Posted By Emma Guerrero-Pavich,
Wednesday, September 23, 2015
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Emma Guerrero-Pavich, LCSW is a graduate of the Behavioral Science Family Systems Education Fellowship program. If you are interested in applying, please click here.
It all started when I got this amazing new job as a Behaviorist for a Medical Residency Program. The first day on the job I felt like I knew nothing. How could this be? I came in with years of clinical experience, a seasoned faculty from a well-respected college yet here I was…lost. I didn’t know what I was supposed to be doing with medical residents who seemed to look at me with faces that showed me that they had nothing to learn from me. Perhaps it was my hallucination but it felt real to me. They were doctors and I was a social worker. I was told by my program director that my knowledge and experience mattered to the team and that what I brought to the faculty was invaluable. Yet I felt like I was in a tunnel, not sure what direction to go or where I was headed.
About 6 months into my job I was invited by my supervisor to attend the annual STFM Conference. He assured me that I would find it rewarding. I arrived to find many people who were very welcoming, and I felt hungry to be a part of this group but was too shy to reach out. I attended workshops which began to ignite my curiosity, I felt activated to try some of the things I was learning. I felt the fog begin to lift and I began to see the big picture but still I felt very green. I kept asking myself "What could I learn from this very uncomfortable situation?” Then the best thing happened. I met Julie Schirmer, a ball of energy and enthusiasm who was most welcoming and genuine. Julie began to talk about the Behavioral Science Family Systems Fellowship (BFEF). She invited me to apply for it. I wondered if I might ask my program to let me apply. She encouraged it, but I was hesitant. Then I told myself "Okay, Emma, just do it”. I submitted my paperwork then asked my boss if I could do it then a few months down the road I got the word! I GOT IT!!! I was so amazed, excited and grateful. Since that day, nothing has been the same. It was as though just being selected began to give me the confidence I had been lacking.
I have learned so much this past year. I have met truly wonderful people who have opened their hearts to me fully. My small group is amazing; my group leaders are seasoned professionals in the field who are incredible women with smarts and hearts of gold. Despite feeling initially terrified by the project we had to do, this group of people was inspirational and dedicated to my success. They helped me see that I did indeed know what I was doing and had much to offer. At our final meeting at the STFM Annual Conference in 2015, I was fortunate to hear presentations from each participant in our class. We were all fabulous. We all grew, we all gave 100% and we all got the wings we needed to fly.
Without giving it all away, let me just say that if you are wondering whether you should apply for the STFM Fellowship or seek some other structured mentoring opportunity, I strongly encourage you to do it! You will be so happy you did. I know people who did not initially get accepted. They are now so excited about participating because they see firsthand the changes in those of us who have done it. If you feel like I felt, green, lost, unsure, and hungry…do it. This program is not only a confidence boost, it is a path to success. Once you finish this program you will be connected to a network of people who are generous with their ideas, who will help guide you and who will care about your success. You will have the knowledge, skill, and confidence to continue contributing to our field which is developing a solid presence in Family Medicine. Behavioral Medicine rocks and your presence in the field will be greatly appreciated. Jump in, play hard, and make a big splash!
Emma is a Licensed Clinical Social Worker in the States of California and Hawaii. She graduated from University of California at Los Angeles with a Bachelor’s Degree in Sociology and a Masters Degree in Social Welfare. Emma serves as Social Work Faculty for the Behavioral Science Department with The White Memorial Medical Center Family Medicine Residency Program. Emma was a participant in Class 5 of the Behavioral Science Family Systems Educator Fellowship. She completed her Scholarly Project on Decreasing Social Barriers to Optimize the Learning Environment during Video Recorded Clinical Observations and presented it at the STFM Conference in April of 2015.
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Posted By John Muench,
Friday, September 11, 2015
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This is the first of several blog posts preparing readers for the upcoming CFHA Annual Conference in Portland. Click here to register for the conference.
We Portlanders like to claim New York Times columnist Nicholas Kristoff as one of our own, despite the fact that he grew up outside our fair city, in Yamhill, Oregon, surrounded by farmland and lumber mills. We’re proud that Kristoff takes on global social injustice issues such as human trafficking and poverty. Occasionally he writes stories about his hometown. In a recent column ("U.S.A., Land of Limitations?” NYTimes 8/8/15) Kristoff related the story of a Yamhill friend, Rick Goff, who died in July of heart failure at age 65.
Death of heart failure at 65. When I hear such stories a petty voice peeps up in the back of my mind trying to calm my own fear of approaching 65 by attributing Rick’s early mortality to behaviors and choices that would, of course, never affect you or I. Rick must have chosen to smoke, use drugs, be inactive, and/or not take those heart failure medications as prescribed, straightforward problems that perhaps we could have addressed with good patient education and motivational interviewing.
Kristoff reminds us that it’s not so simple, that "too often the best predictor of where we end up is where we start.” He relates that Rick’s mother died when he was 5, that his father was alcoholic, and that Rick mainly raised himself and his three siblings. Rick dropped out of school by grade ten, was divorced twice and raised two children on his own. Kristoff encourages us to look at these problems as neither simply biologic, nor social, nor psychological, but a complex stew of all three, because "the best metrics of child poverty aren’t monetary, but rather … how often a child is beaten, how often the home descends into alcohol-fueled fistfights, whether there is lead poisoning, whether ear infections go untreated.” We know now that such early family dysfunction translates directly into poor adult health.
Rick did, indeed, stop taking his medicines shortly before he died. According to Kristoff, Rick felt the need to help a friend in a jam and didn’t have enough money left to buy his own medications that month.
I’ve grown tired of watching similar scenarios play out in the urban community health center where I’ve worked for many years. Too often we see adults in our exam rooms whose real problems are lack of education, poverty, addiction, and homelessness that began with inadequate nurturing during their formative years, or as Kristoff would say "too little being read to and hugged.” By the time they hit our exam rooms, these problems have grown far bigger than my PCP tools can handle and it often feels like trying to empty the ocean with a thimble.
