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What Has CFHA Meant To Me And For My Career

Posted By Christine Runyan, Thursday, November 17, 2016

 Dr. Tina Runyan is the CFHA President-Elect. She spoke at the recent 2016 CFHA Annual Conference in Charlotte, NC.

I’ve worn a lot of hats in my career – Air Force psychologist, academic dean of a graduate school in psychology, behavioral health clinician, post-doctoral fellowship director, and a psychologist in academic medicine to name a few. Throughout this career tapestry, CFHA has been a unifying thread for me. It is the organizational and professional home I can count on for inspiration, information, collaboration, socialization, and opportunities to advance and challenge myself.


Most recently, this opportunity and challenge will be presenting itself as the Presidency baton is passed to me in October, 2016. I am standing on the shoulders of giants in the field of integrated care and honestly do not feel entirely worthy, but I do feel empowered and ready to chaperon the organization for the next two years. When I first joined CFHA and started going to conferences, I struggled a little bit with its softer science and more applied philosophy as compared to other professional conferences I attended and organizations where I sent my annual dues.


However, I quickly realized that the practical focus on CFHA and the collaborative – not competitive – spirit was exactly what kept me coming back and actually fit my needs better. Within CFHA, I have found both likely and unlikely collaborators, mentorship, mentees, and an organization I am proud to introduce new professionals to and encourage them to attend a conference or join the organization.


As I approach the academic promotion process yet again, I undoubtedly owe some of my professional success directly to CFHA. The organization is small enough to find a hook for leadership opportunities and once I ran for the CFHA Board, I was catapulted into what previously seemed like the "private back room” of the organization. However, I was pleasantly surprised and delighted to learn that the engine of the organization was hard at work trying to help CFHA survive and thrive, volunteering copious amounts of time spawned from dedication to the mission in general and the organization specifically.


The board strives for transparency in managing the organization but at times has needed to be cautious to avoid inducing fear or igniting panic when the organization was in financial jeopardy. Being willing to serve on the board (and it is a volunteer, time intensive service role) allowed me the chance to work alongside some of the brilliant leaders in the field, which always serves to elevate my own thinking and contributions. This willingness eventually manifested as an invitation for the presidency role (voted on by the nominations committee and then by the board), which I am both nervous and excited about in relatively equal measure. And I think these are the right emotions for the job actually.


Anytime I step to the edge of my comfort zone, I know I will be challenged and that I will grow in ways I cannot fully predict but trust that whatever is on the other side of this challenge, it will serve me well to face the next one. And I suspect CFHA will be right by my side for that one too … and the one after that … and the one after that. CFHA is the constant thread in the ever-changing tapestry of my career, and truthfully one of my favorites.


Tina Runyan is an associate clinical professor in the Department of Family and Community Medicine at the University of Massachusetts Medical School. She is the Director of an APA accredited, two year Post-doctoral fellowship in Clinical Health Psychology in Primary Care and the behavioral science director for the Worcester family medicine residency. . She recently joined the Board of CFHA and when not writing, practicing, training or talking about integrated care she enjoys being a mom, trail running, and practicing yoga.

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High Jinx in Charlotte: First-Time Faculty Views of the CFHA Annual Conference

Posted By Jodi Polaha, Tom Bishop, Reid Blackwelder, Beth Fox, Brian Cross, Diane Sloan, Leigh Johnson, and Di, Tuesday, November 8, 2016


At East Tennessee State University Department of Family Medicine, we are working hard on team care transformation. Our Department has a long history of embedded pharmacy, psychology, and social work services in each of its three primary care residency training programs. Recently, however, our HRSA-funded project "Collaborative Training in Team Based Care in Appalachian Primary Care Practices” is providing us with the opportunity to develop a more progressive team approach.


We are four medical doctors, two psychologists, a pharmacist, and our director of clinical services. We were excited to have the CFHA annual conference come so close to home for us during our project development. We returned from the meeting so energized we decided to share our notes in a blog.

