Integrating Primary Care & Behavioral Health at Lynn CHC: Kiame Mahaniah & Mark Alexakos

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Primary care models integrating behavioral health services are being adopted across the country. This week, we talked with two leaders at the Lynn Community Health Center (LCHC), Dr. Mark Alexakos and Dr. Kiame Mahaniah, about their experience with integration.

LCHC is unique among community health centers in that it started out as a mental health counseling center, and now has the largest community health center-based behavioral health program in Massachusetts. In this conversation, we talk about what it means to integrate behavioral health services with primary care clinical services – how it can reduce the fragmentation of services to better meet the needs of patients and the demand for mental health care (2:40), why it may better position clinics participating in accountable care (7:40), what successes they’ve seen (8:45), and the resources it has required (12:28). Along the way, our guests make it clear that the staff at LCHC love working in integrated teams. You can learn more about various other models of integrated behavioral health here.

Mark Alexakos MD, MPP, is the chief behavioral health officer of LCHC. He has a joint degree in medicine and public policy and developed an early interest in the interface between policy, research, and service delivery as they relate to access barriers, health disparities, and community health. Before working at LCHC, he spent seven years developing intensive, school-based mental health services that combined health promotion and prevention with quick access to behavioral health treatment in five Boston Public Schools.

Kiame Mahaniah, MD, is the chief executive officer of LCHC, though at the time of this interview, he served as the chief medical officer. His passion resolves around social and restorative justice, in the context of healthcare.   His twin clinical interests are teaching—he holds an appointment at the Tufts University School of Medicine—and integrating opioid addiction treatment into the primary care/behavioral health matrix.

This interview was edited lightly for length and clarity.

photo credit: Lynn Community Health Center

Lori Tishler of Commonwealth Care Alliance – Caring for the Most Vulnerable Patients

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Have you ever felt lonely and overwhelmed in a clinic room with a patient whose needs are far beyond your skills and ability to meet? I have, many times, and so has our guest this week, Dr. Lori Tishler. Dr. Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, duals, or individuals who have both Medicare and Medicaid.

We talk about how CCA’s member-centered approach (as opposed to a physician-centered approach) has helped her feel more effective in caring for these vulnerable patients. We talk about the range of services that CCA offers, the role of their care partners, and the freedom that their financial model permits – for example, they provide 90% of care to patients in their homes.

You can find the Atlantic Magazine article we referenced featuring CCA here, and find a few Health Affairs blogs featuring CCA here, and a blog post focusing on building the business case for a community paramedicine program here.

A bit more about our guest: Lori Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, people who have both Medicare and Medicaid.  She oversees CCA’s physicians and is involved with clinical aspects of quality, utilization, and pharmacy.  In addition, she is an Assistant Professor at Harvard Medical School and an active member of the General Medicine Faculty at Brigham and Women’s Hospital, As a caring and connected physician leader, mentor, and educator, Dr. Tishler’s passion has been providing care for the medically and socially vulnerable and making a difference in health systems for all.   Tishler has found that the most rewarding way to help change and grow our health care systems is to mentor learners who are interested in clinical care, leadership, and innovation.

Her leadership roles have extended outside of the clinic and outside of primary care.  She served on the Partners Healthcare Board of Directors, the Board of Directors for the Office for Women’s Careers, and the Board of the Schwartz Rounds while at the Brigham.  At Commonwealth Care Alliance, she teaches and presents nationally about our care model and innovations.

In addition to her leadership work, she continues to provide clinical care  Tishler feels that working as a clinician informs her choices and decisions as a leader.  Outside of work, Dr. Tishler loves to spend time with her husband and teenaged daughter, to travel, read, and knit.  She is honored to have been interviewed on Review of Systems.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status – Mehta et al

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This week, we are discussing an article from the Journal Women’s Health Issues, entitled: Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status, by Pooja Mehta, Tamala Carter, Cjloe Vinoya, Shreya Kangovi, and Sindhu Srinivas. Pooja Mehta, the lead author of the study, joins us for our conversation. 

You can find the interview with Dr. David Buck referenced in our conversation here.

Dr. Mehta is Director of Maternal & Women’s Health Policy for the Consortium for Health Care Transformation, and Assistant Professor of Health Policy and Systems Management and Obstetrics and Gynecology at the Louisiana State University Health Sciences Center, advising the Louisiana Department of Health and Medicaid Program.

Dr. Mehta’s interests are in the use of health care delivery innovation and community-engaged accountable care models to reduce reproductive health disparities, pregnancy-associated mortality, and low-value care, and to support patients with complex health and social needs. Her research has been supported by the Health Resources and Services Administration, the American College of Obstetricians and Gynecologists, and the Leonard Davis Institute of Health Economics.

If you like the show, please rate and review us on itunes, google play, stitcher or your favorite podcasting app, which makes the show easier for others to find; and share us on social media. We tweet at @RoSpodcastand are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at audrey@rospod.org. We’d love to hear from you.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Tom Bodenheimer – Building Blocks of High-Performing Primary Care and the Quadruple Aim

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Dr. Tom Bodenheimer is one of the world’s foremost experts in primary care re-design, having recently written about high-performing primary care clinics and the Quadruple Aim, which are articles consistently in the most-read list for the Annals of Family Medicine and among his most cited work.  We focused much of our conversation on his work visiting 23 high-performing primary care practices, what he and co-authors learned, how resident teaching sites can also be high-performing, and why we should be seeking a fourth aim in addition to IHI’s famed Triple Aim.

