Strategies for Planning, Implementing, and Sustaining Family-Centered Care Teams in

Specialty and Primary Care Settings

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session E4a Saturday, October 17, 2015

Kaitlin Leckie, PhD, LMFTDirector of Behavioral Health Education

Southern Colorado Family Medicine Residency

Jennifer Hodgson, PhD, LMFTProfessor

East Carolina UniversityDepartment of Child Development & Family Relations

Maureen Davey, PhD, LMFTAssociate Professor

Drexel UniversityDepartment of Couple and Family Therapy

John Rolland, MD, MPHProfessor of Psychiatry & Behavioral Neurosciences

University of Chicago Pritzker School of MedicineExecutive Co-Director, Chicago Center for Family Health

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:• Describe how healthcare teams can feasibly integrate families

as partners in care. • Describe how to transform a clinic into one that utilizes

sustainable family-centered approaches to care. • Describe strategies to overcome common financial, clinical,

and operational barriers to sustaining a family-centered approach to care

Selected ReferencesAschbrenner, K., Bartels, S., Mueser, K., Carpenter-Song, E., & Kinnney, A. (2012). Consumer

perspectives on involving family and significant others in a healthy lifestyle intervention. Health & Social Work, 37(4), 207-215. Campbell, T. L., (2003). The effectiveness of family interventions for physical disorders. Journal of Marital and Family Therapy, 29, 263–281. Campbell, T. L., & Patterson, J. M. (1995). The effectiveness of family interventions in the

treatment of physical illness. Journal of Marital and Family Therapy, 21(4), 545–583. doi:10.1111/j.1752-0606.1995.tb00178.x

Dickinson W. P. (2011). Is there room for the family in our medical home? Family Medicine. 43(3): 207-9.

DiGioia, A., Fann, M., Lou, F., & Greenhouse, P. (2013). Integrating patient- and family-centered care with health policy: four proposed policy approaches. Quality Management in Health Care, 22(2), 137-145. doi:10.1097/QMH.0b013e31828bc2ee Dunst, C. J., & Trivette, C. M. (2009). Meta-analytic structural equation modeling of the influences of family-centered care on parent and child psychological health. International Journal of Pediatrics. 2009, 1-9. doi:10.1155/2009/576840Constand, M. K., MacDermid, J. C., Dal Bello-Haas, V., & Law, M. (2014). Scoping review of

patient-centered care approaches in healthcare. BMC Health Services Research, 14(1), 271.

Duke, N. N., & Scal, P. B. (2011). Adult care transitioning for adolescents with special health care needs: a pivotal role for family centered care. Maternal and Child Health

Journal, 15(1), 98-105.

Selected References

Helsing, K. (2015). Capturing Social and Behavioral Domains and Measures in Electronic Health Records. In 143rd APHA Annual Meeting and Exposition (October 31- November 4, 2015). APHA.Institute of Medicine (1994).Johnson, B. H. (2000). Family-centered care: Four decades of progress. Families, Systems, &

Health, 18(2), 137.Martire, L. M., Lustig, A. P., Schulz, R., Miller, G. E., & Helgeson, V. S. (2004). Is it beneficial

to involve a family member? A meta-analysis of psychosocial interventions for chronic illness. Health Psychology, 23(6), 599.McDaniel, S. H., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005). Family-Oriented Primary

Care, 2nd ed. Springer.McDaniel, S.H, Doherty W.J., & Hepworth, J. (2014). Medical family therapy and integrated

care, 2nd ed. Washington DC: American Psychological Association Publications. Peek, C. J. (2008). Planning care in the clinical, operational, and financial worlds. In Collaborative medicine case studies (pp. 25-38). Springer: New York.Peterson, A.M., Takiya, L., & Finley, R. (2003). Meta-analysis of trials of interventions to improve medication adherence. Am J Health Syst Pharmacology, 60, 657- 665.Rolland, J.S. (2016). Mastering family challenges with illness & disability: An integrative practice model. New York: Guilford.Wolff, J. L. (2012). Family matters in health care delivery. Journal of the American Medical

Association, 308(15), 1529-1530.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted during and at the end of this presentation.