We’re learning. Broader team-based care, we know, can better address patient psychosocial issues. Over the past ten years we’ve welcomed case managers, social workers, and psychologists as partners into our medical homes; it feels like there has been progress. But still, I meet "Ricks” whose problems seem so heavy that neither they themselves, nor I, nor a whole team of people can lift them by the longest of metaphoric bootstraps. The hopelessness that arises is compounded when we think of the children at home, children who are highly likely be caught up in the same cycle of poverty and disempowerment.
This is why I’m excited about our upcoming CHFA conference. There is beginning to be a critical mass of researchers, healthcare providers and policymakers (including at least one influential newspaper columnist) who understand that exam room decisions and relationships are important, but so are the larger environments that affect patients once they go home from the clinic - environments that are physical AND psychological AND social. There is a growing consensus that the triple aim can’t possibly be attained until we address this cycle of biopsychosocial illness begun in early childhood. And we’re nearing a critical mass that can translate this understanding into resources that will help us find and implement better, more comprehensive healthcare.
I can think of no better group to explore these issues than the CFHA membership that has pushed at the edges of biopsychosocial since George Engel coined the term in 1977. We’ve seen enough to know that medications and counseling are necessary, but sometimes not sufficient to fix the problems that begin with adverse childhood experiences. It’s up to us to explore the hard, complex questions, and to go home with new ideas to test. I’m looking forward to our conversation in Portland in October. A hearty welcome to all trailblazers.
Although a native of West Michigan, Dr. Muench has worked at the OHSU Richmond Clinic since its opening in 1995. He completed a National Research Service Award fellowship in 2001, receiving a Masters in Public Health Degree focusing on diabetes screening, and continues to study systems processes for screening in primary care. Currently an associate professor at OHSU, he serves as the Director of Behavioral Medicine for the Department of Family Medicine, director of the SBIRT Oregon Primary Care Residency Initiative (focusing on alcohol and drug screening), and as the OHSU representative to the clinical oversight group at OCHIN, an electronic health record service shared collaboratively with other safety-net clinics.
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Posted By Administration,
Monday, August 24, 2015
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The CFHA Blog turns six years old this month! As a token of respect and work-shyness, we are highlighting all the best posts from the last year.
Last summer, before the CFHA Annual Conference, Colleen Fogarty and Jeff Ring reflected on reflecting while Matt Martin opined the state of PCMH. Paul Simmons and Andrew Pomerantz goaded readers into attending their informative and highly entertaining CFHA presentation in Washington, DC while Don Bloch, the visionary behind CFHA, was honored in a reprint of an interview.
Lisa Zak-Hunter showcased three terrific collaborative triumphs here, here, and here. Cheryl Holt channeled David Letterman by listing the top ten useful measurements and tools for collaborative care and CFHA flexed some of its poetic muscle. The Super Utilizer movement got a bump from Barry Jacobs while Suzanne Bailey, Beth Schreiter, and Meghan Fondow gave us the skinny on effective supervision in primary care.
Wayne Katon, a pioneer in collaborative care, was fondly remembered in one post and Sandy Blount took us all to school for a history lesson on the integration of behavioral health into primary care. Cathy Hudgins and Barry Jacobs discussed the ethics of an intriguing and controversial case regarding caregiving, dementia, and sex while Juliette Cutts and Jackie Williams-Reade battled over the existential value of being an extrovert or an introvert in collaborative care. Finally, CFHA went across the nation to Colorado, Maine, North Carolina, and Oregon to discover the United States of Integrated Care.
Stay tuned for another year of excellent blog posts and be sure to check out Families & Health, a companion blog to CFHA blog.
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Posted By Robin Henderson,
Thursday, August 6, 2015
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This is the fourth in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the third, second and first posts.
I get it. I live in Nirvana. I get to live in one of the most beautiful places in Oregon that just happens to be one of the hottest tourist spots around. Skiing, biking, rafting, beaches, fantastic pinot noir and more craft beer per capita than any other state in America. Life is different in Oregon, especially in Bend. We have that "pioneeer spirit” that drives innovation, independence and even weirdness. Oregon is also home to the largest Medicaid experiment in the country—Coordinated Care Organizations (CCOs)—and at the heart of that experiment is a dedication to integrated care.
The CCO journey started in 2009 in Central Oregon and as luck would have it, that’s my backyard. Anyone who knows me quickly realizes that I have a tenacious spirit. Some would liken it to a honey badger with a beehive—I really don’t care how often I get stung as long as I get results. That tenacity paid off for our region with an early commitment to integrating behavioral health in primary care as part of our Medicaid innovation. It wasn’t a tough argument to make. At least 70% of all behavioral health visits were already happening in primary care, and when people were being referred to mental heath providers for follow up, only about 10% of them actually followed through. These statistics are common everywhere, so logical people reach the logical conclusion that you provide care where people present, right?
I was also naïve. I had the data, the providers, the evidence based practices—but what I didn’t have were regulations on my side. So, I did what most folks do at this point—I created a work around!
Work arounds are great. They allow you to try out new practices, see if they work before you change the big things, and sneak your way about budgetary restraints to innovate. However, they are also dangerous. When we hired our first psychologist and placed him in a primary care clinic in rural Oregon, we had not defined how he would bill and be paid outside of a reliance on "Health and Behavior Codes” and the largesse of my employer, St Charles Health System. People were excited! Finally! They would have access to a psychologist in a community that had so few options for behavioral health; even Lucy van Pelt would have been an improvement! It was glorious….
Then, reality set in. Many payers rejected the H&B codes or set arbitrary limits on their use. Multiple co-pays ensued as folks struggled to figure out how to bill things. And then…the dreaded Regulatory Dragon reared its head and snarled fire, insisting that "mental health services could not be provided in primary care.” It all came down to ancient rules around who could bill for what services in what settings. In other words, it was all about the money.
