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COMMENTARY: Grand Junction Reflections on Collaborative Care.

Fam Syst & Health 17:437-446, 1999

In Grand Junction, Colorado, where the Colorado and Gunnison rivers meet, medical and mental health services are streaming together to serve the poor and uninsured. The nexus of activity in Grand Junction is the Marillac Clinic, a primary care clinic serving uninsured patients with household incomes no greater than 150% of federal poverty guidelines--about $25,000 for a family of four. Over 55% of Marillac patients have one or more psychiatric disorders. Depression is the most prevalent diagnosis, twice the rate of hypertension, the second most commonly diagnosed health problem. Over the last few years, providers and clinic staff felt overwhelmed trying to care for patients whose mental illnesses were inadequately addressed, who took disproportionate amounts of provider time, and whose concurrent chronic medical illnesses were poorly managed. An assortment of nonprofit community mental health agencies(1) and Marillac have formed the Mesa County Coalition on Health (MCCH) to create collaborative care for the poor. From August 1998, through July 1999, our team(2) conducted epidemiological research, and I provided consultation and training to Marillac personnel and to MCCH staff.

This issue of Families, Systems & Health contains four articles addressing referrals from primary care to mental health, implementation of team approaches, conjoint visits of mental health and medical providers, and training marriage and family graduate students to work in medical settings. These articles raise or address many questions about the integration and maintenance of collaborative healthcare designs. The following commentary will blend remarks on these articles with notes from my year's sabbatical in Grand Junction. While the tasks of integrating collaborative care vary across settings, some challenges are ubiquitous. Training clinicians to work as part of a team when they are used to practicing in isolation means asking them to change fundamental mind-sets and behaviors. The healthcare organization embracing collaborative healthcare, be it large or small, is confronted with change at every level including information systems management, appointment scheduling procedures, space allocation decisions, and budgetary redesign. The Grand Junction experience serves as a real life backdrop against which salient findings in these papers can be examined.

Reust, Thomlinson and Lattie (1999) present an intriguing qualitative study examining why patients do or do not, keep behavioral health appointments. Their study occurred in a residency clinic in which a local community mental health clinic had a satellite office. Whether the mental health staff is housed in the same corridors as exam rooms is not clear. While billing and scheduling functions are not integrated, the computerized medical record design allowed sharing of information between the mental health and medical/ nursing providers. Providers in both groups collaborated across a spectrum of modalities. Of the study patients referred from primary care to mental health, 33% did not keep their appointments.

Their research produced several explanations why patients did not keep appointments: financial problems, transportation difficulties, illness related reasons, lack of motivation, previous negative experience with a mental health professional, and administrative issues such as scheduling mistakes. Patients who kept appointments were found to have two distinguishing characteristics. They were five times more likely than those who did not show to identify an important "other" person as a motivating force (58% vs. 12%). Compared to those who did not keep their appointment, twice the number of patients who kept their appointment acknowledged that they had a behavioral health problem (84% vs. 41%).

There is much to learn from the Reust, et al. study. Primary care providers struggle to get distressed patients into mental health treatment. Prior to arriving in Grand Junction, Janet Cameron, M.S.W., the Marillac executive director, and I conducted a survey of Marillac providers, staff, administration, and MCCH psycho-therapists to determine a training curriculum. The topic of greatest interest to all groups was "making successful referrals." The Reust et al. clinic's 67% success rate for keeping first time appointments is a better rate than many clinics report. For example, before making the changes described below, less than one fourth of Marillac patients kept their first mental health appointment at local agencies. When a local mental health agency placed a therapist in Marillac, referral success modestly improved, reaching a 25% success rate. When the recent training and clinic changes had taken place at Marillac, referral success was tracked for the first 25 patients. Ninety-two percent (23) of referrals were successful. While Reust et al. do not acknowledge the role that co-locating behavioral health and medical services has on patient receptivity to referral, it is important to not take this structural feature for granted. However, co-location is not the entire solution for connecting patients with mental health resources.

Reust et al. suggests that one way to facilitate connection to mental health care is for primary care physicians to apply motivational interviewing skills (Miller and Rollnick, 1991). In the motivational interviewing approach providers only recommend changes that patients are ready to hear. When patient ambivalence is apparent, rather than try to convince the patient of a better way to behave, the prudent clinician empathically and respectfully explores the patient's reasons not to change--in this case, to resist meeting with a mental health provider. This is where the barriers to referral are detected and addressed, minimizing the chance of scheduling an appointment not to be kept.

