Integrated Care Management: Or “Process management redeux.”

Have you ever had anyone send you a weird electronic file and when you click on it you get a list of programs from which to choose to open it? If its a graphic-heavy file, obviously you’re not going to select Excel, yet there it is as one of the options. Ever click on Excel just to see what happens? If you put your ear real close to your keyboard you can actually hear the circuits laughing. You’ll get some sort of error message that might mention something about incompatibility with the file.

I mention this because it’s becoming more evident to me that when embarking on an integrated care effort we often leave the gates doomed for frustration and failure. See, we don’t get the benefit of that error message; we humans have to go through a series of trials and errors to figure it out. A couple of blogs back I mentioned the difference between project management vs. process management. I think its important enough to circle back and build a little more on that thought because it is of such fundamental essence that it alone has enormous impact on the success of your implementation in terms of the planning, implementation and final results. To be clear, the implementation of an integrated practice is a process. Nothing short of that. It changes EVERYTHING.

Let’s also be clear about some basic definitions; first of Project Management (Stanleigh, M., Process Management vs Project Management. Business Improvement Architects,–pm-vs-pjm.htm):

  • A temporary endeavor undertaken to create a unique product, service, or result.
  • Time-bound and has a customer.
  • Has clear beginning and end dates.
  • Follows a specific cycle of initiation, definition, planning, execution, and close.


Now, Process Management (Friedman, D., Program vs Project Management. Project Management Consulting.

  • Combines the ability and resources to define, plan, implement, and integrate every aspect of the comprehensive program.
  • The coordinated management of a portfolio of projects to achieve a set of business objectives.

Friedman goes to more specifically spell out the differences:

1. (Processes) encompass a series of projects that in aggregate achieve an overarching set of objectives, where projects have a specific and more singular objectives. In this sense, the difference is driven by scope and scale.

2. (Process) management involves more than oversight of a set of projects. It includes application of common standards and processes to the execution of the projects.

You might be surprised to learn that here at Cherokee Health Systems, where we have been working on an integrated care practice for nearly 40 years, that we still don’t yet consider ourselves done with integration. We’re constantly chasing it. Stanleigh describes a process as “on-going with no clearly defined beginning and end dates, customer driven, and repeatable.” In fact, he would probably best describe integrated care as “Business Process Reengineering.” He defines it as “a fundamental re-thinking and re-designing of a business process in order to exceed customer and quality requirements.” What he’s describing is a process that has dexterity, flexibility and responsive to change – changing customer needs and changing environments – yet has those “common standards and processes” that Friedman mentions. Sound familiar? Anyone hear of healthcare reform?

What does this mean for us? I guess the first question is to figure out what your commitment to this is going to be. To be sure, it is going to be a process. Dr. Edwards Deming, known as one of the world’s most renowned experts on management and efficiency, makes the point quite clearly, “If you can’t describe what you are doing as a process, you don’t know what you are doing.”

During consultations, Joel Hornberger, Cherokee’s Chief Strategy Officer, often walks people through a change management cycle. It is vital because organizations very often short-sell themselves on what is going to be involved if they truly want to become an integrated practice. It is often treated as project, such as EMR implementation – where there is a clear beginning, an implementation phase, and then a completion (often with a nod to ongoing maintenance). An integrated care practice process includes:

  • Clear, explicit, and present leadership from the organization’s CEO
  • A profound re-thinking of the organization’s mission to reflect this new approach
  • A clear understanding of the systemic and program level impact (often including advocacy and lobbying effort at the state level for payer reform)
  • The ability to manage a portfolio of projects and subprojects along the way which may include the development of behavioral templates on the EMR, training on the use of new codes by providers and billing agents, facility redesign, patient flow reconfiguration, screening and scoring tools, etc.
  • Development and adherence to a set of clear set of core standards by which all providers and clinicians will operate under
  • If you are using contractors or partners to supply providers and clinicians (for example, if in partnership with a community mental health provider) that they understand and adhere to your standards, expectations and mission

Shifting to an integrated care practice is nothing short of tectonic. You are shifting the plates of your very foundation to become more responsive to patient needs by repositioning resources, changing key roles, and rerouting workflows. This simply cannot be done by a mid-level administrator who lacks influence equity and who may function as a lateral colleague, or worse yet may report to those to whom he is responsible for changing. This is best led from the top down – clearly, decisively, explicitly, frequently, and with ultimate responsibility and accountability.