For those of you who are unfamiliar with CCOs, I’ll give you a quick overview. Prior to the Affordable Care Act implementation, as part of Oregon’s healthcare reform package, they proposed an experiment to remove many of the restrictions on how Medicaid funds can be accounted for and create CCOs, which managed a global budget for the provision of care to a given population. There are 16 CCOs in Oregon that have been operational since 2013. They have to meet their contractual obligations to a Transformation Plan that includes a plan for integrating care—physical, behavioral and dental—and they must show progress on Quality Incentive Metrics each year in order to receive their full allocation of funds. Most importantly, they must show a decrease in the amount of funds needed to treat the Medicaid population overall—and do this over time for years, with an overall reduction equal to the investment ($11 billion) when the project is over. Suffice it to say, it’s complicated.
Most CCOs in Oregon didn’t have the built in expertise to immediately deal with behavioral health, much less integrated care. Integration was a great idea, but mental health and addiction services had always been the purview of the community mental health system. Their byzantine requirements to code and bill for mental health visits required a special "Certificate of Approval” even for licensed folks. Some CCOs found ways around these requirements, but many did not. That’s where Senate Bill 832 came in. If we changed the regulations, we could remove the barriers to providing integrated care. And so it began….
"School House Rocks” taught us that bills aspiring to be laws must pass through committees in a bicameral legislature then make their way up the long steps during lively debate to eventually become laws. If only it was that simple. The process for bills is far more complicated than that, starting long before the legislative session begins. I had the crazy idea that if we could define the practice of integrated primary care in statute, then we could promulgate rules to support that practice and begin to unwind decades of policy created to keep the provision of mental health services protected from the clawing hands of those who wanted their budget. Who could argue with that! Did I mention I was naïve?
Fortunately, I have friends. Some of my friends like C.J Peek and Ben Miller provided invaluable editorial guidance, grounded in the Agency for Health Research and Quality’s work on defining integrated care. Others are the great folks at CCO Oregon who sponsor the Integrated Behavioral Health Alliance of Oregon, a collection of the movers and shakers in Oregon’s integrated care programs, who served as the "think tank” behind what barriers needed to be removed to facilitate the sustainable practice of integrated care. While not formally able to sponsor the bill itself, their real world experience in a variety of CCO models was invaluable to creating model legislation.
I also have friends where it counts—in the Capitol itself. The path to making good legislation starts with the people who live in the building—Legislators, their staff, and the Lobby. Bills that become laws are part of the intricate dance between competing interests that often have little to do with the substance of a bill itself. In large part, that’s by design, creating a space where large interests don’t always get their way and small interests can find a path. The most import thing about the Capitol in any state is always to remember that your ethics define you. Always speak the truth, and if you make a mistake, own it and clean it up. Never surprise a Legislator unless you absolutely have to. Do favors for people whenever you can—and if you can’t do it, find someone who can (as long as it’s legal?) Be nice to staff—always—because they control your access to everything. And, don’t just come into the building for your own issues. Be there for those others care about—because you never know when you’ll need them.
The true tale of SB 832 is best told over a vodka martini, dirty and bruised, with blue cheese olives. Given that isn’t possible in a blog post, I’ll hit the highlights:
- Run concept for bill past most influential Legislator you know who gets the issue and can move the bill. In my case, Senator Laurie Monnes-Anderson, Chair of Senate Healthcare. Get a note to draft a bill!
- Work closely with Legislative Counsel on language for a concept that is difficult to explain and even more difficult to put into existing law. Negotiate on that language with a large group of your best friends for months.
- Get your "final” Legislative Concept into your Chief Sponsor before the deadline so she doesn’t have to use a "priority bill” slot! Now, go find your friends and convince them to sign on as co-Sponsors. Remember to get plenty of R’s and D’s on both sides of the building! Trade favors with staffers to get sponsors for other bills—always good to build up goodwill!
- Once your Legislative Concept comes out, be prepared for
o Monday Morning Quarterbacks
o Fear Mongers who are convinced you want their money
o Supporters who run away at the first sign of controversy
o Detractors who completely misread your concept and are convinced that PEOPLE WILL DIE IF YOU DO THIS
o Closet Grammarians
- Schedule your first hearing! Beg to be assigned to your Chief Sponsor’s committee, and scramble when you aren’t!
o Bring those friends who helped you get here to tell the story
o Be prepared to find out who really doesn’t like this idea and didn’t have the courage to tell you in advance
- Get schooled in "back room politics”
o Be persistent and flexible
o Open your mind to new ideas, even if you don’t agree with them
o Embrace sausage making!
o Compromise is the art of the deal
- WAIT MORE
- When your bill finally starts to move, stay close and shepard it so it doesn’t get lost in the bowels of parliamentary procedure and legislative process
o Don’t be afraid to call those friends you’ve been helping along the way. You never know when they can help you unless you ask!
- Don’t celebrate until the Governor signs your bill (don’t want to jinx it!)
At the end of the process, SB 832 did more than just define integrated care in Oregon. The new law also defines "Behavioral Health Homes” which will support the provision of primary care in community behavioral health centers, creating access for care to some of our most severely impacted people. There are now definitions for "Behavioral Health Clinicians” that include residents and interns, creating paths for them to be paid for their services and support workforce development. Most importantly, however, the new law promulgates rules that will define how person centered primary care homes implement integrated care in a standardized, evidence-based way, and create outcomes that will support sustainability.
It’s always better to slay the Regulatory Dragon than to find ways to bypass his kingdom. In my little corner of the world, that’s how my friends and I moved integrated care forward. Sure, there will be skirmishes and turf wars as we negotiate and implement these new rules, but we won the war and defined integrated care in statute.
Yup—I get it. I live in Nirvana—and its spelled OREGON.
Robin Henderson, PsyD, Chief Behavioral Health Officer and Vice President of Strategic Integration at St. Charles Health System, is responsible for the strategic direction, operations, and integration of behavioral health services across the health system and throughout primary care, and she oversees the development and implementation of the health system's strategic plan and system portfolio. She also manages the health system's advocacy efforts and its relationships with government programs and community partners, including their strategic partnership with the Institute for Healthcare Improvement. She retains an active Oregon license as a psychologist, and is past president of the Oregon Psychological Association.