A general internist who received his medical degree at Harvard and completed his residency at the University of California-San Francisco, Dr. Tom Bodenheimer spent 32 years in primary care practice in San Francisco’s Mission District, a primarily low-income, Latino community—ten years in community health centers and 22 years in private practice.  He is currently Professor of Family and Community Medicine at UCSF and Founder and Co-Director of the Center for Excellence in Primary Care.  He has written extensively in journals such as the New England Journal of Medicine, JAMA, Annals of Family Medicine, and Health Affairs, on health policy and health care delivery for chronic disease management, including patient self-management, health coaching, and team-based care. He is also co-author of the books Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy text book Understanding Health Policy.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Frederick Chen – Teaching Health Centers

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Teaching health centers (THCs) are primary care residency training sites in community-based organizations, often in federally qualified health centers (FQHCs), in contrast to traditional tertiary care hospital-based training. Federal funding for the THC program, created by the ACA in 2010 and renewed through MACRA in 2015, is set to expire on September 30, 2017.

THCs may be a key part in solving the primary care workforce shortage, so we talked with Dr. Frederick Chen, Professor of Family Medicine at the University of Washington and a recent senior advisor to HRSA’s Bureau of Health Professions for the Teaching Health Center program.

We review flaws in traditional methods of funding graduate medical education in the US (2:50) then discuss Freddy’s research (8:15) showing that residents trained in FQHCs are 3-4 times more likely to go work in underserved settings. He also describes the key factors in creating community health center-family medicine residency partnership (12:20). Freddy’s work led to the THC graduate medical education program, an innovative federal policy that aims to increase access to primary care where it is needed the most, and we talk about some of the early lessons since its inception (18:50). You can also find the controversial 2014 Institute of Medicine report mentioned by Freddy in our conversation here.  Finally, Freddy shares about how his academic career led him to help shape national health policy (23:07).

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Dave Chokshi – Population Health Management

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This week, we are joined by Dave Chokshi. Dave is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest public health care system in the U.S. He practices primary care at Bellevue Hospital and is a Clinical Associate Professor of Population Health and Medicine at the NYU School of Medicine.

We talk about what population health is, how it is distinct from public health, and what value it adds to our healthcare system. We also talk about how in some ways it might contribute to the erosion of relationships between primary care providers and patients, how that can be remedied, and how the small 1 or 2 doctor practice may fit into a population health management vision. We talk about a piece he wrote with Neil Calman and Diane Hauser about what they call the “expanded denominator,” and how that may further goals of public health and accountable care. Lastly, we talk about population health approaches in urban and rural settings, and how we should think about the opioid epidemic from a population health vantage point.

We reference a few articles throughout our conversation: Christine Sinsky’s already classic Annals paper detailing that physicians spend two hours on administrative tasks for every hour they see patients, and our journal club on that paper. Robin Williams’ and colleagues Health Affairs blog on utilizing the HIV cascade of care to battle the opioid epidemic, and Lawrence Casalino and colleagues work calculating what we spend measuring the care we provide. In addition, we reference the Surgeon General Vivek Murthy’s landmark report on addiction.

A quick note about a word we use frequently but didn’t pause to define for listeners – attribution. Attribution is the assignment of a specific patient to a specific primary care physician in a health system. Once a patient is attributed to a PCP or health system, that PCP and health system is held accountable for the patient’s quality measures and healthcare costs within ACOs or other alternative payment contracts. This still applies patients who do not frequently access the healthcare system through traditional channels or most frequently see specialists, who perhaps have never seen the assigned PCP, and is therefore at times controversial.

A little more background on Dr. Dave Chokshi: He was Assistant Vice President of Ambulatory Care Transformation at NYC Health + Hospitals and director of Population Health Improvement at NYU School of Medicine. In 2012-13, he served as a White House Fellow at the U.S. Dept. of Veterans Affairs, where he was the principal health advisor in the Office of the Secretary. His prior work experience spans the public, private, and nonprofit sectors, including positions with the New York City and State Departments of Health, the Louisiana Department of Health, a startup clinical software company, and the nonprofit Universities Allied for Essential Medicines, where he was a founding member of the Board of Directors.

If you enjoy the show, please rate and review us wherever you listen, and share us on social media. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Joshua Freeman – Designing a Fair & Equitable Healthcare System

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Dr. Joshua Freeman is a family physician, health policy researcher, social justice activist, and writer.  He publishes a widely-read blog, “Medicine and Social Justice”, and in 2015 published a book, Health, Medicine and Justice: Designing a fair and equitable healthcare system (Copernicus Healthcare press), which is available on Amazon and other sites, in both softcover and electronic versions.

This week, Thomas Kim chats with Dr. Freeman about some of the major themes of the book: why the US health care system fails to produce a healthy population, the role of profit in American medicine, why he uses social justice to frame his analyses and commentary, and how the American health care system could become more primary care-centered.

