Ethical Challenges Unique to the Primary Care Behavioral Health (PCBH) Model.

The interprofessional nature of the Primary Care Behavioral Health (PCBH) model invites potential conflicts between different ethical guidelines and principles developed by separate professional disciplines. When the foundational model of care and training on which ethical principles were developed shifts, the assumptions underlying the guidance also shifts, revealing gaps and mismatches. This article reviews the extant literature in this realm, and proposes a more unifying set of ethical guidance for interprofessional, integrated primary care practice. We discuss common ethical dilemmas unique to the PCBH model through case examples, and then apply the newly proposed ethical guideline model to these cases to illustrate how the newly proposed model can be efficient and effective navigating these dilemmas.

Burnout among behavioral health providers in integrated care settings.

INTRODUCTION: Burnout in health care, especially among physicians, is a growing concern. It is now well accepted that physician burnout leads to increased depersonalization of patients, lower personal accomplishment, employee turnover, and worse patient outcomes. What is not known, however, is to what extent behavioral health providers (BHPs) in medical settings experience burnout and its associated sequela. METHOD: Participants (n = 230) from a variety of practice settings and levels of integrated care completed practice and burnout questions via an online survey. Practice-related questions and a modified version of the Maslach Burnout Inventory was administered to BHPs who work in different levels of collaboration with other medical providers. RESULTS: Overall, BHPs who work primarily in fully integrated care settings reported higher rates of personal accomplishment in their everyday job (B = 1.49; 95% confidence interval [CI] = 0.40, 2.58). Additionally, those who have worked more than 10 years in these types of settings reported both higher personal accomplishment (B = 1.58; 95% CI = 0.68, 2.49) and lower rates of depersonalization (B = -1.32; 95% CI = -2.28, -0.36). DISCUSSION: In contrast to high rates of burnout among many clinicians in the United States, this is the first study to document relatively low rates of reported burnout among integrated care BHPs. The relationships between lower burnout, working in a fully integrated care practice, and experience as a BHP is important to understand when creating and sustaining team-based primary care jobs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Getting It Off the Ground: Key Factors Associated With Implementation of Wellness Programs.

BACKGROUND AND OBJECTIVES: Many residency programs are developing resident wellness curricula to improve resident well-being and to meet Accreditation Council for Graduate Medical Education guidelines. However, there is limited guidance on preferred curricular components and implementation. We sought to identify how specific driving factors (eg, having an identified wellness champion with a budget and protected time to develop wellness programs) impact implementation of essential elements of a resident wellness curriculum. METHODS: We surveyed 608 family medicine residency program directors (PDs) in 2018-2019 on available resources for wellness programs, essential wellness elements being implemented, and satisfaction with wellness programming; 251 PDs provided complete responses (42.5% response rate). Linear and logistic regressions were conducted for main analyses. RESULTS: Having an identified wellness champion, protected time, and dedicated budget for wellness were associated with greater implementation of wellness programs and PD satisfaction with wellness programming; of these, funding had the strongest association. Larger programs were implementing more wellness program components. Program setting had no association with implementation. CONCLUSIONS: PDs in programs allocating money and/or faculty time can expect more wellness programming and greater satisfaction with how resident well-being is addressed.

Making Sense of Family Medicine Resident Wellness Curricula: A Delphi Study of Content Experts.

BACKGROUND AND OBJECTIVES: The Association of Family Medicine Residency Directors (AFMRD) Physician Wellness Task Force released a comprehensive Well-Being Action Plan as a guide to help programs create a culture of wellness. The plan, however, does not offer a recommendation as to which elements may be most important, least resource intensive, or most feasible. This study sought to identify the most essential components of the AFMRD's Well-Being Action Plan, as rated by expert panelists using a modified Delphi technique. METHODS: Sixty-eight selected experts were asked to participate; after three rounds of surveys, the final sample included 27 participants (7% residents, 38% MD faculty, 54% behavioral science faculty). RESULTS: Fourteen elements were rated as essential by at least 80% of the participants. These components included interventions at both the system and individual level. Of those elements ranked in the top five by a majority of the panel, all but one do not mention specific curricular content, but rather discusses the nature of a wellness curriculum. CONCLUSIONS: The expert consensus was that an essential curriculum should begin early, be longitudinal, identify a champion, and provide support for self-disclosure of struggles.

Integrated primary care could play a starring role in the Amazon-JP Morgan-Buffet health care enterprise.