What strength are you willing to commit to this? If Dr. Richter were to measure your impact would he give you only a 4.5 (noticeable shaking, some rattling), or will your impact be along of the lines of total disruptive innovation of 7.0 and above?




Posted in Behavioral Health, Behavioral Health Consultant, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, healthcare practice, Healthcare Reform, Integrated Care, integrated primary behavioral health, Process management, Warm handoff | Tagged , , , , , , , , , , , , | Leave a comment

That’s Why You’re Here; Or “Maybe one day you’ll earn a t-shirt.”

It’s crazy that it’s been over 20 years since I worked with Ron and his words still echo through my head on almost a daily basis. We worked together on an adolescent inpatient psychiatric unit, and to this day I can still hear his voice and would recognize his unique handwriting in a flash. Ron was a short man, slightly stocky in build, and was one of those people that if you asked ten people to guess his age, you’d get ten different answers probably spread ten years apart in guesses. Was he 40? 50? 45? 55? Hell, I didn’t have a clue. He was protective of his private life, almost shy – but once in the treatment milieu he bloomed into this power pack of energy, of intensity, of laser-trained focus on the kids. He had the gift. The “x” factor. Even the kids that presented in the armor of violence and gangs were drawn to him with a gravity that the rest of us counselors wished we could buy in a bottle.

Ron’s gift was simplicity. Even when dealing with kids who were wrapped in layers of psychosocial restraints and who came from completely screwed family dynamics and who were dealing with complexities adults three times their age would implode over; Ron would break it down in a matter of sentences. His line that still echos in my mind – and the one I find myself saying in almost every situation is his legacy. At his funeral in 1996 I said these words to the couple of dozen people that gathered for his service at a hardscrabble concrete block Baptist church on an otherwise abandoned street corner in Gary, Ind. on a perpetually cold gray day.

“That’s why you’re here.”

Ron had no time for self-pity or blame or resistance or denial. He understood defiance. He understand the pervasive anger and injustice of poverty and the stark lack of opportunity many of the kids we dealt with faced – they were those “innercity” people that Paul Ryan talks about. When one the kids would furrow his brow, or out of anger and frustration mumble under his breath or call Ron a faggot or nigger or some other derogatory term, Ron would pounce on that teaching moment. “That’s WHY you’re here,” he would say. I can’t tell you how many kids upon their discharge presented Ron with a t-shirt with those words on it. Imagine the impression you make on someone to the point where they make you a shirt; or that someone else sits at a laptop 20 years later talking about you. Imagine that.

Ron – that’s why YOU were here.

I thought about Ron this past week while listening to Baltimore Congressman Elijah Cummings talk to a bunch of community health center workers and board members in a large ballroom at a national convention in Washington, DC. Mr. Cummings talks with an authenticity earned from truly understanding poverty and injustice and opportunity and unfairness and commitment and self-reliance. He told us that in our work of helping the underserved that we “change the trajectory of people’s destinies.” He said that many of us could probably make more money or live more comfortable lives in the private sector, except that we “feed our souls” in lifting, healing, supporting, fighting, advocating. “That’s why you’re here,” he shouted, his amplified words bouncing off the fieldhouse-sized walls like superballs.

Seriously? Shivers.

That’s why you’re here.

A universal truth.

One of our certified application counselors was recently working with a woman interested in the healthcare exchange. She walked in politically charged in red state bias, but was also burdened with poorly managed diabetes and steeped in abject poverty. “I don’t want nothing to do with no Obamacare,” she defiantly told the counselor. Well, OK, said the counselor, what about if I told you about the Affordable Care Act and how you could get healthcare coverage? “YES,” she said, “THAT’S what I want – but don’t put me in that Obamacare garbage.”

To that counselor – THAT’S why you’re here. You had no agenda except to get that woman eligible for healthcare coverage. And you were successful. That woman left with her dignity and values intact and can now work on becoming even healthier so she can get to the polls and vote that bum out.

“This isn’t about you!” Mr. Cummings yelled at us, pounding the podium for emphasis and pointing at us – his finger seemingly poking the chest of every one of the 2,000 people in the room. “This is for generations yet unborn!” he bellowed.

That’s why we’re here. That’s why we’ve all made the choice – by clear decision or happenstance – to work in tangle of the safety net. It’s why we endure the snickers from our private practice colleagues. Or why we’re able to shrug away the jealously we might feel when our friends in high-powered sales jobs talk about their quarterly commissions that alone could change the life of one of the people we serve.

