Posted By Matthew P. Martin,
Wednesday, June 1, 2016
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Welcome to the third 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 in the future for additional reports.
European Countries Designing Large Collaborative Care System
Multiple chronic conditions make medical treatment more difficult for physicians. A new cloud infrastructure in Europe will span across 12 partners in seven countries to provide personalized treatment plans for each patient. Hospitals, general practitioners, and social care organizations across the system will be able to exchange information and coordinate care more effectively. The hope is that new models of patient-centered, integrated care will emerge to reduce admissions and costs. The project is funded by EU Horizon 2020 and supported by the Institute of Digital Healthcare, based at the University of Warwick.
The New Hampshire Integrated Care Medicaid Waiver
The Centers for Medicare and Medicaid Services recently approved New Hampshire’s Medicaid waiver for a "sustainable integrated care system”. This new system will serve all Medicaid beneficiaries and will progressively move payments to more outcome-based measures. The goal is to build capacity for transforming behavioral health care services in the state for Medcaid beneficiaries. Program evaluation will focus on the following five performance measures:
1. Quality of care delivered to individuals with co-occurring physical and behavioral health issues
2. Total cost of care for Medicaid beneficiaries with co-occurring physical and behavioral health issues
3. Rate of avoidable re-hospitalizations for individuals with co-occurring physical and behavioral health issues
4. Percentage of Medicaid beneficiaries waiting for inpatient psychiatric care
5. Average wait times for outpatient appointments at community mental health centers
Health is Primary Campaign Focuses on Integrated Care during Month of May
For the past several weeks, the Health is Primary campaign from Family Medicine for America’s Health focused its efforts in May on promoting mental health and its integration into primary care. As part of this effort, campaign workers released a mental health tear sheet that physicians can distribute to patients.
Benefits of Medicaid Expansion for Behavioral Health: DHHS Issues a Report
Under the direction of the U.S. Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation recently released a brief that analyzes national data on behavioral health including the impact of Medicaid expansion under the Affordable Care Act. Here are some key points:
· Many of those who could benefit from Medicaid expansion have behavioral health needs.
· In states that have not yet expanded, Medicaid expansion would provide considerable benefits for individuals with behavioral health needs and their communities.
· Access to appropriate treatment results in better health outcomes.
· States that choose to expand Medicaid may achieve significant improvement in their behavioral health programs without incurring new costs.
· Medicaid expansion also reduces costs that are incurred by state and local governments and state economies as a consequence of behavioral health problems.
· Across the globe:
o Call for major mental health reform in Australia
oCost-utility of collaborative care for major depressive disorder in primary care in Netherlands sample
oIntegrated care for homeless populations in Canada
oCall for mental health reform in Portugal including collaborative care
oCollaborative care is clinically and financially effective in England sample
· Patients prefer substance abuse treatment in primary care compared to specialty treatment centers according to a study at Johns Hopkins Bloomberg School of Public Health.
·Physicians in the Henry Ford System believe that integrated care is satisfying, improves patient care, is a needed service, and reduces personal stress level.
· Tele-health service based on non-clinically trained health advisers supporting patients in use of internet resources was effective compared to usual care in a randomized, controlled trial.
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Posted By Administration,
Thursday, May 19, 2016
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Health care systems across the globe are integrating mental health services into primary care. Click here for last week’s post on collaborative care in Israel.
Recently, Dr. Manjunatha from the National Institute of Mental Health and Neurosciences in Bangalore, India, wrote a report for the Lancet describing an ambitious program to integrate mental health services into primary care systems. The program, called the Manochaitanya Programme, provides mental health services every Tuesday in taluk hospitals, community health centres, and primary health centres in Karnataka. The services are also available during the rest of the week at all primary health clinics. Check out the rest of this fascinating program by clicking on the link above.
I reached out to Dr. Manjunatha, the lead author of the article, to ask a few more questions about the state of mental health care in India.
1. What is the state of the mental health care system in India overall?
Overall, mental health care system in India predominantly depends on public mental health care institutions of the country. In the last decade, general hospital psychiatry at medical schools have begun to take up the burden of mental health care in the country. Even psychiatrists in private practice are starting to take up the significant amount of mental health care burden. But, still in-patient care predominantly lies in public mental health care institutions.
2. How did the Manochaitanya Program get started? What is the overall purpose and structure of this program?
I am not sure how this Manochaitanya program started. But the state of Karnataka in India has always been innovative in the field of mental health. For example, the Bellary model, a community based experiment at Bellary district of Karnataka, in 1970s paved the way for National Mental Health Program (NMHP)/ District Mental Health Program (DMHP) of the country. Even the World Health Organization popularized this model in many countries throughout the world.
I believe the purpose of this program is to integrate mental health care at all public health care institutions of the state with the name of Mano-Chaitanya Clinic (MCC) on every Tuesdays. This MCC will provide mental health care at all primary health centres using respective public primary care physicians and at all taluk hospitals (taluk means administratively a sub-district in a district) by a qualified psychiatrist (either government or private) which includes academic as well as non-academic psychiatrists. Psychotropic medications are provided free of cost. First time, even professional organization such as Indian Psychiatric Society- Karnataka chapter has joined in this venture for successful implementation of this program.
3. How often do mental health and medical professionals collaborate with each other to help a patient?
The collaboration of psychiatrists and other mental health professionals to help a patient is mainly at mental health care institutions. Otherwise, it is often a rare scenario to see collaboration of mental health and medical professionals (I mean, non-psychiatric physicians) to help a patient in India especially in the area of medical comorbidities (Non-communicable diseases).
4. What needs to happen for mental health treatment to become part of all regular and routine medical treatment?
This is exactly the vision of this innovative Manochaitanya program. The basic component of this program is mental health treatment should become part and parcel of all routine medical treatment at primary care institutions. I am in opinion that this is the first of kind public mental health program in the world with exclusive aim to integrate mental health in primary general practice. I hope this model will show significant success and pave the way for many countries in the world.
Dr. N. Manjunatha, MD, DPM, MBBS
Assistant Professor of Psychiatry, Department of Psychiatry
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
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Posted By Administration,
Thursday, May 12, 2016
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Health care systems across the globe are integrating mental health services into primary care. Recently, Dr. Ohad Avny and colleagues from Clalilt Health Services and Talbieh Psychiatric Clinic affiliated with Hadassah-Hebrew University Medical School in Jerusalem, Israel, completed a literature review of collaborative care models in Israel and other countries.