We lead with big praise for CFHA. The trip proved to be funding well-spent. At least three affirmations resonated with all of us. First, kudos on bringing LBGTQ healthcare to the forefront across multiple presentations. This content was an impactful, albeit unexpected, aspect to our attendance. Drs. Heiman and Johnson have already initiated changes to clinic practice to improve care for transgender patients and building more training into our residency programming.


Second, we loved the innovative ideas for building team care. We all agreed we had not seen this caliber of progressiveness in any other professional meetings. We are already looking at next year’s budget to see if there are others on our staff who could have the advantage of learning about these ideas firsthand in Houston.


Finally, we definitely appreciated the spirit of collegiality in the atmosphere including an openness to professional networking and supportive engagement. We valued the validating audience response to our presentation on an implementation strategy for building innovation into primary care. We thoroughly enjoyed the engaging audience discussion with our panel on Interprofessional Education. To sum, even though we were first-timers, we felt like we fit right in.


Thinking critically about our experiences, we wondered if CFHA can stretch to accommodate a wider range of health professions such as pharmacists, nutritionists, and public health professionals. We saw starting places for broader "team care” in multiple presentations and, well, we wanted more! Behavioral health has certainly been one of the leaders of primary care integration and there is substantive content at CFHA that can be readily generalized to another professional member of the team. Our pharmacist (Dr. Cross) said several times how he was amazed at the parallels of so many issues related to integration of clinical pharmacy services into primary care compared to that of behavioral health, both victories and obstacles. We would love to see CFHAs vision expand!

More connections to more diverse professions would add significant value for us. While we recognize that academic medicine accounts for a minority of attendees, there is certainly a priority in university settings for broader interprofessional practice and education. At CFHA, the strong participation of a clinical audience from non-academic settings provides an excellent sounding board for the pedagogical content we develop for our student learners. In other words, we see CFHA as having the potential of providing non-academic health care "ears” to help us "keep it real” and in turn, we can develop training programs that graduate professionals who are better prepared for their needs.

Thank you again, CFHA, for a quality learning experience outside the office. We are looking forward to next year!

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How to Establish a Great Music Festival (and PCBH Group)

Posted By Corey Smith, Friday, October 28, 2016



PCBH groups and music festivals couldn’t be more different experiences, right? Well, sure, most groups don’t suggest earplugs, don’t have food trucks and usually don’t include intoxicated "20-somethings,” but there are a few lessons music festival promoters have learned that are pertinent to PCBH groups. Namely, setting the date, getting useful feedback and clear practical information for attendees.


The biggest limitation to setting a good lineup for a music festival: the date. Once the date is set, 95% of bands have been eliminated thanks to the world’s consistent refusal to revolve around me. ("But I really want to see Coldplay at Coachella!”) The task of coordinating the schedules of multiple groups of people is too much work, better to set your date and send out as many invites as possible. For behavioral providers in primary care, the challenge is similar, starting a group can be a long process and success is not guaranteed.


My typical strategy includes posting information about the group to medical providers and compiling a list of as many patients as possible. Once the date is set, I send out letters with the expectation the date will whittle the list down considerably. If 20-25 patients express interest, I’m doing pretty well. The process of securing "commitments,” scheduling and reminder calls may further dwindle the list. Once we get to the date of the opening visit, we may arrive to find 4-5 people waiting to begin (one of whom needs to leave after 15 minutes).


Thing is, this is pretty successful. Coordinating the schedules of more than two adults can be extremely challenging, especially without any momentum off of which we can feed to inject energy into the process. It’s much easier to get someone to attend a meeting that has been taking place for months or years; the risk it will not be what they are looking for is lower with a known entity. Selling tickets to Bonnaroo is easy, try selling tickets to the Maha Music Festival….


Any music festival worth its’ salt has a twitter handle and at least one hashtag (@govballnyc, @ACLfestival, #youredoinggreat, #smile) to promote the experience via social media. Often, promoters project tweets and Instagram posts onto screens near the stages. The audience, those on the fence about paying for a last minute ticket, and promoters get real time feedback on what is going well ("Gogol Bordello is melting faces in That Tent #Bonnaroo2009”) or not so well, ("The Port-a-lets look like a war crime #ACL2012”) and respond accordingly. While PCBH groups may not rate high enough for a hashtag, feedback measuring outcomes is important and can inform our practice going forward. Determinations of effects will depend upon the type of group and the information the practice believes to be most important.


