A Brief Note From Bob

A note from Bob Franko:

Friday, May 13, 2016 will be my last day with Cherokee Health Systems. I’ve accepted an appointment as CEO of a health center in a neighboring state and will begin there at the end of the month.

Cherokee Health Systems will continue to grow and expand its consultation and technical assistance training reach. We’re exploring different training platforms using web-based portals, and developing new products that we can sell at reasonable costs to our safety net colleagues. We’ve already done much work in that area, especially in the development of our NextGen EMR integrated care templates that we’ve provided to a couple of our friends in different states. I’m a bit biased, but I can attest that in doing this work for the last six years with hundreds of organizations, in 49 states (seriously, Mississippi???), is that there is no one out there with the depth and breadth of Cherokee’s experience in regard to the Behavioral Enhanced Patient Centered Medical Home practice, and who is so readily available and willing to help.

I often tell people that my first experience with Cherokee over 11 years ago was full of skepticism. Looking through a lens that was long smudged with cynicism and apathy from working in community mental health and dealing with constant cutbacks, stigma, and a general unhappiness of a workforce that had a list of demands yet a firm unwillingness to adapt to the times, I initially saw Cherokee’s commitment to its mission as something produced on a Disney back lot. It couldn’t be real. No one working in the safety net could be this eager to serve and share. But it was. It was – is – tangible, it’s like the feeling of fresh ozone in an electrified air. “What’s the secret sauce,” people often ask when they come visit, what makes this real?

Well, any Italian worth his weight in pesto will tell you that any good sauce is a combination of ingredients added carefully, simmered under a watchful eye, and even though it sounds corny, cooked with love. The secret sauce includes culture, vision, a commitment to mission, training, best-in-class clinical services, and recruitment. Those ingredients are added and administered by a leadership that leads by example through humble service, and “simmered” through constant, unwavering commitment to the communities we serve. The binding agent, the secret ingredient that thickens the sauce, is love. It’s a staff of people who love doing what they do. It’s a staff of people who all feel that they contribute; there is very little hierarchy on the teams.

Where do you get the recipe? You don’t. You already have it. You do what’s right for your patients and community, constantly striving to increase access and decrease barriers. I’ve had the privilege of working beside Dr. Dennis Freeman for several years now, both formally as an employee, and as a colleague in the safety net, and no one I’ve ever met communicates his vision and sense of mission better than him. That’s where it starts. It starts with the courage to forge ahead with what you know to be right, and not cower to external forces of payment methodologies or inane regulatory edicts. It’s empowered me, it’s created in me my own personal mission to impact a population the same way. That’s how change happens. That’s how a system transforms. I’m not leaving Cherokee. I’m taking it with me, as I am my experiences from previous stops. But Dr. Freeman, and what the team at Cherokee does on a daily basis, has changed me in ways I can’t possibly explain. That’s how people transform. There aren’t words for me to express my appreciation enough; the only thing I can do is to do my part in changing the world.

So I will.

Someone else will write this blog from now on. Cherokee will continue to support you and be there as a resource and an example of what can be. Use it.

Thank you.

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The Skill of Re-Calibration: Or “I need to know everything right now!”

The exhibit hall was abuzz with looping videos, spinning wheels, scripted sales pitches, candy wrappers unwrapping. Most people walk directly down the middle of the aisle avoiding all eye contact with the medical record and software carnival barkers – just hoping to make it to the coffee station unmolested. It’s sort of the like having to listen to a 2-hour timeshare sales pitch just to get a $50 Outback Steakhouse gift card. And there we sat, Dennis Freeman and I in our humble exhibit booth carnival barking about integrated care. Of course we think of it more as spreading the gospel, but tomAto-tomAHto.

Then she appeared.

I have no idea where she came from, but in the literal blink of an eye she was right in front of me, hand extended for an introductory shake while the other was unloading her large bag onto the cocktail table at which we perched. Before I could even finish my own introduction the questions started. While auctioneering the first 3-4 questions out in under 40 seconds, she was pulling a notepad out of her bag and opened it up to a list of questions that could have only been rivaled by the queries asked by the signers of the Declaration of Independence. Of course there was no time to offer any sort of answer to a question before the next burst out like lead from a Tommy gun, so I just politely nodded and pretended to absorb them while in reality they ricocheted around the booth like super balls. Finally when her lungs could stand it no longer, she relinquished the floor. I turned to Dennis to see if he caught any of it, but he was long gone. The five minute 78-speed stream of buckshot was like pepper spray to him and seconds into it he went to find relief at the coffee urn.