In the article, the authors call for implementing more psychiatry liaison services in primary care to address the high rates of psychopathology. They also cite evidence that collaborative care models are effective and that primary care physicians are motivated to work within psychiatry liaison models. I reached out to Dr. Avny, the lead author of the article, to ask a few additional questions.
1. What is the state of the mental health care system in Israel overall?
Currently mental health care in Israel is going through an ongoing process of reform. All mental health care will eventually be managed by the 3 large HMO health care systems. Up to now, mental health care was financed directly by the state. The argument for this change is foremost financial and medical (growing gap between mental health care in the provinces in Israel as compared to the metropolis areas). As there is growing shortage of psychiatrists and financial strict management I have a sense mental health care is pending crisis. And so primary care physicians who are on the "front line" will share more of this burden.
2. What prompted you to do a literature review of collaborative care in Israel and other countries?
As a primary care physician I can relate to my own clinical experience in my clinic. I have been practicing in my HMO clinic for the last 16 years. I am leading my HMO clinic with six family physicians. Our patients are in the Geriatric "range" and as such need a multi-disciplinary approach.
We have in our district an ongoing psychiatric collaborative enterprise where we have a psychiatrist attending our clinic every two weeks. We refer patients and consult on phone. With time due to my personal interest and growing involvement in my patient's lives ( 16 years is a hell of a long time) I started dealing more and more with psychosocial aspects of my patient's illnesses and narrative . I found it challenging not to stigmatize patients with psychiatric diagnosis on the one hand and yet be able to diagnose and treat those who suffer from mental health diseases. Our collaborative model has empowered me as the main care giver in patients suffering from depression and anxiety disorders. And as I was a bit skeptical of my competency as a family practitioner, less experienced and trained than psychiatrists, I started looking for evidence supporting this model. To my joy my clinical "hunch” for treating my anxious and depressed patients was supported by RCT.
I was thrilled to see that family physicians who treat depression and anxiety of their patients with some collaborative backup model are no less successful and sometime are more successful than psychiatrists providing standard care.
3. How often do mental health and medical professionals in Israel collaborate with each other to help a patient?
In Jerusalem there are 20 large HMO clinic who have this psychiatric collaborative model. Yet it does not exist as an organizational project in other parts of Israel. There are some collaborative enterprises - but these are local initiatives. We have another long standing collaboration model with an endocrinologist who has been with us for the last 14 years. She consults with us once a month by reviewing patients cases without their presence. So you can imagine we have upgraded our knowledge and competency in diabetes management and more. In a sense, since both the psychiatrists and the endocrinologist have been with us for so many years they are actually part of our team and so these consults are enjoyable, fun, and informal which keeps us running together, fighting burnout.
4. What needs to happen for mental health treatment to become part of all regular and routine medical treatment?
I would say:
1. Increased personal interest of primary care physicians to address psychiatric issues,
2. Available backup of a mental health provider - psychiatrist for stat consult and formal assessment if needed
4. Establish close collegial relationships with physicians in subspecialties who are in your collaboration team. Their motivation has to be "pumped" up since burden of care is also at times overwhelming for them.
5. Patience!! Patience!! Patience!!! And accept the fact that you will always be behind schedule.
|Ohad Avny is a certified Israeli family physician. He attended a one year fellowship program in Geriatrics in Canada UFT at Bay Crest Center for Geriatric Care. He is involved in undergraduate medical training (medical humanities, and family clerkship) and post-graduate training in family residency. He has special interests in psychiatry, palliative care, and medical humanities. He is married with three children.|
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Posted By Lauren DeCaporale-Ryan,
Wednesday, April 20, 2016
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About 90% of my clinical practice is focused on caring for
Those suffering from chronic
medical illness, now unemployed,
Those without a home to go to at
the end of the day,
Those with a home but without any
furniture or food,
Racially diverse individuals,
LGBT individuals often afraid to
walk down the city streets that lead to our clinic,
& Medicare and Medicaid beneficiaries.
This list doesn’t even fully capture who might be labeled as
"underserved,” but reflects many vulnerable populations that turn to primary
care settings seeking behavioral health treatment. I work with patients in a
family medicine practice that serves over 20,000 individuals annually, most of
whom are from underserved backgrounds. These are families with low SES, who
frequently have experienced poly-trauma, chronic loss, and environmental
stressors. Often, they do not trust the medical system… and sometimes… when
they first meet me, I’m sure they don’t trust me… The evaluation of the
healthcare system as untrustworthy and unfair is not universally true, but it
is also not unjustified. Bias and discrimination exist – just watch one
political commentary these days and you’re bound to hear something about these
very populations and assumptions about individuals from such backgrounds.
But what do I know about these
things? I am privileged: my skin tone, my education, my SES, & my life
experience make me different from every patient who walks through my door.
There are other factors that distinguish us. And then there are commonalities:
the most obvious for many is gender or age, but there are my own family
experiences of aging and illness that provide me with a shared understanding. Some
patients ask to explore our differences immediately. Others wait, reflecting as
treatment ends that they weren’t "sure about” me but gave therapy a chance and
that they are grateful that they did. Others explore the subject when someone
throws privilege in their face: Questions are posed like, "can you believe this
white lady,” "that doctor doesn’t care about me, he’s just in it for the money,
right?” And suddenly, with these questions, we are processing that I too am a
white woman and doctor. How am I the
same as those who have acted from a space of privilege and how am I different?
Often, I cannot fathom what it is that these families have
been through. Their narratives are burdened by unending stressors that often
lead to pain and anger. They are estranged from family, have limited supports,
and the practicalities of their stressors are real. So…what do I have to offer?