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Posted By Christine Borst, Cathy Hudgins,
Thursday, July 23, 2015
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This is the third in an ongoing series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the second and first posts.
Christine: Most evenings, I have the opportunity to cook dinner for my family. To break up the monotony of this daily task, I try to find new recipes to add to the rotation. Every once in a while, I inevitably mess these new recipes up; I forget a step, I don’t mix things in the order I should have (I mean really, who has time to read all the way through a recipe?), or my two year old enthusiastically offers to help...in her own way.
After some reflection, I have decided that cooking and baking are a lot like implementing Integrated Care. You can have all of the "ingredients” (provider, support staff, behavioral health clinician, patients, families, etc), but without the proper knowledge of how and when to put everything together, you may fall short of achieving that pretty meal pictured in the cookbook (a fluid, functional, evidence-based integrated practice).
So, without further ado, allow us to share with you a little of what we have cooking down in North Carolina.
The Center of Excellence for Integrated Care (COE), a program of the North Carolina Foundation for Advanced Health Programs, is comprised of a team of Integrated Care (IC) experts who are committed to helping develop and advance sustainable IC systems across the state. We have built a multi-faceted, systematic training, assistance, and capacity-building program that provides practice transformation and education to contracted entities as well as IC projects funded by the Kate B. Reynolds Charitable Trust.
All of the sites engaged in COE technical assistance are varied in their model, including primary care, bidirectional, and school-based health centers. Most sites receiving COE services have significant financial barriers to making necessary changes to their care delivery systems. The majority of the participants are safety net providers that have a mission or legal obligation to provide health care and other related services to uninsured and underserved populations. The sites we help provide physical and behavioral health care, including substance abuse services, to low-income, uninsured, and diverse populations. Additionally, the COE also assists universities, private practices, and specialty care groups.
In addition to the TA services, the COE also works with a variety of organizations through its Community Capacity Building services, including community organizations and stakeholder groups, universities, government agencies, AHECs, and other state and national organizations. In this role, we help educate and address the policy and systems barriers that prevent successful IC development and delivery.
Cathy: During my short time in North Carolina, I have had the unique opportunity to work with and learn from the extraordinary experts that comprise my team and the COE and in the community of providers across the state. My current list of lessons learned boggles my mind – just reflecting on what we know now and what we began this journey with is overwhelming and embarrassing, to say the least. I realize that we are all working on helping practices, organizations, and providers transform their services by helping them change their minds about how that can be done. We often apply the Stages of Change, systems theory, and other clinical/theoretical concepts to our work with these practices (it helps us keep down our anxiety and blood pressure while maintaining a healthy empathy bubble). Ultimately, it is not our practice, and we can’t take responsibility for their system change.
Just a few federally funded programs that promote Integrated Care concepts and models in NC:
· Project LAUNCH,
· HRSA Grant awarded to UNC-Chapel Hill to increase the number of Psychiatric Nurse Practitioners,
· 2014 HRSA PCMH grant awarded to 18 community health centers,
· SAMHSA/HRSA 2014 Workforce Training grant awarded to 4 universities
· Other non-federal groups include the Kate B. Reynolds Charitable Trust, Duke Endowment
We present to a wide variety of groups, including the sites in which we are providing technical assistance. Recently, I have noticed how the focus of the questions and conversations has turned from "why” Integrated Care to "how.” The "why” has been so widely established across the state and many other parts of the country that we rarely have to pitch it prior to being asked to assist in practice transformation. We still encounter some hold-outs, but overall, if a provider or practice is ready to evolve to meet the changing definition of health, it usually is a soft-sell. To help illustrate more of the work we do, we put together our Top 10 Lessons Learned as Practice Transformationists (sort of sounds like we belong in a circus):
Top Ten Practice Transformation Lessons Learned
10. We do not take credit for the successes of our sites. If they fail at some aspect of IC, we look at our part of the issue, take responsibility for what was ours, and then we hand it back to them.
9. People can hear about Integrated Care all day long, but many do not understand the complexities until they try to do it.
8. Transforming a practice does not happen in a linear fashion -- it is often a one step forward, two steps back proposition.
7. Accepting where the practice and providers are when they begin to implement Integrated Care is key in helping them move toward a more successful, team-based approach -- even if they are still across town and just beginning to talk to each other!
6. Always include the patient and their families into the team-based approach.
5. Practices and systems will follow the physics of relationships -- they will try to suck us into their conflicts and systems’ roles, but we resist, resist, resist. We are very often thankful to both have backgrounds as licensed clinicians - it’s pretty amazing how helpful our multisystemic therapy training has been! We do not do drama!
4. Practices naturally want to jump right ahead to money, payment, and the bottom line. While these things are very important, it’s also important to learn how to integrate. HOWEVER: Even though the best approach to building effective, successful Integrated Care services should be based on the needs of the practice’s patients, we can’t ignore the currently billing and payment issues that are influencing reimbursement.
3. Integrated care is not the same as integrative care...and yes, it’s usually worth taking the time to educate the practices on the difference.
2. Providing assistance to sites attempting to integrate follows a parallel process -- so much so that we sometimes slip and call the practice our patient!
And, the #1 Lesson Learned (drum roll, please) is:
1. Integrated Care is not for everyone!
Dr. Christine Borst is the associate director for the North Carolina Center of Excellence for Integrated Care, under the North Carolina Foundation for Advanced Health Programs. She has a master’s degree in Marriage and Family Therapy from Purdue University and a PhD in Medical Family Therapy from East Carolina University. Prior to joining the Center of Excellence team, Dr. Borst spent several years working in a rural community health center to set up and implement an integrated care model. Her research interests include brief behavioral interventions for use in medical settings, and identification of the needs of children and their families in rural 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. Dr. Hudgins has experience in Integrated Care management and development, crisis assessment and intervention, community-based and college-based outpatient counseling, in-patient assessment and intervention, and community mental health consulting. She has practiced in community mental health agencies, hospital and healthcare settings, as well as in private practice. She has also held a variety of posts in higher education administration and student affairs. She is an active member of the Collaborative Family Health Association and AAMFT and presents locally and nationally on Integrated Care.