Family-Centered Care Teams in Specialty and Primary Care Settings

(Presentation Outline)

Planning

Implementing

Sustaining

Kaitlin Leckie

Maureen Davey

John RollandJennifer Hodgson

A family approach to careDOESN’T

• Have to mean doing things differently

• Always diagnose and treat• Mean being less scientific• Mean either/or

DOES

• Mean thinking about things differently

• Always assess situation• Mean being more scientific &

less trade-like• Mean both/and• Mean considering the family in

context when dx problems• Join with the family• Engage the social environment

(Dickinson, 2011)

An Example: Stephen and Sandra Sheller 11th Street Family Health Services

• Nurse-Managed Primary Care Clinic in partnership with Drexel University --designated by the federal government as “medically underserved.”

• African American (90%), median family income of $13,000, lowest in Philadelphia.

• Highest percentage of unemployed adults, families living in poverty, and highest rate of diabetes in Philadelphia.

• Most patients (66%) are insured through medical assistance, and rest are uninsured.

Mission of Clinic• Identify needs of community and customize best evidence-based services

to address those needs

• Partner with Community Advisory Board made up of members of the community

• Focus on wellness and health promotion

Patient-Centered Approach to Primary Care

Clinical Services • Primary Care • Behavioral Health • Dental Services • Nurse Family

Partnership • Family Planning • Prenatal • Physical Therapy

Primary Care• Open Access • Group Visits • Integrated Behavioral

Health • Chronic Disease Self

Management

Transforming to a Family-Centered Approach to Care

Patient FactorsDemographics, socioeconomics, environment, disease severity, comorbidities

Patient-Physician Interactions Communication, trust, access to care

BehaviorPatient self-management, treatment adherence and retention

Psychosocial FactorsMental health, family support, kinship network and other social support, church

Health-Related Quality of Life OutcomesPhysical, mental, and social health

Clinical OutcomesLong-term survival

Engaging Families to Promote Health at 11th Street

NINR: R21 PA-14-113 Grant

First Step: Met with Providers and Director at 11th Street Clinic

• Provided rationale for proposed NINR R21 two-year study

• Gave stakeholders overview of proposed study and rationale—why transform their clinic?

• Sought staff, community advisory board input about study objectives, process, and feasibility

Why Apply for NINR Grant Right Now?

• Clinic was expanding—new larger building in June 2015, increased patient volume

• Development and implementation of Drexel Couple and Family Therapy Department (master and PhD interns)– Money in grant to staff and coordinate study

• Chronic care groups (e.g., diabetes, HTN)

Rationale for Proposed Study

• Many resources go to high-utilizers (adults), yet little evidence of clinically significant positive outcomes and reductions in cost of healthcare

• Currently 11th street providers focus on patient-centered self-management of adults

• Complex patient and family situations impacting patients’ management of chronic health conditions (e.g., trauma, family conflict, poverty)

Why transform to a Family-Centered Approach to Care?

When positive family support is available, it can lead to:

• Improved medication and treatment adherence• More open and positive communication between

patients, family members, and treatment team• Improved treatment retention and clinical outcomes• Reduced costs of care in health care settings  

Define Family Centered Approach to Care• Coordinated clinical team who identify the medical AND

psychosocial support patients and their families need to manage and cope with chronic illnesses (e.g., diabetes, asthma, and heart disease). 

• Use family-centered approach to care at front end to tap into natural supports in family and community. 

– Use John Rolland's Families Systems Illness Model (conference call with John Rolland, 1999; 2011)  

Primary Aims of Proposed Study

• Develop and evaluate family-centered approach to primary care with a cohort of adults coping with chronic health conditions.