I have learned over time that I can
very rarely fix the actual problems: the bed bugs, the lack of food, the
violence in a neighborhood. I am aware that these factors will cause continued suffering,
but there may not be the resources in my community to address the practical,
environmental needs of each individual. What I can give instead is empathy,
warmth, and compassion. I can provide a safe space that allows for processing
an acute stressor or remote hurt that has only furthered an individual’s
vulnerability. I can provide human contact that demonstrates that the patient
is someone valued and that even when they feel no one else cares, their
treatment team does. I can help them develop problem solving skills and work
with their team to identify community resources (when they exist) that will
help them overcome the limits that exist in their lives. I can simply be
present, listen, and hear their stories. I can advocate for change with them. I
can push myself to continuously learn about the value in what makes us each
different. And I can educate others to have better knowledge, tolerance, and
acceptance of differences.
I often end my days feeling drained, but then I remind
myself of how fortunate I am and turn to gratitude. Of course, there is gratitude
for my own upbringing and family, for the many gifts and opportunities I was granted…
but it is more than that. I am
grateful for patients’ wisdom and insight. As they battle obstacles in their
everyday lives, I am motivated to make change in my own and hopeful that I can
make even the slightest bit of difference in improving equality.
I leave work every day feeling lucky that families have had
enough faith, hope, and trust to show up at my door and share their stories
with me: that is privilege.
PhD is a Family Geropsychologist and Assistant Professor of Psychiatry,
Medicine & Surgery at the University of Rochester Medical Center. In
addition to clinical work, she provides coaching on patient-family centered
communication skills and team-effectiveness to physicians and interprofessional
teams in Internal Medicine and General Surgery. She is the Associate Track
Director of the Primary Care Family Psychology Fellowship at URMC and serves as
the Early Career Representative to CFHA’s Board of Directors. |
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Posted By Randi Dublin,
Tuesday, April 5, 2016
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A monolingual Spanish-speaking patient from Ecuador
was injured on his job in the northeastern US. He was prescribed medicine for
multiple physical injuries and had been previously diagnosed with depression
prior to the incident. He carries shame about his history of depression and a
suicide attempt before he was left unemployed, struggling financially as head
of household, with physical injuries. Now the patient begins to experience
mental health symptoms again; depressed mood, lethargy, low self-esteem. He
begins to meet with me weekly in a pain management clinic for psychotherapy
sessions. And he develops suicidal and homicidal ideation … voices telling him
to hurt himself and a family member. My question to you is: how many barriers
does this man face to obtaining appropriate and comprehensive, collaborative
care to ease his suffering?
Let’s be sure to separate barriers to
comprehensive, collaborative care that result from mental illness and barriers
that result from health inequality. To address the first set of barriers, he
carries shame that he is experiencing mental health symptoms which he perceives
others aren’t experiencing, and self-stigma that he shouldn’t be feeling the
way he is. But apart from these mental health roadblocks to comprehensive,
collaborative care, this patient experiences barriers related to health
inequality. He speaks a different language than I do and only with the help of
a translator can we communicate effectively. He lacks funds to pay for medical
services and can only see me because our visits are paid for by workers
compensation. Furthermore, men from his country do not show "weakness” or a
need for medical help, let alone mental health services, which are stigmatized.
He doesn’t recognize that he is being denied certain medications by insurance
because they are very expensive, not due to a personal flaw. The barriers posed
by health inequality make it likely that this patient will not obtain
comprehensive, collaborative care. A white male patient with adequate financial
means may not face the same barriers.
This case example is not unique,
unfortunately. Health outcomes often differ across groups, a term commonly
referred to as health disparities. Factors such as poverty, economic barriers, limited
access to healthcare, neighborhood problems and lack of education are just a
few which lead to unequal
health outcomes between groups. What about other reasons for different health outcomes? Do
some individuals not seek effective healthcare because they turn to their own
remedies or they don’t know what beneficial treatments might be out there? Or perhaps
they don’t want someone in the Western medical establishment telling them how
to get well? Or maybe the medical provider is of a different cultural
background? Power dynamics between patient and provider plus history may make
some groups not want to be "experimented upon.”
Recent accumulated evidence suggests
that there is a longevity difference between the rich and poor in America,
which is a continuing trend, attributed to economic and social inequality. When
certain treatments are too expensive for some, they miss out on potentially life-saving
solutions. The question ultimately is: can
collaborative care, in its least restrictive definition (the integration of
behavioral and physical health services and communication between care
providers), help to reduce these health disparities and barriers to beneficial healthcare?
Although we lack sufficient research
in this area, I propose that collaborative care can help to reduce health
disparities. Collaborative care is geared towards focusing on the whole person,
their biopsychosocial status, and not just on a mental health diagnosis or
physical symptoms. A collaborative care team can first address whether certain
biological factors predispose a patient to specific diseases or disorders. To address
social factors which impact health such as poverty, unemployment, and access to
healthy food, the treatment team can work together to assess nutritional needs,
find financial benefit programs and unemployment resources. Collaborative care
also brings the treatment to where the patient is physically located, which can
ease financial burden for transportation costs. Behavioral health providers can
assess for factors (i.e., depression, trauma) which may impede upon patient
self-care or lead the patient to avoid health clinics for treatment. By
focusing collaboratively on the whole patient, perhaps we can help reduce the health
disparities that exist based upon someone’s race, education, and financial
We have an aging population to contend with for the next few decades. The
People 2020 project is a national endeavor aimed at
improving the health and longevity of Americans. Specifically, with regard to
health disparities, this
program aims to "achieve health equity, eliminate
health disparities, and improve the health of all groups”. To meet this aim, we
ultimately need to minimize barriers to healthcare for all people: economic,
transportation, education, medical, and nutrition barriers. The list goes on. We
need to work as a team to help the patient take care of their own health.
Collaborative care is one way to break down these
barriers. Let us, as the CFHA community, conduct more research to demonstrate
how effective collaborative care can be in the fight to end health disparities
and health inequality.
|Randi Dublin, Ph.D. is a
licensed clinical psychologist with particular interests in mental health
advocacy and destigmatization, dissemination of evidence-based psychotherapy,
integrated behavioral health & primary care, and promotion of psychological
science in the community. She has worked across urban settings treating adults
with psychological and health-behavior issues. Currently, she works with
injured workers who are struggling with chronic pain, trauma, depression and
other issues. She hopes health disparities will be addressed by collaborative
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Posted By Thomas Bishop, Jodi Polaha, Colleen Cordes,
Thursday, March 24, 2016
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A few weeks ago the ETSU Academic Health Sciences Department was holding its second full-day experience for students enrolled in the Interprofessional Education (IPE) Program. The day’s experiences centered on values and ethics in team based care, and the importance of considering social determinants of health. Student teams (nursing, medicine, pharmacy, psychology, public health and a range of allied health disciplines) worked with patient actors that presented with social problems that were intertwined with chronic medical conditions. These budding health professionals found themselves uncertain in determining their roles, how to work together, and in what they may have to offer.