She was excited. She heard Dr. Freeman’s presentation earlier in the day on Cherokee Health Systems’ journey to integrated care, and she was inspired. Her own organization had recently crested the hill of precontemplation to seriously thinking about transforming its own practice, and she wanted the goods. All of them. Right now. Dennis peeked around the side of the booth and saw the lady, exhausted and spent, elbows on the table fixated on me and ready to listen, so he returned.

We actually ended up having a very pleasant conversation. Of course we could not answer many of her questions without learning more about her organization and gaining better perspective, but I think we were able to harness her excitement and sense of overwhelmedness into a more productive, actionable plan. Many of her questions were about things that would occur in much later steps; things that we could not answer without providing proper context – like describing a brief behavioral intervention in primary care for a diabetic patient. Recall, her organization was only now thinking about integrating primary and behavioral health. Trying to describe the level of detail of a skilled behaviorist in a transformed practice environment that has built new patient flow models, aligned specific screening procedures with real-time medical record submission, re-engineered the team-based workforce, and aggressively advocated for a payment methodology to support it, was impractical.

Instead I focused on her own ability – and her organization’s ability –  to re-calibrate. In reality we spend about 20-percent of our lives knowing what the hell we’re doing, and the other 80-percent just trying to figure it out. We talked about what that has looked like at Cherokee Health Systems where we certainly undertake comprehensive strategic planning and use advanced metrics and analytics to make the best decisions we can, but also rely on the ole’ “Ready-Fire-Aim” approach as well. Long ago Dr. Freeman established a vision, created the culture to achieve that vision, hired the right people to implement it, and in the meantime was already into implementation. There was no waiting until the time was right, or for when payers caught up with the practice, or for when we hired the perfect candidate. We just did it. And then re-calibrated with what we learned. Know better, do better. I shared that organizations often saddle themselves with deadlines and timeframes by which something of which they know precious little about is to be achieved. It creates overwhelming pressure, which begets irrational decisions and missed opportunities. Take a deep breath. Relax. Trust in your ability to absorb and learn, to adjust and re-calibrate. Create in your organization a culture that doesn’t punish failures and missteps, but rather dissects them and learns from them. Know better, do better.

Just this morning I had one of those rare magical moments with my teenage daughter as we drove to school. We talked about how we sometimes have to make huge decisions in our lives. I told her that right before her older brother was born – and again right before her birth – that I had this overwhelming sense of doom and calamity. I felt like the universe was playing a cruel joke on this baby in that I was going to be its parent. I didn’t know the first thing about being a dad. Even when No. 2 came along, I still felt like I somehow skated by on the first one. She said “yeah, but you figured it out.” I wasn’t really sure about that until that very moment when she validated it to me. Her, and her opinion and perspective on that is the ONLY one that matters.

So just do it. Today at your fingertips you have more information and resources than anyone had even yesterday. Use it, but don’t wallow in it. Just do it.



Posted in Behavioral Health, Behavioral Health Consultant, Cherokee Health Systems, healthcare, Healthcare Reform, Integrated Care, integrated primary behavioral health, Uncategorized, Warm handoff | Tagged , , , , , , , , | Leave a comment

The Primus Inter Pares Effect: Or “We’ve got it worse than you!”

I have a friend who is a Navy lifer, and he said it’s easy to figure out in a large group of officers who the pilots are. “Give ’em two minutes and they’ll tell you,” he jokes.

