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News & Research Column

Posted By Matthew P. Martin, Tuesday, January 26, 2016

Welcome to the first 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 reports.


Reimbursement Codes

A new bill introduced by U.S. Senator Debbie Stabenow (D-MI), U.S. Senator Barbara Mikulski (D-MD) and Congresswoman Barbara Lee (D-CA) aims to help older individuals with mental illness by changing the way Medicare reimburses clinical services performed by social workers. According to Congresswoman Lee, a psychiatric social worker herself, “social workers are not adequately reimbursed for the vital services they provide”. The bill was introduced in the Senate on October 8th, 2015 and is now moving through the Committee on Finance.

The new bill, called Improving Access to Mental Health Act of 2015, would align Medicare payments for licensed clinical social workers (LCSW) with that of other non-physician providers like nurse practitioners and physician assistants. Specifically, this means that LCSW's would be allowed to deliver and bill for Health and Behavioral health services (codes 96150 - 96155) that are presently restricted to clinical psychologists only by Medicare. An LCSW would not need to use a mental health diagnosis but could instead use the medical provider’s diagnosis and focus on behavior change. This may especially help improve chronic disease management and expand behavioral health services to older patients.

ACO for SNFs has Positive Outcomes

Collaborative care works for Medicare beneficiaries in skilled nursing facilities (SNF), according to data from a joint venture by the Atlantic Accountable Care Organization (AACO) and Optimus Healthcare Partners. In 2014, ACOs in New Jersey started working with SNF leadership to improve collaboration and performance outcomes (e.g., length of stay, lowered hospital admissions). Within six months, there was significant improvement across all performance measures as well as a reduction in nursing home costs for sub-acute care patients. Sub-acute care is for patients who require more intensive skilled nursing care, but not hospital acute care.

How did they do it? The ACOs worked with administrators and leaders from each of the 61 participating SNFs to review facility performance and collaboratively revise or design new protocols and processes. Managers then worked with clinical staff to provide training and ongoing support to implement the new ideas which included great patient and family engagement. The success of the new network of SNFs is attracting other facilities in the state of New Jersey to join.

According to Poonam Alaigh, M.D., corporate consultant to the Atlantic ACO, “these results are proof that when you remove silos and work collaboratively across the health care continuum reduced costs are possible, while improving the quality of care.”

Global Payments for Behavioral Health Integration

A new report from the SHAPE pilot study in western Colorado suggests that global payments for primary care and integrated behavioral health services results in lower total cost per patient. "We are pleased, but not really surprised by these findings," says Patrick Gordon, MPA, associate vice president, Rocky Mountain Health Plans. According to Benjamin Miller, director of The Eugene S. Farley, Jr. Health Policy Center at the University of Colorado, "This is about changing the rules of the game to allow for seamless, unfettered access to behavioral health care in the setting where patients most often present with behavioral health issues."

Fixed-dollar payments for patient care, otherwise known as global payments, are nothing new to healthcare. The goal of global payments is to reduce costs while also not punishing providers for treating sicker patients. Instead, providers act as stewards over limited resources; they must deliver good outcomes while also eliminating waste. Historically, there has been less data for global payment systems compared to traditional payment systems like fee-for-service. The SHAPE study provides important analysis for determining the effectiveness of a fixed-dollar payment for integrated behavioral health services.

The SHAPE project is funded by the Colorado Health Foundation and supported by the Collaborative Family Healthcare Association (CFHA). Stay tuned for more information about this project in the future.


·         A case example from the University of Washington demonstrates the effectiveness of treating serious mental illness in a primary care setting using a collaborative care model. Primary care physicians consulted with on-site psychiatrists to successfully reduce symptoms and increase functioning for a 36-year-old patient. Click here for more information.

·         In the past, there has not been much research available on the effectiveness of integrated behavioral health services for pediatric populations. Now, a systematic meta-analysis from researchers at UCLA suggests a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models. Check out the additional commentary from David Kolko at the University of Pittsburgh. He considers this type of research a “national priority” and praises the researchers for their methodological rigor.

·         Several studies suggest that collaborative care is especially effective for chronic disease management. A recent systematic literature search from the Tilburg University in the Netherlands examines the relationship between context, mechanisms, and outcomes for thirty-two studies of integrated care and type 2 diabetes. The researchers concluded that most barriers to implementation are related to the organizational context level, including workflow changes, logistical barriers, and staff turnover or limited staff capacity. They also concluded that most facilitators for implementation occur at the social context level, which include involvement of staff in decision-making and planning, the ability to find committed staff and generate staff buy-in, and good leadership and intra- and inter-practice resource-sharing and cooperation.

·         Finally, researchers from the Mayo Clinic in Rochester, Minnesota conducted a retrospective cohort study of 7340 patients with depression to see if collaborative care management (CCM) was superior to usual care (UC). They compared the two treatments using (9-item Patient Health Questionnaire [PHQ-9] score <5) and persistent depressive symptoms (PDSs; PHQ-9 score =10) as end points. The results show that the median time to remission was 86 days for the CCM group versus 614 days for the UC group. Likewise, median duration of persistent depressive symptoms was 31 days for the CCM group versus 154 days for the UC group. The researchers conclude that patients enrolled in CCM have a faster rate of remission and a shorter duration of PDSs than patients choosing UC.

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Inside Medicine at Weill Cornell: Meeting in the Middle

Posted By Administrator, Thursday, December 10, 2015

This piece is a reprint of a post from Weill Cornell Medicine. Click here for the original post. Reprinted here with permission. 



She calls them her "miracle men and women," the Weill Cornell doctors who saved her from a stroke and figured out how to manage her recovery as she grappled with other, longstanding health issues. But Jennifer Harmon knew that her experience in the healthcare system had provided her with equally important wisdom — that of a patient — and she's now sharing it with the medical college's doctors in training.

Harmon, the subject of Episode 3 of the online video series Inside Medicine at Weill Cornell, was flattered when her internist, Associate Professor of Clinical Medicine Dr. Keith LaScalea, asked her to mentor students as part of theLongitudinal Educational Experience Advancing Patient Partnerships (LEAP) program. The program became a mandatory part of the medical school curriculum last fall in order to expose students to patient care over time, their psychosocial support, and to barriers to their health. "I consider it a huge compliment to be invited to join," says Harmon, a New York actress who has worked in theater for decades. "I was on board immediately. You need to develop every aspect of your humanity to be a good doctor.

"Being a patient, I was thrilled with the idea of a medical school going back and looking at what happens when a doctor and a patient go into a room together and the door is shut," says Harmon, 71, who has battled breast cancer, chronic swelling known as lymphedema, a hip replacement and immune suppression from a kidney transplant. "What is that relationship? What was the patient looking for, what was the doctor looking for? What does it mean to really listen to you, to really see you? Which I would think as a doctor, if I'm going to treat you, I need all the information I can get on every level."


Harmon brings memories of both positive and negative interactions with physicians to her work with students Peter Chamberlin '18, Christopher Reisig '17, Sam Woodworth '16, and Justin Granstein '15. (Newer students are paired with those farther along in their studies, providing a peer mentorship component.) While she once had to ask a doctor at another institution to talk with her from her hospital bedside, rather than from the door to the room, Harmon praises Dr. LaScalea and her neurologist, Assistant Professor of Neurology Dr. Halina White, for making eye contact with her while they take notes on their computers. They and her nephrologist, Associate Professor of Clinical Medicine and Medicine in Clinical Surgery Dr. David Serur, have additional qualities that make their relationships effective at promoting her wellbeing: compassion, empathy, and the ability to listen.