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Posted By Becky Boober, Neil Korsen,
Thursday, July 2, 2015
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This is the second in a five part series of blog posts highlighting states across the US that support integrated care initiatives. Click here for the first post.
Almost 50% of primary care practices in Maine now offer some level of behavioral health integration. Integrated care is an expected component of the Patient Centered Medical Home (PCMH) and Health Home initiatives in Maine, thanks in large part to the work of two statewide organizations.
The Maine Health Access Foundation (MeHAF), whose mission is to increase access to quality health care and to improve the health of all people in Maine, launched its 12-year, $14 million Behavioral Health Integration Initiative in 2005 to increase access to behavioral health services and to reduce stigma. MeHAF awarded 42 integrated care grants to projects involving over 150 partnering organizations. One-year planning and three-year implementation grants were awarded in three rounds of funding for both clinical practice and systemic transformation levels. MeHAF also supported technical assistance, evaluation and research, and a robust learning community. A self-assessment tool was developed to help practice teams examine their level of integration. MeHAF also engaged key stakeholders in a five-year public policy effort to embed integrated care into state funding and health care reform initiatives. Because of an emphasis on sustainability by MeHAF, most of those organizations are still integrated and have expanded their integrated care services, according to a follow-up evaluation completed in 2014. Stories about a few former grantee organizations are shared below.
Parallel to the MeHAF funded efforts, Maine Quality Counts, a statewide quality improvement organization, worked with other key organizations to start the multipayer PCMH pilot. As part of a grant from MeHAF, Maine Quality Counts included the integration of behavioral health and primary care as one of the 10 core expectations for pilot participants in the PCMH. Over 200 primary care practices are working to increase their level of integration as part of their engagement as PCMH, Health Homes (Medicaid version of PCMH) , or Behavioral Health Homes (mental health agencies working on better integration of physical healthcare).
Embedding integrated care into statewide practice improvement and payment reform pilots, such as PCMH and Health Homes, proved instrumental to being able to sustain the work in practices across the state. Both public and private payers expanded support of integrated care through enhanced payments, opening of reimbursement codes, and allowance of same-day services. Use of the per-member-per-month enhance payments were sometimes used by the practices to support needed services such as care/case management and consultations. The State continues to support integrated care as a core element of its State Innovations Model initiative.
A six-year evaluation of integrated care in Maine identified factors that facilitated successful implementation, including:
- top administrative and clinical leadership support,
- adequate infrastructure such as reimbursement and shared electronic health records,
- behavioral health specialists who are flexible and who market their potential contributions to the team,
- integration of behavioral health specialists in all primary care team functions (morning huddles, warm hand offs, case reviews), and
- tracking and using data for continuous improvement.
Another lesson learned was the extensive work required to build trusting relationships that bridge the cultural variances between the behavioral health and medical professions. Developing a framework was essential to guide discussions about how differently the professions perceive use of time, relationship with patients (or what to call patients/consumers/clients), confidentiality requirements, and definitions of phrases such as care/case management. Professional flexibility facilitated this process of integrating the different professional cultures. Because of issues such as this, the complexity of integrating care requires a long-term view and concerted efforts to build both relational and organizational infrastructure to support the work over time.
Because of all the support provided for practices to integrate, there are many stories to be told about the successes of integration in Maine. A few examples include:
- MaineHealth has created a partnership between hospital-owned primary care practices and the regional Maine Behavioral Healthcare system to place behavioral health specialists, mostly LCSW’s, in those practices. Thanks to a number of years of MeHAF funding, MaineHealth was able to pilot a variety of approaches to integration in twenty different practices and learn a lot about what works and what doesn’t. Using that knowledge, an approach has been spread that places the LCSW at least half time in the primary care practice, uses warm handoffs or other provider referral, a focused treatment model, and includes regular (and as needed) psychiatric consultation. There are now more than 30 FTE’s of behavioral health clinicians in more than 60 different practices. Developing population health pathways that target behavioral health services to priority populations is a next important step for the program.
- Tri-County Mental Health Services and Central Maine Healthcare developed a sustainable contract model between the community mental health system and the local health care system’s primary care practices. Using two MeHAF integrated care grants, Tri-County implemented integrated care by fully embedding its Licensed Clinical Social Workers (LCSW) as the behavioral specialists Central Maine Healthcare primary care practices. The LCSW participate as equal members of the care team activities, such as morning huddles, team meetings and case reviews, warm hand offs, follow up to electronic screening, brief interventions and transitions of care.
- Tri-County also developed a toolkit for other sites interested in this model. The integrated care contracting arrangement has been so successful that it has now spread to 25 Central Maine Healthcare primary care sites and is being spread to other health care systems. It is also a critical component of the area’s developing Accountable Care Organization (ACO).
- Penobscot Community Health Care used MeHAF grant funding to pilot integrated care in a low-income housing setting in Bangor, Maine. Since then, they have expanded integrated care into its homeless health clinic and into all 12 of its primary care clinics. Staffing includes a licensed MHP, substance abuse clinicians, psychologists, psychiatrists, 10 psychiatric nurse practitioners, 18 licensed social workers/counselors, peer specialists, care managers and Behavioral Health Homes case managers.
- When they build or renovate clinics, behavioral health specialists share office pods with primary and specialty care and are fully integrated into all clinical functions. Screening tools are built into the electronic health record to facilitate warm hand offs and other integrated care strategies.