We’re all guilty of that little indulgence, aren’t we? We love to brag a little, even if its something as routine as being a parent, or being a doctor, or living in a particular place. However, those of us that work in public health and social services tend to take a different spin on it: We can’t wait to tell others how bad we have it. Often when we’re working with someone from – pick a state – within a few sentences of the introduction something like this comes out:

“We’re number one in the country in (pick a distinction):”

  • heroin overdoses
  • meth use
  • alcohol abuse
  • smoking
  • obesity
  • diabetes
  • poverty
  • pain medication addiction

And it might well be true. Someone’s got to be number one each of those things. In fact, one time during introductions in a training we had two groups from two different states debate with each other who was number one in a particular malady.

Beyond that, we all tend to believe our area to be unique. Folks will often start with “well, I don’t know how it is in Tennessee, but here in (insert state) it’s much different.” And it is. Every state is different is some aspect or occurrence. All problems are unique. They might have similar bases, but their impact is varied according to a multitude of regional variances. But of that list above, is there any one region of the country immune to any of them? Does it really matter in the grand scheme who is number one by any ranking or definition? Take for example this study that ranked deaths per 100,000 people due to drug overdoses (Prescription Drug Abuse: Strategies to Stop the Epidemic. Trust for America’s Health, October, 2013). According to this data, West Virginians can claim top billing, while folks in North Dakota might claim superiority of its efforts. I’d bet if we talked with safety net providers in North Dakota, though, they might tell a different story. Just this past week, in fact, there was a story in the Williston, N.D., news about a string of heroin overdoses in the last several days where a person died and eight more hospitalized. The reporter states that while drug overdoses are on the increase across the state, she could not corroborate it with police or the local hospital which stated it doesn’t release that sort of data (Hacklenburg, E., 1 Dead, 8 Others Treated After Overdosing on Heroin in Williston. Forum News Service, Jan. 11, 2016). I’ll bet to the people in Williston it feels like they might be the top ranked region for heroin deaths right now.

There is even a term for this phenomenon: The primus inter pares effect, or “first among equals.” It is also referred to as the above average effect or in more contemporary phrasing as the Lake Wobegon effect where “all the children are above average.” Except in our case, instead of being of above average intellect or good looks, we’re above average in terrible things like diabetes and mortality, which, I suppose, evokes a sense of empathy from others as to how bad we’ve got it here in (insert state).

Studies and rankings are important because we have to have some sort of context, and be able to learn what is working somewhere else. The rub comes when those rankings wear us down, when they erase all hope. When they become an obstacle, or excuse as to why nothing new will help. “We can’t do integration like you all in Tennessee because”:

  • “Our Medicaid system is different”: Yes. They all are, thanks to President Reagan. Some will be more restrictive, and some will be more integrated care-friendly. That’s true.
  • “We can’t do same day billing”: That is another obstacle. There remain some portion of states that have not allowed two separate billed services in the same site on the same day, for example between a family practitioner and a BHC.
  • “Our CFR-42 Rules are more restrictive than yours”: There are states that have more restrictive standards above and beyond CFR-42, particularly with substance abuse. Another hurdle, for sure.
  • “We don’t have the workforce like you do”: We do have a BHC post-doc internship where we grow our own BHCs, that’s true.
  • “We’re in a managed care environment”: Some are very new to it, some have had for a long time, others not at all.
  • “We’re rural.”
  • “We’re frontier.”
  • “We’re urban.”
  • “We’re deeply impoverished, uneducated, and cash-strapped.”
  • “We have a crazy Governor.”

Those are all real issues. They are all real obstacles that require a lot more than just showing up. But not a one is a death knell to integrating primary and behavioral health. In fact, not even a cluster of them can prohibit the practice. That’s not to stay it won’t be a challenge and require strategic alliances with primary care associations, provider networks, payers and stakeholders in order to aggressively advocate when necessary. We’ve yet to find one state – and we’ve worked with just about all of them – where it is impossible.

Our problems and challenges aren’t really so unique, but our solutions have to be in regard to the resources available. Our biggest challenge is not to focus on what makes us the “number one” in some certain disparity, but rather view that as an opportunity. I recently participated in an interview process with a potential BHC of a health center of which I’m affiliated. I asked her one simple question: “What problem do you want to solve.” If you’re concerned about heroin or obesity or diabetes, let’s focus on the solutions and how increased access, more efficient and effective teams, and a stronger workforce can address it. A best practice is a best practice regardless of any of these factors. If payers insist on paying for anything less than the best practice, then the payer has to change, not the practice.