The initial phase of Marillac training introduced clinicians to Motivational Interviewing. Clinicians were taught to assess patient receptivity for mental health professional involvement. Careful questioning searched for fears of abandonment, financial concerns, logistical problems with transportation or childcare, poor family support, prior negative experiences, and stigma fears. A flexible approach to integrating the family health counselor offered providers a menu of strategies to match patient receptivity. Highly motivated patients could simply ask the receptionist for an appointment. Providers were discouraged from rushing referrals and instead coached to request follow-up visits to explore patient hesitance. Three-way consultations or ad hoc introductions of the Family Health Counselor allowed the provider to gradually insert his or her preferences into the patient's thinking. The primary care provider becomes an influential "other." Moreover, these three-way meetings display the close working relationship between psychosocial and biomedical providers. When patients believe that their medical and mental health providers have a close working relationship this may enhance referral success, if not overall treatment outcome.

We discovered Marillac patients want their medical and mental health providers to communicate. Our recent epidemiological survey of 500 consecutive patients included a question about patient preferences for communication between mental health and medical providers. Eighty-nine percent of patients indicated they wanted their providers to communicate, whether or not receiving care in the same setting. I interviewed roughly 50 of the patients in the Marillac study. Almost all had the same reaction, at times surprised that I would even ask a question with such an obvious answer. In my 20 years of practicing in medical settings. I always ask permission from patients to share information with my biomedical colleagues. At least 1000 patients, with the exception of a handful, have given me permission, often expressing appreciation.

In addition to these clinical interventions, we instituted operational and financial changes to create a system that supported our clinical mission. Mental health records were placed in the medical chart, although in a separate section. The process of making appointments with the in-house family health counselor became the same as making medical appointments, decreasing the risk of "administrative" mistakes described by Reust et al. A revised behavioral health consultation form asked providers to note both the patient's and the provider's reasons for requesting a consultation/referral. This decreased the chance that providers would request consultation without considering the patient's readiness. To decrease the risk of long waiting times, the family health counselor had weekly time slots available only for "new' appointments." Finally, fee structures for mental health care were made the same as fees for primary medical care.

Mullins, Balderson, and Chaney (1999) discuss implementing team approaches in primary care and tertiary care settings: applications from the rehabilitation context. They make the following five points. 1) Team models should be theory driven; 2) A common explanation for struggles in sustaining collaborative care is poor leadership and the absence of relationships between members of different disciplines; 3) More outcome studies validating the quality and cost advantages to team approaches are needed; 4) Health care designs should pay more attention to family variables. That is, family dynamics affect healthcare outcomes and family experience is influenced by the health status of its members; 5) They call for a new team curriculum. The subtext of their message is that for collaborative care designs to become more abundant, the research and experience within healthcare professions should be shared across disciplinary boundaries.

In discussing the need for theory driven models, Mullins et al. (1999) describe a continuum of relationships in teams: multidisciplinary, interdisciplinary, and transdisciplinary. This last stage is characterized by "role release," the sharing of responsibilities between members of different healthcare professions. Sharing of responsibilities also means sharing vulnerabilities. Neither occurs without the building of relationships between members of different disciplines. All too often I have consulted with clinicians that work in multidisciplinary settings where communication is formal, terse and where creative efforts to solve problems are rare. What are the forces that push a system to move from multidisciplinary to transdisciplinary? Mullins et al. cite a model developed by Doherty (1995) wherein the potential for collaboration is thought to be determined by the degree of healthcare system integration. For example, do information systems hinder or help communication between providers? Do financial designs support patients in seeing mental health professionals and fund space for co-location of service? In recent years, many others have emphasized the critical link between systems integration and collaborative care success (Blount, 1998; Devers, Shortell, Giles, et al., 1994; Peek & Heinrich, 1995; Seaburn, Lorenz, Gunn, et al., 1996; Wagner, Austin, & Von Korff, 1996).

Part of the answer to developing a transdisciplinary team is in the training design. Mullins et al. (1999) recommend "in-house" training. This design, used to create collaborative care cultures (Mauksch & Leahy, 1993; Peek and Heinrich, 1995) brings members of different disciplines together in the educational process. Transdisciplinary training was a central feature of the Marillac plan. All didactic sessions included medical, nursing, and mental health personnel from Marillac and the MCCH community. Some sessions were for Marillac medical assistants, receptionists, and administrative staff. Language and concepts once unknown became the shared property of teams, helping to form a new culture. However, didactic training is not sufficient.