She views them — and ideally, all doctors — as her partners in care.

"The doctors at Weill Cornell can tell me their expertise," she says. "They are very good at imparting information to help me understand — they take the time to help me understand. Since the stroke, things are harder for me sometimes to grasp the first time around. They're willing to explain it again.

"But it's a partnership," she says. "I have to be on board with them. I have to take my medications. I have to do my exercises. I have to try and eat well. I have to get enough sleep. I have to not do so much in a day. That's what I mean about a partnership."


The approach is working. Though doctors are monitoring her blood pressure and she is due for a second hip replacement this fall, Harmon describes her health as "excellent." She'll return to the stage this summer in a production of "Outside Mullingar" at the Dorset Theatre Festival in Vermont.

Harmon is an effective patient mentor for several reasons, says Dr. LaScalea, who directs LEAP. She receives care from across the Weill Cornell-affiliated campus, is willing to allow students to be present at her appointments, and to share her experiences with them, he says. "She's the ideal LEAP teacher," Dr. LaScalea says. "She is very interested in giving back. She really cares about the next generation of doctors and how they're educated. She's kind and generous with her time. Unfortunately she has multiple diagnoses, but that is very educational for the students to see."

Harmon is equally impressed with her student mentees. And she's confident that their intelligence, curiosity and kindness will come through when they begin practicing medicine themselves.

"They're going to be studying anatomy and all that, but when they walk into a textbook they're looking at, it's an actual human being whose heart's in trouble, or kidney's shutting down, or they have cancer," she says. "That must be an amazing moment for them, and my hope is that the LEAP program will make that transition not quite so daunting.

"I'm a recipient of the medical field, and now I'm meeting the young men and women who've decided to take this on as a career. And I'm just — I'm in awe," she says. "They really make me stand in awe."

  Founded in 1898, and affiliated with what is now New York-Presbyterian Hospital since 1927, Weill Cornell Medical College is among the top-ranked clinical and medical research centers in the country. In addition to offering degrees in medicine, Weill Cornell also has PhD programs in bio-medical research and education at the Weill Cornell Graduate School of Medical Sciences, and with neighboring Sloan-Kettering Institute and The Rockefeller University, has established a joint MD-PhD program for students to intensify their pursuit of Weill Cornell's triple mission of education, research, and patient care. 

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Harnessing the Power of Collective Impact

Posted By Natalie Levkovich, Tuesday, November 17, 2015

This post is a reprint of the incoming CFHA President's message given at the 2015 Annual Conference in Portland, Oregon. Reprinted with permission.

I am so honored and excited (and a little intimidated) to be the incoming President of CFHA. First I would like to offer my thanks to our Executive Leadership Team.  The powerful thing these folks all have in common is an unassailable commitment to CFHA -- past, current and future. This is a commitment that I wholeheartedly share and that I will be proud to help harness and encourage as CFHA’s President.


In my day job I am CEO of an association, albeit one that is quite different from CFHA. That notwithstanding, I know first-hand some of the challenges of leading a member-driven organization, of being both strategic and responsive; inclusive and equitable; efficient and transparent in serving the needs of the membership while meeting the mission of adding value to the field -- AND while sustaining the organization itself. I will bring that perspective to my new role as your President.


There is another experience that I bring to CFHA and that is a deep and personal appreciation for its uniqueness. Over the 32 years of my career in public health and nonprofit leadership, I have been a member of a number of associations and served on a number of Boards. Each experience has had its value; however, none has matched the value I have derived from CFHA and from the friends and colleagues I have gained through CFHA.


I first heard about CFHA in about 2000 when I assisted in the management of an international healthcare development project in Kiev, Ukraine.  Through the project, we enlisted the involvement of Barry Jacobs, David Seaburn, and Suzanne Daub – all early members of CFHA and early adopters and ambassadors for collaborative care. With their help, we added the principles of Integrated Behavioral Health (IBH) into the overall scheme for community-oriented primary care that we were advocating and helping to develop in post-Soviet Ukraine.


Later, when we began to advance larger scale IBH closer to home in Philadelphia, I remembered how I first came to appreciate its principles and decided to attend my first CFHA conference in 2007 in Asheville, NC. What I discovered is what you, as members, know: this is an amazing association that convenes thought leaders and dedicated practitioners, educators, researchers and advocates who are extraordinarily generous, welcoming and accessible; who are focused on advancing the field, not their respective guilds; who are intellectually open and curious about a variety of evidence, models and approaches to whole-person, system-oriented healthcare; who are eager to share what they know and to learn from others; and who take it as their personal responsibility to nurture those newer to the field so that collaborative care can spread, strengthen and come to scale as the national standard of care. As a case in point, we now have a record number of participants in our formal Mentoring Program and scores more who have formed those connections informally. And, of our record number of new members one-third are early career professionals, which I consider to be a very powerful indicator of our vitality.


As a clear example of CFHA exceptionalism, we can look at a bit more of my own CFHA story. I am not a medical, mental health or any other kind of clinical professional; I am not a researcher or a university educator; I do not have a doctoral degree. Yet, here I am, talking to you today as CFHA’s incoming President. While I do believe I have a contribution to make, can you think of any other professional association that would embrace someone with my profile as its President? I can’t. The willingness to find a place for anyone who can contribute to the organization’s mission underscores the culture of inclusion, shared learning and movement building that characterizes CFHA. This is YOUR association and a place where YOUR talents and contributions will be recognized, encouraged and gratefully accepted.


So, what can you do to advance CFHA’s future and the future of IBH? Be a movement builder -- maintain your membership and encourage your colleagues of every stripe to join us. Get involved in a committee or SIG, share your experience through a blog or webinar, volunteer to be a mentor, encourage your team to attend the next conference, submit a manuscript to our journal Families, Systems & Health, include your CFHA affiliation in your bio and your introduction whenever you make public presentations, vote in Board elections and/or nominate yourself, share with us the advances occurring in your community or reach out to us if you have an idea for how CFHA can help you to advance collaborative care in your setting.


Given the direction in which health care reform is going with ever-increasing momentum – toward a more value oriented, population based, and integrated delivery system across all levels of care – CFHA has within its expertise and within its membership the capacity to disseminate the  “how to” strategies that accelerate the adoption of effective team-based care, patient and family inclusion and efficient integration of behavioral health in medical settings across the continuum. If you share those values, vision and sense of purpose with CFHA, add your voice and energy to our collective influence. As members of this association, you are CFHA and it is through you – each of you – that we can harness the power of collective impact.

Natalie Levkovich  Natalie Levkovich is CFHA President. She has served as the executive of the Health Federation of Philadelphia (HFP) for nearly three decades. HFP is the SE Pennsylvania network for community health centers that provides comprehensive primary care to nearly 300,000 low income and underserved individuals per year.  

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What You Should Know About Preventable Harm

Posted By Emily Newhook, Wednesday, November 4, 2015

This post is a reprint of a piece from MHA@GW, the online master of health administration from the Milken Institute School of Public Health at the George Washington University.


