webinars, and the special interest group teleconferences throughout the year. Where else can you meet the people who authored your favorite IC books, articles, and videos? These experts do not just present; they sit beside you during the sessions and plenaries because they are there to learn about the newest advances and successes from their peers and emerging IC talent.


To offer a broader view of the IC work in NC, we will have the first CFHA state showcase. Working in North Carolina has opened my mind to the creativity and effort that it takes to customize models that the IC pioneers and early adopters developed, researched, and refined over the last 3 decades. NC has had a long history of public and philanthropic funding devoted to developing IC in NC.


We will have the first CFHA state showcase 


Charitable organizations, such as the Kate B. Reynolds Charitable Trust, the Cone Health Foundation, and the Duke Endowment, continue to support providers and organizations who are determined to keep their patients from falling through the cracks of a fractured system. I encourage you to stop by the NC Showcase to meet representatives of some of these projects and programs.

You will also meet members and staff of our NC Integrated Care Steering Committee, State Departments, and countless IC task forces and workgroups. They will gladly share first-hand stories about the energy and movement going on behind the scenes – a story is full of herculean effort, deep commitment, and dogged tenacity. Many hard-won victories and lessons learned are shared at CFHA by people across the nation – it is truly an affirming, unifying event.

I wouldn’t have the job that I have today at the Center of Excellence for Integrated Care if I had not gone to a CFHA conference several years ago. There have been so many CFHA members who have influenced my work and career since then -- people who I am honored to call friends and colleagues; people who I would have never met had I not discovered this organization.


When I tell people that going to CFHA is better than any holiday for me (which I really mean!), it is because I never know what magic will result each year. Now it is my turn to give back as co-chair – and I can’t wait to see all of the wonderful gifts that come from these 3+ exciting days of all things IC. I hope you will join us in Charlotte to experience the magic as we celebrate the many faces and places of Integrated Care!

Cathy Hudgins, PhD, LMFT, is the Director of the Center of Excellence for Integrated Care under the North Carolina Foundation for Advanced Health Programs.  She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care. 


Paths to Integration and CFHA 2016

It’s always intriguing to hear personal accounts about how people became interested in their current profession and what drives them to continue pushing the limits within their field. Some of us who were trained in and began our careers in more traditional behavioral health environments had an epiphany somewhere along the way when presented with a new and exciting team-based integrated care (IC) delivery format, and decided to pursue this new path.

This epiphany happened for me in the ninth year of my career as a behaviorist. My work to this point was fulfilling and I was able to advance into exciting positions within clinical leadership. In 2004 North Carolina made sweeping changes in the care delivery system away from state run community treatment to a privatized system, and after a few years, the changeable environment became very complicated for many to work within.


While managing an outpatient behavioral health unit I began to notice how our nursing staff focused on a broader comprehensive profile of the patient’s health beyond the presenting issue. My curiosity grew deeper following a few encounters where physical illness was exacerbating the patient’s behavioral health presentation, a factor which began to broaden my perspective of which professionals should be a critical part of the patient’s care team. How had I missed these important variables before?


When presented with a unique opportunity to bring my behavioral skills to medical settings, while simultaneously learning more about treating the whole person in one setting, I chose this new path. IC provided me with an exciting new area of learning and the opportunity to meet others who were inspired by the creativity and targeted services that integrated settings offer to patients. Shortly afterwards the path led to learning about the esteemed CFHA while assisting with the conference in Asheville, NC in 2007.

Integrated Care provides enhanced service delivery for patients, while at the same time does its part to strengthen the broader continuum of services needed to manage the range of healthcare needs in any one community. Along this continuum of services, in North Carolina we are beginning to see expanding interest beyond traditional IC to bi-directional integration, the use of peer support and community health workers to engage patients, cross-training in behavioral health clinics on common chronic illnesses such as diabetes, and greater strides in the use data for decision-making and collaboration with each other across town.


In North Carolina we see expanding interest beyond traditional IC to bi-directional integration


As you well know, our current healthcare environment is in great flux as we move away from fee-for-service models towards accountable care. Many states, including NC, are somewhere in the middle of this transition, but one thing is clear, integration will continue to propagate and is gaining tremendous momentum as new clinicians discover it every day. While providing technical assistance to IC sites I often meet clinicians who are just learning about integration and are as excited as I am to envision the possibilities it can provide. Do you remember when this happened for you?


This year’s conference theme, Celebrating the Many Faces and Places of Integration, celebrates the shift many have made towards IC and will inevitably increase the size and breadth of the CFHA family. CFHA veterans are in a unique position to welcome new conference attendees by sharing CFHA’s collegial environment which is focused on supporting best practice approaches to integrated treatment.


As Co-Chair for our conference this year, I’m excited to hear the stories of newcomers and how their new path of exploration is inspiring them to stretch the constructs of care provision while ultimately contributing to our collective movement to provide whole person care. See you when our IC paths cross in Charlotte!