Many Mainers now expect that when they enter the primary care practice, they will receive integrated screening, care, and follow up. Sites report improved consumer and provider satisfaction. This increased satisfaction, improved consumer health outcomes, bending health care costs, and infrastructure support across the payers and the State have made the spread of integrated care in Maine not only possible, but inevitable.
|Becky Hayes Boober, PhD, Senior
Program Officer at Maine Health Access Foundation (MeHAF), leads initiatives
that transform health care systems to provide Patient-Centered Care. In 2013,
MeHAF established the community-based Thriving in Place initiative to keep
persons with chronic health conditions, including older persons, in their
homes. She also oversees MeHAF’s $14+ million investment to integrate behavioral
health and primary care. Starting with 42 grants involving over 150 partnering
organizations, integrated care has now spread to about 46% of primary care
practices in Maine. Dr. Boober is a member of the Grantmakers In Health Behavioral Health Funders’ Network Steering Committee. Prior
to joining MeHAF, Dr. Boober retired from the State of Maine with over 20 years
in public policy and administrative leadership working in the Commissioners’
Offices of three state departments (Education, Health and Human Services, and
Corrections). She assisted with interagency, systemic improvement initiatives.
Korsen, MD, MSc is a family physician/geriatrician with 18 years of practice
experience, mostly in small towns in Maine. Since 2001, he has worked for
MaineHealth, an integrated delivery system in southern and central Maine. He is
the medical director of the Behavioral Health Integration program for
MaineHealth. He has received funding support for this work from the MacArthur
Foundation, the Robert Wood Johnson Foundation and the Maine Health Access
Foundation. He has a number of peer
reviewed publications related to behavioral health integration and depression
in primary care, and has spoken extensively on these topics regionally and
nationally. Dr. Korsen is a member of the AHRQ National Integration Academy
Council, an expert panel working with AHRQ to develop resources related to
behavioral health integration in primary care. He is principal investigator for
the AHRQ Atlas of Integrated Behavioral Healthcare Quality Measures. Dr. Korsen
received his undergraduate degree from Dartmouth College in 1975, his medical
degree from Hahnemann Medical School in 1979, and a Masters of Science from the
Center for the Evaluative Clinical Sciences at Dartmouth (now the Dartmouth
Institute) in 2002.
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Posted By Ben Miller,
Friday, June 26, 2015
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This post is the first of a five part series highlighting states across the US that support integrated care initiatives. Check back later for more posts.
Every so often, an opportunity comes along in healthcare that must be pursued. These opportunities often build off the recognition that there is: a) a problem; and, b) a solution, that while difficult, could be pursued to address the problem. The state of Colorado is currently in the process of pursuing an innovative solution to a longstanding problem; however, before I get to that, let me start with some context.
Fragmentation in healthcare has led to a place where we spend more and get less. While there are many examples of where fragmentation is problematic in healthcare, there is no more prominent example than in the artificial separation of the so called "mental health” from the so called "physical health.” Years of stories, backed by data, support the need for us to treat the whole of health rather than pieces. Specific to many exciting initiatives, integrating behavioral health services into primary care truly creates a more patient-centered and community friendly approach that can help achieve the Triple Aim (decrease cost, improve outcomes, and enhance the patient experience).
What is integrated behavioral health and primary care you may ask? According to the Agency for Healthcare Research and Quality (AHRQ) Lexicon for Behavioral health and Primary Care Integration:
"The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, ineffective patterns of health care utilization.”
Colorado, not wanting to play politics with people and rest on its laurels, has decided to aggressively pursue a strategy that sets it head and shoulders above the rest of the country in its level of innovation. You see, many states have decided they have got to do something about healthcare cost. Some states expand Medicaid; some don’t. Some states have the best intentions to do something beautiful only it doesn’t quite work out.
Colorado has decided to integrate behavioral health into 400 primary care practices. Yes, I said 400. This is no goal to balk at, but what would you expect from a state whose lowest elevation is 3,315 feet? We live a mile high and aim our healthcare goals even higher. This "State Innovation Model” (SIM) is just another innovation in an already innovative state around healthcare. But unlike other healthcare initiatives, SIM, at its core, is about payment reform. Payment reform that can support integration through practice transformation.
And no, it is not just like riding a bike. You see, like unlearning how to ride a bike, Colorado has to literally unlearn how to deliver fragmented care. We have to set aside all our culture, history, politics, and antiquated protectionist tendencies to do what’s right for people. For some, mainly our communities, this will change lives. For others, like some of the special interests who love to protect their pot of the pie, there will be "much rejoicing.”
This is transformation at its finest.
Will we succeed? I believe so, but in order to answer that question, we have to try first. We have to create a framework by which our state can pursue integrated efforts. We have to bring people together to have our "trellis moment.”
Here are the top three reasons why I believe Colorado is leading the nation in healthcare innovation:
We do not have a dominant payer (hint: can help increase competition amongst payers);
We have the support of our state (including our Governor who created an entire office around integration through an executive order); and,
We have an engaged community.
As we all know, to truly transform healthcare, we have to change it clinically, operationally, and financially. We have to look at the state policy levers that enable change and pursue them with reckless abandon.
Make no mistake, Colorado’s reputation as a leader in healthcare is cemented through such forward thinking ideas as that of the SIM. With strategic partners, including health plans, Colorado has a chance to successfully create an approach to healthcare that is person-centered, remains focused on the whole, and is committed to seeing that investment reap positive benefits from all who participate.
So can Colorado right a wrong when it comes to separating out behavioral health from the larger health system? Possibly. But for SIM to be a success it will require a fundamental departure from legacy systems and antiquated ways of delivering and paying for healthcare. Because after all, isn’t the notion of integrating behavioral health into primary care just another example of good care? Regardless, you will be hard press to find another state that is leading the way like Colorado.
|Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. He leads the Agency for Healthcare Research and Quality’s Academy for Integrating Behavioral and Primary Care project as well as the Sustaining Healthcare Across Integrated Primary Care Efforts (SHAPE) project in Colorado and Oregon. He is the co-creator of the National Research Network’s Collaborative Care Research Network and is the past President of the Collaborative Family Healthcare Association. He is the section editor for Health and Policy for Families, Systems and Health and reviews for several academic journals. Dr. Miller is a technical expert panelist on the Agency for Healthcare Research and Quality Innovations Exchange and on the International Advisory Board of the British Journal of General Practice. Dr. Miller’s research interests include models of integrating mental health and primary care, health behavior interventions, primary care practice redesign, using practice-based research networks to advance whole person healthcare, and healthcare policy.
