New Staff Feature: Lisa Tyndall Joins the Center of Excellence for Integrated Care.
In June, Lisa Tyndall joined the Foundation as a technical assistant for the NC Center of Excellence for Integrated Care (COE). With over fifteen years of experience, she will help to provide technical assistance for integrated care program development to a variety of medical practice settings. We asked Lisa a few questions to get to know her better.
Q: Where are you from and how did you end up in North Carolina?
A: I am originally from Florida, but I have lived in North Carolina since I was in elementary school. I have spent most of my time in eastern North Carolina, with my undergraduate education taking me to Chapel Hill and have also spent some time in Raleigh with my husband.
Q: What drew you to the Foundation?
A: I love the idea of being a part of helping shape health policy at the state level. Even in the short time I have been on board I have been able to be a part of conversations that have given me huge light bulb moments of understanding how system wide change occurs. I love that the vision of the Foundation is geared towards helping all of those in North Carolina have access to quality healthcare.
Q: What types of organizations have you worked for in the past?
A: The majority of my employment time has been spent in an academic setting teaching, conducting research, service, and administration. I have also had experience in administration at two independent schools, as well as working in a local nonprofit family violence prevention agency.
Q: What are you most excited for in this position?
A: I think two things excite me the most about this position. First, as a Marriage and Family Therapist, I love building relationships and I am excited about building relationships with our various sites across the state in an effort to help them advance along the continuum of integrated care. Second, I am excited to continue to be involved in the advancement of integrated care across our state as a whole. I have always believed people are more than the sum of their parts and I am excited that our healthcare system is beginning to acknowledge this as well.
Q: What do you like to do for fun/in your free time?
In my free time, my most favorite thing is playing a game with my family. We will pick up a game of kickball, wiffle ball, or most recently monopoly, usually at the urging of one of my boys. While my husband and I may be tired, within a few minutes we are so glad we said yes to the request. Of course, I also love my personal quiet time through running and walking with my dog and time spent on the back porch in the early evenings with my husband.
In May, Irina Kolobova joined the Foundation as a technical assistant for the Center of Excellence for Integrated Care (COE). With years of experience and a passion for improving health, she will help to provide technical assistance for integrated care program development to a variety of medical practice settings across North Carolina. We asked Irina a few questions to get to know her better.
Q: Where are you from and how did you end up in North Carolina?
A: I was born in St. Petersburg, Russia and grew up on the west coast, spending 6-8 years each in San Diego, Seattle, and Portland. I moved to North Carolina to pursue my doctoral studies in 2013. When I finished my PhD this May, I decided to stay and call North Carolina my new ‘home’.
Q: What drew you to the Foundation?
A: Working for the Foundation with the Center of Excellence for Integrated Care provides me an opportunity to apply everything I learned through my educational training while also being true to my passion of supporting marginalized communities and increasing access to high quality healthcare. Working alongside the multiple programs within the Foundation, I get the opportunity to be part of the systemic approach to improve the health of our community.
Q: What types of organizations have you worked for in the past?
A: A significant portion of my work history has been in research, starting with my earliest experiences at the University of Washington. During college, I was a research assistant for Drs. John Gottman and Jessica Sommerville. Following my love for research, after college I worked as a research assistant for a NIDA Clinical Trials Network protocol that evaluated a manualized 12-step program at an outpatient treatment center in Portland, Oregon. Later and until I moved to North Carolina, I worked as a research coordinator in the department of Endocrinology at Oregon Health & Science University (OHSU). In the position, I managed a large NIH-funded randomized-controlled study that looked at the effects of thyroid function on metabolism and cognition. During my doctoral studies, I worked as behavioral health provider at a Federally Qualified Health Center in Eastern North Carolina. Beyond these longer work experiences, I’ve also worked with a variety of other organizations including Cascade AIDS Projects, The Parry Center for Children, the Knight Cancer Adolescent and Young Adult Cancer Psychosocial Program, and the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse Services.
Q: What are you most excited for in this position?
A: I get to show people how to integrate physical health and behavioral health and why this is important to improving population health. I enjoy getting them exciting about the work!
Q: What do you like to do for fun/in your free time?
A: As my colleagues would say, I have a life-long case of ‘wanderlust’. I love to travel near and far and do so with just about every minute of my free time. I enjoy exploring different cultures, trying new foods, finding treasures, and embracing different ways of being. I also enjoy nearly all outdoor activities including hiking, kayaking, paddle boarding, and snowboarding.
Just this month, Monica Harrison joined the team as Technical Assistant for the Center of Excellence for Integrated Care. With years of experience and a great deal of passion, she will provide tools, techniques, training and technical assistance to organizations and healthcare professionals that will help them implement best practices for integrated care. We asked Monica a few questions to get to know her better.