Eric Christian, MAEd, LPC, NCC is a Licensed Professional Counselor and a Nationally Certified Counselor who has been working in the field since 1998. He works as the Director of Behavioral Health Integration for Community Care of Western North Carolina, where he provides technical assistance and consultation to providers interested in integration. 

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Telementoring: How Technology Enhances Mental Health in Primary Care

Posted By Jennifer Richman, Monday, September 19, 2016



We all know that primary care doctors have to wear many "hats” in taking care of patients. Unfortunately, with the shortage of mental health providers and the fact that those with mental illness are living longer and more often than not, have multiple medical illnesses, it is often left to the primary doctor to wear the psychiatrist "hat”.


As if the shortage of mental health providers wasn’t difficult enough, there is little time or incentives to seek out more education or to attend conferences, which often have high registration fees and involve even higher travel expenses.

What if there was a free, biweekly mentoring program that you could participate in from the comfort of your office, which provides advice and education in treating those with mental health issues as well as provides CME? What’s the catch, right? There is no catch. The ECHO© model was developed by the University of New Mexico to provide best-practice specialty care and reduce health disparities through tele health.


In 2003, Dr. Sanjeev Arora, MD was a liver doctor at the University of New Mexico, and was frustrated that many people in the underserved areas were not able to receive treatment for Hepatitis C because they could not travel to one of two specialized centers in New Mexico and the primary care doctors didn’t feel comfortable prescribing medications that often had serious side effects.


The solution came to him in the form of technology. Weekly virtual clinics were set up to engage primary care doctors in remote areas with specialists at the academic medical center where they would present de-identified patient cases and the specialist would provide recommendations. Over time, the hope was that primary care doctors would learn how to treat these patients on their own, providing better care for more specialized illnesses in rural areas.


The University of New Mexico studied the providers who participated in the ECHO© program and discovered that the viral load of patients who were taken care of by specialists at the academic medical center were no different from those taken care of by PCPs involved in the ECHO© program and a movement was born.


The solution came in the form of technology

With the help of the ground breaking work from University of New Mexico, providers, both nationally and internationally began to be trained in the ECHO© model and brought it back to their institutions. There are now multiple ECHO© models in every specialty you can think of all over the world. Just over 2 years ago, the University of Rochester became trained in this model and provided geriatric mental healthcare mentoring to primary care offices as well as nursing homes.


While the participating providers found the model helpful and supportive, they felt that they needed more help in learning how to treat the adult population with mental illness and the University of Rochester Project ECHO© PSYCH was born.

How does it work? The ECHO© Psych team, which consists of a moderator, psychiatrist, Psych NP, psychiatric social worker, psychiatric pharmacist and a psychologist sit around a table and listen to cases presented by the primary care sites. The cases are de-identified and only include the bare minimum information to generate a useful discussion.


Recommendations are made by the treatment team as well as those at other sites who have recommendations based on their experience and the ideas are collated and provided in written form. In addition, there is an evidence-based didactic provided by one of the expert panel which primary care sites can receive CME credit for. Clinics are typically biweekly for 90 minutes.


The goal is to not only help the primary care sites with the individual patients they present in clinic but to educate them on strategies to treat mental health issues common in primary care practices. The other hope is that it creates a community of practice where all of those involved in the program feel supported with difficult cases and where sites often feel isolated. The team also hopes to model how to provide team-based care even when there are disagreements.

What is needed to participate? The beauty of the program is that most people don’t need to buy any fancy equipment. The application that our program uses can run on smart phones or any computer and only requires a basic camera. Although we encourage video participation, it is also possible to call in through a phone without video capabilities.


Since ECHO Psych was launched in March of 2016, we have had 12 clinics with over 60 attendees. Most attendees have returned for multiple clinics. The average attendance per session has been 17 and these attendees include multiple spoke sites with multiple providers often present at each site. ECHO Psych currently provides telementoring for psychiatric issues to participants in over 13 counties in New York State, spanning over 350 miles.


The goal is to educate them on strategies to treat mental health issues common in primary care practices 


Spoke sites have presented 20 cases for recommendations, with a number of them presenting for follow-up recommendations. Twelve evidence-based didactics have been presented on topics ranging from evaluation of post-partum depression to identification and behavioral treatment of OCD, to lessons that have been learned from the STAR*D trial. An overwhelming number of participants have graded the didactics as "very good” or "excellent”.

Although it is too early to have data on ECHO Psych, we have qualitative data derived from 26 interviews from the Geriatric Mental Health in Primary Care ECHO that ran previously. Most found that the format was interactive and engaging, but also struggled with finding time to attend as well as time to present cases.


Participants felt they expanded their knowledge base in all areas including psychopharmacology, non-pharmacologic treatment modalities and available social supports. Participants also felt they there was large increase in their confidence in handling older adults with mental health issues. Overall, Participants felt the ECHO model was highly beneficial to their practice.