• Evaluate and compare patient outcomes for group of patients receiving enhanced traditional as usual (ETAU) to family-centered approach to primary care (Rolland, 2011)

Recruitment Patients: Demonstrate Feasibility

•Adult patients (new) with a diagnosis of HTN, diabetes, cardiovascular disease, asthma

•Patients willing to complete measures: psychosocial vital signs & medical vital signs on a web-based tool, utilization at baseline, 6 months, 12 months

•For patients in intervention group, need to be willing to involve key family members in care/partners in care

•Estimate recruiting 2 new adult patients per day

Interdisciplinary Research Team

• Waite (PI; Nurse), Davey (Co-PI; MFT), Gerrity (Co-I: Nurse), Methodologist (TBD) (Co-I), Rolland (Consultant; MD)

• IRB approval• Develop a Community Advisory Board to collaborate with team (~4 people)• Provide education to both Teams

Enhanced Treatment as Usual- Process, screen, get consent forms signed and biopsychosocial assessments completed, CFT master’s student to administer (at clinic or convenient location)

Intervention team- Process, screen, get consent forms signed and biopsychosocial assessments completed, train team to use a family-centered approach to primary care; regular meeting time to plan/coordinate family centered approach to care

Medical & Psychosocial Vital SignsPsychosocial Assessments (2015 IOM Committee)

• Patient Activation (13 Q) • Stress (Elo et al 1 Q)• Depression (PHQ-2) (2 Q)• Tobacco use & exposure (NHIS 2

Q)• Alcohol use (AUDIT-C (3Q)• Social connections and social

isolation (NHANES III (4Q)• Exposure to violence (HARK 4Q)• Anxiety (GAD-7)• Life orientation revised (6Q)• Family/Social Support • Family Resource Scale (Financial)

Medical Assessments (TBD)

• Blood Pressure• BMI (Height/Weight)• Hb A1C

Met with Resistance at Meeting• Late spring 2015 meeting, most providers were not ready for a family centered

approach to care

• Clinical director is committed to transforming clinic, but values staff input & wanted to be sure there are stakeholders in process

Comments indicating staff were not ready:

1) “We are already providing a family centered approach to care—yet when asked what that means they described spontaneous partnering with

family members and not routinely taking psychosocial and medical vital signs at beginning of care and throughout care”

2) “Partnering with family members of patients could compromise strong alliance between provider-patient”

3) “I feel overworked and worried about who would be in new care teams”--- not understanding the grant would fund these positions and role of CFT

department”

Next Steps• We decided to back up and first build consensus among providers and

community members

• Continue to educate and meet with stakeholders (providers and patients) to help them understand how partnering with families can make their jobs easier and improve care for their patients, especially those who have complex medical and psychosocial issues and poor adherence to care.

• Now working on smaller projects, not transforming entire clinic, to first demonstrate positive outcomes when partnering with patients’ families (e.g., trauma patients with chronic health conditions)

KAITLIN LECKIE, PHD, LMFTDirector of Behavioral Health EducationSouthern Colorado Family Medicine Residency

Collaborative, interdisciplinary treatment team Integrative patient careExpected family involvement

Pediatric:OncologyIntensive Care Unit (PICU)Inpatient

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Clinical Setting• Integrated Primary Care Clinic • Embedded in a Family Medicine Residency• NCQA Level III (Highest) Patient-Centered

Medical Home (PCMH)

St. Mary’s Family Medicine ResidencyGrand Junction, CO

Clinical Setting

Inter-professional collaboration• Shared patient care• Joint appointments• Behavioral health consults• Shared EHR

– Case management – Occasional home visits

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From patient-centered to family-centered: Implementing family-activated coordinated care

planning in primary care Problem: Complex patients Fragmented care

Inappropriate utilization Provider burden

Solution: Expand care plans from individual patient focus to include the

family/couple Promote continuity of care across visits, providers, systems Activate high-risk & high-utilizing patients Encourage more appropriate use of healthcare services “Everyone working at top of his/her license”

Directing Resources: Pt Identification & Selection2-step process:1. Complexity/Risk category* (esp. > 4 visits to the Emergency Department (ED) in

the past 5 months,2. Primary Care Physician (PCP) identified 5 patients whom s/he deemed high-

risk/complex who would benefit from comprehensive, coordinated care planning.