The Latin phrase “Primum non nocere” is familiar to all physicians: First, do no harm. Care providers do their best to avoid hurting people in the process of treating disease, but despite their best efforts, patients are sometimes harmed while undergoing medical care. Some harm is considered unavoidable, such as post-operative bleeding despite perfect surgical technique. Preventing other harm — harm due to mistakes — is a cornerstone in the movement to improve patient care and safety. This issue is serious. Up to1,000 patient deaths per day can be attributed to preventable medical errors. This means preventable harm is the third leading cause of death among Americans, behind only heart disease and cancer.

What Is Preventable Harm?

Lack of a clear, agreed-upon definition obfu¬scates a full understanding of the nature of preventable harm. Most working definitions include the idea that the harm is “identifiable” in that it can be attributed to medical care and “modifiable” in that it is possible to avoid. For the purpose of this article, we will be using TheInstitute for Healthcare Improvement definition of preventable medical harm as “Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.” Defining preventable harm is important because some studies suggest that up to half of the harm patients experience in hospitals is not preventable or not the result of an identifiable error. In addition, there is conflicting evidence regarding the prevalence of preventable harm.

Eliminating preventable harm is certainly a desirable goal, but, in practice, it may not actually be possible. The sad fact is, while harm may be “preventable,” a certain level of harm is considered inevitable because health professionals, like everyone, make mistakes. Hospital-acquired infections, misdiagnosis, wrong surgeries, medication errors, in-hospital falls and burns, some cases of deep vein thrombosis, surgical site infections and bedsores are common examples.

Most Common Types of Preventable Harm


Type of Harm Explanation Prevalence/Incidence
Hospital-Acquired Infections Hospital-acquired infections are caused by bacteria, viruses or fungal agents. Common types include blood stream infections, pneumonia, surgical infections, urinary infections and methicillin-resistant Staphylococcus aureus (MRSA). A Centers for Disease Control and Prevention survey found that, on any given day, an estimated 1 in 25 hospital patients are affected by a hospital-acquired infection.
Surgical Error - Wrong Site Surgery Wrong site surgeries include performing surgery on the wrong side or site of the body, performing the wrong surgical procedure and performing surgery on the wrong patient. An Agency for Healthcare Research and Quality study that analyzed information from nearly 3 million operations between 1985 and 2004 discovered a rate of 1 in 112,994 cases of wrong-site surgery.
Medication Errors Medication errors include prescribing errors, dispensing errors, medication administration errors and patient compliance errors. Somewhere between 3 and 6 percent of patients experience medication errors every year.
In-Hospital Injury Most in-hospital injuries are the result of falls. Rates of falls in U.S. hospitals range from 3.3 to 11.5 falls per 1,000 patient days. 

There are three types of medical misdiagnosis:

    • False positive: misdiagnosis of a disease that is not actually present.
    • False negative: failure to diagnose a disease that is present.
    • Equivocal results: inconclusive interpretation without a definite diagnosis.
No reliable data is available on misdiagnosis. Available studies vary widely in their conclusions. 
Deep Vein Thrombosis DVT is a blood clot that forms deep in the body, often in the lower leg or thigh. When a blood clot breaks off, it can travel through the blood stream and block blood flow in the lungs, heart or brain, resulting in an embolism. Risk for DVT is greater when in the hospital because major surgery and immobility can both cause DVT.  A Centers for Disease Control and Prevention study found the estimated annual hospitalization rate for DVT at 547,596 from 2007 to 2009. It is unknown how many of those cases were preventable. 


What Are the Costs?

The human toll of preventable harm is staggering. The most cited statistics come from a famous 1999 report by the Institute of Medicine (IOM) “To Err is Human.” This report, one of the first of its kind to bring hard science to the study of preventable harm, shocked readers by reporting 98,000 people die every year due to preventable adverse events. While many still quote this figure today, newer, similarly rigorous studies estimate the actual prevalence of preventable harm to be much higher — between 210,000 and 440,000 instances per year.

Besides the toll preventable harm takes on human life, ample evidence suggests medical errors cost health consumers billions of dollars each year. A 2012 study broke down these costs into additional medical bills ($17 billion), increased mortality rates ($1.4 billion) and lost productivity ($1.1 billion). If we include the indirect costs of preventable harm, the economic impact could easily reach $1 trillion annually. It should be noted that these cost analyses are based on the incident numbers provided by the IOM’s “To Err Is Human” study — if these calculations were redone using the higher numbers reported by more recent studies, the resulting costs would be up to 10 times higher.

Preventable harm also levies an emotional toll on everyone involved. Treating instances of preventable harm means doctors have patients under their care for a longer period of time, nurses have more patients, and resources get stretched — creating an environment that could produce more instances of harm and a loss of morale. Family, friends and caretakers are affected as they put extra time and effort into helping loved ones recover. Finally, patients take more time off from work, school and other activities they enjoy in order to fully regain health.

What Can Be Done to Prevent This from Happening?

In order to prevent harm, administrations, governing bodies and professional organizations do their best to develop evidence-based guidelines and best practices to raise the standard of care. When things go wrong, it is typically multifactorial and involves a systematic or human error (and sometimes both). Systematic safeguards are typically in place to prevent human error. So systematic failures, such as dysfunctional teams, lack of resources, bad communication, poor health administration, disregard for safeguards and checklists, or malfunctioning technology often predicate and facilitate human errors such as lack of knowledge or skill, caretaker fatigue and technical mistakes. Continuous monitoring of adverse events, along with working to update policies and safeguards, is the best defense against repeated adverse medical events.

As we develop new treatments and safeguards, what seems inevitable today can be preventable tomorrow. How do standards of care get developed and put into practice? Lets look at a common example: An elderly patient falls getting out of her hospital bed to go to the bathroom. The patient requires further care to set her arm and prevent infection, and she does not leave the hospital until several days past her original discharge date. After getting back home, friends and family must monitor her and assist her with every day tasks.

Back at the hospital, a team of health care providers and administrators investigate if an intervention on their part would have prevented the patient’s fall. Was the nursing staff spread too thin to respond to her call promptly? Should she have been fitted with a catheter or bedpan? Was the floor wet? Was she given non-slip socks? There are three possible outcomes to such an investigation: (1) they could find that the current standards of care would not have prevented the fall and modify them as a result; (2) they could find there were reasonable safeguards in place but they were not followed; (3) they could find there was no way to prevent the incident in the first place.

The hospital’s analysis finds that while all current safeguards were adhered to, no one discussed the high risk of falls with the patient, and the patient did not consider herself at a high risk for a fall. To prevent this from happening in the future, an additional safeguard was put in place where the nurse on duty communicates with the patient about the danger of hospital falls and encourages her not to leave her bed without assistance.

There are many resources available to those looking to reduce the number of adverse medical events. Many nonprofits, health organizations and governmental organizations work to provide both the public and the medical community with the latest and greatest in health care innovations. In addition, it is important that we educate the next generation of doctors, nurses and health administrators to understand the gravity of preventable adverse medical events and encourage innovation in finding solutions.

Additional Resources

National Patient Safety Foundation 

A 501(c)(3) nonprofit, the National Patient Safety Foundation (NPSF) has been a central voice for patient safety since 1997. NPSF organizes Patient Safety Awareness Week and offers resources for patients, families and health care professionals.