Earlier this year, Amazon, J. P. Morgan, and Berkshire Hathaway announced plans to launch a joint health care company with more than a million covered lives. Dr. Atul Gawande, the prominent Boston-based surgeon and health care thought leader, will become the first chief executive officer of this health care venture, with a mission to get the best results at the lowest costs and remain free from profit-making incentives and constraints. In this presidential column, the author explores what this has to do with the mission in the Collaborative Family Health care Association (CFHA) and the promulgation of integrated health care. (PsycINFO Database Record

Assessing social determinants of health in primary care: Liability or opportunity?

Health care is never boring. It changes rapidly based on political winds, financial models, novel terminology, and biomedical advances. In the past decade, there has been large-scale implementation of integrated health care, routine screening for common behavioral health conditions, and the rollout of alternative payment models in primary care. However, even before these advances have been inculcated as the standard of care, we are now witnessing the implementation of health coaches and recommendations to screen for social determinants of health. Social determinants of health (SDOHs) include nonclinical factors that impact health, such as income, education, and the social the conditions in which people are born, grow, live, work and age. While there is strong evidence that health outcomes are only marginally determined by direct clinical care and largely determined, it is unclear what "system of care" (public health vs. medical care) bears the responsibility of identifying and addressing these issues. Is this really the responsibility and role of primary care? Whether we as a health care system decide that systematically asking about and addressing SDOHs is within our job descriptions remains to be seen. Further research is needed to determine the cost and clinical impact of screening and addressing SDOHs. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Dissolving the dichotomy in health and healthcare.

The New England Journal of Medicine Catalyst recently published an article entitled "It's Time to Treat Physical and Mental Health With Equal Intent" (Compton-Phillips & Mohta, 2018). The article describes a survey of the NEJM Catalyst Insights Council, a qualified group (n=565) of U.S. executives, clinical leaders, and clinicians who are directly involved in health care delivery. Ninety nine percent of council members responded that mental health should not only be integrated into ambulatory medical care settings but also embrace a "shared concept of mutual responsibility" (p. 11). As a long-time clinician, educator, and advocate for integrated care, Runyan was so pleased to see this dogmatic statement in a New England Journal of Medicine publication. Labeling disease as either physical or emotional has never served the individual well and may further exacerbate existing stigma and reluctance to seek the most appropriate services. Runyan argues it is time to use intentional language to avoid deconstructing physical and mental health in our discourse or be complicit when others dichotomize measurement and funding. Runyan challenges leaders and aspiring leaders in the field of integrated care to use language and advocate for measures that blur, if not dissolve, this unhelpful and artificial dichotomy. (PsycINFO Database Record

"Joy" in practice requires workforce well-being.

In this column, the president of the Collaborative Family Healthcare Association notes that the national conversation about physician burnout has recently shifted to discussing the importance of finding joy in practice. However, she is concerned the current culture of medicine, hidden curricula in medical training, a draconian financial system, and an emotionally ill-prepared workforce may preclude sustained joy in practice. Formal curricula do not include resiliency skills, mindfulness, cognitive flexibility and reframing, conflict-resolution skills, emotional-regulation skills, or how to practice empathy and compassion without crumbling from vicarious trauma. With all the emphasis on technical proficiency, there has been insufficient emphasis on strategies for maintaining personal well-being. To the extent investment follows what we measure, the well-being of the entire health care workforce is a worthwhile data point to chase. Collaborative Family Healthcare Association membership is infused with the knowledge and skills to design and promote health care teams and systems that can foster, measure, and sustain joy. (PsycINFO Database Record

The future of collaborative care without the Affordable Care Act: We did it before and will do it again.

This article provides insight into the challenges we face in 2017 following the repeal of the Affordable Care Act by the newly elected Republican Congress and president. (PsycINFO Database Record

An interview with Neftali Serrano, PsyD: Collaborative family healthcare association's new executive director.

The Collaborative Family Healthcare Association (CFHA) is continually evolving along with policies, funding, and models of healthcare in the U.S. With a vision of integrated healthcare for all as the standard of care, the new executive director of CFHA describes his perspective on how we can move closer towards this vision, the remaining barriers, models of integration, and why CFHA is a unique and necessary professional organization for those with a passion for delivering whole-person comprehensive healthcare. (PsycINFO Database Record

Mentorship during transitions.