Cross-referenced lists 1 & 2Focused on 2-3 high-risk patients per PCP

*Factors Contributing to Patient Complexity– high level of resource use (e.g. visits, meds, trmt, or other measures of cost); – frequent urgent or emergent care visits (>2 in last 6 mo); – frequent hospitalizations ( >2 in last year); – multiple co-morbidities (e.g. mental health); – noncompliance with prescribed treatment or medications; – terminal illness; – psychosocial status, lack of social or financial support impeding ability for care; – advanced age, with frailty; – multiple risk factors (NCQA, 2013; Pope et al., 2011)

Operational Overview• Grants clinic access to incentive money • Aligned with PCMH and Grand Junction model

• Relationship between social support, patient health activation, healthcare service utilization

• Measures: multiple lifestyle, health outcome, & psychosocial assessments

Research

Family-Activated Care Team (FACT) Coordinated Care Plans

• BPSS intervention• Engage the family and

healthcare team • Better identify & address

patients’ challenges• Build on strengths and past

successes

Family centered care & comprehensive care

plans have been shown to improve

outcomes in complex patients

(Council et al., 2012)

FACT Coordinated Care PlanPrimary Components

Important people & care team members Patient voice Provider voice Meet patient where s/he is

Survey scores Health hx Long- & short-term SMART goals

Family-Activated Care Team = Patient + Family + PCP + Medical Family Therapist + Case Mgr + MA + RN + Other Health Professionals

Clinical Practice

• Asynchronous process• Team approach

Identify and Involve Family• Attend visit if possible• Individual patient? Be systemically minded

– With whom are you closest? Who is your #1 fan?

Family & Important PeopleThe most important or supportive people to my health are: (for example: family, partner, friends, co-worker, sponsor, roommate, religious leader, etc.). *Include people who are already involved in your health in some way, as well as other people you might want to involve in your care. For ex., who might be supportive of you and your health goals?

Is this person

involved in your health

or care?

How is s/he involved (if applicable)

?

May we contact him/her

in the next few months

to support

your health?

Name Relation Contact y/n y/n y/nIma Example neighbor 555-555-5555 yes Walks w/

meyes

Family Activation

• SMART goals and built-in supportShort-term Goal

1: I will _________________________ ______________________________

How often? When?

Start date:_____ Date to check in on my progress: _____

For Goal 1a, rate the following from 1 (not at all) to 10 (extremely):

How IMPORTANT is this goal to me?

__

How SURE am I that I can reach this

goal? __

Current PROGRESS I’ve made toward this goal: 1

(None) to 10 (achieved) __ Identifying Barriers Overcoming barriers with Personal support

What are the biggest barriers I face in working toward this goal? If I don’t achieve this goal, it will most likely be due to:

Who in my personal support system can help me overcome these barriers & reach this goal?

How can this person help me?

Lessons Learned: Clinical

• Use EHR to your advantage• Adapt for your setting

• Continuous QI – Involve team (all roles

represented)– Re-examine process

periodically– Patient feedback

Lessons Learned: Operational

• Leadership buy-in: essential• Involve key players early

(e.g., IT)• Update Clinic/Team• Maintain momentum &

motivation• Beware change fatigue

Lessons Learned: Financial

• Use available resources• Complex Care Coordination billing codes

– 99487 (1st hour, w/o face-to-face patient visit) - $140.00– 99488 (1st hour, w/ face-to-face patient visit) – $320.00– 99489 (each additional 30 minutes) - $75.00

Chicago Center for Family Health

• Family systems-oriented institute. Non-profit University of Chicago affiliate

• Provides specialized training & services to promote healthy family functioning and adaptation to stressful life challenges

• Community-based, collaborative, resilience-oriented practice model to strengthen families at risk, in crisis, or facing persistent challenges

• Promotes systems-based family-oriented collaborative healthcare

Basic Premises:

• Family, broadly defined, as the psychological and caregiving focal point and as a key resource and partner in care

• Comprehensive biopsychosocial healthcare delivery model from the time of diagnosis

• Behavioral component addresses both patients’ and family members’ needs using a developmental, life-span model that is culturally sensitive

• Integration directly in healthcare settings.

Keys to Design & Implementation• Buy in by Medical/APN Directors, Admin. Leadership, and Board(s)

Boards generally include consumer family members with personal exposure to illness and family impact.