Synesis is a Georgia-based consulting company that works with hospitals to help them pursue “zero preventable harm.” Their clients include the Mayo Clinic, Inova Health System and the United States Department of Veterans Affairs.

Patient Safety Movement 

Founded by Joe Kiani, the Patient Safety Movement calls on hospitals, physicians and medical device companies to make pledges to reduce preventable harm. Massachusetts General Hospital, Baylor Scott and White Health Care System, and GE Healthcare are among the health care organizations that aspire to reach zero preventable harm deaths by 2020.

National Quality Forum 

The National Quality Forum (NQF) is a “not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in health care.” In 2012, NQF endorsed the implementation of 26 patient safety measures related to medical errors.

Patient Safety America 

Dr. John T. James, the former chief toxicologist for the National Aeronautics & Space Administration (NASA), created Patient Safety America. He started the organization after his son died in 2002 as a result of what he describes “as uninformed, careless and unethical care by cardiologists at a hospital in central Texas.” A National Hospitalized Patient Bill of Rights is among the organization’s policy goals.

Beth Israel Deaconess Medical Center 

Beth Israel Deaconess Medical Center is a model of hospital transparency. Its website provides up-to-date preventable harm statistics by injury type and detailed accounts of how it is working to address those issues.

Hospital Safety Score 

Founded by the Leapfrog Group, Hospital Safety Score assigns safety scores to nearly 2,500 hospitals around the country. The scores allow patients and families to understand how reliably a particular hospital delivers safe care from the correct use of antibiotics to the frequency of employee hand washing.

Partnerships for Patients 

Spearheaded by the Center for Medicare and Medicaid Services, the Partnerships for Patients is a collaborative effort between health providers and federal and state governments to make hospitals safer.

Gordon and Betty Moore Foundation 

Through its Patient Care Program, the Gordon and Betty Moore Foundation spent $49 million in 2013 on projects that “eliminate preventable harms and unnecessary heath care costs.” Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, and the University of California, San Francisco, were among its grant recipients.

IHI Global Trigger Tool 

The Global Trigger Tool allows researchers to comb for triggers or clues to “measure the overall level of harm within a health care organization.”


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Live Blogging At 2015 CFHA Conference: Plenary Session 3

Posted By Matt Martin, Barry J. Jacobs, Tuesday, October 20, 2015

This is the third in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check out the other posts here and here

"End of Life In Our Time"

CFHA 2015 Conference Plenary Session 2

Saturday October 17, 2015 – 12:00 p.m. to 1:00 p.m.

The Grand Junction Players

Randall Reitz
Amy Davis
Lucy Graham
Sabrina Mitchell
Stephen Mitchell
Paul Simmons



Summary: Matt Martin

The final plenary session opens with muted blue light and the voice of a woman piped from the speakers singing “You’re a sky full of stars”. Images of telescopic views of space and microscopic views of skin and flowers flash across dual projector screens. Various quotes from various thinkers like E.O. Wilson, Neil deGrasse Tyson, and Carl Sagan appear as the first presenter, Paul Simmons, reflects on our shared humanity including our molecular makeup, the intertwined relationship of life and death, and the gratitude for life we can feel in the face of unavoidable death.

The second presenter Sabrina Mitchell shares a personal story of visiting her father in the hospital in the midst of applying for medical school. She recalls seeing her father strapped to a hospital bed with a twisted gown and terse conversations with hospital personnel. Her father’s mental status deteriorates and she receives little compassion or understanding from the medical staff. No one outside her family acknowledges her suffering. What a poignant example of how medical professionals struggle to adequately witness death in a meaningful and supportive way.

Stephen Mitchell, the second presenter, shares the loss of his unborn son Bo which the medical community terms a “miscarriage”. How do you give birth to death? “I have never found the words to this abrupt ending.” He felt love for Bo and held all four inches, .7 ounces in his hands following the birth. He wonders aloud “Can I call this a death? Is there meaning and acknowledgement in the scientific realm? It feels like a death, still does.”

The fourth presenters, Amy Davis and Lucy Graham, walk onto the raised stage next. The first shares a story of treating a young Cora Indian with AIDS named Francisco. At first, he was engaged in treatment, dutifully attending all appointments. Later a case worker informed the presenter, a physician, that Francisco was deteriorating and that he was refusing treatment. During one home visit, she held his hand to understand his decision and asked what he was thinking. “The black gods have told me not to take anymore pills” he said through interpreters. He was choosing a preventable death, in other words a passive suicide. She wondered about his mental health and about his cultural and spiritual beliefs. What is my responsibility now, she wondered. The second presenter shares her reflection on this patient. She recalls how the patient changed her focus from problem-based to more of discovery. The first presenter returns and recalls consulting with the psychologist who encouraged her to be at peace with what Francisco was requesting. They tried to find family before he died but could not do so. He died two weeks after ending treatment.

Randall Reitz recalls early memories of his father including his death and funeral. The moral of my story is that death destroyed my family, death created my new family, and death forever affected my career. He shares the story of meeting his future stepdad who had lost his wife. Randall's mom and new stepdad married and raised a large family. This intimacy with illness and death focused his mind and prepared him for a career in health care.

Two presenters return to finish the presentation. The narratives they shared today have common themes: What is death? What role do others play in our deaths? What autonomy do we have? How do we reassert our humanity in the face of god-like technology? The 2015 CFHA Conference theme this year is a perfect match for a discussion on death. When a tree dies in the forest it dies a natural death, becoming part of the ecosystem. It continues to nourish the forest. When considering patients who recently have died, were they nourished in their last days? How did the forest sustain their needs? Some hospitals are using AND (Allow Natural Death) instead of DNR (Do Not Resuscitate) designations to allow patients respect of a natural death.

We need to come alive for the dying, focus our energy on allowing natural deaths. We can raise our voices to share stories of grief, anger, and hope of our patients and families. This is the greatest spiritual and moral imperative of our time. 

Reflection: Barry J. Jacobs

During the third plenary of the CFHA conference, in the middle of listening to Dr. Sabrina Mitchell’s searing story of her father’s death, I was struggling to choke back tears. I heard others around me sniffling in the dark. It wasn’t just the description of her dying father, strapped to a hospital bed and in agonized delirium, or of the treating nurse’s irritated callousness toward the visiting family members that so stirred the emotions. It was the spectacle of a fellow healthcare professional on stage, sharing raw, personal pain, but also implicitly revealing the rationale for many of our careers: We are wounded healers committed in our bones to relieving others’ suffering.


Dr. Mitchell’s story was one of several told by the Grand Junction Players (Amy Davis, Lucy Graham, Stephen Mitchell, Paul Simmons, and CFHA board member and the production’s organizer, Randall Reitz) during the plenary entitled “End of Life in Our Time.” Each player’s story—about our transience as beings, a fetal demise, cultural and spiritual reasons for a patient’s refusal of care, and the creation of a new family following the deaths of two young parents—evoked grief and made the point that we need to restore humanity to our healthcare system’s overly technological approaches to life and death. Their stories were various--a reminder of the respect we must have while listening for the particularity of every person’s story. The whole—illustrated with family photographs and enhanced by strummed music--was overwhelming.