Mentorship has been repeatedly shown to be a necessary component of successful professional development. However, effective mentorship can be elusive to define insofar as "you know it when you have it," but it is hard to match the objective qualities of mentorship with the subjective experience of effective and helpful mentoring. This article explores the Collaborative Family Healthcare Association's mentorship program from the perspective of one mentor and two mentees over the course of a yearlong formal relationship. During the year, both mentees had to navigate significant transitions, including changing jobs and having a baby; these experiences are relevant for many new career professionals. (PsycINFO Database Record

Confronting the new epidemic: Integrated care for opioid use disorders.

The inaugural Collaborative Family Health Care (CFHA) regional conference took place March 17, 2017, in St. Louis, Missouri. The conference theme was opioid use disorders and the potential of medication-assisted treatment using team-based care to address this epidemic. The conference ended with an emphasis on the importance of and strategies for self-care among caregivers working with this population and their families. This intensive meeting was crafted as a proof in concept for CFHA; however, the content was timely with regard to its importance in health care as well as compelling in the opportunity for collaborative care to offer an effective approach. In this article, the authors highlight five impotance topics: (1) opioid use disorders should be addressed in primary care; (2) a team is essential; (3) harm reduction; (4) sustaining self through mindful practice and self-compassion; and (5) medication-assisted treatment. (PsycINFO Database Record

A low-intensity intervention to prevent annual weight gain in active duty Air Force members.

Elevated body weight among active duty Air Force (ADAF) members is a substantial and growing problem, and typically results from gaining small amounts of weight each year over many years. We designed a strategy to prevent annual weight gain in ADAF members using self-directed behavior change booklets followed by weekly e-mails about diet and physical activity for a year. The intervention was universally offered to ADAF members meeting selection criteria at five U.S. Air Force bases (n = 3,502); members at 60 other U.S. Air Force bases served as controls (n = 65,089). The intervention was completely effective at preventing weight gain in a subgroup of men (those above the lowest three ranks, with baseline weight above maximum allowable) and in women, while controls continued to gain weight. Since the intervention did not require personalized contact, this approach has promise for large-scale population-based efforts aimed at preventing weight gain in working adults.

Better together: Collaborative family healthcare association and the promise of team-based care.

In this presidential column is a personal introduction of the new president of the Collaborative Family Healthcare Association (CFHA), Christine Runyan. As president she hopes to continue to support the existing organizational initiatives. CFHA remains a preeminent organization of experts to advocate for meaningful, patient-centered quality metrics and to educate, train, mentor, consult, and realize the vision we have been asserting for 25 years. (PsycINFO Database Record

Impact of a family medicine resident wellness curriculum: a feasibility study.

BACKGROUND: Up to 60% of practicing physicians report symptoms of burnout, which often peak during residency. Residency is also a relevant time for habits of self-care and resiliency to be emphasized. A growing literature underscores the importance of this; however, evidence about effective burnout prevention curriculum during residency remains limited. OBJECTIVES: The purpose of this project is to evaluate the impact of a new, 1-month wellness curriculum for 12 second-year family medicine residents on burnout, empathy, stress, and self-compassion. METHODS: The pilot program, introduced during a new rotation emphasizing competencies around leadership, focused on teaching skills to cultivate mindfulness and self-compassion in order to enhance empathy and reduce stress. Pre-assessments and 3-month follow-up assessments on measures of burnout, empathy, self-compassion, and perceived stress were collected to evaluate the impact of the curriculum. It was hypothesized that this curriculum would enhance empathy and self-compassion as well as reduce stress and burnout among family medicine residents. RESULTS: Descriptive statistics revealed positive trends on the mean scores of all the measures, particularly the Mindfulness Scale of the Self-Compassion Inventory and the Jefferson Empathy Scale. However, the small sample size and lack of sufficient power to detect meaningful differences limited the use of inferential statistics. CONCLUSIONS: This feasibility study demonstrates how a residency wellness curriculum can be developed, implemented, and evaluated with promising results, including high participant satisfaction.

A novel approach for mental health disease management: the Air Force Medical Service's interdisciplinary model.