The one thing that was clear to them, indeed it was the aim of the exercise, was that they needed each other to address the patient’s needs. The students saw the utility of the "pit crew” referenced by Atul Gawande1, and, we hope they started to see the value of team based care, which has been recognized for some time and has been shown to have a positive impact on range of measures including access to care, prevention, and movement toward health goals.2-4 While the Agency for Healthcare Research and Quality suggests that team training improves patient care and safety, 5providers continue to be largely trained in silos. IPE is trying to move the needle with training like this one, and move the new-in-training toward readiness for a team care environment.
IPE is a fast-growing area as academic health sciences training programs scramble to bring their students up to speed with the evolution of health care toward a team focus. It was in the 2000s that IPE represented a paradigm shift in health care with the Institute of Medicine’s report Crossing the Quality Chasm: A New Health Care System for the 21st Century calling for fundamental changes in addressing quality and service. The Interprofessional Education Collaborative (IPEC) was established in 2009 when six national education associations representing health professions formed a collaborative to promote and advance interprofessional learning experiences that would prepare health professionals for a new health system. The first Collaborating Across Borders conference was held at the University of Minnesota in 2007. The World Health Organization (WHO) Study Group on IPE and collaborative practice was formed with the report Framework for Action on Interprofessional Education and Collaborative Practice being published in 2010.6
The WHO defines IPE as when "two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.7 The WHO has identified a number of competencies that are widely accepted, but when examined more closely, are very broad and not operationalized. The members of our IPE initiative at ETSU reviewed a number of competencies addressed in the literature and pooled input from those doing team based care to formulate a list of competencies deemed important for the teaching rather than the practice of team based care (see Table 1). We have been working to identify specific, measureable behaviors for each of these competencies, and how they would be addressed in a curriculum. Most institutions who have been developing curriculum and IPE programs have moved from simply championing the benefits of team based practice to the identification of just how they may teach competencies and measure the impact of instruction through simulation and orchestrated exercises.
Table 1 Interprofessional Competencies
- Roles and Responsibilities
- Knowledge of Healthcare Policy Relating to Team Care
- Learning Healthcare Systems
But where do we go from here? In reading the current literature on IPE and noting the aims of many presentations offered at national conferences addressing IPE, it seems that discussion is only beginning in how and in what way IPE is being translated to health care change and practice. A useful "tool” in examining this issue may be to consider three legs to IPE where instruction moves between being informational, formational, and transformational. The footers or building blocks to IPE are found at the informational level of instruction, instruction centers on concepts, ideas, and the identification of skills. It could be argued that most approaches to IPE are only at this informational level of instruction. A second leg, formational instruction, is where the focus centers on team member function, practice, and role-identity. Instruction moves beyond being about information and the learning of instruction, but to engagement and the practice of skills. To suggest that IPE instruction can and should be transformational, the third leg, is to capture the spirit of the WHO in championing team based care, where there is actual change in the "dance” of team members and a revolutionary change in health care. A true paradigm shift.
So, we are preparing future providers to change or influence the landscape of health care’s future. But we wonder if they will be ready for what they will find in the marketplace today. It is a difficult balance to be idealistic and innovative, while also training health care workers for actual positions. For this to work, the health care system needs to be willing for flexibility and open to change. We are beginning to see changes in payment incentives that encourage some movement toward team based care. Health care institutions are asking applicants about their experience and training in team based care. But once employed, how are current members of the healthcare workforce adequately prepared to operate in teams when their own educational experiences reflect historical educational silos? There is some talk of certifications and recognition for these experiences and there is a growing number of sites that offer training and tools for teaching and doing team based care, such as the Nexus Center for Interprofessional Education and Practice website (https://nexusipe.org/); however, utilization of these resources outside of educational institutions remains unclear.
In the same way that we have seen IPE evolve from a few championing the cause to the unifying of educators and providers behind a common goal (such as the formation of IPEC), we are now in need of organizations with similar passions to join forces in furthering research and a common set of principles in doing IPE. There are several organizations, such as the Collaborative Family Health Association, The Society of Teachers of Family Medicine, and certainly the Interprofessional Education Collaborative, as well as others, who have addressed aspects of IPE, though often indirectly under the auspices of "workforce development,” and not necessarily tied to articulated competencies. While many belong to a number of these organizations, there is a lack of shared vision and mission at the organizational level. This could be addressed by conferences occurring in tandem or perhaps having combined conferences from time to time where common efforts and collaboration could take place. The leadership of organizations could request that there be positions for representatives of other similar minded organizations so as to enhance common infrastructure for IPE. Perhaps there could be a national IPE commission that encompasses leadership representatives from the various organizations that are invested in IPE.
Just like that early day in February at our University, ETSU, as early health professionals were attempting to find their roles, work together, and determine what they may have to offer in regards to patient care, those with a passion for IPE could become more united in moving toward being transformative and in reaching a common ground. Perhaps then there would not only be pit crews for patients, but a common set of tools these mechanics can use.
1. Gawande, A. (2011). Cowboys and pit crews. Harvard Medical School Commencement Address. Retrieved from http://www.newyorker.com/news/news-desk/cowboys-and-pit-crews
2. Grumbach, K. & Bodenheimer, T. (2004). Can health care teams improve primary care practice? Journal of the American Medical Association, 291(10), 1246-1251.
3. Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
4. Leape, L. Berwick, D., Clancy, C., Conway, J., Gluck, P., Guest, J., Lawrence, D., Morath, J., O’Leary, D., O’Neill, P., Pinakiewicz, D., & Isaac, T. (2009). Transforming healthcare: A safety imperative. Quality and Safety in Health Care, 18(6), 424-428.
5. Agency for Healthcare Research and Quality. (2009). TeamSTEPPS™: national implementation (online). Retrieved fromhttp://teamstepps.ahrq.gov/index.htm.