Shared experience is critical and was an integral part of the Marillac process. Having providers see patients with one another fosters vulnerability. Providers voice their uncertainty in the face of abundant unexplained medical and psychological symptoms (Kroenke & Mangelsdorff, 1989). In this space of not knowing, one clinician can provide consultation and support, often freeing the another clinician from "thinking within the lines". Clinicians begin to think out-loud, educating each other about their respective disciplines. Eventually, disciplinary boundaries blur (role release) and the physician offers psychosocial solutions while the psychotherapist introduces biomedical ideas.

Shared clinical experience in training is discussed further in connection with the Taylor et al. (1999) article. However, before moving on I am compelled to relate one of the defining moments in my collaborative care career. It occurred while watching a "transdisciplinary" team discuss a patient they had all interviewed. The team included a family doctor, a medical anthropologist, a psychiatrist, and the noted author-psychiatrist-anthropologist, Arthur Kleinman, M.D., Ph.D.. Following the panel discussion a member of the audience stood up and spoke in an angry, critical tone. "I can't tell which of you is the doctor, the psychiatrist, or the anthropologist," he said. Arthur Kleinman, M.D., Ph.D. rose to his feet and spoke calmly. "Sir, you could not pay us a higher compliment."

Mullins et al. (1999) suggest that team designs should be determined by patient needs. This principle reflects an increasing emphasis in healthcare, including mental health, to adapt treatment efforts to meet patient and community needs. With limited resources, healthcare systems are wise to allocate funds and personnel to address problems that are prevalent and that have the greatest impact on health status and quality of life. No disease fits this bill more than depression (Katon, Von Korff, Lin, et al. 1997). Beyond being a prevalent diagnosis, it often impedes the management of common, chronic medical diseases like diabetes and hypertension.

The versatility of the Marillac consult and referral system exemplifies a spectrum (Seaburn, Lorenz, Gunn, et al. 1996) of options for responding to the diverse needs of the patients, families, and providers. At one end of the spectrum, collaborative practitioners work alone but with a breadth of clinical curiosity, feeling the influence and support of the additional expertise down the hall. Informal discussions occur in that hallway, sometimes leading to a formal consultation with the patient. In many cases, providers from more than one discipline become co-providers of care. And in complicated cases the envelope of collaboration is expanded to include needed specialists and agencies.

In designing a process to integrate collaborative care in the Marillac clinic and surrounding community, three guidelines were defined that echo the messages from Mullins et al. (1999). They proved helpful in designing our training, as a compass in planning and in the pursuit of grant support.

1. Education of clinicians is not enough to create a useful and sustainable collaborative care system. In evaluating methods of collaborative care to manage depression in a primary care clinic, Elizabeth Lin and her colleagues (1997) discovered that primary care providers' detection and treatment approaches reverted to pre-intervention levels after grant-funded mental health professionals left the clinic. Therefore;

2. Relationship building between members of different disciplines is essential. Relationship development coupled with a shared mission and appropriate education increases the possibility of enjoying transdisciplinary teamwork.

3. Meaningful changes in service requires systems change. To maintain creative and efficient healthcare delivery for patients with complicated, chronic illnesses, it is necessary to align financial, operational, and clinical role designs (Peek and Heinrich, 1995; Wagner et al., 1996).

Taylor et al. (11999) describe a study of "conjoint" collaborative care. This was a multi-agency effort putting together family medicine faculty and residents with mental health professionals from a community mental health center. Clinicians from these two settings saw patients together at a regional medical center serving mostly poor patients. Researchers examined provider and patient experience of the conjoint model across 397 interviews over a 12-week test period. Data came from pre- and post-structured group discussions with providers, two patient surveys, and utilization data.

Overall, providers liked the conjoint experience, appreciating growth within the team relationships. Physicians valued the therapist's ability to detect subtle or hidden patient concerns. Other attractions included educational benefits and the ability to treat psychosocial disorders that physicians might not have the skills or time to address. Questions about the conjoint model focus on affordability, determining which patients benefit from this approach, and whether the physician should enter the room first or both clinicians at the same time. Patients subjected to the conjoint model were as satisfied as controls in response to all survey questions except one. Conjoint team patients had higher satisfaction ratings than patients of controls in being able to "talk about personal problems with my provider."

Conjoint visits jump-start the development and promote the durability of collaborative relationships. Interns in our Family Medicine Residency, Mental Health Internship in Collaborative Care, and at other programs around the country, begin their experience by following faculty and senior residents. One of the first things I did upon joining the Marillac clinic was to "shadow" the primary care providers. The nurse practitioners, physician assistants, and physicians were, for the most part, hungry to learn new skills and have someone to share the burden of treating the ever-waiting patient in severe psychosocial distress. Time in the exam room helped me understand the style and pace of primary care. Observing primary care clinicians juggle their multiple tasks was humbling and usually increased my respect for their work. Making periodic conjoint visits is a central part of the job description I created for my replacement at Marillac and for MCCH psychotherapists who will spend half their time at Marillac.