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Posted By MHA@GW Staff,
Thursday, June 11, 2015
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This post is a reprint of a piece from the MHA@GW Blog. Click here for the original post. Reprinted with permission. MHA@GW is the online master of health administration from the Milken Institute School of Public Health at the George Washington University.
“Population health.” It is a term that is widely used in the health care world, but not universally understood. Some definitions of population health emphasize outcomes. Others focus on measurement. Still others emphasize accountability. So what does population health truly mean? Who is responsible? What impact does it have on our current health care environment?
In recognition that there is no uniform definition of this important and emergent concept, we sought out to create a new dialogue featuring a variety of thought leaders in the field. We reached out to over 100 health care leaders and asked them to define the term “population health.” What follows are their responses.
What We Learned
The concept of population health first came about in 2003 when David Kindig and Greg Stoddart defined it as “the health outcome of a group of individuals, including the distribution of such outcomes within the group.” While accurate, some complain this definition focuses strictly on the measurement of health outcomes without explaining or acknowledging the role that health care providers must take to impact those outcomes.
Our survey reflected that notion. Of the 37 leaders who participated, only two people directly cited Kingdig and Stoddard’s original definition. While interpretation and understanding of the phrase “population health” differed greatly in the responses we received, many did view it as an opportunity for health care systems, agencies and organizations to work together in order to improve the health outcomes of the communities they serve. Two other key trends and questions we observed include:
- A question of responsibility. Do the health outcomes of a specific population rely on the behaviors of the population? The actions of the provider? Or both?
- A take on Triple Aim. Several participants referenced the Triple Aim Initiative, an approach developed by the Institute for Healthcare Improvement for optimizing health system performance.
While we may not have reached a universal consensus on what “population health” means, we discovered that now is the time to think differently — not only about the definition of population health — but also about the way health care is delivered. In our ever-evolving health care environment, perhaps the “traditional way” may not be the right answer.
We welcome discussion regarding the ideas we present here and look forward to creating an ongoing, open dialogue about the role population health plays in the health care industry today.
- Wayne Brackin, Chief Operating Officer and Executive Vice President, Baptist Health South Florida
- Paul Brashnyk, MPH, Interim Director of Clinic Operations, UW Neighborhood Clinics
- Fred L. Brown, LFACHE, Chairman, Fred L. Brown & Associates, LLC
- Brian Churchill, Director of Clinical Content and Decision Support, PeaceHealth
- Todd M. Cohen, Director, AtSite Inc.
- Dr. Kenneth Cohn, CEO, Healthcare Collaboration
- Dr. Dennis R. Delisle, Director of Operations and Support, Thomas Jefferson University Hospitals
- Gigi DeSouki, MHA, Founder/CEO, Wellness On Wheels, Inc.
- Jack Friedman, CEO, Providence Health Plan
- Richard J. Gilfillan, MD, President and CEO, Trinity Health
- Jim Goes, Managing Partner, Cybernos LLC
- David Harlow, Principal (Attorney & Consultant), The Harlow Group LLC
- Jay Henry, Chairman & CEO, The James Marshall Group
- Dr. Patrick Herson, President, Fairview Medical Group
- Jay Higgins, Senior Director of Network Strategy and Surgical Program Development, Brigham and Women’s Hospital
- Ryan Jensen, CEO, The Memorial Hospital of Salem County
- Tammie Jones, Senior Health Policy Officer, US Army Office of The Surgeon General
- Dr. Christy Harris Lemak, Professor and Chair, the Health Services Administration Department at the University of Alabama at Birmingham
- Dr. Stephen Martin, Executive Director, Association for Community Health Improvement
- Dr. Larry Mullins, President and CEO, Samaritan Health Services
- Roy J. Orr, Director of Business Development and Supply Chain Services, Salem Health
- Joseph Paduda, Principal, Health Strategy Associates
- Bonnie Panlasigui, Chief Administrative Officer, Alameda Hospital
- David C. Pate, MD, JD, President and CEO, St. Luke’s Health System
- Janet Porter, Principal, Stroudwater Associates
- Barry Ronan, President & CEO, Western Maryland Health System
- David Rubenstein, FACHE, Clinical Associate Professor, Texas State University
- Kathryn Ruscitto, CEO, St. Joseph’s Hospital Health Center
- Marie Savard, MD, Managing Director of Health Care Practice, Diversified Search
- Dr. Nancy Seifert, Instructor, Oregon State University
- Dr. Peter Slavin, President, Massachusetts General Hospital
- Mari K. Stout, MHSA, Quality Improvement/Provider Engagement Specialist, ATRIO Health Plans
- Amy Stowers, CEO, OptimizeIT Consulting
- Quint Studer, Founder, Studer Group
- Bahaa Wanly, Administrator, UW Medicine
- Jennifer Weiss Wilkerson, Vice President, MedStar Health
- Dr. Stephanie Works, Senior Medical Director, Providence Medical Group
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Posted By Alexander Blount,
Wednesday, May 27, 2015
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The comparative flood of new users of opioid medication and heroin in the population has led to a crisis. That it is a crisis is agreed to by politicians, medical professionals, substance abuse professionals, and the public in general. I am told that the Chinese character for “crisis” is made up of a combination of the characters for “danger” and “opportunity.” I recently heard a report from Beth Tanzman, the Assistant Director of the Vermont Blueprint for Health, that Vermont has taken the opportunity presented by this danger to respond with a distinctive approach to creating integrated behavioral health in primary care. Instead of small changes in payment or regulation, they simply funded salaries for behavioral health clinicians in primary care. The chief duty of these clinicians is to address substance abuse concerns, but they are inevitably addressing a broader array of behavioral concerns.
I think there are two important points that this example brings to mind.