Mental health disorders are one of the most substantial public health problems affecting society today, accounting for roughly 15% of the overall burden of disease from all causes in the United States. Although primary care (PC) has the potential to be the frontline for recognition and management of behavioral health conditions, this has been a challenge historically. In order to more effectively address the broad scope of behavioral health needs, the Air Force Medical Service (AFMS) established a new model of behavioral health care. Through a series of coordinated steps, the AFMS ultimately placed trained behavioral health providers into PC clinics to serve as consultants to PC providers (PCPs). Behavioral Health Consultants (BHCs) provide focused assessments, present healthcare options to patients, and deliver brief collaborative interventions in the PC setting. BHCs see patients at the request of the PCP, in 15-30-min appointments. In the pilot study, patients averaged 1.6 visits to the BHC. Over 70% of patients fell into six categories of presenting problems: situational reactions, depressive disorders, adjustment disorders, anxiety disorders, health promotion, and obesity. Patient data (n = 76) suggest 97% of patients seen were either "satisfied" or "very satisfied" with BHC services, and 100% of the PCPs (n = 23, 68% response rate) were highly satisfied and indicated they would "definitely recommend" others use BHC services for their patients. Both the implications and the limitations of this pilot study are discussed.

Collaborative Family Healthcare Association commentary on the "joint principles: Integrating behavioral health care into the patient-centered medical home".

The Collaborative Family Healthcare Association (CFHA) welcomes the opportunity to comment on the complementary set of Joint Principles underscoring the Integration of Behavioral Health Care Into the Patient-Centered Medical Home (The Working Party Group on Integrated Behavioral Healthcare et al., 2014). CFHA is an organization that promotes comprehensive and cost-effective models of health care delivery that integrate mind and body, individual and family, patients, providers, and communities. CFHA appreciates that the Joint Principles do not explicitly endorse any single model of collaboration between behavioral health and medical practice. Rather, they broadly emphasize integration, affirming the only way to have a whole person orientation is to adopt a biopsychosocial-spiritual perspective. This commentary will highlight areas of notable strength within the Joint Principles, as well as challenge the language, if not perspective, on a few critical elements.

The ethics of complex relationships in primary care behavioral health.

Primary care settings are particularly prone to complex relationships that can be ethically challenging. This is due in part to three of the distinctive attributes of primary care: a whole family orientation; team-based care; and a longitudinal care delivery model. In addition, the high patient volume of primary care means that the likelihood of encountering ethically challenging relationships is probably greater than in a specialty setting. This article argues that one ethical standard of the American Psychological Association (APA, 2010, Ethical principles of psychologists and code of conduct, www.apa.org/ethics/code) (10.02, Therapy Involving Couples or Families) should be revised to better accommodate the work of psychologists in primary care. The corresponding Principles of Medical Ethics from the American Medical Association (AMA, 2012, Code of medical ethics: Current opinions with annotations, 2012-2013, Washington, DC: Author), most notably the principle regarding a physician's duty to "respect the rights of patients, colleagues, and other health professionals as well as safeguard privacy" are also noted. In addition, the article details how the three attributes of primary care often result in complex relationships, and provides suggestions for handling such relationships ethically.

Ethical issues facing providers in collaborative primary care settings: do current guidelines suffice to guide the future of team based primary care?

This special issue discusses the ethical issues providers face in collaborative primary care settings. It is organized in three sections: (a) Common Themes, (b) Context-Specific Quandaries, and (c) Research and Training. It provides case examples to illustrate ethical dilemmas, describe professional ethical standards pertinent to the case, identifies gaps in available guidance and how guidelines might be elucidated in state statues (without going into detail about specific states), offers feasible recommendations to BHCs for deciding an ethical course when extant guidance was lacking, and then demonstrates and applies the recommendations to achieve an ethical resolution to the case example.

Multiple role relationships in healthcare education.

Healthcare training environments, particularly in multidisciplinary training settings, present unique ethical dilemmas as a result of the multiple relationships faculty must balance while working with trainees. The historical and current perspectives on multiple roles in training environments will first be summarized. Evidence of a gap between the extant discipline specific guidelines and the realities of situations that occur in healthcare training will then be revealed, as illustrated in a case example. Primary care medicine training environments are highly nuanced, potentially leading to an infinite number of ambiguous situations that require a generalizable model for managing multiple roles. Rather than recommend specific modifications to existing ethical guidelines, a new model emphasizing role awareness and decision making when challenges in healthcare training settings arise is proposed. Recommendations for the case example using the model are offered. All professionals are prone to boundary transgressions; explicit training about and the maintenance of appropriate role balance will help to ensure high-functioning relationships and maximize the quality of patient care, resident education, faculty and resident satisfaction, and modeling of professional behavior to improve competencies as clinicians and educators.