6. Thompson, B., Kelman, G., Romanoff, B., Pieper, B., & Dacher, J. (2012). Interprofessional education and collaborative practice. Retrieved from http://www.sage.edu/centers/asset/IPE_PPT_Final_Integrated.pdf
7. World Health Organization. (2010). Framework for action on interprofessional education and collaborative practice (WHO/NRH/HPN/10.3). Retrieved from http://www.who.int/hrh/nursing_midwifery/en/
|Thomas W. Bishop, Psy.D.Assistant Professor of Family MedicineDirector of Behavioral MedicineEast Tennessee State University|
|Jodi Polaha, Ph.D. is a licensed clinical psychologist and Associate Professor in the Division of Primary Care Research, Department of Family Medicine, East Tennessee State University. She has worked exclusively in integrated practice since 1998, and describes herself as a "pracademic,” engaging in a balance of clinical training, program development and research. She has directed the integration of behavioral health into over 25 primary care clinics, has developed and implemented interprofessional training curricula across disciplines and learner-levels, and conducted funded research on integrated behavioral health in pediatric primary care.|
|Dr. Colleen Clemency Cordes is a licensed counseling psychologist, and the Director and Clinical Associate Professor in the Doctor of Behavioral Health Program at Arizona State University, the first graduate program dedicated to training the integrated behavioral health workforce. She has worked in primary care within multiple organizations, including Banner Good Samaritan Hospital in Phoenix, AZ, the VA Hospital in Long Beach, CA, the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, MA, and HonorHealth's Neighborhood Outreach and Access to Health (NOAH) clinics. She received a certificate in Primary Care Behavioral Health from the University of Massachusetts Medical Center, and is currently on the board of directors for the Collaborative Family Healthcare Association (CFHA).|
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Posted By Matthew P. Martin,
Thursday, March 10, 2016
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Welcome to the second 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 each month for additional
Privacy Rules on Medical Records for Substance Use Treatment
The U.S. Department of Health
and Human Services (HHS) and the Substance
Abuse and Mental Health Services Administration (SAMHSA) are seeking
to make it easier to access and share substance use treatment records.
The confidentiality rules for substance use records (42 CFR
Part 2) were developed in the mid-1980s to give patients confidence to seek
substance abuse treatment without fearing disclosure of the treatment. Under
the current rules, identifiable information can be released only with the
affected individual’s consent.
The rule differs markedly from the Health
Insurance Portability and Accountability Act, which does not require
patients' consent for a provider to disclose their records for treatment,
payment or other healthcare operations.
According to the proposal, "Significant changes have
occurred within the U.S. healthcare system that were not envisioned by the
current regulations, including new models of integrated care that are built on
a foundation of information sharing to support coordination of patient care,
the development of an electronic infrastructure for managing and exchanging
patient information, and a new focus on performance measurement within the
The modifications would allow the federal government, and
subsequently the Centers
for Medicare and Medicaid Services, to develop a new infrastructure for
managing and exchanging patient information, with an increased focus on
performance measurement and quality improvement. The modifications would also
help to decrease stigma toward substance use treatment and make it easier to
integrate behavioral health services.
Public comment on the proposed rule is open until April 11. Click here for an opinion
New Depression Screening Guidelines
Preventive Services Task Force (USPSTF) recently published recommendations
for depression and autism screening. For the general
adult population, including pregnant and postpartum women, the USPSTF
recommends screening for depression "with adequate systems in place to
ensure accurate diagnosis, effective treatment, and appropriate follow-up”.
adolescents, 12 to 18 years of age, the USPSTF recommends screening for major
depressive disorder with the same care systems mentioned for the adult
Finally, for autism spectrum screening in children aged 18 to 30
months, the USPSTF "concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening for autism spectrum disorder
(ASD) in young children for whom no concerns of ASD have been raised by their
parents or a clinician”.
For a blog commentary, click
Call for Social Work to Move Toward Integrated Care
at the Silver School of Social Work at New York University are encouraging
their discipline to embrace and move toward integrated care. They argue that
the Patient Protection and Affordable Care Act centers on the promotion of
integrated health, thus creating a timely opportunity. The authors argue that
traditional social work roles of care coordinator, case manager, and community
organizer fit well within collaborative care and disease management models.
They call for more leadership roles from social work in the growing integrated
care field as well as a focus on workforce development for future social
New data suggests that
depression management in primary care can help older adults with depression
and diabetes. Researchers examined the mortality risk of 1,226 patients from
multiple practices who received algorithm-based depression management for 98
months (2006-2008) from a depression care manager. They found that patients
with depression and diabetes who received the intervention treatment were less
likely to die post-2008. For heart disease, persons with major depression were
at greater risk of death, whether in usual-care or intervention practices. The
study is part of the Prevention of Suicide in Primary Care Elderly:
Collaborative care has a modest benefit (effect
size 0.3) over usual care, says
data from the University of Manchester. Nineteen general practices in
northwest England were randomized to collaborative care and twenty to usual
care. Collaborative care included patient preference for behavioral activation,
cognitive restructuring, graded exposure, and/or lifestyle advice, management
of drug treatment, and prevention of relapse. Mental health professionals
provided up to eight sessions of psychotherapy, with two sessions attended by a
practice nurse. Patients in the intervention arm reported being better self
managers, rated their care as more patient-centered, and were more satisfied
with their care. Michael
Sharpe wrote commentary on the study saying we know integrated care works
but we still don’t know much about which interventions work best. He also
believes there were several limitations to the study (e.g., care was not
integrated with medical care, treatment was psychiatry-directed). He also
believes we need more intensive treatment for co-morbid patients.
Data from one study at the
University of Southern California suggests that patients are generally
accepting of automated remote monitoring of their depression. From 2010 to
2013, the Diabetes-Depression Care-management Adoption Trial (DCAT)-a
quasi-experimental comparative effectiveness research trial aimed at
accelerating the adoption of collaborative depression care in a safety-net
health care system-tested a fully automated telephonic assessment (ATA)
depression monitoring system serving low-income patients with diabetes. They
found that the vast majority of participants would participate in the future
and found the technology useful and secure.