1. Whether the impetus for adding behavioral health in primary care is to treat people with serious depression, to provide better care for people with trauma histories, to attempt to intervene before people are involved in the criminal justice system, or to address serious substance abuse is a choice based on administrative and funding opportunity, because as a population THEY ARE MOSTLY THE SAME PEOPLE.
2. If you only target serious substance abuse with your behavioral health resources, you are seeking to intervene in the process too far downstream. Unless you are offering behavioral alternatives in chronic pain therapy, so that physicians have some way of helping their pain patients other than opioid pain medications, you are not helping stem the tide of new addicts.
(To see a 24 minute interview with a patient who got off narcotic pain meds after 18 years with the help of behavioral health in primary care - go to: click on “watch in Vimeo” and use “pillman” for the password. http://umassmed.edu/cipc/resources/videos/ )
And, today only, you get 50% more important points than promised:
3. If you define the behavioral health clinician that you put in a primary care practice (a “general medical setting”) as only addressing substance abuse, you make your program fall under the strictures of 42 CFR (the federal statute regulating the exchange of information about a patient’s substance abuse care). The clinician and physician cannot exchange information without further releases. If you define the role as a behavioral health generalist, though they may do a good deal of work with substance abuse, 42 CFR does not apply. (Your state may have other regulations that do apply.)
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Posted By Jacqueline Williams-Reade,
Thursday, May 21, 2015
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This is the second in a two-part series on which personality type (extrovert or introvert) works best in collaborative care. Click here for Part 1.
To all my fellow introverts, tell me if this sounds familiar. You’ve probably heard all your life that introverts are people who don’t like being around people, like to spend their free time in a cave, and are shy and withdrawn. While that is often society’s definition of introversion (I’m looking at you, extroverts!), this is not the case. Introverts don’t have problems being around people, but, in general, introverts need alone time to recharge while extroverts recharge through being around others. Susan Cain clarifies that introverts "prefer to devote their social energies to close friends, colleagues and family,” in her book Quiet: The Power of Introverts in a World That Can't Stop Talking. "They listen more than they talk, think before they speak, and often feel as if they express themselves better in writing than in conversation.”
So introversion and extroversion are really about where we get our energy and the type of environments we prefer. Just because someone is outgoing, doesn’t mean they’re an extrovert. Similarly, just because an extrovert can be quiet or get tired of being around people doesn’t mean they’re an introvert. There is no clean line between extroversion and introversion – we all reside along a spectrum of these personality traits. In fact, some people who can’t seem to agree on which "side” of the spectrum they fall are labeled "ambiverts” as they have traits of both sides fairly equally.
While a job at a fast-paced integrated care setting can appear to run counter-cultural to the introvert’s preferred, not overstimulating environment, I think there are a few key things to keep in mind that can help introverts take their place as a valued and successful team member in these settings. For me, this process involves examining the typical challenges faced by introverts and re-defining and re-framing them in a way that provides a way to elicit my inborn traits that are both useful and deeply valuable in any setting. Let me show you what I mean…
Everybody’s talking a mile a minute!
While at first glance, a day filled with quick interventions with patients and brief reports to colleagues may sound antithetical to an introvert’s values, I’d like to reframe these interactions as a way to bring out the best of an introvert’s personality. For instance, while this way of talking can often be interpreted as being difficult for introverts as they typically don’t like to interrupt or speak off the top of their head, I like to re-frame this as an interaction which can be a boon for introverts in that you can skip the small talk (which introverts typically dislike) and go straight to the substance of an interaction. In essence, communication in integrated care is often about getting to the essential point quickly and introverts have the capacity and skills to do this well.
Rush, rush, rush
Granted, most any integrated care setting keeps a pretty fast pace due to the busy nature of the medical setting. While on the surface, this seems like a way to quickly drive an introvert mad by presenting them with interruptions and an unbridle pace of work, I find this to be an excellent opportunity for introverts to practice their preferred way of feeling centered and calm. While there may be a rush around you, an important aspect of maintaining your ability to do and think your best is to not allow people to make you feel rushed. An introvert who can practice their natural preference of calm, mindful interactions can be a valuable asset to his or her colleagues and the medical setting at large. There, of course, will be times when you have to speed up your natural rhythm, but harnessing your ability to find your sense of calm within the busy-ness is something that will help an introvert survive and thrive in this kind of setting.
I don’t fit in here
If you ever find yourself awash in what feels like a sea of extroverts, look around and you might be surprised to find other introverts in your midst. There are varying statistics regarding how many introverts there are in the general population (somewhere between 25 and 40%) so I bet if you look around the typical integrated care setting you will find physicians, PA’s, nurses, schedulers, managers, etc. who identify as introverts and are making integrated care a better place. You are never as alone as you think and this is important to remember when you can feel like you’re swimming against the current of the preferred, extroverted way of being in an integrated care setting.
"Stay true to your own nature.” (Cain)
For introverts in integrated care, we need to figure out how to take care of ourselves as the environment can often stretch our natural boundaries and use up our reserves. To re-charge, introverts need alone time and it is important to know how much you personally need and when. Do you need an hour after work each day? Do you need a weekend day devoid of people plans? Do you need to log off all social media for a certain amount of time? It’s important to take care of yourself and it’s a mandatory part of thriving in a setting that can work against our innate nature and preferences.
Overall, I think the most important aspect of being an introvert in integrated care is to be happy with who you are. It is important to believe that you can be different and still be liked. If you are agitated at your introverted nature, you will fight against the very things that are your greatest assets by trying to be someone you’re not. However, if you appreciate your indelible strengths of introversion, you will believe your skills are valuable and look for ways to let those skills shine through – even in the midst of a busy medical clinic.
Jackie Williams-Reade is an Assistant Professor and Director of Medical Family Therapy at Loma Linda University. If she had a quarter for every time she was either 1) told she was definitely not an introvert after a delightful conversation with someone new or 2) told she was definitely an extrovert after giving a well received public presentation or 3) mistaken for being aloof or distant when using her deep listening super-power or 4) mistaken for not having any ideas simply because she feels everything has been said already and why waste words, she would be filthy rich... and still an introvert.
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