I left the conference ballroom at the plenary’s end, sad and exhilarated and suffused with thoughts: I remembered my father, dead at age 52 of brain cancer when I was 15. I thought about how his death put me on the path to becoming a psychologist working in medical settings. I reflected on how he sits on my shoulder—sometimes heavily, sometimes lightly—during my days of trying to bear sure witness to patients’ lives. 


Matt Martin, PhD, LMFT, is director of behavioral science education at the Duke/SR-AHEC Family Medicine Residency Program in North Carolina. He is the current CFHA blog editor. Interested in writing? Send a message at

Barry J. Jacobs, Psy.D. is a clinical psychologist and the Director of Behavioral Sciences for the Crozer-Keystone Family Medicine Residency Program in Springfield, PA. He is the author of The Emotional Survival Guide for Caregivers—Looking After Yourself and Your Family While Helping an Aging Parent (2006, Guilford)

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Do some research and you’ll find…

Posted By Colleen Fogarty, Saturday, October 17, 2015

Hats off to the CFHA research and evaluation committee for developing a research and evaluation track for the 2015 CFHA Conference in Portland, Oregon. The session track consists of five workshops, the first two of which this blog post will review.

Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example

Session 1, presented by Jodi Polaha, J.D. Smith, and colleagues, “Unlocking Implementation in Primary healthcare: The Family Check Up as an example” provided excellent information for attendees on some crucial concepts in implementation science, using an illustrative case of implementing the Family Check Up in a primary care setting.


Implementation science, defined by the NIH, is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within real-world public health and clinical service systems.


This level of investigation is particularly crucial in our field, where we believe that integrated, family and patient-focused care matters, yet need to understand the barriers and facilitators of making and sustaining these actual changes in practice settings and take them to scale.


The EPIS model describes four phases in the implementation process:


E: Exploration

P: Preparation

I: Implementation

S: Sustainment


This group used the Family check up intervention, an evidence based model of family assessment and intervention, in a primary care setting to work with obese children and their families. J.D. Smith and his colleagues’ work have published using the model in other settings as well. To identify families for the intervention, they used the PSC-17 (Pediatric Symptom Checklist) as a screener.


While discussing the process outcomes of implementation, Jodi Polaha notes that these can reinforce behavior change at the system or team level. So, as the processes become established and more successful “on the ground” it feeds back to the ‘actors’, i.e. clinicians and staff, suggesting that the implementation efforts are ‘working.’ Thinking about this as system-level feedback for positive change represents an important parallel process to what patients, clients, and families may experience!


Jodi, who reflects that she is now a facile iMovie maker (as evidenced by the fantastic marketing video for the research track!), showed a video of physician and behavioral health consultants reflecting on the positive experiences of adopting the Family Check-Up using the PSC-17. Involving the whole team is key; providers are happy with the process and the intervention.


Stay tuned for more learning about implementation science and its role in evaluating collaborative and integrative healthcare settings!

Joe Grasso, Andrew Pomerantz

An Interactive, Case-Based introduction to quality improvement in Integrated care 

Andrew Pomerantz Joe Grasso, Ph.D. 


The second session on Friday, “An Interactive, Case-Based introduction to quality improvement in Integrated care” presented by Joe Grasso, PhD and Andrew Pomerantz, MD provided an excellent overview of the Quality Improvement process and a solid rationale for why this method is important to make change in integrated care practices.


For anyone who needs to learn or teach about Quality Improvement, check the definition and other resources in the Health Resources and Services Administration (HRSA) toolbox here.


Joe reminded us that QI is not research, mainly because it has a different purpose. Focused on local level questions and answers, the goal of QI is not to create generalizable knowledge, but to ask small questions and test small changes in series to result in sustained improvement in a system. Given that systems vary, seeking generalizability is not the point. Likewise, sampling is done within the defined local system, and the processes are the key element being studied.


The process of change can be modeled on key elements of LEAN concepts that arose largely in manufacturing engineering. These are the 5S--Sort, straighten, shine/scrub standardize, sustain.  “Just like your kitchen” according to Andy Pomerantz! If only my kitchen could attain this bar! Plan, Do, Study, Act, or PDSA cycles focus on small, iterative tests of change around a carefully constructed objective.


To begin the PDSA process, the team must agree on one goal to start, and this should be in the “SMART goal” format: Specific, measurable, attainable, relevant, and time-based. Joe and Andy provided a structured small group activity for practice on this seemingly simple activity. The work in my small group demonstrated the difficulty of developing a SMART goal: we had lots of discussion about screening, identifying, referring, prescribing for depression. What were the important elements? Who should do what? Was the PHQ-9 the right tool? And on went the conversation. Eventually, the group achieved a SMART goal: in patients who screen 11 or more by the PHQ-9, the clinic would see an increase in the # of referrals by the primary care clinicians to the behavioral health clinicians by 15% in 3 months.


Large group reflection on this process revealed that other groups found this difficulty too. Joe pointed out that this realization mirrors life, and is one of the strengths of the short cycle test of change: PDSA cycles can identify other concerns or problems needing attention.


"Where are we going to find the time to do QI??" This question is heard across systems as we are called to improve our systems, maintain our physicians board certification, and reach PCMH or other national level certification. Joe Grasso says that stakeholder and administrator buy-in helps!


Both of these sessions “knocked it out of the park” in introducing conference attendees to important methods for evaluating and improving our work. I look forward to more sessions in this well-crafted track!

Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine.

Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example 


Jodi Polaha, J.D. Smith, et al

Unlocking Implementation in Primary healthcare: The Family Check Up as an example 


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Live Blogging at 2015 CFHA Conference: Plenary Session 2

Posted By Colleen Fogarty, Stephanie Trudeau, Saturday, October 17, 2015

This is the second in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for one more.

The ACE Study: Linking Childhood Trauma to Long-Term Health and Social Consequences

CFHA 2015 Conference Plenary Session 2

Friday October 16, 2015 – 8:30 a.m. to 10:00 a.m

Vincent J. Felitti, MD, Co-Principal Investigator, Adverse Childhood Experiences (ACE) Study


Colleen Fogarty: Dr. Felitti is the past Chief of Preventive Medicine for Kaiser Permanente, and co-PI for the Adverse Childhood Experiences (ACE) Study. He begins by showing two pictures. There’s a question embedded in these two pictures: a newborn infant, and a 20 year old lying on the sidewalk; Dr. Felitti poses the question of how we can predict or create the outcome for the 20 year old depicted and he notes that in the 17 years since the first ACE publication, despite intense academic interest there has been essentially no clinical implementation of the findings.

He summarizes the findings that show ACE’s are common, powerfully predict health risks and social malfunction. “If we thought that smoke billowing out of the house was the cause of the problem, then fire departments would bring fans to blow the smoke away.”

Stephanie Trudeau: Dr. Felitti notes that the study began as a process of how to understand physical and mental traumas better. Studying findings show that the repressed role of ACE in adult wellbeing, disease and social function turns gold to lead. ACE indicators are common and disturbing and are mostly unrecognized. However, they are powerful predictors of adult social malfunction, health risks, biomedical disease and premature death. Integrating these finding into primary care medical practice appears to produce a significant reduction in health care costs.

Dr. Felitti presents a case study of what he calls the “Index Patient” whom he treated while working in a San Diego obesity clinic. He shows a photo at age 8, age 28 at 408lbs, and then age 29 at 132lbs. What is the core diagnosis? Which photo represents the patient’s problem??