Dr. Freeman is Professor Emeritus at the University of Kansas Medical Center in Kansas City, where he served as the Alice M. Patterson MD and Harold L. Patterson MD Professor and Chair of the Department of Family Medicine from 2002-2016, and was also Professor in the Departments of Preventive Medicine and Public Health and of Health Policy and Management. He was a Fulbright Scholar in São Paulo, Brazil in 2003 and served nationally as Treasurer of the Society of Teachers of Family Medicine and the Association of Departments of Family Medicine. He received STFM’s highest honor, the Recognition Award, in 2006. He served as a member of the board of trustees of Roosevelt University in Chicago, as assistant editor of the journal Family Medicine, and also on the board of Southwest Boulevard Family Health Center in Kansas City, KS.

Dr. Freeman is a graduate of the Loyola-Stritch School of Medicine, family medicine residency at Cook County Hospital in Chicago, and faculty development fellowship and Preventive Medicine residency at the University of Arizona.

This interview was lightly edited for clarity.

Reprise – David Buck, Caring for High-Need, High-Cost Patients

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This week, Thomas Kim hosts the show and interviews Dr. David Buck, a family physician and professor of family and community medicine at the Baylor College of Medicine.  He is the founder and president of Patient Care Intervention Center (PCIC), an organization that uses advanced population health methods to target super-utilization of the health care system and intervenes through intensive care coordination and case management. It’s based in Houston, Texas and recently opened a branch in Dallas, and they were recently featured on PBS NewsHour. Prior to Dr. Buck’s work at PCIC, he founded Healthcare for the Homeless – Houston (HHH), now a federally qualified health center for over 7,000 homeless in Harris County, as well as the associated Houston Outreach Medicine Education and Social Services (HOMES) clinic, a student-managed clinic at HHH in conjunction with BCM and the University of Texas Health Science Center. He is a co-founder of the Houston-based physician advocacy group Doctors for Change, and founded the Houston-Galveston Albert Schweitzer Fellowship. He helped found the international street medicine institute, and was appointed to the 15-member Consumer Operated and Oriented Plan Program advisory board created as part of the Patient Protection and Affordable Care Act in 2012.

You can find some CDC resources about Adverse Childhood Experiences, or ACEs here, and a New Yorker article about the effects of ACEs on health here.
Dr. Buck is a graduate of the Baylor College of Medicine and the University of Texas School of Public Health, as well as family medicine residency at the University of Rochester.

Lauren A Taylor – Integration of Healthcare and Social Services

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Today we’re joined by Lauren A Taylor, a health services researcher based at Harvard Business School, where is she is earning her doctorate in health policy and management. Prior to joining HBS, Lauren co-authored The American Health Care Paradox, which has become required reading at a variety of medical and public health schools across the country. Our discussion spans a range of topics and should excite clinician and policymaker listeners alike, especially those interested in addressing upstream factors that affect health in our American society.

We start with reviewing the initial research paper that lay the groundwork for her book and what other countries show us about how government spending on social services can affect health outcomes, as well as what she learned interviewing caregivers and social services workers in the US.  We also talk on how American sociopolitical factors influence our discourse on the distribution and allocation of resources as well as how research is done in her field. We discuss whether health systems are moving in the right direction addressing social determinants of health through ACOs, why management gets overlooked and undervalued as a key ingredient in healthcare delivery, and why it’s just so hard to get all of this right.

Lauren’s work focuses on organizational theory and strategy in health care, with a particular emphasis on the integration of health and social services. She holds a BA in the History of Medicine and a Master in Public Health from Yale University. She has also worked as a health care chaplain and studied ethics as a Presidential Scholar at Harvard’s Divinity School.

If you like the show, please subscribe on our website www.rospod.org, and rate us on iTunes and Stitcher and share us on social media. Get in touch via twitter @RoSpodcast or drop us a line at contact@rospod.org. Thanks for listening!

Seth Berkowitz – Food Insecurity and Chronic Disease

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This week we are joined by Seth Berkowitz to talk about his research examining the associations between food insecurity and health outcomes. Seth is a primary care physician, Instructor of Medicine, and is on faculty in the Division of General Internal Medicine and the Diabetes Research Center at Massachusetts General Hospital.

Seth’s research interests include population management, food insecurity, cost-related medication underuse and the impact of adverse social circumstances on chronic disease management. His goal is to develop and disseminate interventions and care delivery models that address social and economic needs.

Today he joins us to talk about a recent collaboration, funded by an award from the Robert Wood Johnson Foundation Evidence for Action Program, with Community Servings. Community Servings is a Boston-based non-profit organization dedicated to bringing medically tailored meals to chronically ill adults. The study aims to assess whether individuals receiving the medically tailored meals have lower rates of inpatient hospitalization, ED utilization, and medical expenditures.

You can find a piece co-authored by Seth and David Waters, the CEO of Community Servings here, and the Health Affairs article Seth and I talked about examining the effect of eliminating use of SNAP, or food stamps, for sugary sweetened beverages here.

Lastly, if you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.