So you may be thinking, this sounds great, how do I get involved in an ECHO program? More information about the University of Rochester ECHO program can be found at programs are state based, so it would be helpful to check the UNM ECHO© website at to determine what programs are available in your state.


Dr. Richman graduated with a BS from Cornell University and received her medical degree from the University Of Rochester School Of Medicine.  She completed her psychiatry residency at the University of Rochester School of Medicine and Psychosomatic Fellowship training at Georgetown University.  She is currently an Assistant Professor at the University of Rochester and is medical director of ECHO© Psych and Telepsychiatry.  She also runs the psychiatric consultation service at Strong Memorial Hospital and specializes in perinatal psychiatry. 

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Integrated Care in Indigenous Populations

Posted By Melissa Lewis, Laurelle Myhra , Monday, September 12, 2016

Indigenous people of the United States and the world suffer from some of the worst health disparities. Disparities are linked to historical trauma, healthcare barriers, and epigenetic processes due to social, political, cultural and environmental violence. Indigenous health disparities are a result of historical oppression of these communities, as well as, the current inequities that exist in these settler-colonial states.


The systems of living that Indigenous people have continued to assert (e.g., Traditional ecological knowledge [TEK], Indigenous knowledge [IK], Indigenous economics, health knowledge, family and community systems) have been challenged or outright legally banned. These include the right to fish, hunt, forage, and use medicine, religious and cultural practices for health and well-being. In fact, until 1978, due to the American Indian Religious Freedom Act, many of these activities were illegal. Therefore, without the land, access to traditional food, and right to practice traditional cultural ways of being (including spiritual practices and medicine), health and wellbeing was compromised with increased incidences of cancer, heart disease, depression, and suicide. These diseases were uncommon before colonization and the subsequent disruption to Indigenous lifeways.

Indigenous communities continue to practice their traditions today, but with continued obstruction from state and federal government, as well as private citizens. For instance, treaty rights (which were granted by the United States government in exchange for land cessation-think of it as rent) allow fishing, hunting, foraging, and cultural/spiritual practices.


Despite this treaty obligation, Indigenous communities who practice these rights remain at risk for being (unlawfully) arrested, cited or jailed. Several northern Minnesota Ojibwe tribes- with leadership from Winona LaDuke, White Earth Ojibwe and executive director of Honor the Earth-are fighting for rights guaranteed by their 1855 Treaty to hunt, fish and gather, which are being threatened by the two major pipeline proposals, Sandpiper and Enbridge Energy’s Line 3 Replacement, which would impact wild rice waters and wildlife habitat and could adversely affect health for generations.


Further, the Dakota Access Pipeline has received approval by the United States Army Corps Engineers without the consultation of the original and current owners of the land, the Hunkpapa Lakota (and others) of the Standing Rock reservation, which, again, is a violation of treaty obligations. This pipeline threatens the health of the land and water-the very tools that these communities need to maintain their traditional ways of being. In other words, "If the land is sick, we are sick.”


While research with Native communities has historically been focused on problems, a shift has occurred and there is an increased amount of research on the resilience of Native people highlighting the importance of cultural practices for the health of Native people. For instance, Native people that identify strongly and positively with their identity and take part in traditional cultural activities are more likely to have improved academic performance, positive mental health for youth and adults, reduced substance use for and youth and adults, and improved physical health. Therefore, programs that facilitate cultural knowledge and pride may be able to redress the imbalance that so many Indigenous communities see by improving health and well-being outcomes.


In our own research we discovered that collaborative/integrated care appears to be an effective healthcare system for Native people. However, when Native culture was also integrated into care (see Figure 1 below), the positive effects appeared stronger. Integrated care at Native-serving sites resulted in a wide variety of health and well-being improvements including reduced depression, smoking, drinking, and criminal behavior; improved general health, employment status, and housing status; significant reduction in ED visits and hospitalizations; reduced turnover and increased employee satisfaction (see reference list).

Integrating behavioral healthcare into a medical setting resulted in discovering that Native-serving healthcare systems had a lack of mental health screening, lack of resources, and a high comorbidity of physical and behavioral health diagnoses. Healthcare systems integrated behavioral health care for a variety of reasons including:

1.      High comorbidity of behavioral and physical health symptoms

2.      Acculturation and general life stress related to a complex of physical and mental health problems are related to behavior-related mortality

3.      High disease burden (both behavioral and physical) that requires quality, collaborative care

4.      Patients with active mental health symptoms see medical provider but failed to be properly screened and treated

a.       Untreated behavioral health symptoms can be ‘caught’ at medical sites due to comorbid physical complaints, i.e., medical visits

b.      60% of presenting problems in IHS primary clinic are attributable to mental health problems

5.      More likely to seek mental health services from medical providers than behavioral health when compared to White population.

a.       96% feel comfortable talking to medical provider about their mental health

6.      High turnover rates of physicians at IHS so rapport can not be built.

7.      IC is validated by national health organizations for effective assessment and treatment of an array of health concerns.