Q. Where are you from and how did you end up in North Carolina? I was born in New Orleans, LA. However, I’ll say I’m from everywhere, as I am what they call a “military brat.” Both of my parents were in the army and we moved to Fayetteville (Ft. Bragg), NC in 1991. I decided to attend college at the University of North Carolina at Greensboro for my Bachelor’s Degree in Human Development and Family Studies, and then attended NC A&T for my Master’s Degree in Social Work.
Q. What drew you to the Foundation? Talk about the universe smiling down on me. I was eager to learn all I could about integration and making sure my agency participated in continuing our integration efforts in the most concise and evidence-based way possible. I’ve been on this endeavor since 2010. When I met the Center of Excellence staff in 2011, I thought, “wow it would be great to have had a blueprint to build off of and follow.” I’ve kept pushing forward ever since and have hoped I would have the opportunity to help others in their journey. Now I get to do just that.
Q. What type of organizations have you worked for in the past? Believe it or not my first career was as an educator/teacher so, I hold a Birth Through Kindergarten Teaching License. Since then, I’ve held multiple positions with the Guilford County Head Start/Early Head Start program (teacher, education specialist, professional development coordinator, consultant). I’ve worked for Wake Forest Outpatient Dialysis Centers as a Nephrology Social Worker and Social Worker Manager in which I traveled to facilities in different parts of North Carolina as a part of an interdisciplinary team. I’ve worked for Win-Win Resolutions where we focused on character education, mentoring, bullying and conflict resolutions for the school system as well as juvenile justice led family programs. I’ve been the clinical lead for a residential home (group home) conducting clinical groups, and I’ve also worked at a pediatric primary care office to consult with other pediatric offices to work on integrative efforts. Lastly, I transitioned to working in a Federally Qualified Health Center as a part of and manager of their integrative endeavors.
Q. What are you excited for in this position? I am excited to get the opportunity to spread my love and joy of integration and to be able to assist others to be successful in their integration efforts.
Q. What do you like to do for fun? Well if not running around crazy to my children’s sporting events (I have five boys who all play a different sport, some of which travel constantly – and yes I am the loudest yelling mom on the team) then you will find me out with my husband trying out a new or favorite restaurant – we are “foodies.”
The Center of Excellence for Integrated Care (COE) is a program of the Foundation that works with health providers across the state to integrate primary care and behavioral health services. COE’s model of integrated care is well-suited for substance abuse issues, which can harm both the mental and physical well-being of a patient. COE Director Cathy Hudgins says that “integrated care provides those struggling with addiction an opportunity to be treated as a whole person.”
The COE helps organizations develop their ability to provide integrated health care. One of their longstanding partners is Family Service of the Piedmont (FSP) in Guilford County.
The primary care provider for FSP is Anthony Steele. Steele is a nurse practitioner with a certificate in family medicine and psychiatry. He has spent 16 years serving individuals with addiction. He says he’s a “one-stop-shop” for patients because he has the training to address their physical and mental health in one setting. In the time that the COE has been working with FSP, Steele has assisted in building exemplary integrated care services.
We asked Steele a few questions to understand how he uses the integrated care model to help patients suffering from addiction.
When did you realize that you wanted to work with addiction? I was done with inpatient healthcare. I needed to do something different. When I came in 16 years ago I knew nothing about addiction. But guess who were the best educators? My patients. They were the ones who taught me about the disease. They even taught me how to change my language when speaking to clients. I had to really adjust. Because when you’re looking at a patient and you’re calling him or her an addict, it’s one of those things that just makes them cringe. ‘No, I’m not just an addict. My name is John,’ or, ‘my name is Suzie.’
I also had to work on my perception and how I addressed individuals. I had to look at them as a patient and as a client. This is someone’s son. This is someone’s daughter. This is someone’s brother. In treatment we always want to keep people alive. Every day you see someone alive is a success. Then you work on developing tools to help them stay alive. You work on helping them build resources and you meet them where they are. Within the first month of working with addiction I became engrossed with learning about the disease process and I thought if not me, then who?
What’s encouraging about your work? When I have a patient come in who’s been using 10 bags of heroin a day and then within a week of treatment, they are looking at me in the eye, they are taking a bath, and they are beginning to see changes in their life. When you see a pregnant mother who’s been using every drug under the sun get stabilized and she’s now able to have a normal labor and delivery. When I see those patients, I know this is where I need to be.
How does integrated care help you serve individuals with addiction? We look at the whole picture. We do a comprehensive assessment when people come in. We have screening tools that look at depression, anxiety, trauma, addiction history, and physical health issues. When a patient comes in, they have bared their souls to us, and it’s a judgment-free zone. It just makes sense for us to treat the mind, the body, and the soul. If a patient is struggling with opioid addiction, but also high blood pressure and diabetes, I’m not going to ignore those physical issues. I’m not going to send them to another primary care doctor that doesn’t know them or who may prescribe other medications that could get the patient into trouble. It’s important to be mindful of not causing a relapse.