Colleen: Dr. Felitti reflects on the Index Patient who lost so much weight in one year. Then he shows the re-gain curve the same patient experienced after the successful treatment intervention. He reflects on the patient’s disclosure of being sexually propositioned after her weight loss, and this contributing to her re-gain of weight. Further patient interviewing led her to disclose incest during her childhood. Many subsequent patients in the program disclosed child sexual trauma or other significant family or personal traumas. This collection of clinical disclosures, stories led Dr. Felitti and his collaborators to design and carry out the ACE study, which contained both retrospective and prospective design.

Dr. Felitti notes substantial difficulty in IRB approval, as the board was concerned that patients, upon being asked about difficulties in their childhood, would become suicidal. The IRB approved the study when they agreed to have a clinician carry a cell phone 24x7 for 3 years; they did this and received no calls during that time. In contrast, Dr. Felitti reports that the team received many notes of gratitude, summed up by a patient who wrote that, “I was afraid that I would die and no one would know what happened to me.”

Stephanie: ACE indicators/categories (with %) fall into three categories: Abuse, neglect, and household dysfunction. Abuse includes psychological abuse by parent (11%), physical abuse by parents (28%) and sexual abuse by anyone (28% or W, 16% for M). Neglect includes emotional (15%) and physical (10%). Household dysfunction: alcoholism or drug use in home (27%), loss of parent, death, divorce, mother abandonment (23%), depression or mental illness (17%), mother treated violently (13%), imprisoned household member (5%).


The ACE study questionnaire is 4 pages long, completed at home, and includes a face-to-face interview and a full medical assessment. ACE researchers used this style to ask the questions:  “I see on the questionnaire that … can you tell us how that has affected you later in life”.  This open approach turned out to be powerfully effective.

Study results show that 67% of participants experienced at least one category of ACE and that one ACE predicts an 87% chance of at least one other category of ACE being present. Women are 50% more likely than men to have a score over 5.

Colleen: Dr. Felitti shares comments via video of a man who had losses in his childhood and subsequently became a smoker, alcoholic, and user of drugs. The man says, “Twenty five years, [I had] poor childhood experiences with drugs, alcohol, cigarettes. I had no idea that the nicotine played such an important part in…keeping the door closed to the memories. I found that it blocked emotions and memories…” Dr. Felitti notes that addiction highly correlates with characteristics intrinsic to that individual’s childhood experiences.


In another video a morbidly obese woman shares her reaction to the recommendation of bariatric surgery. She reflects, “I cope with life with food…I feel like he’s taking away my safety [by suggesting bariatric surgery] I’m not ready yet to get the weight off and not be able to get it back. I can’t be safe then.”

Stephanie: The patient videos are very powerful! Dr. Felitti suggests clinicians with a focus on ACE can ask “How old were you when you first started putting on weight…why do you think that age and not another”?  What function does the “dysfunction” serve to our patients? Let’s ask! What is perceived as the problem is actually someone’s unconscious solution to problems we know nothing about. For example, what if depression is a normal response to abnormal life experiences?

Colleen: So, what can clinicians do? Gather a trauma informed history from patients and develop an approach to patient care using that information. Primary prevention is crucial; but we don’t yet know how to do this!

For more information about the ACE study, click here:

Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine. 

Stephanie Trudeau, MS, LAMFT, PhD student University of Minnesota. Behavioral Health Intern and Research Assistant in the Department of Family Medicine and Community Health at their Broadway Family Medicine Residency Clinic.

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Policy Summit at 2015 CFHA Conference

Posted By Matthew P. Martin, Friday, October 16, 2015


According to Senator Elizabeth Hayward, the process of health care change is "messy and organic”. And so agrees the rest of the expert panel at the 2015 CFHA Policy Summit in Portland, Oregon which included wonks from both the public and private sectors in Oregon and Colorado. This first-of-its-kind meeting covered current initiatives and barriers, stories of success, and future challenges. Robin Henderson and John Muench opened the summit and Deborah Cohen moderated the discussion among panel members who represent two states leading the health care transformation charge.

The expert panel included the following:


Janet Meyer, MHA

CEO, Health Share of Oregon 

Ron Stock, MD, MA

Director of Clinical Innovation, Oregon Health Authority 

Sean Kolmer, MPH

Principal, Health Management Associates 

Lynne Saxton      

Director, Oregon Health Authority 

Robin Henderson, PsyD

Chief Behavioral Health Officer and Vice President of Strategic Integration

St. Charles Health System 

Patrick Fox, MD

Chief Medical Officer

Colorado Department of Human Services 

Patrick Gordon, MPA

Associate Vice President

Rocky Mountain Health Plans 

Judy Zerzan, MD, MPH

Chief medical Officer/Director of Client & Clinical Care Office

Colorado Department of Health Care Policy and Financing 

Vatsala Pathy      

Director, State Innovation Model 


The format for the summit meeting was conversational and off-the-record. Panel members enjoyed a sense of safety in the intimate setting as they discussed mutual challenges with only a small sympathetic audience within earshot. According to one audience member, meetings between policy experts from different states rarely happen but they need to in order to push change farther. Two factors were clear at the onset of the meeting: 1) both Oregon and Colorado have had tumultuous histories with health care reform and 2) both states have taken advantage of recent crises to try new and bold initiatives.

For example, in 2010 Oregon faced huge financial problems in supporting state health services. In response, the state legislature approved (57 to 3) plans to create Coordinated Care Organizations (CCO) to "treat the whole person” and organize previously fragmented services for the Medicaid population. In Colorado, several factors lead to innovation including fallout from years of managed care, state fiscal issues, and the indomitable Colorado spirit of independence. State leaders began to invest in a new multi-payer system and integrated behavioral health services. Today, both states are finding success with their recent investments in groundbreaking policies strategies as well as facing ongoing, inherent challenges.

Some of those challenges include:

-          Working with federal, state, and local stakeholders: allowing for flexibility while striving for standardization in policies and protocols

-          Creating a clearinghouse for data management and sharing

-          Federal administrators have short tenures which disrupts momentum and working relationships

-          States are not collaborating enough to share successes and brainstorm new strategies

-          Fear and misconceptions of change and the health care industry prevent stakeholders from making progress

-          Moving customers from Medicaid to private insurance


Despite these challenges, both states have made remarkable progress. Colorado boasts one of the lowest uninsured rates in the country, has multiple integrated care clinics across the state, and utilizes an effective multi-payer model. Oregon has 16 CCOs across all parts of the state to cover over 2 million Medicaid recipients, is moving away from volume-based to outcome-based productivity models, and is working closely with counties across the state toward a global budget.


All panel members agree that there is much more to be done. Ron Stock believes that states should be as transparent as possible when reporting outcomes of various quality metrics. He also notes that a more cohesive and comprehensive advocacy plan will carry the message of reform farther. Patrick Gordon reminded the audience that hospital systems need reform as well to completely move away from the fee-for-service model of yesteryear. Robin Henderson predicts that success with reforming the Medicaid systems will lead to future success in improving state employee health systems. Finally, Sean Kolmer believes that state governments can drive the conversation on integrated health care services and that state budget crises are real opportunities for designing innovative policies that take health care systems in new directions.