This isn’t a self-congratulatory back-patting piece. It isn’t meant to be altruistic or even a feel good story. It’s meant to just illustrate the simple truth. It’s why you’re here. So never be satisfied that today was enough. Even when you’re overwhelmed and can’t squeeze another minute out of the day to complete everything on your list, don’t forget the unmet need – those that have yet to be leveraged to cross your path. Your choices and experiences and maybe even an unseen force if you believe in such things led you to this day, to this moment, to this exact point. That’s why you’re here.

So get after it. Feed your soul…it’s why you’re here.


Posted in Behavioral Health, Behavioral Health Consultant, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, Healthcare Reform, Integrated Care, integrated primary behavioral health, NACHC, Warm handoff | Tagged , , , , , , , , , , | Leave a comment

Managing the Process of Integrated Care: Or “Manage processes, lead people.”

Now that we’re getting a few years into a growing number of collaborations between primary care providers and mental health centers, we’re getting a better sample size of data by which to assess successes and challenges. I wish there was a data set that looked at the success rate of “integrated” efforts, but I fear it would be a very difficult set to assemble given a few factors:

  • What exactly is meant by “integrated care?” (See previous post)
  • By what standards determine the degree of implementation that differentiates a co-located model from one that would be determined to be “fully integrated?”

Obviously research wonks can add another dozen variables to this list that demonstrate the difficulty in collecting and doing any sort of beneficial analysis of the data. I’m sure the Center for Integrated Health Solutions, the innovative partnership of SAMHSA, HRSA and the National Council of Community Behavioral Health has data related to its far-reaching project of involving primary care in mental health systems.

From an observational standpoint, one feature of these collaborations is what I refer to as the “rubberband effect.” We’ve learned that implementing an integrated care model is a process. That’s an important distinction because it is not a project, or even a program. It’s a vital distinction because it will determine as to how you manage it. Process management establishes that you manage processes, not people – or in other words, you manage processes and lead people. Project and program management have very different principles.

A common approach in these collaborations is that a mid-level manager, or rarer yet, someone from the executive team from the partner organizations is appointed to head up the project of implementation. Avid readers of this blog can no doubt already start recognizing the warning signs in this approach. At its foundation it is already being treated as a project, and as pointed out, that is a very different management approach to the process of integration. The problem is, is that the project management approach works. At least for a while. Task forces are developed, plans are made, objectives outlined – so far so good. But too often the continued success and responsibility of the project stays balanced on the shoulders of one person, or a couple of key people. This is where process management and project management veer away from each other. Projects tend to have a start and an end. There is a clear trajectory of a beginning and some hallmark that determines when the project is complete. Processes tend not to have that determinant. They’re ongoing.

So what happens when you have a personnel change? What happens when that person in charge of the project leaves?

BOING! The rubberband effect.

It doesn’t seem to matter if even the tightest of policies,  practice guidelines and protocols are written; the staff was conditioned from the jump that this is a project, and if the person in charge of it leaves, it’s probably human nature more than anything that allows the positive tension of progress to SNAP and the project reverts. In practice this tends to look like this:

Main Street Mental Health Center (MSMHC) and Downtown Community Health Center (DCHC) collaborate on a project to put a BHC in the primary care center. A division director at MSMHC and the COO at DCHC meet frequently to plan the implementation. The MSMHC person eventually assumes more of the leadership of the project and finds a LCSW that they determine is qualified to work at DCHC as a behaviorist. They scramble to find some training online and then start working her into the primary care clinic a couple of days a week. It all seems to be going well. There is buy in from the providers, the BHC’s hours increase. She’s learning more about brief interventions in primary care, but is struggling with separating herself from being identified as just the mental health specialist in the clinic. Through supervision with her MSMHC director and contact with the COO, she is beginning to make some headway in being accessed more in medical cases, but its a challenge and still feels a bit out of her wheelhouse. The MSMHC director then leaves for another job. The health center COO tries to step in, but hasn’t been as involved with the direct supervision of the BHC; meanwhile MSMHC fills the position with someone totally unfamiliar with the project beyond just the concept.