While there were many positive outcomes, there were also a number of challenges to integrating care:

1.      Provider anxiety around asking personal questions

2.      Being able to address behavioral health symptoms in limited time frame

3.      Behavioral health providers concerned that physicians had the appropriate skills to address depression symptoms

4.      Adequate staff to support the follow-up appointments

5.      Time Management (Case managers spent a lot of time calling and scheduling appointments)

6.      Human resistance to change

7.      Departmental turf wars

8.      Reluctance of staff to take on additional work

9.      Staff turnover

10.  Lack of resources for providers

a.      Which is related to lower performance of clinical quality

11.  Lack of funding

a.      IHS receives only half of the funding needed to care for the patients it serves


A model program for integrative care in an Indigenous community is the Nuka System of Care at the Southcentral Foundation in Anchorage, Alaska. Dr. Myhra and Dr. Lewis had an opportunity in 2012 to present our results and tour this system, and we were blown away! As you enter the primary care building the first thing you see on the outside is a traditional medicine garden. As you walk in past the stunning Alaskan Native art and photos of customer-owners (not patients) the first service you see is traditional healing. With several specialties inside, this large primary care center operates as a one-stop shop. In Family Medicine, all care providers (physicians, nurses, behavioral health coordinators, administration) sit in an open-air, team setting, which facilitates communication. Large patient rooms allow many family members to attend. Health outcomes include (Gottlieb, 2007):

  • Evidenced-based generational change reducing family violence
  • 50% drop in Urgent Care and ER utilization
  • 53% drop in Hospital Admissions
  • 65% drop in specialist utilization
  • 20% drop in primary care utilization per patient
  • 75-90%ile on most HEDIS outcomes and quality
  • Childhood immunization rate of 93%
  • Diabetes with 50% of HbA1c below 7%
  • Employee Turnover rate less than 12% annualized
  • Customer overall satisfaction 91% 

This system of care provides a model for integrated care across the world and demonstrates that integration of behavioral health care into medicine should not be linear but be regional and community specific and address the culture and needs of the community.


Melissa Lewis, PhD, LMFT is an Assistant professor at the University of Missouri School of Medicine in the Department of Family & Community Medicine.

  Laurelle Myhra, PhD, LMFT is the Director of Health Services at Catholic Charities of St Paul and Minneapolis. Her clinical work and research has focused on families, resiliency, trauma, mental health, substance abuse and integrated care among American Indians. She received her doctorate in Family Social Science/Marriage and Family Therapy from the University of Minnesota.  


 Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: Considering the Role of Healthcare Systems in Health Disparities. Part I. Under review at Families, Systems, & Health.

Lewis, M. E., & Myhra, L. L. (Under review). Integrated Care with Indigenous Populations: A Systematic Review of the Literature. Part II.

 Integrated Care in Indigenous Communities

 1.      Abbott, P. J. (2011). Screening American Indian/Alaska Natives for alcohol abuse and dependence in medical settings. Current Drug Abuse Reviews, 4(4), 210-214.

2.      Doorenbos, A. Z., Demiris, G., Towle, C., Kundu, A., Revels, L., Colven, R., . . . Buchwald, D. (2011). Developing the native people for cancer control telehealth network. Telemedicine and e-Health, 17(1), 30-34. doi:10.1089/tmj.2010.0101

3.      Gottlieb, K. (2007). The family wellness warriors initiative. Alaska Medicine, 49(2), 49-54.

4.      Madras, B. K., Compton, W. M., Avula, D., Stegbauer, T., Stein, J. B., & Clark, H. W. (2009). Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug and Alcohol Dependence, 99(1-3), 280-295. doi:10.1016/j.drugalcdep.2008.08.003

5.      Parker, T., May, P. A., Maviglia, M. A., Petrakis, S., Sunde, S., & Gloyd, S. V. (1997). PRIME-MD: Its utility in detecting mental disorders in American Indians. International Journal of Psychiatry in Medicine, 27(2), 107-128. doi:10.2190/C6FD-7QWB-KNGR-M844

6.      Sequist, T. D., Cullen, T., Bernard, K., Shaykevich, S., Orav, E. J., & Ayanian, J. Z. (2011). Trends in quality of care and barriers to improvement in the Indian health service. Journal of General Internal Medicine, 26(5), 480-486. doi:10.1007/s11606-010-1594-4

Indigenous Resilience and Culture

1.      Whitbeck LB, Hoyt DR, Stubben JD, LaFromboise T. Traditional culture and academic success among American Indian children in the upper Midwest. Journal of American Indian Education. 2001;40(2):48-60.