Does integrated behavioral health services in
primary care work for patients with serious mental illness? Researchers in one study
compared minimally enhanced usual care with collaborative care for 404 patients
with PTSD enrolled in Federally Qualified Health Centers. They found no
difference in effectiveness between the two care models. In a similar study examining
patients with bipolar disorder, researchers found that collaborative care
was superior to usual care. James
Phelps recently wrote a blog post on this topic for CFHA.
Representatives from SAMHSA
are calling for integrated care services to meet the mental health needs of
children and adolescents. They state, "What may be needed is not a health home
as currently conceptualized for adults, nor a traditional medical home, but a
family- and child-centered coordinated care and support delivery system
supported by health homes or other arrangements.”
Qualitative data from 59
interviews suggests that collaborative care helps clinicians to see
patients more holistically, gives patients space to talk about their mental
health, and decreases stigma toward mental health care. Interestingly, patients
also reported a desire to "discussing emotional health problems in a separate
therapeutic space away from the” medical staff. Patients saw medical staff
members as insiders who managed their medical care and behavioral health staff
members as outsiders "which paradoxically granted patients freedom to talk
emotionally about their life circumstances and medical conditions in ways that
were not possible with” medical staff.
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Posted By Jim Phelps,
Friday, February 19, 2016
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“The difficult we do immediately. The impossible takes a little longer.”
(motto of the WWII Army Corp of Engineers)
Consider three primary care buckets, for simplicity: in the first bucket, you’ll find patients with the many forms of depression and anxiety that can benefit significantly from the brief interventions commonly provided by Behavioral Health Consultants.
In the third bucket, you’ll find those who clearly need specialty mental health services: psychosis, significant borderlinity, complex or treatment-resistant substance use, and complex medication regimens. Left over is a large group of patients our behavioral team has lumped in “Bucket Two”. These are folks whose depression and anxiety is complex, or not responding to the interventions of Bucket One, but who are unable or not inclined to go see a mental health specialist.
Bucket Two includes a mix of difficult-to-treat depression, anxiety, and bipolarity. And, as CFHA providers well know, trauma histories in this group are extremely common. Patients in this bucket represent the majority of patients referred to our Primary Care Psychiatric Consultation (PCPC) program. Their diagnoses include substance use, GAD, borderlinity, ADHD – but most common of all are PTSD and bipolar disorders. Unfortunately, these are difficult to treat in primary care: their complexity level is often very high (e.g. prior therapies, prior medications, co-morbid mental health conditions, and co-morbid general medical problems), potentially swamping busy behaviorist and primary care providers; and with their trauma histories, they often do not respond fully to brief interventions.
The Collaborative Care model for psychiatric consultation has demonstrated efficacy in patients with Major Depression, and is sometimes promoted over other models on this basis. But it has less evidence for efficacy for PTSD (e.g. the recent negative trial by Meredith et al, 2016) and bipolar disorders (e.g. Cerimele et al, 2014). However, the news for Bucket Two is not all bad. A recent randomized trial in the Netherlands showed that a collaborative care approach to bipolar disorders reduced the frequency and severity of depression symptoms relative to treatment-as-usual (van der Voort et al, 2016). And a Behavioral Integration program for small and solo primary care practices, being studied in a randomized trial (sponsored by a large insurance company!), utilizes an intervention designed to treat both unipolar and bipolar depression (Kilbourne et al, 2014).
Consider a review from Dr. Kilbourne’s group, on integrating bipolar disorder management in primary care (2012). In it she and her colleagues emphasize the unrecognized burden of bipolar disorder in primary care (“the de facto site of care for persons with bipolar disorder”) , noting:
Subthreshold bipolar diagnoses, such as bipolar disorder not otherwise specified and cyclothymia, are not only prevalent and clinically significant but also go largely untreated in primary care. In a nationally representative sample of U.S. adults diagnosed with depression, 40% of participants also had a history of subthreshold bipolar manic symptoms… Notably, the role impairment associated with these subthreshold disorders is similar to that of bipolar I disorder and present with significant psychiatric comorbidity and symptom severity predisposing them to an increased risk for suicide and general medical conditions.
That’s Bucket Two – or rather, a portion of it. As noted, the other common diagnosis in there is PTSD, which is similarly role-impairing and similarly likely to present with comorbidities, psychiatric and medical.
Suffice to say that if your program is having difficulty managing the folks in Bucket Two, so are we: they need more than can be provided in Bucket One, the main territory of the primary care behaviorist, but either can’t or won’t access specialty mental health (in our case, access is a huge problem: our psychiatry residency program is just about the only place in a large catchment area that will take patients with Medicare, for example, so we have a chronic long wait list). In a later post I will return to describe a program for the bipolar disorders in Bucket Two. Hopefully, between us all here in CFHA, the PTSD will take “just a little longer”.
James Phelps, M.D., Staff Psychiatrist at Samaritan Mental Health, has specialized in bipolar spectrum variations for over 15 years. He has authored multiple peer-reviewed articles on mood disorders, and serves as Bipolar section editor for Psychiatric Times. His no-profit website, www.PsychEducation.org, focuses on complex bipolar variations; it has received over a million visitors. He accepts no honoraria from pharmaceutical companies, but does receive royalties from McGraw-Hill and W.W. Norton for books on the bipolar spectrum. His new book from Norton, A Spectrum Approach to Mood Disorders, will be out in June 2016.
Dr. Phelps received his M.D. from Case Western Reserve University, and completed his residency in psychiatry and a fellowship in medical education at the University of New Mexico. Current grant funding focuses on primary care psychiatric consultation.
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Posted By Marianne McPherson,
Wednesday, February 3, 2016
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100 Million Healthier Lives is an unprecedented collaboration of change agents across sectors who are pursuing an unprecedented result: Mission: 100 million people living healthier lives by 2020. Our vision is to fundamentally transform the way the world thinks and acts to improve health, well-being and equity to get to breakthrough results. Together, we are systematically creating a community of solutions to the most intractable challenges that stand in the way of achieving health, wellbeing and equity across the globe. Our theory of change follows:
Unprecedented collaboration + innovative improvement + systems change to remove barriers = 100 million people living healthier lives by 2020.
Our 700+ members have signed on because we believe the time is right for a major leap forward in the creation of health, wellbeing and equity. The rising tide of chronic disease, an aging population, structural inequity in health outcomes (despite advances in health care), and technology demand a fundamentally different approach, one which brings us together across sectors to address the physical, social and behavioral contributors to health together.