BOING! The BHC reverts back to her comfort zone of seeing only patients with depression, anxiety and stress issues. She does “warm handoffs,” but they are really just to establish the next appointment, usually an intake into a more traditional mental health approach of 30-45 minute appointments. Eventually the primary care staff starts to experience some delays in accessing the BHC, and has hears that it will take several weeks for their patients to be seen by her. So they BOING! right back to do doing what they did before her arrival – treating the patients as best they can (usually with a prescription pad) or referring out to other mental health providers.

I wish I could say this is an isolated event, but it happens all too frequently. In later blogs we can talk about how to avoid this, but for now the best advice when starting off is to establish this as a process; not a project. Words matter. Learn a little bit about process management – you can’t be expected to be an expert in everything; give yourself a break and allow yourself the opportunity to learn. Make sure too that this is a loud and clear mandate from the executive suite; that this will be a part of your culture.

It’s important to get out of the blocks on the right track.

Posted in Behavioral Health, Behavioral Health Consultant, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, healthcare practice, Integrated Care, Integrated Care Assessment, integrated care, integrated primary behavioral health care, primary care, integrated primary behavioral health, Warm handoff | Tagged , , , , , , , , , , , , | Leave a comment

Defining Integrated Care: Or “Road Trip to the Kentucky Bourbon Trail!”

The U.S. Department of Health and Human Services (HRSA) recently released a $50 million grant application to expand behavioral health services in existing federally qualified health centers. In reviewing the requirements listed on a technical assistance webinar, it listed this:

Applicants must propose a plan for achieving or enhancing a fully-integrated primary care and behavioral health services model of care. The plan must include:

  • Use of screening, brief intervention, and referral to treatment (SBIRT) and other evidence-based practices.
  • Use of a team-based integrated model of care.

I was reminded of bourbon. Not that the application caused me to knock back a heavily iced glass of nice smoky, caramely Four Roses single barrel select. But more accurately to think about the definition of bourbon in comparison to the definition of integrated care. A couple of the key distinctions that allow a certain whiskey to carry the designation of “straight bourbon” is that it must be reduced with water to less than 125-proof at the end of the distillation process and stored for at least two years in new oak barrels that have been charred on the inside. There are a few other distinctions, but the new charred barrels and proofing are the key features that give bourbon its unique flavoring, coloring and what separates it from the swill it has to share shelf space with in your local package store like “birthday cake vodka” and “coconut rum.”

You see, there are distinctive features that by law enforce the accurate labeling of a product. Unfortunately “integrated care” is not afforded such protections, and is often lumped as a generic commodity. It can mean anything. Like the “fish” in a Filet-o’-Fish. We think of the best practices of integrated care to include the following:

  • Blended care team
  • Shared support staff and physical space
  • Well orchestrated clinical flow
  • One clinical record, unified treatment plan
  • Immediate communications
  • Shared patient population
  • Reimbursement mechanisms that support the model
  • Expanded, behavior-focused Patient Centered Medical Home
  • Blended and blurred professional roles
  • Targeting high-risk, high-need populations
  • Integration defines the corporate identity and mission
  • Partnerships with payers
  • In sync with the goals of healthcare reform (Triple Aim)

Beyond that, we have defined standards that we promise our payers in return for their support of integrated care payment methodologies. Think about bourbon again – that it is aged in new, oak, charred barrels. Those are three very distinct, specific standards. If any one of those three are not met, the end result might be a nice whiskey, but it will not be a bourbon. We think the same about our standards of integrated care:

  • Weekly multidisciplinary care team meetings
  • A BHC that is embedded on the primary care team
  • Real-time psychiatric consultation is available
  • Behavioral health screening of every primary care patient
  • Integrated clinical record and treatment plan
  • Teleconference capability to import providers as necessary

Further, we define the scope of work of that embedded BHC; that she is not just doing “case finds” of mental health diagnoses and treatment of only depression and anxiety. They are population-focused generalists whose caseload is that of the primary care clinic. Anything short of that might still be a beneficial service, such as the co-location of a traditional mental health provider in primary care. Like whiskey stored in used charred oak barrels (I’m looking at you Jack Daniels), it is not a bourbon, and neither is a co-located traditional therapist really doing integrated care.

So are we splitting hairs? Why is this important? There are about 50 million reasons why this is important. When the government puts out a mandate specifying “fully integrated,” it is important that we understand what that means and that there should be some measurable standards by which to assess the attainment of that distinction. We see a recent resurgence of this in consumer labeling, from what can be called “low fat,” all the way to what can be accurately labeled as a Greek yogurt, to whom can actually claim to make Brie cheese. Consumers have the right to know what they are buying, just like payers and patients have the right to be educated on what “fully integrated” really means.