2.      Petrasek MacDonald J, Ford JD, Ross NA, Cunsolo Willox A. A review of protective factors and causal mechanisms that enhance the mental health of indigenous circumpolar youth. Int J Circumpolar Health. 2013;72(1):1-18. doi: 10.3402/ijch.v72i0.21775.

3.      Garroutte EM, Goldberg J, Beals J, et al. Spirituality and attempted suicide among American Indians. Social Science and Medicine. 2003;56(7):1571-1579. doi: 10.1016/S0277-9536(02)00157-0.

4.      Yu M, Stiffman AR. Culture and environment as predictors of alcohol abuse/dependence symptoms in American Indian youths. Addict Behav. 2007;32(10):2253-2259. doi: 10.1016/j.addbeh.2007.01.008.

5.      Stone RAT, Whitbeck LB, Chen X, Johnson K, Olson DM. Traditional practices, traditional spirituality, and alcohol cessation among American Indians. J Stud Alcohol. 2006;67(2):236.

6.      Wilson K, Rosenberg MW. Exploring the determinants of health for First Nations peoples in Canada: Can existing frameworks accommodate traditional activities? Soc Sci Med. 2002;55(11):2017-2031. doi: 10.1016/S0277-9536(01)00342-2.


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News & Research Column

Posted By Matthew P. Martin, Thursday, August 4, 2016


Welcome to the fourth 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.


Texas Lawmakers Focus on Integrated Care

The state of Texas is in a state of mental health crisis. Part of the problem is a shortage of mental health professionals. The Select Committee on Mental Healthwas specifically createdto tackle the issue. In June, the committee — headed by Rep.Four Price, R-Amarillo— met to discuss on how the state wants to take a holistic approach regarding mental health treatment. The committee heard from experts on insurance and criminal justice mental health professionals including Dr. William Lawson at Dell Medical School. His goal is to get more minority mental health providers into the underserved areas of Texas.He says integrated care is key.

"We now know that early intervention can actually change the trajectory of what happens with folks who develop a mental disorder,” said Dr. Lawson.

Family-Oriented Program in England Partners Nurses with Patients

The Family Integrated Care program, at St. James’ Hospital in Leeds, England, empowers parents to take control of their baby’s care by being given the skills to become more involved and build confidence. Parents are coached by nurses on feeding and changing as well as taking regular observations and giving medication. Rates of breastfeeding at discharge from hospital have doubled to nearly 60 per cent and the length of stay has been reduced by up to nine days in babies born up to 10 weeks early. Infections and complications also seem improved.

Collaborative Care in Various Special Populations

· Pharmacy: New push for more pharmacy collaborative care

· Patients with disabilities: Occupational therapists collaborating with other services

· Substance Use, Serious Mental Illness: call for more integrated services

· Women’s Health: International group calls for stronger integration of services to improve health outcomes among adolescent girls and young women

· Dental Care: Oral health screening for kids in Colorado medical office

Integrated Care is Not Sustainable

The latest NHS Financial Temperature Check survey out of England of more than 200 finance directors shows that just 16% were ‘very or quite confident’ that their organization could deliver a sustainable integrated care service for the period up to March 2021. Paul Briddock, director of policy at HFMA, said: "The scale of the NHS deficit continues to reach unparalleled levels, and it is unlikely the provider position will be in balance at the end of 2016-17, as originally planned.

"Our report confirms that while finance directors are feeling the pressures of the current financial situation, many also feel like short-term gains such as cash injections and non-recurrent savings are merely storing up more problems for the future.”

Mobile Clinics Could Revolutionize Health Care

A senior Annapolis doctor says that just four mobile clinics could revolutionize healthcare for rural Nova Scotians — and they will come cheap.

Dr. Ken Buchholz, a former senior physician advisor with the Department of Health, estimated that four fully-equipped trailers plus their support vehicles would cost just over $1 million. This is the same average price tag as a single bricks-and-mortar collaborative care clinic that the government plans to roll out across the province.

"Nova Scotia was once a leader in the country with this mobile health model, but it fell victim to fiscal restraint and a lack of vision by health department officials. Perhaps it is time to revisit the notion of mobile healthcare, but this time with an open mind and a more positive approach,” said Buchholz.


· Meta-analysis of collaborative care for anxiety: Collaborative care seems to be a promising strategy for improving primary care for anxiety disorders, in particular panic disorder. However, the number of studies is still small and further research is needed to evaluate the effectiveness in other anxiety disorders.

· Checklist for family meetings: Researchers developed the Family Meeting Behavioral Skills Checklist (FMBSC) to measure advanced communication skills of fellows in family meetings of critically-ill patients based on a literature review and consensus of an interdisciplinary group of communications experts. The FMBSC demonstrated internally consistency and structural validity in assessing advanced communication skills.