Posted in Behavioral Health, Behavioral Health Consultant, Care Coordinator, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, Integrated Care, integrated primary behavioral health, Uncategorized | Tagged , , , , , , , | 1 Comment

The War Against the Warm Hand Off; or So, what’s the secret sauce?

Lake Superior State University recently unveiled it’s 41st Annual List of Banished Words. Among those included this year are:

  • So – as in beginning a sentence with “So, I learned how to…”
  • Secret Sauce
  • Conversation  – as in “join the conversation…”
  • Stakeholder
  • Walk It Back
  • Physicality
  • Problematic

I particularly love “physicality.” It’s a word that is often used to try to smarten up a generally simple concept. “Their defense uses a lot of physicality to limit the running game.” What? Of course it does. And using five syllables to describe it doesn’t make you smarter.

Is it too late to add another? (Right now my colleagues in Knoxville are rolling their eyes – they know exactly what’s coming).

Warm Hand Off. Or Warm Handoff.

Hate is a strong, ugly word that should be reserved for the darkest of the dark, the meanest of the mean, and with absolute resolution. “I hate peas.” No you don’t. You dislike them, so don’t eat them. You probably couldn’t care less of their existence or if anyone else enjoys them. “I hate getting stung in the eyelid by a bee.” Now we’re getting somewhere. Yes, you hate that. So, let’s walk it back to the conversation of Warm Hand Off, and why it’s so problematic among us stakeholders.

I hate the phrase Warm Hand Off for several reasons:

  1. It sounds creepy. If you go the County Fair and engage in a warm hand off, you’re apt to get arrested, have your picture in the paper and eat a lot of meals alone from then on. Why is it warm? Is it also damp? How about the “Clammy hand off?” Unnecessary words muddying up a simple concept. It sounds like there should be a Carpenters song playing in the background. Ugh. Hate it.
  2. It means nothing out of context, and it is often what some people believe is the key notion of an integrated care practice. “Oh yes, we’re integrated because we do the warm hand off.” It sounds like they’re describing the latest line dance you learned in a gin fog at your cousin’s wedding. Watch me whip, watch me warm hand off. Ugh. I hate it.
  3. Most importantly, beyond the creepy semantics, it perpetuates siloed care. It suggests that the provider is the quarterback of the team and “hands off” the patient to a teammate while he scuttles out of the fray and leaves the teammate to get mauled by the physicality of the defense. Ah, wrong, Champ. You’re still involved in the care and treatment of that patient; you’re not going anywhere and you’ve not actually handed anything off.

In this day of 140 character bursts and search engine optimization, we tend to gravitate to key words and hot phrases. However, that’s often where we stop. I’ve worked with dozens of organizations and read about many more that believe that the simple act of having someone available to receive warm hands integration makes. This “hand off” is but one small, albeit important, feature of a truly integrated practice. More on that in a second.

If not Warm Hand Off, then what?

How about “engaging a teammate.” Or “involving a teammate.” Those are verby, they paint a more clear, descriptive picture of the act, and imply collaboration. When we engage a teammate in the care of a patient, we know there is more to that story. There has to be processes and protocols involved, it is an orchestrated, well-honed and practiced routine part of care. A doctor hands off a completed chart (remember those days?) to a nurse. If he or she were to engage the nurse in the completion of the chart, that suggests a completely different scenario. Let’s definitely stay away from “referring to the BHC.” Referrals and referring is a whole different animal; it implies a more complicated process that includes writing, delays, and the probability of failure. When you refer to the BHC, it may or may not happen. When you engage the BHC, it’s in the present – it’s happening now. There is no failure or delay.

The actual physical engagement of the BHC in a face-to-face encounter with a patient is but one component of an integrated practice. It starts well beyond and above that with the organization’s mission and values, to it’s clinical patient-centered approach that values team above individual. It includes robust communication systems such as an integrated EMR and well-planned regular team huddles or meetings. It involves facility planning, extensive training in brief interventions for a population-based practice, and stout data collection and outcome management systems that focus on populations and greater impact. There is a financial model that not only sustains the practice, but pushes it forward and creates new opportunities based on the quality of data and outcomes it produces. It accounts for the “almost codeable” actions such as phone/hall conversations, follow-up calls, care coordination, and outreach. Indeed, it changes EVERYTHING.