When conjoint visits occur periodically over time, the availability and value of psychosocial care remains in the front of the primary care provider's consciousness instead of gradually drifting to the periphery, upstaged by daily routines that understandably leave many behavioral health problems under-detected and undertreated. Similarly, periodic conjoint visits counteract a pervasive professional ethos creating a subtle but ever-present gravity pulling psychotherapists into isolation.

The conjoint teams in the Taylor et al. (1999) study reported gradual relationship changes as the numbers of shared visits accumulated. This is my experience, too. At Marillac, I functioned both as trainer and family health counselor, adding another role to the one-dimensional, peer experience of the clinicians in the Health Center experiment. I see three levels of the conjoint relationship, sometimes occurring in sequence and always influenced by the organizational context and relationship maturity of the clinicians working together. In the Observation Level, I say nothing, only watch, doing my best to show interest, concern, and support for the patient and the provider. In the Feedback/Consultation Level, the primary care clinician asks for (or receives from the trainer) feedback or consultation after leaving the exam room. In the Collaborative Interchange Level, various kinds of interaction occur during the patient visit. The primary care provider might request the psychotherapist's opinion. And for patients where prior plans include combined interventions, the psychotherapist performs assessments, demonstrates ways of getting patients to talk about sensitive topics, uncovers occult disorders, or helps to tease out the intricacies of a belief system. I have enjoyed all three forms of conjoint interaction when biomedical colleagues accompany me seeing patients. These are usually training situations, but often I invite a colleague to join me to address questions about medications or around management of chronic illnesses.

Is conjoint practice necessary for all patient encounters? Probably not. It would be too costly and not desirable by all patients or for all healthcare problems. The obverse is also true. Many psychotherapy efforts could benefit from medical consultation but not all of them. Should conjoint care be a ready feature of collaborative care systems? Yes. The conjoint visit provides expanded perspective for clinicians, additional expertise for patients, and assistance to a patient-provider relationship struggling to find common ground. High utilizing (Lefever, Reifler, Lee et al. 1999) patients with chronic medical and mental health problems, patients with belief systems (Wright, Watson & Bell, 1996) that conflict with western medical practice, or patients in psychosocial distress but reluctant to see a mental health provider alone would all benefit from conjoint visits. As noted earlier, conjoint care is one phase on a spectrum of collaborative care. The visit may facilitate ongoing involvement of a mental health provider or give the primary care clinician and patient a new perspective that alters their future work.

Population characteristics should influence the degree to which conjoint care is available. In the poor, the prevalence of mental disorders is greater (Bruce, Takeuchi, Leaf, 1991; Lynch, Kaplan, Shema, 1997) and the resulting disability (Ormel, Von Korff, Ustun, 1994) perpetuates poverty. In Marillac, patients with the most severe mental disorders reported 19 disability days in the prior three months compared to 3.5 disability days for patients who had no evidence of a mental disorder. Taylor et al. (1999) found, as have others (Lefever et al. 1999), that patients with more mental health problems use medical services more often. Recent research suggests that psychological and social issues affecting health related quality of life are as important to patients as physical concerns (Sherborne, Strum & Wells, 1999). A concern for one's psychological and social well-being is a profoundly obvious preoccupation for the poor. Primary care clinics serving the poor, whether insured for not, should take these needs into account in staffing designs. At Marillac we joked that for most patients it made sense for me to put a stethoscope around my neck to appease the patient's sensibility, see the patient first and, when necessary, consult with a biomedical colleague.

Both Mullins et al. (1999) and Taylor et al. (1999) remind us of the need for more outcome research supporting the value of collaborative healthcare. Patients in the Taylor et al. study were given the SF-36, an instrument designed to measure health related quality of life. This self-report instrument, and its sister versions, the SF-12 (Ware, Kosinski, & Keller, 1996) and the SF-20 (Stewart, Hays & Ware, 1988) when used in combination with measures that track mental health and physical health, assess the patient's view of physical and mental illness on physical functioning, bodily pain, role functioning, general health perception, social functioning, and mental health. Readers interested in this research are referred to the work of Wells, Stewart and Hays et al. (1989) and Spitzer, Kronke, Lizer et al. (1995). They compared the impact of mental illness versus physical illness on health related quality of life and showed mental illness to be equal to and usually greater than most chronic medical illnesses in causing disability. At Marillac, using a recently validated version of the PRIME-MD (Spitzer, Kroenke, and Williams, 1999), a measure of medical comorbidity and the SF-20, we have similar findings. The development of these instruments has progressed to the point that they are easy to administer and require little or no professional time for interviewing. To date, their use has been limited to epidemiological studies comparing the relative influence of physical or mental illness on health related quality of life. They also provide practical ways to study patient health status before, during, and after exposure to collaborative care.