· Collaborative care in Nigeria: It is feasible to scale up mental health services in primary care settings in Nigeria, using the WHO Mental Health Gap Action Programme Intervention Guide and a well-supervised cascade-training model. This format of training is pragmatic, cost-effective and holds promise, especially in settings where there are few specialists.

· Collaborative Care in HCV Clinics: Depression collaborative care resulted in modest improvements in HCV patient depression outcomes. Future research should investigate intervention modifications to improve outcomes in specialty hepatitis C virus treatment clinics.

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Integrated Primary Care: The (Somewhat Extended) Elevator Speech

Posted By Alexander Blount, Thursday, July 14, 2016

This piece was originally published on April 18, 2013. Click here for original post.




One of the roles of leadership in a field is being comfortable speaking on behalf of the field. To do that, it helps to have a clear summary that is understandable to someone outside the field. One name for that summary is an "elevator speech. It is called that because it designates what a person could say to another person while making conversation riding together a few floors in an elevator.

I had an opportunity to try out my skills at the elevator speech for integrated primary care not long ago on an airplane. I was seated next to a gentleman for a couple of hours but we didn’t start to speak until the last 10 minutes of the flight. He was a guy who has to fly a fair amount because he has several small businesses. The businesses were quite varied. He was clearly a self-made guy who was doing OK but was not extremely successful, an entrepreneur on a comparatively small scale. He knew about doing everything his own way and he made his own decisions. It was not in an elevator, but we were changing elevation and the length was only slightly longer that a 15 floor ride in a high rise. This is not verbatim, but close, and the last line is a quote.


The conversation went something like this:

Bob: So, do you come to San Diego on business or pleasure?

Sandy: Business, I’m here for a conference on integrating mental health into primary care.

Bob: What’s the advantage of doing that?

Sandy: It’s the best way to improve the health of the people who come to Primary Care. Primary care is where people bring all the problems that they don’t know what to do about. A lot of times those problems, even the problems that are clearly physical, are related to the fact that they don’t take care of themselves. They are depressed or they are anxious, or they drink too much, or they don’t eat right, or don’t take their medicine, so they feel bad, so they hurt.


Sandy: When people are hurting it tends to make them more anxious or more depressed, or they drink more, or exercise less. If the doctor says he/she can take care of the part that hurts but they are going to send them to a mental health service or a substance abuse service for their anxiety, or depression, or drinking, a majority of the people don’t go. For them it doesn’t feel like two separate things. It feels like one thing. It’s only when you bring a person who can deal with anxiety and depression and alcohol use problems into the primary care and put them on a team with a doctor that the patient feels like he/she can get their whole situation cared for. It even costs less because if the person doesn’t get the whole situation dealt with effectively, they tend to go other places like emergency rooms to try and get enough care to relieve their various pains.

Bob:I’m trying to imagine what that would be like in the doctor’s office. How would it work?

Sandy: Well, if you came because you had a pain or because it was time for your physical, the doctor might talk to you about how your life was going or give you a screening test that would take about 5 minutes. The test would help pick up if you were having troubles with depression or anxiety or drinking. And if any of those seemed to be a part of the situation that you’re bringing, the doctor might call in a psychologist or a clinical social worker or some other person that they would probably call a behavioral specialist. The doc might introduce you to the behavioral specialist and go see another patient or two while the both of you talked.


Sandy: Just like primary care doctors take care of everyday kinds of problems after they make sure it’s nothing that’s going to kill you, behavioral specialist would probably do the same. He/she would ask you a couple of questions to be sure that you weren’t in a very serious or dangerous situation but then they would focus on getting you better as quickly as possible. They might work with you to find something that you like to do everyday, which actually has been shown to start improvement for people with depression, orthey might teach you some breathing exercises that actually make a difference with people with anxiety. When the doctor came back in the behavioral specialist might make a recommendation to the doctor about whether the doctor might consider prescribing you some medicine. You might come back to see the behavioral specialist a time or two to be sure that things are heading in the right direction. But in the long run you just go back to working with your doctor and the behavioral specialist would be somebody who would be available if you ever needed them again.

Bob:That sounds terrific, sign me up!

Alexander Blount is Director of the Center for Integrated Primary Care and Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School in Worcester, MA.  His books include Integrated Primary Care: The Future of Medical and Mental Health Collaboration and Knowledge Acquisition, written with James Brule’.  He is Past President of the Collaborative Family Healthcare Association, a national multidisciplinary organization promoting the inclusion of mental health services in medical settings and he is past-Editor of Families, Systems and Health.

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What if Prince had a Waivered Family Physician?

Posted By Matthew P. Martin, Friday, July 1, 2016

This piece was originally posted on the STFM blog. Click here for the original posting. Reprinted here with permission.