(steps off soap box)

So, we can avoid calling a presser to harp on this any further. Just please, PLEASE stop using warm hand off. Please. And eat your peas.



Posted in Behavioral Health, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, Integrated Care, integrated primary behavioral health, NACHC, Warm handoff | Tagged , , , , , | 3 Comments

Measuring Integrated Care: “or trying to weigh a moving wave.”

About once a week I get a call from a colleague asking me if I could send them information and/or data as to how we measure the effectiveness of our integrated care project. First off, those of you who might have read previous posts on this site know what I think about the term “project” in relation to integrated care. For now, we’ll set that aside.

I’ll usually start by asking them what specifically are they looking for? A lot of times they aren’t really sure, but generally they want to see some comparative data as to the efficacy of the model versus those who have not received integrated care. In a vacuum where we can control for the dozens of variables involved, that might be possible. In practice, though, it’s like measuring the weight of a specific wave. How much of it exactly do you want to weigh? How do you define a wave? At what point in its development from just a surge to full-on surfable wave? Where does it start and stop? What about the debris and sealife that might be rolled up in the wave? Do we measure that too, or just the water? So the point is made – it’s a bit of a loaded question, and frankly one that in a truly integrated system is impossible to answer to the satisfaction of someone wanting that level of detail. Now, in theory, measuring a wave is really as simple as measuring its height times width and factoring it at a measure of one cubic meter of water weighing one ton. But we’re not talking about theory here, are we? We want to compare a specific patient versus another specific patient controlling for specific variables. Patient A received interventions from a behaviorist (BHC), Patient B didn’t. Who is better?

Clearly we see the problems with this. We have to control for a lot of variables, set some very clear definitions, and design some very specific measures and procedures to vet this with any degree of accuracy. This is why we choose to focus on population health measures. This is for a couple of reasons:

  • This is a population-based practice
  • Causality and correlation is impossible to identify
  • It’s not really a choice at all. It’s the only way to ethically and accurately measure its effectiveness

In a truly team based integrated setting, there are a number of connections, relationships, and communications that may benefit a particular patient. For example, Patient A comes in, scores high on her PHQ-9, and gets to chat with a BHC, and leaves with a few self-interventions she can apply in her life to decrease the impact of her depression (leaving out, of course, the medical interventions which may also play a significant role in the patient’s mental functioning – but we’ll control for that in this example). Patient B comes in, scores the exact measure on his PHQ-9, but does not see the BHC. Could we figure out some measures to track their outcome from that point? Maybe. But the scientists quickly start raising alarms about reliability, validity, distortion, bias, correlation, causality, etc. In a truly integrated setting, we need to ask a whole lot of questions about Patient B. Did the provider consult with a BHC (a “curbside consult”)? Did the provider use skills and protocols he might have learned from a BHC to assist the patient and his depression? Is the patient receiving counseling from an external therapist? Is he already on an anti-depressant and has suffered with depression for a long time? Quickly we’re trying to measure waves again, right?

In a behavioral enhanced patient centered medical home practice measuring specific patient outcomes in comparisons to others is a fool’s chase. It is a rabbit hole the size of the Holland Tunnel. And in the end its meaningless. This practice helped that patient. Great. So what? Are we prepared to transform an entire healthcare system based on isolated cases in statistically insignificant sample sizes? Is a grantor or payer going to be dazzled by that and commit to collaborate?

We measure our impact on populations and the unique challenges facing each particular practice. I always start with this graph based on data from an external payer that compares our practice with other local providers serving safety net patients:

Comparison Slide - Graph

In this graph you see that our practice produces more primary care encounters, and significantly decreases ER utilization, specialty care, and hospitalizations to the tune of an overall cost savings of 22 percent. We can dive deeper into this by looking at the factors that keep our patients out of the ERs 68 percent less than our peers. Better care coordination, accessibility to care, more targeted services, etc. This data, by the way, covers a very large sample size and time period, for those asking (and rightly so) about its context.