What’s more, all members of 100 Million Healthier Lives agree to adopt five following core principles in our work together. Several of those resonate strongly with the founding principles of CFHA of collaboration and family-centered care:
- Partner deeply and respectfully in the process of creating change with people, organizations, and communities.
- Promote equity, justice, strength, and wholeness in the process of creating health.
- Adopt a humble posture of learning and improvement that acknowledges the importance of both stories metrics that matter.
- Intentionally work to remove barriers in critical areas (e.g., payment reform, spread of good ideas) through intentional collaboration with traditional and nontraditional partners.
- Make the way we work an example of what’s possible.
We set an audacious goal of 100 million healthier lives precisely so that there was a goal so big that no one organization or community or stream of work could achieve it alone.
A key priority in the movement to is to shift culture and mindset to one of partnership, co-design, and wellbeing. Some examples:
· Partnership means that, for example, we have shared leadership and decision making at every level of the initiative. We believe that everyone holds a unique and important piece of the puzzle in creating health. We are committed to seeing how those pieces fit in different combinations, letting go of the pieces we hold to combine them in innovative ways.
· Co-design means that we are working with rather than for communities. We are working to create 1000 “communities of solution” around the world, believing that sustainable change for health, wellbeing, and equity, will come when communities, themselves are full partners in the work, when they set meaningful goals rather than having goals set for them. The 61 communities in the SCALE and Pathway to Pacesetter initiatives are working in multi-sector teams and using improvement science techniques to test and learn their way into their community’s health goals.
Wellbeing means that we define and measure health as broader than physical health to include physical, mental, social, and spiritual wellbeing. The importance of integrating mental health into primary care resonates deeply with our work and goals, including a stream of work aimed to “make mental health everybody’s job.”
We have organized work by focusing on the following “9 Whats and 9 Hows":
- Close equity gaps – this is “the “price of admission” in 100 Million Healthier Lives
- Help veterans to thrive
- Address and improve social determinants across the continuum
- Improve wellbeing of indigenous communities
- Help all kids have a great start to life
- Make mental health everybody’s job and take a prevention approach
- Engage people in their own health (nutrition, exercise, sleep, stress, food security)
- Improve employee health and wellbeing
- Create wellbeing in the elder years and end of life
- Shift culture and mindset to one of partnership, co-design, and wellbeing.
- Develop the health workforce
- Elevate peer to peer approaches
- Build improvement capability at the community level
- Use chronic diseases and risk factors to build the health continuum
- Improve high quality primary health care access for all
- Integrate data across siloes (health care, community, public health, social services)
- Create new financing strategies
- Transform health care to be great at health and great at care
The movement is more than words and ideas, it is coming to life around the world in everyday action. The story below is from the online community—anyone is free to join the community and share stories about a recent success partnering with high school youth in Algoma, Wisconsin, shared by Teal Vanlanen:
Through the recognition of our Live Algoma work, our local high school received a $5000.00 Hands-Only CPR kit from the American Heart Association and Bellin Health. The students were tasked with "being creative" in using this kits - I think they went above and beyond creativity!
The students decided to partner with Live Algoma because "Live Algoma is by us and for us," they said. As a result, we presented our Driver Diagram, our AIM, and how to complete a PDSA [improvement science tools]. The students were thrilled. We told them to start small and SCALE up in the community.
For their first small scale test, the students wanted to train Hands Only CPR to members of our community at two local basketball games (basketball is a huge draw in our community). They were aiming for to train a minimum of 20 people per game; they trained 130!
How are they planning on SCALING up in our community? Wait until you hear this: next semester they are developing a class where they can go out to local businesses and train all of the employees on Hands Only CPR. Then, they will meet with the local government, school administrators, and local business owners to share their data and convince them to make system and policy changes within their organizations to require all employees and students (grades 7-12) to be trained in Hands Only CPR each year.
Thank you for the opportunity to share our voices on your blog. We invite you to join with us via www.100mlives.org; you can join the movement, register for monthly momentum calls, visit our map of the movement, and share your stories. Thank you for all you do to improve health and wellbeing!
We invite you to join the 100 Million Healthier Lives Community at our spring gathering in Orlando, Florida, from March 19-22 in conjunction with the Institute for Healthcare Improvement’s (IHI) 17th Annual Summit on Improving Patient Care in the Office Practice and the Community. IHI is honored to announce that Vice Admiral (VADM) Vivek H. Murthy, MD, MBA, the 19th Surgeon General of the United States, will deliver the closing keynote address. For more information, click here.
Marianne McPherson, PhD, MS, is Director, 100 Million Healthier Lives Implementation at the Institute for Healthcare Improvement. Her responsibilities include developing and implementing new programs; building external partnerships; and supporting a culture of unprecedented collaboration, innovative improvement and system transformation to support 100 million people worldwide leading healthier lives by 2020. Marianne received her MS in Public Health from Harvard School of Public Health, her MA in Women’s and Gender Studies from Brandeis University, and her PhD in Social Policy from the Heller School at Brandeis University. Connect with her directly at email@example.com (email), www.100mlives.org (web), or @MariannePhD (Twitter).
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Posted By Jeffrey M. Ring,
Wednesday, January 27, 2016
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"The truth is of course is that there is no journey. We are arriving and departing all at the same time." David Bowie
Just over a year ago I transitioned from my clinical and teaching practice at a family medicine residency to healthcare consulting. This was no easy farewell. I would be leaving a residency program where I served as psychologist/clinician, educator, mentor and colleague for 19 years. I was leaving a place where I felt deeply imbedded in an integrated and beloved vulnerable safety net healthcare community in East Los Angeles. The night before I was to announce my resignation, I made a pact with myself that I would do my best to be mindfully present for each and every farewell encounter over the weeks ahead. My connections with others are important to me, and I felt a strong need to honor each relationship as well as I could in the face of this impending departure. I bolstered myself for the emotional intensity to come and made a plan for how I would take care of myself.
My bolstering and planning were imperfect at best.
Over the course of the month, a patient would arrive for counseling, enter into the content of their exploration, and I would do my best to listen and assist. About twenty minutes into the session, I would find a way to say something like, “I have something important to talk to you about our work together…” At this point I would let them know of my tenure at the clinic drawing to a close.