A Prince in Crisis

On April 21, at 9:43 a.m., the Carver County Sheriff's Office received a 9-1-1 call requesting that paramedics be sent to Paisley Park. The caller initially told the dispatcher that an unidentified person at the home was unconscious, then moments later said he was dead, and finally identified the person as Prince. The caller was Andrew Kornfeld, son of Howard Kornfeld, a California addiction medicine specialist. Andrew had flown to Minneapolis with buprenorphine that morning to devise a treatment plan for opioid addiction. Emergency responders tried to revive the talented musician, but later pronounced him dead at 10:07 a.m.

On April 20th, the day before, Prince’s representatives contacted Dr. Howard Kornfeld, a California addiction medicine specialist, who agreed to see Prince later that week. Dr. Michael Schulenberg, a family physician in Minneapolis, saw Prince on April 7 and April 20 apparently for opioid withdrawal. However, Dr. Schulenberg is not a waivered physician and thus could not prescribe buprenorphine. If he had, perhaps Prince would now be recovering in a comfortable treatment center in California receiving state-of-the-art medical care. He would likely be receiving buprenorphine treatment to prevent opioid withdrawals. Recent autopsy results show that Prince died from an accidental overdose of Fentanyl.

Prince Rogers Nelson, a "master architect of funk, rock, R&B, and pop”, was 57 years old when he died and leaves behind a massive catalogue of music and a legacy of showmanship and flair. He was an extraordinary individual with immense talent and energy but all confined within the same physical limitations you and I have: a human body. Despite his magnificent gifts, Prince had a very real human problem: opioid dependence. Many people might wonder what might have happened if Prince could have attended that medical appointment on April 21st in Minneapolis or what might have happened if he could have met Dr. Kornfeld in California and started opioid treatment.


The Value of a Family Doc

Here’s another question, though: what if Prince had a waivered family physician who knew him and his body and could have started buprenorphine treatment months, even years, before April 21st, 2016? The conversation with his family physician might have gone something like this:

Doctor: "Mr. Nelson, it’s good to see you. I want to ask you a few questions about your health that I ask all patients during an annual visit. Is that OK with you?”

Prince: "Sure, that’d be fine.”

Doctor: "Mr. Nelson, do you use any tobacco products?”

Prince: "No.”

Doctor: "How many times in the last 12 months have you had 5 or more drinks in one day?”

Prince: "I don’t drink alcohol, doctor.”

Doctor: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”

Prince: "Well, doctor, I don’t do illegal drugs but I think I’m using my painkillers too much.”

Doctor: "OK. Let’s talk more about that. Perhaps I can help.”


Opioid Calamity

The data is clear about two things when it comes to opioids: one, it’s a growing problem in virtually every state; and two, prevention and treatment work. While opioids have been used for decades to treat chronic pain, rates of prescription opioid abuse have increased in recent years. Get ready for some big numbers. Treatment admissions for primary abuse of prescription pain relievers surged from 18,300 in 1998 to 113,506 in 2008. The number of unintentional overdose deaths from prescription pain relievers has quadrupled in the U.S. since 1999. Even though hundreds of thousands of patients misuse prescription opioids, only 3 percent of primary care physicians offer them treatment.


Addiction to opioids can successfully be treated with medication-assisted treatment (MAT) which is a combination of medication (buprenorphine, methadone) and behavioral health services. Buprenorphine, a partial agonist, is prescribed in primary care settings to help suppress withdrawal symptoms, reduce cravings, and induce tolerance to protect against overdose. To prescribe buprenorphine you must meet certain requirements, complete eight hours of training, and then apply for a waiver. Having at least two waivered physicians to prescribe buprenorphine is becoming a recognized best practice for primary care clinics using MAT.


Barriers to Treatment

Here’s another gigantic number: almost 30 million persons have no access to a waivered primary care physician. What’s getting in the way? Some barriers include lack of physician training, stigma of addiction, bias against MAT, policy and regulatory issues, and financing. Education and training can easily help overcome the first three barriers; however, we need more institutions to support and offer buprenorphine training. Current state and federal policies cap the number of patients physicians can treat with buprenorphine, deny prescription rights to nurse practitioners and physician assistants, and make it difficult for providers to communicate about a patient’s care. The U.S. Department of Health and Human Services is reviewing several policies and considering changes which is very encouraging.


Opioid addiction is not going away any time soon. The next generation of family physicians will be at the front line of this battle and will need the knowledge and skills (and prescription rights!) to effectively help patients. They will need to know how to screen for opioid misuse and how to counsel their patients. As the STFM Addition Group, we recommend that future curriculum include, at a minimum, training in the following areas: SBIRT, Motivational Interviewing, and an introduction to addiction medicine and buprenorphine treatment. We encourage all family medicine training programs to review their substance use curriculum and consider requiring residents to become waivered.