When stakeholders or payers ask about specific outcome data, it should not be a point of stress, but rather an opportunity to educate them on what integrated care truly is. As described by Parinda Khatri, Ph.D., our chief clinical officer, we need to also consider the common factors that tend to impact patient outcomes: Culture, family dynamics, habits, and health literacy. In the very least, the model helps mitigate barriers to care and does not contribute to the problems of access and the delivery system. In the ideal, we have some impact on keeping patients out of ERs and hospitals, and help with personal resiliency.

I know that is often an unsatisfactory answer to people who want simple measures and results. It would be far easier if we were segregating one population from another (for example, adult patients with a diagnosis of depression that all receive identical protocols from a trained team of specific providers that is responsive to this population). Sure, that’s an effective approach that will likely yield terrific results – but it is not what we think about in terms of integrated, population-based care.

So, surf’s up…who’s ready!?!



Posted in Behavioral Health, Behavioral Health Consultant, Cherokee Health Systems, Healthcare Reform, Integrated Care, integrated primary behavioral health, Uncategorized | Tagged , , , , , , , | Leave a comment

Medical Expenses & Poverty, What We Now Know: Or, “The poop on MOOP.”

I had the opportunity this week to attend a panel presentation on poverty hosted by a local church. The event was billed as a discussion on poverty and “to help bring awareness of the all-too real problem of poverty and homelessness within our county.” I needn’t identify the county, because one could insert any county in the title and it would still apply. On the panel was an esteemed gathering of homeless shelter/housing directors, the sheriff, a charity that helps with small bills and expenses, a school superintendent, and an attorney who specializes in guardianship and poverty law.

Naturally the discussion initially focused on homelessness which is the all-to-visible face of poverty. The director from the small charity, though, asked that we also consider poverty in whole; while not that we ignore homelessness, but the epidemic of poverty is by-in-large unseen – hidden right in front of us in plain sight.

Earlier this week I participated in an all-day strategic planning session for a health center for which I’m honored to serve as a board member. There we had a consultant present on a series of data that she collected about our area including health disparities, penetration rates, demographics, and poverty. What quickly emerged is that in our area – despite news reports of declining unemployment and an improving economy – is that poverty rates increased, health disparities worsened, and that demographics radically changed in several markets. Community Health Centers, by their very mission, tend to go where the grass is browner, so the ground is fertile for expansion of services.

But I’m drawn again to the panel discussion. Who was missing on that panel? Many discussed mental health and substance abuse as a key indicator – not cause – of poverty. Yet there was no representative from any mental health and substance abuse providers. Who else was missing?

In 2013 the U.S. Census released a report on poverty related to medical expenses. Depending on where you look, the national rate of poverty hovers around 15% in the United States. In data from 2011-2012, the report found that medical out-of-pocket (MOOP) expenses alone added nearly 3.4% of all Americans to the poverty rolls – or more accurately, 10.6 million people.(1) Digging deeper, of those working age adults living in poverty, 50% of them spend ten percent of their income on MOOP, the single highest expense other than shelter and food – and at a rate that doubled since 2001.(2)

So who was missing on that panel?

We already understand that the people living in poverty often live in food deserts, lack access to exercise facilities, and often work long hours at multiple jobs, and tend to not have advanced degrees. All of these factors are indicators in poor overall health and where you find health disparities, you’ll often find these indicators. Yes, education, employment, shelter are all important factors in stemming the rise of poverty, but clearly, access to affordable medical services and coverage is also important – if not on equal weight.

I often think of a 3-legged stool in terms of community stability: Housing, employment and healthcare. If any of those legs fall out of balance, the stool is unstable. It rings true for individuals as much as a community. Strength in one positively impacts the other, as much as a depletion of one burdens the others. If you want to add a fourth leg of education, you’ll get no argument from me.