• Family and resilience-oriented biopsychosocial clinical model that addresses service needs & can be translated into specific

healthcare context

• Conceptual plan addresses both high risk/utilizers/poor adherence& prevention-oriented component from time of entry/Dx

• Staff in-service across all disciplines and healthcare team membersOn-going psychosocial rounds/case discussion

• Engagement of consumer families through community & multifamily format psychoeducation

Family Systems Illness Model in Healthcare

• Collaborative ApproachPatient – Family - Healthcare Team - Community

• Family Resilience - basedShift from Deficit, Problem Focus toStrengths & Resources for Positive Patient / Family Adaptation

• Developmental, life-span View: Illness – Individual - Family

• Attuned to socio-economic, cultural, spiritual diversity & varied family forms

Overall Design: Four Components

1) Family-centered clinical & psychoeducational services

2) Professional education & development

3) Community education & outreach

4) Family resources

Component 1Family-Centered

Clinical & Psychoeducational Services

• Routine screening family consultation & brief psychological screening of the patient at time of diagnosis or entry into the Diabetes Center.

• Identify & Refer complex or “high risk” cases

• Periodic family psychosocial “check-ups” & consultations

-- at key illness-related transitions -- disruptive individual and family transitions

Routine Screening & ConsultationBenefits

• Engages patient and their families

• Provides orientation & psychoeducation to treatment plans and family’s role

• Identifies family strengths as a resource for optimal diabetes care

• Facilitates early identification of high-risk cases

Periodic Psychosocial ‘check-ups’ & Consultations

• Available at key disease-related or disruptive individual/family transitions.

• Address illness and management complications that frequently arise at stressful transitions such as starting a family, transitioning to adulthood, job loss, loss of a loved one, divorce and remarriage

Psychoeducational Workshop Days

• Initial workshop for newly diagnosed patients and their families

• Topical workshops for major life transitions (transition to adulthood, early marriage) and family challenges (communication/problem-solving, caregiving).

• Format: Large group presentation & discussion Facilitated break-out sessions for groups of families.

Component 2:Professional Education and Development

• Continuing Education programs for physicians, nurses, social workers, dietitians and other allied health professionals

• Psychosocial Rounds with collaborative presentation and discussion of complex cases

• Intensive training for core Diabetes Center team members

Component 3:

Community Education and Outreach

• Free educational events offered to the consumer community

 

Component 4:

Family Resources

• Database to link families

• Resource to families:• with a newly diagnosed member • those going through a difficult transition

such as starting a family or launching to adulthood, independent living.

Sustaining

Three-World View

(Peek, 2008)

• Organizations operate simultaneously in three worlds: the clinical, operational, and financial worlds.

• These worlds hold different views of the same underlying reality; like a front view, a side view, and a top view.

• Taken together, they represent the whole organization as viewed from these three key perspectives.

OPERATIONAL

CLINICAL

FINANCIAL

• Quality care

• Patient driven

• Systems; Organization

• Communication

• Process improvement

• Reimbursement

• Coding

• Billing

Three Worlds

Peek, 2008

Three-World view Continued3 World View

Clinical Operational FinancialBasic Questions What care is called

for? Is it high quality?What will it take to accomplish care? Is it well executed?

How will care utilize resources? Is it a good value?

Object Unfolding casework Systems NumbersProcess Actions by clinicians

and patientsOperations Accounting

Outcome Achievement of health goals

Production Bottom line

Standard Technical and service quality and elegance

Efficiency and facility

Price and value

(Peek & Heinrich, 1995)

Financial Barriers & Solutions # 1

Barrier: Including family in medical care sounds expensive

Solutions1. In a study that had 292 participants, those who were in family therapy and high

utilizers had a decrease of 78% in urgent care visits, 56% reduction in laboratory/X-ray visits, and a 68% reduction in health screening visits (Crane & Christenson, 2008; Crane & Christenson, 2014).

2. In a study that looked at “high utilizers” (defined as four or more healthcare visits within the first six months of the study), who engaged in therapy, there was a decrease in healthcare use by -57% for the family therapy participant who was not the identified patient (n=22), -50 to -57% were participants who were in marital or family therapy (n=43), and those in individual therapy (n=22) had a reduction of -48% (Crane & Christenson, 2014; Law, Crane, & Berge, 2003).

Financial Barriers & Solutions # 1 (Cont.)