I don’t know about you, but that $58 bottle of Four Roses single batch is doing no one any good just sitting on that shelf. Consumer products really only expel their value when actually consumed. So I guess I’ll take one for the team and do my part.

Posted in Behavioral Health, Behavioral Health Consultant, Billing Claims, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare practice, Healthcare Reform, Integrated Care, integrated primary behavioral health, NACHC, Warm handoff | Tagged , , , , , , , , , , , , , | 2 Comments

Innovations in Integrated Care: Or “Out ridin’ fences to better healthcare.”

I know my friends in Western Kansas won’t mind me referencing the wonderful time I recently spent with them and the lessons I learned about integrated care. Yes, I was there to provide some technical assistance on their shift to an integrated model, but I believe it was I who learned the most.

I’m from Indiana. I know from rural. I can drive you to the nearest grain elevator quicker than you can Google “what is a grain elevator.” We can swing through any small town and see crudely painted on the water tower the evidence of young burning romances. If you don’t live within a holler of a Tractor Supply, consider yourself city folk. Heck, we have TWO country stations on the radio dial. But what I learned in Kansas is that there is a difference – a vast, wide open, tumbleweed-infested, empty gap – between rural and frontier. If you’ve never driven 90 minutes and passed nothing, and I mean NOTHING, you haven’t visited the frontier. We drove to a hospital on a dirt road. I’m not kidding.

And at the outposts I met some simply amazing people. I met a physician who was recently discharged from the military who lives and works in a hospital not much bigger than a suburban shoe outlet. She was born and raised on the frontier and couldn’t wait to return to the wide open spaces to practice. I met a family physician from Garden City who left for medical school and returned and during our discussion on behavioral-enhanced patient centered medical homes nodded approvingly and said “if it’s good for the people of Garden City, I’m all for it.” There was no need to advocate for the need for population-based health. Hell, these people invented the concept.

What I learned was something I had already known, but didn’t really appreciate – that like politics, all healthcare is local. Often we’ll hear from people who want to know how an integrated approach works for specific populations, such as pediatrics. There are some differences in the packaging, but the core concepts of accessible brief interventions don’t change. However, I found some new grains in the wood. For example, necessity being the mother of invention, we problem-solved through the potential of a “tele-BHC.” In an ideal world the BHC is a busy person, moving in and out of exam rooms, documenting on the fly, and executing more warm handoffs than the biscuit maker at a Cracker Barrel.

The frontier is an ideal world for ranching and um, well, um, ranching. It is not an ideal world for healthcare. The challenge of recruiting is exponentially multiplied; any wrinkle in the weather is extrapolated by the wide open spaces – wind doesn’t just blow, it whips and carries whatever else it can pick up with it creating dust clouds, and even snow flurries can produce impassible drifts when its blown and accumulated over several miles. We talk about silos of care. Those people know about silos. They don’t have silos of care; they have islands of care, and usually those islands are at least a hour’s drive apart. Us city folk complain about a 30-40 minute wait in our doctor’s lobby; imagine having to carve out at least a half a day for a routine check-up.

An integrated care model is fueled by access. And access to healthcare often requires innovation and technology. Thus the introduction of the tele-BHC in addition to the services of a consulting psychiatrist who may beam in via videoconferencing equipment as if she were Captain Kirk. So understanding that perfection is often the enemy of progress, pushing an agenda of ideal doesn’t fly in a vast archipelago of healthcare.

It often amazes me in states like that where the policy makers are well aware of the challenges, but are so closed to the solutions of innovation. We often talk about that phenomenon at Cherokee Health Systems; we recognize that payment reform often lags long behind innovation. It takes courage and gumption to provide a service that you know won’t reimbursed, but that you know has immense value to the patient. Heck, there are any number of services that fit that bill. The difference with Integrated Care is that it’s simply inevitable. The dominoes of resistance are falling- albeit at a rate most of us would like to see accelerated – but the writing is on the wall. The results are pouring in and the outcomes are good.

So thank you Western Kansas. And thank you to all of you other rural and urban providers finding ways to overcome challenges and barriers. Together we can pool our results and our methods and finally get down the business of healthcare reform.