What does the policy summit mean for you? The takeaway messages seem to be, yes, change is messy AND stakeholders can have honest conversations about the barriers and challenges facing health care reform. Senator Hayward concludes that moving to new care systems is really hard for most people but that we can change our frame of reference from fear-based to what works. 

  Matt Martin, PhD, LMFT, is director of behavioral science education at the Duke/SR-AHEC Family Medicine Residency Program in North Carolina. He is the current CFHA blog editor. Interested in writing? Send a message at


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Live Blogging at 2015 CFHA Conference: Plenary Session 1

Posted By Jennifer Hodgson, Laura Sudano, Friday, October 16, 2015

This is the first in a series of live blogging posts from the 2015 CFHA Conference in Portland, Oregon. Check back for two more! 

Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehensive Population Based Care

CFHA 2015 Conference PLENARY SESSION 1

Thursday, October 15, 2015 - 6:00 p.m. to 8:00 p.m.

Moderator: Kristian Foden-Vencil, Reporter and Producer, Oregon Public Broadcasting

The CFHA opening plenary, “Dismantling a Partialist Healthcare System: Implementing a Vision for Comprehension Population Based Care” was a powerful opener to the 2015 conference in Portland, OR. Each panelist described their perspectives on promising research, clinical innovation, and health policy change germane to the advancement of integrated behavioral health and primary care.

Panelist One: Maggie Bennington-Davis, MD, Chief Medical Officer, Health Share Oregon

Dr. Maggie Bennington-Davis 


Jennifer Hodgson: The plenary opened with a question posed by Kristian to Maggie Bennington-Davis. He asked whether or not the changes we are making to the healthcare system are working.  Dr. Bennington-Davis is a psychiatrist who has experience administrating services across the lifespan with a keen respect for cultural competence in the delivery of healthcare services. She is on faculty at the Sanctuary Institute and Oregon Health Sciences University and expressed great interest in how we can think differently about workforce redistribution and healthcare expenditures. She shared examples of Coordinated Care Organizations targeting energies and services to those who use healthcare the most. These programs were effective in reducing ER visits and connecting high utilizers with the primary care system; however, she wonders how we can prevent patients from becoming high utilizers. Her focus has shifted over the years to wrapping care around early life (i.e., children) and those most at risk, lowering cumulative disadvantages and eventually high utilizers.

Laura Sudano: According to Dr. Bennington-Davis, childhood events impact mental health conditions in later life which affects individuals as well as the healthcare system. So the question becomes what does it mean to be “Kindergarten ready”? How can we prevent unwanted and high risk pregnancies? Wrap around programs are a different level of integration and service.

Kristian: What kinds of wrap around services can you provide to head things off?

Maggie: The way that Health Share approaches this is to identify moms at great risk (e.g., substance use disorders). Interventions include parenting lessons, housing/food, safe environment, and staying with them for up to a year in order to provide skills for that child.

Kristian: How about the money?

Maggie: It is a $60,000 question or more! If that program prevents that one child to have months in a prenatal intensive program then you have paid for the program; however, it is tricky. Oregon needs to follow its own values and look for a way to transform health to make a difference in that way.

Jennifer: I just admired how she is thinking about prevention as a part of health and not exclusively treatment only after pathology has taken root. Her words illuminated an opportunity for healthcare providers to exercise being strength-based and channeling money toward prevention. I have been waiting my whole professional life to hear it spoken so eloquently! Music to my ears!

Laura: Barry Jacobs (audience member with a question) works in a super utilizer program and questions what you need to get the most bang for your buck. What are the resources you need to put in place for a program to be successful? He has witnessed the most need for housing. The other question is how to make changes sustainable and to help others take control of their own lives?

Maggie Bennington-Davis: Redistribution. Some services have fewer resources than traditionally and this is a hard question. At the ACO level, there is incentive money in Oregon transformation system to use it to explore to use it more upstream. In regards to housing, Maggie suggests that you need to work with social services to coordinate this.

Panelist Second: Jennifer E. Devoe, MD, DPhil, Associate Professor, Oregon Health & Science University, Department of Family Medicine; Chief Research Officer, OCHIN Community Health Information Network  Devoe-Jennifer-web 


Jennifer: Dr. Jennifer Devoe is a highly funded PCORI researcher and a recently elected member of the Oregon IOM and helps lead the innovative OCHIN. She said there is some thinking outside of the box with Medicare and sending insurers a bill for not offering preventative services. Dr. Devoe shared a story of a patient who was self-medicating, self-mutilating, had a trauma history and rendered Dr. Devoe feeling incredibly helpless against the issues that weighted her down. Her patient is now more stabilized and functional: She is now out of the ED, ICU, is not cutting or utilizing as much. Dr. Devoe credits that to the care of the biopsychosocial team. She stated that as a healthcare worker she knows now that she can provide better care alongside a biopsychosocial team and prefers it that way.

Laura: Dr. Devoe notes that her satisfaction improved because she was able to provide comprehensive care to her patient once a behavioral health provider was integrated into the clinic. How are we going to measure what we are doing in care? We saved on healthcare cost, but now they are incarcerated for the next 20 years. They dropped out of school but are on welfare. She notes, “Dare I say, but we might actually need to spend more money on certain healthcare services. On primary care.” We need to look at wrap around services to provide preventative care services. We’ve come along baby since 2003! But, we are revisiting history and we are learning how.

Jennifer: What Dr. Devoe described as being immeasurable, is how much better she feels as a provider. She stated “We have come a long way baby!” …but we need to think about how we are going to reimagine and rethink measurement. How are we going to measure what we are doing here? How can we invest on the front end and spend more money on certain healthcare services (e.g., primary care, behavioral care) and save people from unemployment, the prison and foster systems, etc which also results in great costs.  

I like her systemic perspective and agree completely that measuring gains cannot be exclusively done by examining the healthcare system’s bottom line.  We have got to think about the entire service system…there is no wrong door for patients to gain access to healthcare. Lastly, Dr. Devoe stated that the voice of the patient is critical.  The patient with their healthcare team should decide how the money is best spent. She wants to know when integrated behavioral health care will be the standard of practice! This blogger agrees!

Laura: Dr. Devoe also believes we need to scale it, sustain it, and study the who, what, when, and where. We need systematic approaches to figure it out. The question becomes: Can technology help? Who needs the care? And who needs to provide it? Measuring needs to happen and how to do it is important. Where should care be delivered? What are the patients’ expectations? When should we refer? When will integrated care be standard practice?

Panelist Third: Somava Saha Stout, MD, MS; Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement; Lead Transformation Adviser at Cambridge Health Alliance (former Vice President).  


Jennifer: The third panelist, Dr. Somava Stout, is Executive Lead for 100 Million Healthier Lives at the Institute for Healthcare Improvement and also the Lead Transformation Adviser at Cambridge Health Alliance. She recently received one of 10 inaugural Young Leader Awards nationally from Robert Wood Johnson Foundation for leadership and dedication to improving health and healthcare. She wants us to push integration models and find who is doing integration successfully and why. She described how Cambridge Health Alliance is a Safety Net System and they invested in behavioral and primary care.  She said they flipped their finance model from fee for service to a global payment one, now being able to cover 60% of patients. Subsequent to the change, providers reported that they enjoyed their jobs more and felt they could do things now to actually save patients’ lives.