For example, outcomes for a group focused upon Acceptance and Commitment Therapy for chronic pain may include patients’ subjective reports of their pain levels, changes in narcotic medication dosages or number of visits to the Emergency Department for treatment of out of control pain. Providers working on a mood management group may simply choose the PHQ-9 and/or GAD-7 to determine efficacy; this is certainly acceptable and may yield significant and actionable results. The word actionable is used intentionally in this context.


Rather than simply serving as formative and summative evaluation of the intervention, measurement may be used to inform changes to the process, intervention or make up of the group. Outcome measures are easiest to track and disseminate within the electronic health record (If you find yourself in a setting where this is possible, practice gratitude and enjoy! #youredoinggreat). Without such tracking capability my strategy has been to record data via my own excel file and, although more time consuming, this works just fine.


Festival goers like to know what to expect, as most humans do, and a festival’s smartphone application can facilitate or limit the flow and organization of the event. People need to know where to eat, how to find the bathrooms and on which stage their bands are playing. PCBH groups, similar to warm hand offs and initial visits with a BHC, should be described effectively at the outset. For some clinics, group therapy can be an effective adjunct for patients that would normally be considered for referral to specialty mental health but lack the insurance coverage for a successful referral. However, the expectation of many patients, as we often see in the PCBH setting, may be reflective of their understanding of traditional mental health. This misunderstanding can be corrected with clear conversations regarding the nature and duration of treatment prior to starting.


Over-all, the business case for group visits is clear and the increased efficiency in primary care makes group visits a wonderful addition to your practice. Behavioral providers are well trained in running groups and can take the lead with the recruitment, planning and execution of a traditional group, shared medical appointment (SMA) or other innovative group process to meet the specific needs of the practice. You won’t always get Desert Trip but you can certainly have fun, make a difference and demonstrate again the value of behavioral health providers in primary care. #smile

Corey joined the faculty at the Maine Dartmouth FMR in 2015 after serving as the director of behavioral health at MidValley Family Practice in Basalt, CO and the Lincoln Family Medicine Residency in Lincoln, NE. He completed his doctoral training at Spalding University in Louisville, KY and internship at the Wyoming State Hospital. Corey is enthusiastic about integrated behavioral health care, primary care and education. In his spare time he practices martial arts and enjoys cycling, reading, hiking, and spending time with friends.  Corey and his wife Karen are anxiously awaiting the arrival of their first child in January of 2017.

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2016 Conference: Second Plenary Session

Posted By Matthew P. Martin, Monday, October 17, 2016



The second plenary session of the 2016 Annual CFHA Conference in Charlotte, NC was on Friday 14 October and included a panel of experts on opioid dependence and treatment. The first speaker was Brooke who shared her personal struggle with opioid dependence. Here is her story in her own words.

Brooke: "I first took opioids after gall bladder surgery. I liked the way it made me feel. I felt like super girl. I could do anything. Eventually though I started to spiral. I didn’t understand physical dependence when I first started. Before I knew it though I was using just to feel normal. Some people describe it like flu-like symptoms which makes me laugh because it’s nothing like that. I was in and out of many, many rehabs. I had brief moments of sobriety but it never stuck and I never got completely well. I heard about methadone but I also heard about the stigma, how it was replacing one drug for another. Even professionals along the way would say things like that. I felt ashamed to go to a methadone clinic for a long time. Finally I decided I had nothing to lose. There was a clinic one-hour away. I had immediate success. I only failed one drug screen and haven’t failed one since then. After a year of detoxing very slowly, I was diagnosed with post-acute withdrawal syndrome. I was not right and needed a lot of help.


Fred Brason, President and CEO of Project Lazarus, then shared his journey. He was hospice director and had no idea what was happening in the community with drugs like opioids. "We had families from our clinic who were using it, selling it, and sharing it. How did we get here?” he asked. He recounts how the medical community had begun implementing asking all patients about their pain level and then connecting patient satisfaction with pain outcomes.