So there was a glaring gap on that panel – as strong and passionate as the speakers were. The lack of access to quality affordable healthcare and MOOP costs are every bit a factor of poverty as anything else that we already knew, and according to the data, it’s worsened in since 2001. Will the ACA and state expansion of Medicaid help curb this tide? The early data is promising. In the small sample size that is our local health center, due to the tireless work of healthcare navigators, a sizable percentage of previously uninsured patients became covered from 2014 into 2015. That conversion alone shifted the payer mix significantly and helped provide better access to healthcare for those individuals – healthcare that will now be at least partially covered.

Look around your own community – really look. It will be hard to see the poverty, but if you look, you’ll find it. Single parents who line up at Minute Clinics in the early mornings before school; the waitress at your favorite restaurant who also works at the nursing home on weekends; the grocery store check-out lady who worries about her job as her store adds four more self checkout kiosks. Encourage your community to have similar conversations and panels.

And who will YOU remember to include?

(1) Weissmann, J. Census: Medical Expenses Put 10.6 Million Americans in Poverty. The Atlantic. Nov 3, 2013.

(2) Collins, S. New Census Poverty Measure Shows Medical Expenses Push 10 Million Americans into Poverty. The Commonwealth Fund. Nov 10, 2011.


Posted in Behavioral Health, Cherokee Health Systems, Federally Qualified Healthcare Center, healthcare, healthcare management, Integrated Care, integrated primary behavioral health, Medical Expenses, NACHC | Tagged , , , , , , , | Leave a comment

The Value of True Integrated Care: Or “Vying for shelf space in a competitive market”

We all remember that time when our parents returned from the grocery store with a two liter of cola. Not Coke or Pepsi, but just some nondescript plastic bottle of something that on first glance sure looked like cola. The label said “Cola,” and it even fizzed like cola when you opened it. But then…you tasted it…and it wasn’t Coke or Pepsi. It was, I suppose, by definition cola, but you still felt gypped.

There will come a day when patients and payers feel the same way about healthcare. They will be sold something called “integrated care,” but once the product is served, they’ll soon realize they’ve been given the healthcare equivalent of cola when they were expecting Coke. So what’s the big deal? Buyer beware, right?

In the marketplace, inferior products soon find themselves relegated to the bottom shelves, if at all. They are replaced with the items in demand, the items that provide value, be it financial or satisfaction. And it tends not to take long. The difference in healthcare, with integrated care, specifically, is that the discovery period is much longer, much more expensive, and in the meantime, lives are affected. Maybe even lost.

Recently, the Agency for Healthcare Research and Quality took on the task of defining integrated care. A panel of experts from across the country was convened and this is what they developed:

“The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systemic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress related physical symptoms, and ineffective patterns of health care utilization” (Peek CJ & NIAC. Executive Summary: Lexicon for Behavioral Health and Primary Care Integration – Concepts and Definitions Developed by Expert Consensus. AHRQ Pub No. 13-IP001-1-EF. Rockville, MD. 2013).

While it certainly forms some boundaries around the concept of integrated care, it is hardly prescriptive and still leaves ambiguity. It clearly states that it is team-based care of behavioral and primary care clinicians working together, it may still lead some to believe that the clinicians are separate and only come together when indicated. In fact, what is fast becoming the gold standard – or best practice – is that the behaviorist is embedded on the primary care team and for all intents and purposes, functions much like a primary care provider in their delivery and scope. This is well described in Understanding the Behavioral Healthcare Crisis: The Promise of Integrated Care and Diagnostic Reform (Cummings, N., and O’Donohue, W., Routledge, New York. 2011).  Clear definitions between co-location of specialty care and primary care, and true integrated care are described. What many call “integrated care” is in actuality a co-location of services, care collaboration, care coordination, or something else. There is, in fact, nothing wrong with those approaches, but they are not by definition, integrated care. They will not produce the cost-effectiveness results, nor will they impact broad health disparities in a population-based healthcare model. These will be the value standards by which payers will seek to negotiate payment with providers. If you aren’t delivering the value – even if it seems to fizz when the bottle is opened – you will soon find yourself vying for shelf space with other inferior products in the clearance aisle.

It is vital that as payers and stakeholders become wiser to integrated care, that they are smart shoppers, and we as providers are beholden to some accountability of our labels and services. Only then can true value be recognized and extracted. The importance of this cannot be understated as we evolve through value-based payment reform.





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