Posted in Behavioral Health, Behavioral Health Consultant, Billing Claims, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, healthcare practice, Healthcare Reform, Integrated Care, integrated primary behavioral health, Uncategorized, Warm handoff | Tagged , , , , , , , , , , , , , | Leave a comment

Essential Elements of the BHC: Or “Newark Airport, where dreams go to die.”

Sitting for four hours in Newark’s Liberty International Airport waiting on delayed flights is the perfect place to watch your motivations and enthusiasms die slow deaths. Wallowing in a shadowy incandescent nook next to a chatty Dunkin Donuts, the sounds of a nearby wet hacky cough and frequent overhead announcements by what appears to be Charlie Brown’s teacher at least stirs my senses from lapsing into sleep mode. A crackled Sinatra and Billy Joel play overhead, the cliched soundtrack of a foggy northern New Jersey January night. But after a medium Dunkin’ coffee and a quick peek through some emails and correspondences, I’m reanimated and ready to blog!

If you’ve followed this page at all over the last year or so, you know that I tend to depend on patterns to create my content. I’ll typically write about recent chats or issues that have surfaced that I think have some relevance for the greater good. And tonight is no different. I’ve spent a lot of time in recent weeks explaining and describing the role of a behaviorist in primary care to different groups and individuals. To be sure, its much more descriptive as I’m not actually a behaviorist; I am just the play-by-play commentator describing what I see and what I’ve learned from my colleagues. But in that role, I can relate a few cornerstones that are hallmarks of an effective Behavioral Health Consultant (BHC). I’ve spent considerable keystrokes in previous entries describing what a BHC is NOT, surmised best by saying he is NOT a traditional mental health therapist.

I believe there to be three things you start with when thinking about what makes for an effective BHC:

1. Access, access, access. Providers have to have access – immediate access – to a BHC. Often I’ll hear about a clinic that is starting out with a BHC two or three days a week, or for a number of half-days. The adage “out-of-sight, out-of-mind” rings especially true in those situations. That approach often teaches providers how NOT to use the BHC. Likewise, even if the BHC is in the clinic full-time, she has to be accessible to the providers, even when she is with another patient. Interruptable isn’t an adjective used to describe therapists from the traditional school, but BHCs are anything but traditional.

2. The answer is always yes. One of the key tasks of the BHC is to make the providers’ job easier. It’s not one of all the glory or the center of some clinical universe. It’s sort of like an offensive linemen (look at me violating my own promise of never using sports analogies). You’re job is to just gain yardage and move the ball forward. Can you help this patient get glasses? Yes. Can you help this guy manage his diabetic diet a little better? Yes. Can you…Yes. Yes. Yes.

3. You function as a primary care generalist. The BHC is not an adjunct or guest on the primary care team. He doesn’t run some renegade schedule of hour long appointments in the primary care setting. He doesn’t just self-select the tired, the weak, the depressed. You are not the Statue of Liberty. Your caseload is the primary care caseload, whatever may come. You are well-versed in the variety of issues and complaints that surface in primary care and you have a toolbox of resources and strategies to deal with them.

Starting with these three concepts, it won’t take you long to be thought of as one of the primary care team members. Someone who is important to the functioning of the clinic. You come with an unique skill set that allows you to make quick and accurate assessments – not necessarily diagnoses – but assessments. You can assess a patient’s readiness to change and their level of acceptance and cognition of what you’re transferring to them – and meet them exactly there. You can communicate in descriptive, focused briefings with your teammates. You can document like the wind. You understand the importance of self-resiliency and passionately impart that to the patients you work with. Ultimately we are all responsible for our own health. You don’t need detailed written protocols or checklists to guide you through your encounters. You ask questions, Lord Almighty, you ask questions. You ask questions of the providers you work with, of the patients you see, of your teammates; you never stop learning, nor do you shy away from your important role in transferring knowledge to your teammates. You understand that the only way a patient-centered medical team really clicks is by having a high-functioning, intricately connected, well-informed TEAM. No one owns the knowledge.

You get the idea that this is much more than “well, we hired a LCSW to see patients in our clinic, so we’re integrated.” A pile of tires, fenders, axles and a motor is not a car. It is a pile. It does not become integrated and useful until it is assembled, calibrated and someone is trained to drive it.