In 1990 Prince wrote "Thieves in the Temple” a song about rejection and deception. "I feel like I’m looking for my soul, like a poor man looking for gold. There are thieves in the temple tonight”. We will never know how Prince might have responded to a waivered family physician’s invitation for opioid treatment. Undoubtedly he was struggling with real addiction and should have received help sooner. As the rest of the nation grapples with the epidemic of opioid addiction, buprenorphine treatment remains underused. Physicians can keep the "thieves” of misuse and addiction out of people’s lives using effective, state-of-the-art treatment.


Matt Martin, PhD, LMFT teaches behavioral medicine at the Duke/SR-AHEC Family Medicine Residency Program in Fayetteville, North Carolina. He is the CFHA blog editor.

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The Change Pace Paradox

Posted By Andy Valeras, Friday, June 10, 2016



  "Change has never happened this fast before, and it will never be this slow again.”1


Graeme Wood wrote these words to describe the ways social media and technology have redefined communication. The fact that you’re reading a blog right now is example of such change. An increased velocity to change seems to be the norm in the modern era. In fact, we have come to expect it of our technology, and this expectation is extrapolated to the multitudes of evolutions of thought, culture, and policy … and for our society as a whole.


Change, however, does not always equate to progress. Why not?

The accelerating pace of change, and change itself, is uncomfortable. Wood’s quote serves as an emotional epithet for the shaky ground that is inherent to change. Discomfort with change, being on unsteady foundations and uncertain futures, sometimes prompts instinctive reactions towards homeostasis - seeking what is known and grounding. These reactions are pitfalls, however, when they prevent perspective-sharing and dialogue. Dialogue, as defined by Peter Senge2, is a willingness to share and question one’s own worldview, while also being willing to hear and be influenced by another’s worldview. Engaging in dialogue serves the purpose of exploring and expanding one’s "pool of meaning” through conversation and critical personal reflection.


Adapted by Andrew S. Valeras from Senge2


When changes are made without a willingness to engage in dialogue, a tension is created between those who strive towards change and those who resist it. Those who do not need change are often in a position of privilege, and for those individuals, change does not feel like progress, but like loss, particularly when the change threatens the status quo of privilege and power.


It is this tension – for and against change – that seems to be driving the debate, not a discussion, surrounding HB2, the North Carolina House Bill3 also known as the "bathroom bill” and widely considered to be anti-LGBT. [To be clear, I oppose HB2, as does CFHA, in that it goes against the fundamental values of inclusion and integration of all forms of diversity, including gender expression.] All of us are seeking ways to feel safe, not necessarily from each other, but in a world that is changing too fast for some and not changing quickly enough for others. HB2 serves as a symbol of control. It is the assertion of a worldview, not to expand the pool of meaning, but in attempt to slow, halt and even reverse the momentum of change. It is a policy that acts like a door, separating not only individuals, but attempting to shut out progress.

How does CFHA remain relevant in such a rapidly and gradually-changing and politically-charged environment?


CFHA can grow in an uncertain future by continuing to demonstrate and model the tenets of an adaptive organization. We, as individuals and as an organization, can seek to understand, to be part of, and to adapt to the environment by how we thoughtfully choose to act, not react, upon it. We can engage in dialogue with each other, and with those with opposing worldviews. A call to revoke HB2 and to boycott North Carolina may lead to change, but it will not be progress. Progress can only come when those with privilege are not coerced to change, but understand and aknowledge the need for the change. CFHA, as a collective voice of its members, is pushing ahead that work by obtaining, sharing and advocating for the narratives of those without privilege, and the impact an inequitable system has on people’s lives - on their health, their families, at work, at school, on the bus, on the street.


The 2016 CFHA Conference theme of "many faces and places of integration” embodies an opportunity to bring people together and strive for dialogue. We can be part of the change, helping set the incredible pace, rather than be overrun by it, by recognizing actions like HB2 for what they are. Remaining steadfast to the mission of CFHA, while providing the secure space to regroup, allows CFHA the momentum to push the next door down – and maybe the next door knocked down will be a bathroom door in North Carolina. I hope to see you there.


1. Wood, G. (2009). 

2. Senge, P. (2006). The Fifth Discipline. NY: Doubleday Publishers.

3. North Carolina House Bill 2. 


Andrew S. Valeras, DO, MPH is a faculty physician at NH Dartmouth Family Medicine Residency.  He received his undergraduate degrees in Biology and Philosophy from Boston College, his Doctor of Osteopathy from Midwestern University, and his Masters of Public Health at The Dartmouth Institute.  Dr. Valeras completed both the NH Dartmouth  Family Medicine Residency and the Dartmouth Hitchcock Leadership Preventive Medicine Residency.  Dr. Valeras currently seeks to integrate quality improvement and systems based thinking with the clinical practice and education of family medicine providers in integrated teams.  Dr. Valeras does this through the [Systems] course, taught via 320 hours of longitudinal experiential learning, over three years for primary care teams.  Dr. Valeras currently serves as a Board Member for CFHA.

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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.