Laura: Somava: She describes herself as a primary care clinician and is interested in how to change the system to provide comprehensive care. Why should there be a public health care system by 2020? It would improve experience for people and population health, and lower costs. It will be worth supporting for the Massachusetts. What would it be like to transform the system from the population up? In 2008, we need to flip it to fee for service to global patients. Sixty percent of patients were covered under the global payments, and the transformation was fulfilling. The satisfaction and joy of meaning and work went up for both physicians and mental health clinicians.

Jennifer: Dr. Stout argued further that everyone who touches the patient is a part of their outcome. She expressed that there is great joy and satisfaction for patients in knowing they can get help no matter where they lived.  She noted, “If you could know that you could lower absolute healthcare costs and improve outcomes on the mental health and medical side….that is the Holy Grail right?” She then said, “That is really only the beginning of the story.  We now need alternate payment models and have nothing to lose by trying. We have to move beyond screening for behavioral health issues only and then medicating poverty…the silent cause. I do not recommend medicating poverty. We need to do something about it. We need to be part of a system that takes care of patients holistically” Her solution-focused perspective was infectious and her belief that we can make a difference is exactly what we needed to hear at the start of the conference!

Laura: Somava notes that we need to include the social and behavioral determinants of health (SDOH). If there is no housing, then that doesn’t help anything. I (LS) think it is important to capture SDOH in primary care, and wonder how primary care clinics can capture this data in our electronic health records. Also, I wonder how people are teaching primary care providers SDOH.

Housing seems to be a theme between all presenters. Housing is an important aspect for individuals and we, healthcare providers, need to recognize this as an impact on patient’s health. Employees who can address SDOH have improved provider satisfaction across the board, i.e., staff, physicians, behavioral health, etc.

It costs 46,000/year a year to incarcerate one person. Dr. Stout notes that we should consider assessing SDOH and notes that patients are grateful for the questions. The challenge becomes how we ask the questions, when we ask the questions, and how we enter the data and track the outcomes.

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All But the Kitchen Sink?

Posted By Robyn L. Shepardson, Monday, October 5, 2015


Robyn L. Shepardson, PhD, is the 2014 CFHA Fellowship Award Recipient. Below is her reflection on her research project.

As a clinician working in the Primary Care Behavioral Health (PCBH) model in integrated primary care, I have a short amount of time to make a difference with my patients. I figure I have about a half-hour for each session if I’m lucky, or really more like 10-15 minutes after conducting a functional assessment or providing empathic listening when a patient really just needs to share his or her story. I never know if a patient will return for follow-up, as about 50% of patients attend only 1 PCBH session.


With so little time, and perhaps only one chance, to give my patients something (information, support, skills) they can use, I am eager to make a lasting impact. As a result, there are times I am guilty of throwing all but the kitchen sink at my patients and seeing what sticks. Based on the results of a new survey I conducted with PCBH providers, it seems I am not alone in this tendency to offer all but the kitchen sink...


At last year’s CFHA Conference, I received the 2014 Research Fellowship from the CFHA Research and Evaluation Committee. For the fellowship, I conducted a national survey of PCBH providers (N = 291) to identify the types of interventions used for anxiety in real-world clinical practice, as well as the types of comorbid symptoms/problems seen in patients referred for anxiety. I focused on anxiety because it is common and burdensome in primary care, but tends to receive less clinical and research attention compared to depression and PTSD.


I surveyed PCBH providers about their most recent session with a patient referred for anxiety. As anyone working in primary care knows, primary care patients are complex and often present with a multitude of both mental health symptoms and medical problems. In this case, 95% of patients had other behavioral health concerns (e.g., depression, insomnia) besides anxiety.


So, how did PCBH providers handle these complex patients? It appears they used a lot of tools from their clinical toolboxes – an average of 6.5 intervention techniques – despite sessions being less than 40 minutes on average. Clearly providers are drawing upon a variety of interventions to treat anxiety and/or comorbid symptoms. Of necessity, the time spent on any one intervention technique is likely very brief.


The high number of interventions used within a single session brought to mind the idea of "all but the kitchen sink.” Reflecting on my own clinical practice, I often use a combination of elements of various brief interventions, such as psycho-education, relaxation or mindfulness training, cognitive restructuring, and behavioral activation, as well as broader approaches/themes such as supportive therapy, stress management, problem solving, and increasing social support. I weave threads of these concepts into the discussion as appropriate, spending more or less time on a certain topic or skill depending on various patient factors.


Is this a good approach? How much is too much? Could we be overwhelming our patients with so many ideas that they don’t know where to start? How do we find the right amount of education to provide and the right amount of skills to teach? How do we strike a balance between providing support and helping patients develop specific action plans?



I tend to view my role as a PCBH provider as helping patients identify their options. I can provide information and describe skills likely to be helpful, and if time allows I include a brief demonstration of a relevant skill to illustrate how this might help. But in 30 minutes or less, there’s just no way I can learn everything I would need to know to make definitive recommendations on what would be best for them. It’s up to individual patients to decide what resonates and what they are ready and willing to try. We know "one size fits all” approaches will not work because every individual is so different and has unique challenges and psychosocial circumstances. So perhaps the "all but the kitchen sink” approach is not a bad idea after all, as it gives patients a menu of options from which to select what appeals most to them. PCBH providers and PCPs can then support patients in their efforts to make behavior changes and implement healthier coping skills. What do you think about the "all but the kitchen sink” approach we often take in PCBH?


As our field works toward building a larger evidence base on effective brief interventions to inform clinical practice in integrated primary care, clinicians can play an active role in evaluating what works. Clinicians can use program evaluation and quality improvement methods to collect outcome data to monitor individual patients’ progress in treatment. For example, collecting data on the types of interventions we use as well as mental health symptoms and overall functioning would allow us to empirically answer the question of whether "all but the kitchen sink” is a helpful approach. It is not as hard as you might think and could help provide valuable evidence to help us answer this very important question.


One way you might help overcome any fears you might have about doing research is by learning essential basic research skills and how to conduct program evaluation and quality improvement. The new Research and Evaluation track at the 2015 CFHA Conference in Portland provides an opportunity to learn these skills. This track (5 talks) is designed to provide practical "how to” lessons on how to plan and conduct research, quality improvement, and program evaluation in real-world health care settings. Or if you have the skills, but just have not collected the data—help us answer this question in addition to the multitude of others that impact routine PCBH clinical practice.


If you are interested in hearing more of my results or sharing your take on using "all but the kitchen sink,” please join me at 10:30 am on October, 16th at the 2015 CFHA conference in Portland


Robyn L. Shepardson, Ph.D., recently completed a two-year postdoctoral research fellowship with the VA VISN 2 Center for Integrated Healthcare (CIH) and is now a clinical research psychologist at CIH. She earned her Ph.D. in clinical psychology from Syracuse University after completing a pre-doctoral internship in health psychology/behavioral medicine at the Brown Clinical Psychology Training Consortium in Providence, Rhode Island. Dr. Shepardson’s research interests include developing, testing, and implementing brief, evidence-based interventions for anxiety and depression in primary care patients. She is interested in increasing engagement in integrated behavioral health care by incorporating Veterans’ treatment preferences using novel resources, such as peer support and mobile technology, to reach more patients.

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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.