An article by Yeager et al. (1999) conveys the experiences of eight Marriage and Family Therapy (MFT) Trainees placed in a radiation treatment waiting room to learn about: a) the impact that illness has on families, b) the needs of patients in medical settings compared to "other" (presumably mental health) settings and c) the value of promoting agency and communion as described by McDaniel, Hepworth, and Doherty (1992). An orientation process introduced students to the technology and language of radiation oncology. Students spent two years in the waiting room on the same day each week for a four-hour shift. The students' supervisor (Yeager) met with each student weekly and the entire group every other month. Students also kept notes on patient interactions.

Discussion thus far has focused on collaboration between providers of different disciplines. Yeager et al. (1999) remind us of an equally important form of collaboration--between patients, their families, and the healthcare system. Healthcare providers have invaluable allies in family members as advocates, in-home providers, decision makers, and experts on family response to suffering. And families caring for sick, loved ones are themselves at risk for physical, psychological, social, and financial disability (Levine, 1998; Rolland, 1994) Training at Marillac emphasized collaboration with patients and families. The evidenced based (Stewart, Brown, Boon et al., 1999) value of soliciting the patient and family agenda(s), eliciting perspectives on illness, and pursuing mutual investment in treatment planning was presented in didactic sessions and reinforced during conjoint visit training. Providers were taught to routinely weave "family curiosity" into every interview. The result was enhanced understanding of the social underpinnings of depression, heightened appreciation of how family turmoil can undermine the management of chronic illness, and delight in successfully recruiting family assistance with diabetes management or smoking cessation.

The students in the Yeager et al. (1999) project grappled with discerning the difference between care and cure, between disease and illness (Kleinman, Eisenberg, Good, 1978). Cancer draws out individual and family coping styles, some appearing less adaptive than others. From a young (or experienced) therapist's perspective, a family's stoic approach to grief, its tendency to avoid conflict, or its overprotective manner is easily pathologized and thus viewed as a "disease." But from the family's perspective, the struggle of coping with cancer is their "illness", not a disease for which they seek a cure. I constantly remind myself and the trainees I serve that curiosity about and empathy for the patient's experience should precede the definition and pursuit of therapeutic goals. In this way, care is always delivered first, helping define what, if any, cure-directed interventions are appropriate and desired. I admit it is often more difficult to make these distinctions than to write these words.

Across healthcare disciplines there exists an understandable drive to "fix" the problem; frustration occurs when clear outcomes are not available. When the boundaries between care and cure blur, our desire to "fix" (cure) problems imposes clinical directions that may ignore patient needs and even do harm. At Marillac and in a family medicine residency, teaching "caring" skills has been directed towards doctors, physician assistants, and nurse practitioners. But clinical work in the psychosocial domains involves both cure and care as well. In this sense, psychotherapists face developmental challenges similar to physicians. The tangible but often non-curable nature of chronic and terminal disease starkly defines the limits of a clinician's influence more clearly than intangible mental "illnesses". Perhaps working in a medical setting catalyzes this part of maturation for mental health professionals much as learning to listen to emotional pain does for physicians.

Readers of this issue of Families, Systems & Health are prompted to develop a smooth interface between physical and mental health services, to collaborate with families, to use conjoint visits in primary care settings, and to help trainees care, reflect and acculturate. These efforts require teamwork, only viable when supported by integrated healthcare systems fostering relationship growth between members of different disciplines. Maybe the true grand junction is creating healthcare organizations that mirror the complexity and dynamic nature of the patients, families and communities we serve.

ENDNOTES

(1) The Center for Enriched Communication, Colorado West Mental Health, Individual and Family Counseling and St. Mary's Hospital Psychiatric and Recovery Services. The only local health maintenance organization, Rocky Mountain HMO, has also provided support and attended planning meetings.

(2) Larry Mauksch, M.Ed., Susie Tucker, Ed.D, Wayne Katon, MD, Edward Walker, MiD, Janet Cameron, MSW with enormous help from the entire Marillac staff

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Larry B. Mauksch, M.Ed. Clinical Associate Professor, Department of Family Medicine, University of Washington and Collaborative Care Consultant, Marillac Clinic, Grand Junction, Colorado. Email: mauksch@u.washington.edu.
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