He continues: "70% of diversion happens between friends and family members. We realized we had to reach everybody in the community. Our collaboration had to be person-focused.” They worked to educate prescribers in outpatient and emergency settings. They started having success but realized that it required a community-wide effort to solve this community-wide problem.

Don Teater, a physician with the Meridian Behavioral Health Services, then described how he started treating opioid dependence. He believes that one of the major problems in medicine is that we separate medical and mental health. He recalls, "In 2004 I became certified to prescribe buprenorphine and it changed my life to start helping people with opioid dependence.” His wife is a mental health professional and worked alongside him to counsel the patients receiving buprenorphine. He encourages all physicians to consider incorporating medication-assisted treatment into their practice.


He says, "The number of opioid deaths is correlated to the number of opioids we prescribe. Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply.” He points out that US physicians prescribe so many opioids today and yet pain levels seem to be rising which suggests that medications may be leading to more pain. The problem is that with the first dose, the human body decrease the number of opioid receptors in response to the flood of medication in the system. However, these opioid receptors help treat anxiety and depression which can then lead to intense anxiety, depression, and even pain during the withdrawal process.


Donnie Varnell, Policing Coordinator, North Carolina Harm Reduction Coalition, then stood up to talk about the law enforcement side of the opioid epidemic. In a former life he jumped out of airplanes and consequently dealt with a lot of pain and medication. "I’m very familiar with opioids” Donnie says. He continues by saying law enforcement is trained very well in many things but they are not trained in how to deal with substance users. Incarceration does not work for these individuals. "In the past, we used stigmatized language in their presence and so did family members. We were not ready for when opioid epidemic hit our state. We did not know how to help.”


When Donnie took over the prescription drug abuse unit, he knew that traditional methods would not work. So, first he started training police officers in how to correctly investigate these cases and then how to respectfully address people. He collaborated with Fred Brason at Project Lazarus and Robert Childs at the North Carolina Harm Reduction Coalition. "Instead of arresting people, we are trying to get them into the systems they need.” For example, he says that police officers in Fayetteville, NC are implementing a drug diversion program called LEAD which is a pre-booking program for substance users. There are four other agencies in NC starting LEAD programs.

Robert Childs, Executive Director, North Carolina Harm Reduction Coalition, the final speaker, made a strong case for making naloxone, an opioid overdose reversal drug, available to as many people as possible. "We can’t get rid of cars and highways to reduce traffic deaths, can we? No, that’s ridiculous. Instead we make cars as safe as possible.” In the same way, he argues, we can’t completely get rid of harmful drugs so we have to reduce their harm as much as possible. "We handed out 35,000 naloxone kits which lead to over 4,000 overdose reversals in North Carolina”. Naloxone kits work, he argues. For clinicians who want to get involved, he recommends first reducing stigma about opioid dependence treatment and prevention.

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2016 Conference: Opening Plenary Session

Posted By Matthew P. Martin, Friday, October 14, 2016



Welcome to the 2016 CFHA Annual Conference! The opening plenary session included remarks by current president Natalie Levkovich and incoming president Tina Runyan. The Don Bloch award was presented by John Rolland and given to Barry Jacobs, a worthy recipient. Check here for a video of the presentation.


The actual plenary session was an incredible, multimodal presentation of video, music, and live speakers. Directed by Randall Reitz and moderated by Jodi Polaha, the theme was "LGBT at CFHA” and included a panel with Beth Evelyn Barber, Michelle Evers, Steven Migalski, and Stacey Williams.


The first video introduced the audience to several LGBT advocates: a University of Chicago student, a state department worker in Brazil, and a Mormon couple in Seattle. Jodi started with a question: what does an organization do when they’re locked into a conference site in a state that passed controversial legislation affecting the LGBT community? Here is our response: we will hold up the LGBT community!


During the first video, the Seattle couple shared their experience of raising a 10 year old transgendered boy. When he was younger, he hated his hair and insisted on wearing hats to hide his hair. One day, when the boy was three years old, the mother found him in bed crying and asked him what was wrong. He said, "Why would Heavenly Father make me a girl when I’m a boy”. The mother responded, "I love you no matter what”. Years later, the boy was teased at a Sam’s Club store which upset the entire family. The mother pleaded with the father "Get us out of this state. We can’t raise our child here”.


