Ep. 3. The Big World of Integrated Care: Population Health, Complex Patients & More

The CFHA Podcast Team discusses the work of community health workers, promotoras, peer specialists, care managers and other new members of the modern medical care team. Special segments include a review of the Association for Community Health Improvement Conference by Dr. Jeffrey Ring and an interview with Family, Systems & Health co-editor Dr. Jodi Polaha who sponsored a conference recently on the podcast topic. News Items: Deepu: https://theincidentaleconomist.com/wordpress/do-antidepressants-work/ Grace: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm599560.htm Amber: https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2017.9b9 More information about the Brief Addiction Monitor mentioned in Amber’s news item: https://manual.jointcommission.org/BHCInstruments/RomInstr00017 Neftali: https://www.macrumors.com/2018/01/24/apple-health-records-update/ Topic Discussion: Faculty webpage of Dr. Frank DeGruy, whose talk Deepu summarized for us: http://www.ucdenver.edu/academics/colleges/medicalschool/departments/familymed/about/faculty/Pages/FrankdeGruy.aspx The four websites Deepu was recommended to follow were: https://theincidentaleconomist.com https://morningconsult.com/ http://thehealthcareblog.com http://healthcare-economist.com Website for Dr. Parinda Khatri with Cherokee Health (also cited by Deepu): https://www.cherokeehealth.com/about-us/our-leadership-team Website for Dr. Katie Kanzler who is doing the work with Promotoras & Acceptance and Commitment Therapy: http://profiles.uthscsa.edu/?pid=profile&id=47C0WR06D; https://reach.uthscsa.edu/node/108 SAMSHA-HRSA Center for Integrated Health Solutions page on Peer Providers - https://www.integration.samhsa.gov/workforce/team-members/peer-providers The Rural Health Info Hub has a helpful, brief explanation of some of the types of care coordinators: https://www.ruralhealthinfo.org/toolkits/care-coordination/2/care-coordinator-model/types Jeff’s Segment Association for Community Health Improvement: http://www.healthycommunities.org/ The Institute for Diversity & Health Equity (Affiliate of the American Hospital Association): http://www.diversityconnection.org/ Equity of Care Pledge: http://www.equityofcare.org/pledge/online-form.shtml National Urban League: https://www.nuljobsnetwork.com/ American Public Health Association: https://www.apha.org/ Jodi’s Segment Dr. Jodi Polaha’s faculty page: https://www.etsu.edu/com/familymed/faculty/polaha_jodi.php A 2017 Profile of the work being done by Dr. Polaha’s team that was published in the Atlantic: https://www.theatlantic.com/health/archive/2017/06/therapy-for-everybody/531120/ AAFP Risk Stratified Care Management Rubric - Preview & link to purchase (free to AAFP members): https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric Peek, C.J., Baird, M.A., & Coleman, E. (2009). Primary care for patient complexity, not only disease. Families, Systems & Health, 27, 287-302. doi: 10.1037/a0018048 In this article from CFHA’s journal Families, Systems, and Health, the authors argue that an organized method for assessing complexity is necessary for providing patient-centered (rather than solely disease-focused) care. Reddy, A., Sessums, L., Gupta, R., Jin, J., Day, T., Finke, B., & Bitton, A. (2017). Risk stratification methods and provision of care management services in Comprehensive Primary Care Initiative practices. Annals of Family Medicine, 15, 451-454. doi: 10.1370/afm.2124 This study reviews four methods that practices use to stratify patient risk, including the AAFP rubric that Dr. Polaha mentioned. Closing Discussion The MeHAF Tool for assessing integration: http://www.mehaf.org/learning-resources/tools-materials/ (Neftali specifically referenced the Integrated Care Site Self Assessment Survey)