Solutions (Cont.)3. In a study that had 292 participants, those who participated in family

therapy (n=172) had a reduction in healthcare of 21.5% compared to the 10% reduction those in individual therapy (n=60) saw at one year after the initiation of psychotherapy. In addition the family member of those in individual therapy (n=60), therefore not involved directly in psychotherapy, also had a reduction in healthcare of 30% indicating the benefits of family therapy could have an affect beyond the identified patient (Crane & Christenson, 2014; Law & Crane, 2000).

Financial Barriers & Solutions #2

Barrier: Fears about who is the patient and if the provider is liable for what the support person discusses about his or her own mental health

Solution: 1. Redirect patient’s support person to his or her PCP for

symptoms expressed if the support person is also not a patient of the facility

2. Screen and refer- We do this in pediatric settings where parents/legal guardians are expected to accompany the child to a medical visit and may be screened for things such as post-partum depression. Why does it stop here?

Financial Barriers & Solutions #3Barrier: How to get paid for relational work

Solution: We are beholden to the current diagnostic system, but if a mental health issue is present for the patient, there are codes that may be billed if working with a family member. For example there are the following CPT codes:

– 90846 - Family psychotherapy (without the patient present)– 90847 – Family psychotherapy with patient present (conjoint therapy)– 90849 – Multiple family group psychotherapy

• Research shows that family members have a direct benefit to the patient’s getting behavioral health intervention and that there is a reduction in healthcare utilization by about 50%, as well as other reductions in medical interventions and urgent care visits (e.g., Law & Crane, 2000; Law, Crane, & Berge, 2003; Crane & Christenson, 2008; See chapter 22 in Hodgson et al’s, 2014 Medical Family Therapy: Advanced Applications text).

Clinical Barriers & Solutions #1Barrier: Patients and support persons may not be receptive to Integrated Behavioral Healthcare.

Solution1. Some patients have difficulty understanding that

their physical (biological) health is affecting their mental (psychological) health. Integrated Behavioral Healthcare (IBHC) providers’ duty is to assist patients in understanding the relationship between BPS-S health (Peek, 2009).

Clinical Barriers & Solutions #2

Barrier: Patients either come in and try to tell PCPs what they need or cannot seem to follow the treatment plan as written.

Solution1. Some patients may have access to information regarding

diagnosis, treatment, and prognosis from various sources (including the internet, support groups, social networking, and advertisements). Integrated Behavioral Healthcare providers can utilize the resources that patients may have (Peek, 2009) to increase their agency within their healthcare, while maintaining the patients’ appropriate level of communion with their support persons and healthcare team (McDaniel, Hepworth, & Doherty, 1992).

Clinical Barriers & Solutions #2 (Cont.)

Solutions (Cont.)2. Integrated Behavioral Healthcare providers have the ability to

utilize their systems perspective to assist PCP, patients, and support persons to build trusting and close relationships to increase patient outcomes (Marlowe Hodgson et al., 2014; Peek, 2009).

3. Some patients experience large barriers (e.g., safety, financial problems, social isolation, resignation, and high levels of distress and distraction) that can present as patients being “noncompliant” (Peek, 2009). By utilizing an IBHC provider there can be a shared language, better assessment that includes barriers, help proposing actions, as well as assisting in the patient-provider relationships (Peek, 2009).

Operational Barriers & Solutions #1Barrier: Measuring continuity of care is inconsistent due to the barriers of multiple measurement tools, utilizing a site/practice vs. a provider and private practice vs. community clinics with higher demands and less flexibility (Carrier et al., 2009).

Solutions:Join Practice-based Research Networks in your area/region to help build a data-base for studying family-based care models.

Operational Barriers & Solutions #2Barrier: Time, Space, and Training

Solution: There is no evidence that working with families takes more time in the exam room. It just takes adequate skill and training. Space and training can be issues, but what are some ways you have worked around them?

Relationships Matter

Collaboration does not only need to happen between IBHC providers and families, but within each of the three worlds

(financial, clinical, and operational) in order to provide balanced healthcare for patients and families (Peek &

Heinrich, 1995).

Take-Away

Write down 1 “take-away” point or next step that you will implement upon

returning to your setting.

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!