Stacey Williams then took the stage to explain the terrible health disparities that LGBT patients face. She attributes these disparities to minority stress at the individual and structural levels. "Even if they don’t experience it firsthand” Stacey says, "they can experience it through anticipation, constantly monitoring the environment to see if it’s safe”. She quoted one study that demonstrated the higher rates of mortality that LGBT face compared to the general population.


Beth Barber then identified the barriers to affirmative healthcare. "One of the easiest ways to demonstrate your acceptance of LGBT as a clinic” Beth says, "is to place a rainbow sticker or sign on your building”. Other strategies include developing non-discrimination policy, labeling bathrooms as gender neutral, placing LGBT-friendly reading materials in the waiting room, and being willing to open the conversation about LGBT health-related issues. She cited the Fenway Institute Guidelines as an excellent resource for talking to patients about gender, assigned sex, and preferred names.


The panel then discussed together the need for addressing LGBT health in every health setting and how clinicians can assess if minority stress is contributing to the presenting problem at a medical visit.


Steven Migalski continued the plenary by recounting his story of coming out as a gay man. After growing up in Chicago, he completed graduate studies at Auburn University where he came out and then became involved in LGBT advocacy efforts. At one point he was interviewed on CNN which is how his family learned about his orientation. "We have come a long way since I started at Auburn” Steven says. "The fact that I can speak to you this openly is a sign of that. Please, let’s keep it moving forward.”


The next video included the student, the state department worker, and the couple all suggesting ways in which clinicians be person-centered and address LGBT health issues.


Steven then took the stage again to deliver ten guiding principles for compassionate care:

1. Use sex and gender accurately

2. A binary for gender and sex does not reflect reality

3. Differentiate between gender role, expression, and identity

4. Know and use gender queer appropriately

5. Use transgender and cisgender

6. Appropriately use transman and transwoman

7. Distinguish between social, emotional, and medical transitioning

8. Understand intersectionality of sexual and gender identity

9. Mange pronouns sensitively

10. Don’t assume homogeneity of identity and experience


Steven also identified several common missteps to avoid: education burdening, gender inflation, gender narrowing, gender avoidance, gender generalizing, gender repairing, gender pathologizing, and rigid gate-keeping. He encouraged clinicians to show their humanity to patients because then that gives permission to patients to do so as well.


The final story was given by Michelle Evers who shared her experience of growing up in a loving family in Ohio and then slowly discovering her identity as a lesbian woman over time. This discovery included periods of uneasiness, recognizing she did not fit in with the normative. She considers herself to be on a continuum of sexual orientation rather than a concrete binary. She then shares how her story has affected her work as a nurse practitioner with LGBT patients.


The audience left feeling inspired and informed. The presentation ended with a quote by Mia Kirshner: "I think one’s sexuality can be the center of life, and coming out and discovering your sexuality is something that really can define your existence”.

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Scaling Integration through Health Policy: North Carolina Policy Summit

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



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


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

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


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

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

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


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


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

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


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

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

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A Taxonomy of CFHA Keynote Questioners

Posted By Randall Reitz, Monday, October 10, 2016


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

Vox populi, vox diaboli.

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

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

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

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

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


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

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

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

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

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

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


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

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


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

Good Luck!


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

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Zero Suicide

Posted By Michael Hogan, Tuesday, October 4, 2016

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



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

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


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

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


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

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


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


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

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

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


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

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

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Welcome to Charlotte!

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

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


Come See for Yourself!

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


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

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


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


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


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


We will have the first CFHA state showcase 


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

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

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


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

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


Paths to Integration and CFHA 2016

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

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


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


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

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


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


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


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


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

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

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Telementoring: How Technology Enhances Mental Health in Primary Care

Posted By Jennifer Richman, Monday, September 19, 2016



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


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

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


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


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


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


The solution came in the form of technology

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


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

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


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


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

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


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


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


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

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


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


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


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

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Contact Us

P. O. Box 23980,
Rochester, New York
14692-3980 USA

What We Do

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