As clinician colleagues, you already can imagine the variety of reactions I received. These ranged from tearful sadness, bitterness, and helplessness to tearful appreciation and celebration of our work together. Blame, abandonment and unfairness surfaced often in our conversations as well. I struggled with having shifted from a source of support to a source of consternation and loss.
The most painful aspect of these conversations was the unfinished work, the ongoing losses and health and trauma challenges, the poverty and immigration and deportation threats that impacted mind, body and spirit. Some of these patients were relatively new to counseling, others had taken advantage of counseling off and on as needed over many years, returning to the safety and intimacy of my office as needed.
This pattern of delivering news of my departure repeated itself hour after hour, day after day, for the entire month. The clinical meetings were punctuated by colleagues and residents stopping by my office to also say farewell. It was hard to catch my breath. I did my best to stay present, but the pull to turn away, to close off and to escape the overwhelming emotions was deep and powerful. This is not an unfamiliar response of medical caregivers in the face of strong emotionally laden patient encounters.
On the other hand, my announcement also invited a rich and unexpected opportunity (from patients and colleagues alike) for conversation about our relationship, our mutual impact, and reflection on life and change and the power of empathic human connection. The immediacy and honesty of these conversations filled me with joy, appreciation and humility. I celebrated the many gifts of profound human connection I had enjoyed in the context of that remarkable community. In these moments, my breath returned deep and full.
When the month of farewells drew to a close, I was depleted and spent. It would take several weeks to find my way back to myself. A year later, I now wonder how I might have managed the emotional intensity differently and more effectively. My self-care model of recuperating wellbeing at the end of each day or two through movement, nature, family, and play now appears less than adequate. I presume I would have fared better if my self-care strategy was woven into the fabric of my encounters throughout the day.
While the stressful situation I describe was unique to my career transition, the larger issue of workforce vitality in health care is pressing and relevant. Health care delivery is an honorable profession marked by concern, altruism and sacrifice. Yet worrying about and intervening with others can be uniquely depleting when practiced in the context of complex patients, uncertainty of decision making, onerous record keeping, and demanding time and productivity pressures. With the arrival of the Affordable Care Act, and in the shadow of health disparities, practitioners and health care systems are working furiously to meet the many pent-up medical needs of patients along with the onerous reporting/documentation requirements of practice. Systematic attention to practitioner sustenance is an essential but missing link in the ongoing effectiveness of the U.S. health care system. This is especially true for practitioners working with underserved and minority communities, and where social determinants weigh heavily on patient health.
Our health system can ill afford practitioners who have lost their calling to care for others. Burnout and cynicism are risk factors for poor quality care, medical errors, and low morale. Moreover, practitioners under pressure are at increased risk for a whole host of medical and mental health conditions. Colleagues who leave their job due to burnout leave a wake of consequences ranging from lost continuity of patient care, to the costs of hiring and training. A colleague who resigns due to stress (or in worst case scenario takes his or her own life) impacts the emotions, morale and workload of remaining colleagues.
What is a practitioner to do? What are key elements of a practitioner wellbeing initiative or policy? What are the costs and losses experienced in organizations that remain insufficiently attentive to the vitality of their practitioners? What is the wellbeing imperative for healthcare organizations? I propose enhanced attention to mindful practice, meaningful practice, collaborative practice, and sustaining practice.
Mindful practice grows out of a tradition that speaks to fully immersing oneself in the moment at hand. It is built on a foundation of observation of self and other. It is bolstered by an awareness that stress lives in the transitions in life. This includes big transitions as in a marriage, a new job or a death. It also includes the small transitions from patient to patient, from home to work and back again, and from work in the clinic to rounds in the hospital. Pathways to mindful practice can include focusing on the task or conversation at hand, minimizing internal thought distractions as possible. Attention to breath can be a very powerful pathway to mindful presence.
Meaningful practice can grow only from the rich soil of reflection. One must enter into a conversation with oneself and others about priorities, values, and calling, and the ways that these are vulnerable to erosion and change in the face of external demands that outpace internal resources. Shared celebration of the successes and positive impact of one’s work on others is essential rocket fuel. An enlightened healthcare organization is one that creates and welcomes opportunities for reflection on the meaning of one’s work, encouraging sharing of practical examples of positive impacts on others. Humanities can provide a powerful on-ramp for just this type of reflection. Consider the words by Rumi from the 13th Century:
Don’t turn your head.
Keep looking at the bandaged place.
the Light enters you.
Collaborative practice facilitates an interpersonal approach to patient care. This encompasses shared decision making models and optimally functioning health care teams. Success in each of these arenas requires investment in learning innovative ways of communicating and of navigating conflict while enhancing nurturing. Collaborative practice is built on a strong foundation of listening, caring and expressed empathy. In the hectic pace of healthcare delivery, is there a place for appreciation and gratitude for patients, colleagues and for oneself?
Sustaining practice draws upon finding joy in one’s work and in one’s life. It grows from the rich soil of social support and humility. For me, mindful movement, immersion in nature and the richness of sharing time with family, friends and beloved colleagues are powerful sources of sustenance. Enlightened leaders in healthcare are willing to take on the impressive task of considering the costs (financial and otherwise) and benefits of practitioner vitality initiatives that support a humane life balance.
So if life is in fact a series of constant and simultaneous arrivals and departures, it makes sense to do what one can to be there for all of them. It makes sense to show up and to pay attention. It lends an argument for enduring the painful farewells and for celebrating the precious reunions. And it makes sense to share this wisdom with others who are arriving and departing all around us all of the time.
Jeffrey M. Ring, Ph.D. is Principal at Health Management Associates where he works with health care organizations and medical education programs to provide innovative whole-person integrated behavioral health care to vulnerable and safety net populations. As a certified leadership coach, Dr. Ring works with leaders and teams to strengthen effectiveness and efficiency. Most recently, he is involved in projects aimed at improving practitioner and team wellbeing. He is Clinical Professor of Family Medicine at the Keck School of Medicine at the University of Southern California, and is the first author of Curriculum for Culturally Responsive Health Care: The Step-by-Step Guide for Cultural Competency Training (Radcliffe Oxford, 2008).
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