Now if you’ll excuse me, Francis is singing Fly Me to the Moon overhead and I’m quite sure wet-hacky-cough guy down the counter will enjoy my vocal stylings….”Let me see what spring is like on Jupiter and Mars…”


Posted in Behavioral Health, Behavioral Health Consultant, Billing Claims, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, healthcare practice, Healthcare Reform, Integrated Care, Integrated Care Assessment, integrated primary behavioral health, Warm handoff | Tagged , , , , , , , , , , | Leave a comment

The Importance of Connections: Or “hey, librarians can be sorta cool!”

A decade or so ago I met a man through Jimmy Buffett’s website; he wrote a short-lived column on the site about baseball in the Caribbean. His name was Frank Walsh. I built a correspondence with him over the next several years where we would exchange columns and stories. It was a relationship built on a common love of writing and learning.

Frank was an amazing character; a Michigan native who was a bookshop owner, librarian, instructor and brilliant story teller. He grew up in baseball as a fan and keen observer of the people that played the game. His story is weaved with springs in Florida among the ballplayers awaking from winter slumbers, summers in Tiger Stadium, and being curled next to a radio at his family’s lakehouse listening to games on a crackly transistor. He retired to St. Pete and spent his last years trekking to Al Lang Field – spring home of such teams as the Yankees, Mets, Cardinals, Orioles and Rays. A classic stadium of wood bleachers, broad vistas and one of the most spectacular views of all ballparks – it sits on right on the bay where views of sail boats bobbing gently on gulf coast breezes paints the perfect picture. They play soccer there now. The Rays have glided 90 minutes south to train.

I never actually met Frank despite carrying on a pen-pal relationship for several years. In fact, Frank and I were once both in Al Lang Stadium watching a Rays spring training game, but we weren’t able to connect. At least in person. He died several years ago and I always regretted not finding a way for us to meet that day. Guess I just assumed it would happen some other time. After his death I bought his book “Shoes of Giants,” a pocket-sized paperback that is a collection of columns he wrote for a small weekly neighborhood paper in St. Pete. To my delight he had autographed – in pencil – the cover page. It is one of my most prized possessions. Frank2

Connections are important. In the work we do in primary care, and especially behavioral health, the human connection between provider and patient is vital. Certainly I’m not breaking new ground here, but in this world of healthcare reform and patient-centered medical homes and integrated care, it is time we found a new appreciation for that connection. We’re trained to understand disease processes, symptoms and plans of care. We give lip service to understanding the person behind those presentations, but in the interest of time and efficiency we often lowball our value proposition in the importance of that connection. A skilled behaviorist – or a medical provider who is armed with similar talents – can often place patient presentations in better, i.e. correct, contexts. A patient that is “noncompliant with his appointments,” or who “habitually seeks meds,” or who may be a “frequent flyer” in a clinic may have a load of psychosocial or biopsychosocial challenges that won’t make themselves evident in an EENT exam or while the patient is being chastised for smoking or drinking. Placing those symptoms/processes in their proper contexts often opens up whole new paths to improvements and wellness. All it takes is a little trust, a little sharing, a little give-and-take.

Likewise, the connections between a provider team are as important. We’ve all been to restaurants where poor communication, bumpy relationships, bad processes and ineffective leadership leads to bad service and bad food. Why would our world be any different? What happens when you’re meal is served cold, or if your waiter seemingly disappears off the face of the earth for 20 minutes? How likely are you rush back to eat there again? Good results can ONLY come from good processes. And good processes are led by good people who have good communication, who are well trained and function under a common mission and desires to provide good care. Nothing has to be extraordinary or state-of-the-art or cost millions of dollars. This can be done on the cheap, but the results are world class. A provider team that communicates, that has an appreciation for context and the patients’ global experience is a successful practice in every way measurable. Or at least soon will be – because once you see success in one area, achieving excellence in other areas becomes addictive.

At first Frank was a just a faceless scribe writing about people and times of which I had no clue. Once the formulation was complete with his background, his interests and our connection of commonalities was established, his stories had a new richness and depth. The same is with our patients. Each and every one of them. They all have a story. You don’t have to squeeze it out on the first visit, but through a true team approach using skilled behaviorists and invested providers, that story will start to emerge under that protective patina and a proper context can be found.

Posted in Behavioral Health, Behavioral Health Consultant, Care Coordinator, Cherokee Health Systems, co-located behavioral health, Cherokee Health Systems, Dennis Freeman, Bob Franko, healthcare, healthcare management, healthcare practice, Integrated Care, Integrated Care Assessment, integrated primary behavioral health | Tagged , , , , , , , , , , , | Leave a comment