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Observations from home: the Patient Centered Medical Home, Integrated Behavioral Healthcare, teams and teamwork.

Medicine is no longer a single's game, it's a team sport. Long true in surgical specialties where the operative effort led by the chief surgeon is a carefully choreographed ballet of surgical assistants, surgical nurses, anesthesiologist, and other technical staff, now medical subspecialists are also assisted by teams composed of advanced practice nurses, physician assistants, social workers, and pharmacists.

In primary care, the new vehicle for care teams is the Patient Centered Medical Home (PCMH; Kellerman & Kirk, 2007), which is designed to serve 85%-90% of patients' needs with the broadest "basket of services" possible. As with our specialist colleagues' team efforts, PCMHs are adding a broad variety of health professional colleagues to care for panels/ populations of patients including nurse care managers, social workers, pharmacists, behavioral health professionals (BHPs), nutritionists, integrative medicine professionals, and health coaches. When these health professionals join with family medicine physicians, who themselves provide diverse clinical services (primary care for all ages, maternity care, office surgery, sports medicine, preventive medicine, and population health services), there is both an opportunity and a requirement for true team development. With high-functioning teams, the modern family medicine PCMH should really be able to deliver on the promise of the Triple Aim: better care, better health, and lower cost (Berwick, Nolan, & Whittington, 2008).

Many PCMHs will have only one or two of these additional health professionals on their teams. But a challenge arises in operating PCMHs that have added several of these peer health professionals to their staffs: when to involve whom to help our patients. In part, this confusion derives from the fact that there is some overlap in services provided by these teammates. Nurses have always taken on many duties in medical offices and now are working on transitions of care coordination, chronic care management, and population health. Pharmacists in their expanding role with "medication therapy management" (MTM) are evolving from regimen rationalization and adherence problems to broader involvement in behavior change in patients with chronic diseases. Integrative medicine mind-body professionals promote increased physical activity, stress reduction, and healthy eating in addition to hands-on modality care. Social workers have expanded from coordinating community services to providing direct counseling to patients. And BHPs also work on promoting positive health behaviors in chronic disease while consulting on common mental health, substance, and family interaction problems in primary care. So, one can see how primary care physicians (PCPs) might be unclear on which teammate is best suited to help out on any given patient.

In our University of California-San Diego (UCSD) Family Medicine offices, we needed to clarify for the PCPs which services different members of the team might be able to provide to help the physicians with specific patients and problems. We used several mechanisms to create a shared understanding of each team member's role. We developed a written protocol for PCPs describing the scope of services provided by each team member. We also developed a shadowing experience between PCPs and new staff to introduce these teammates to each other and allow them to observe and learn about each other's skill sets, perceptions and personal backgrounds. We've found that even one 4-hr shared patient care session can jumpstart solid collaborative relationships for the long-term. As our teams have learned about each other and have settled into routines, role clarity has become less of an issue. Our journey points up the need for lots of direct exposure, sharing, and communication among ALL team members to achieve optimal team functioning.

Another observation from my own medical center is that the Department of Psychiatry is now transforming itself into a much more collaborative partner interested in integrating its services across our health system. Upon learning about this expansion, our Family Medicine-based Integrated Behavioral Healthcare (IBH) team felt a bit threatened by what we perceived as a possible desire to take over the services we had developed. But our psychiatry colleagues were actually respectful of our team and quite solicitous of our advice on how to accomplish integrated care more broadly. For a number of years, they have had similar integrated efforts going on with some patient populations; for example, in our cancer center and on our pain service. This work, along with our own PCMH-IBH efforts, now serves as models for expanding psychiatry's integrated services throughout our medical center. Psychiatry's local effort reflects national themes in support of integration declared at the May 2014 American Psychiatric Association meeting in New York City ("Integration of Behavioral Health and Primary Care," 2014).

Reflecting on the stressful life events faced by our patients in many of our outpatient specialty services from the infertility clinic to the heart failure clinic, as well as on acute care hospital services, the mandate for IBH throughout our health care institutions becomes apparent. Patients suffer life-altering changes to their bodies and functioning, often without a lot of warning, and require support to manage these stressors in the context of their own and their families' lives. Collaborative care in these settings can benefit from applying the principles of IBH and will require local adaptation and innovation for each service location. In our department, we have recognized this by adding IBH services to our family medicine inpatient service.

Collaborative Family Healthcare Association (CFHA) has been engaged in reflecting on this national trend in our own strategic planning. One key question we are considering: Is our mission solely to integrate behavioral healthcare (BH) services in primary care settings OR does our goal need to shift to advocating integrating BH services across all medical care settings? Thus far, CFHA has developed three special interest groups (SIGs): primary care behavioral health, families and health, and one for our young professionals. These groups have allowed CFHA's larger constituencies to develop and refine their models of service delivery, create educational programming to promote fidelity in what they do, and to promote research on their outcomes. It's time for a SIG in "specialty care behavioral health" to allow our members who work in both outpatient and inpatient specialty settings to achieve the same goals. It may just be that the notion of integrated behavioral health care has now achieved enough recognition and acknowledged value throughout the health care industry that CFHA needs to expand its vision, mission and scope of its member-supporting activities.

We are following this path as we seek to engage other key organizational partners to increase CFHA's reach and influence on policy and health care today. We are establishing relationships with the Patient-Centered Primary Care Collaborative (, the Eugene Farley Health Policy Center (, and with our Canadian sister organization Shared-Care ( We have likewise engaged with national psychiatry and psychology professional organizations about our shared experiences and ideals of integrated care. This expanded horizon of IBH across all medical settings demonstrates proof of concept implemented in large part by your collective efforts! We should feel good about that for a few minutes, and then join health care teams across the spectrum of health care delivery to take on the need for IBH wherever our patients are facing their greatest physical, emotional, and social health care challenges.

Received July 1, 2015

Revision received July 5, 2015

Accepted July 7, 2015

Gene A. Kallenberg, MD

Collaborative Family Healthcare Association, Rochester, New York, and University of California, San Diego


Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs (Project Hope), 27, 759-769. http://

Integration of behavioral health and primary care to be featured at APA annual meeting in New York City, May 3-7. (2014). Retrieved from http://www integration-of-behavioral-health-and-primary care-to-be-featured-at-apa-annual-meeting-in new-york-city-may-3-7

Kellerman, R., & Kirk, L. (2007). Principles of the patient-centered medical home. American Family Physician, 76, 11A-115.

Correspondence concerning this article should be addressed to Gene A. Kallenberg, MD, Department of Family Medicine and Public Health, School of Medicine, University of California-San Diego, 9500 Gilman Drive, Mail Code 0807, La Jolla, CA 92093. E-mail: gkallenberg@ucsd .edu
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Author:Kallenberg, Gene A.
Publication:Families, Systems & Health
Article Type:Report
Geographic Code:1USA
Date:Sep 1, 2015
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