If we don’t begin to address the fragmentation of care, then our opioid addicted individuals will continue to be stigmatized. We need providers that know a patient’s history, won’t judge them, and will meet me where they are. Some of these patients don’t have their basic needs being met. When you add addiction on top of that, their addiction takes precedence over food and shelter. That’s why we help clients get their cravings under control, and then we work on the other aspects of life. Let’s get you gainfully employed. Now let’s work on relationships with your family so you can be supported on that road to recovery. Instead of disconnecting the head from the body, my goal is to connect it all together.
[box type=”bio”] “If we don’t begin to address the framentation of care, then our opioid addicted individuals will continue to be stigmatized.”[/box]
How does addiction tie in with other health issues? People who have addictions have the same chronic medical issues that anyone else has, but they might be highly elevated because they aren’t typically treated. If you look at most statistics, more than one in five adults have a co-occurring mental health and substance abuse issue. And so it just makes sense to figure out how to treat them in a collaborative perspective.
One thing I’ve noticed is that dental care is much needed and sought after. A patient who’s addicted to opioids, one of their side effects is dry mouth. If you have dry mouth you aren’t producing enough saliva, and then bacteria grows and your teeth decay. But if you’re in active addiction, you’re not going to be worrying about brushing your teeth. It’s a perfect storm for dental problems. If I have dental issues, they effect my self-esteem, and now I have self-doubt, now I’m depressed, now I’m isolated. And it continues that cycle of relapse and recovery, relapse and recovery. Oftentimes our patients are also IV drug users which opens up the risk for Hepatitis C transmission with potentially shared needles. They may not know or have any symptoms, so they keep sharing needles, snorting drugs with dollar bills and having unsafe sex.
Why do you think that integrated care for opioid addiction isn’t more widely used? Sometimes I think it’s a comfort level. Most medical programs don’t give you a lot of training in substance abuse and mental health. In primary care you maybe get one to two week’s rotation in substance abuse, and that’s it. You’re taking on the responsibility of something you really don’t know much about. And sometimes in primary care, if you don’t ask about addiction, you don’t have to deal with it. Some primary care providers do want to deal with it, but guess what? They are limited in terms of where they can refer patients. The amount of money that’s available for substance abuse treatment compared to all the other diseases is a drop in the bucket. If I’m a primary care provider and I screen for addiction, where can I get this patient into treatment? The hospital is limited and here in Guilford County we only have one in-patient detox facility, which is also limited. I think there might be 15 beds.
In your opinion how do we better address this epidemic? We’ve got to do a better job with screening and treatment. You really need to meet the patient where they are. But once we screen for it, we also need funding to cover the cost of these patients who need this service. We have to stop ignoring the issue. Because it’s here, and it’s prevalent. Until we take a very hard look at this disease, we are going to continue these vicious cycles of chronic relapse and people dying on the streets. Most people look at it as a character flaw. We in the addiction world know that it’s not. This is a disease of the brain that needs to be dealt with like any other disease. You don’t tell your diabetic, ‘you’re obese so we aren’t going to treat you.’ No. You work with that patient where they are. Oftentimes with our addicted individuals, we just don’t have that same tolerance.
Psychologist Neftali Serrano remembers when the concept of integrated care—the combination of behavioral health and primary care—clicked with him.
Dr. Serrano was working in a health center, down the hall from the primary care physicians. He only had two or three patients a day. “I was open for business and had no one coming in,” he said.
Out of that futility, he said he started spending time with providers instead of sitting alone in his office. This evolved to walking into exam rooms and working with patients directly.
“Within 30 seconds, patients were opening up about their behavioral health issues and getting to things that would usually take hour long visits or even a series of visits,” said Serrano.
Dr. Serrano said he connected faster to patients in a primary care setting. “They trusted their primary care doctors and they extended that trust to me,” he said.
Dr. Serrano now works with the Center of Excellence for Integrated Care, a program of the Foundation that trains health care professionals and providers to treat behavioral and physical health in one setting.
[box type=”bio”] “They trusted their primary care doctors and they extended that trust to me.”[/box]
Integrated care can work especially well among the aging population. Two out of three Americans aged 65 and over have chronic illnesses, which are often coupled with mental health distress. The Centers for Disease Control and Prevention estimates that 20 percent of adults over 55 have a mental health concern. Decreased mobility, isolation and health complications can cause anxiety, depression, and severe cognitive impairment among our aging community members.
Integrated care can offer older adults a safe place to get help with these behavioral health issues.
“Some older adults are not as willing or able to go outside the walls of a primary care office to see a therapist,”” said Dr. Serrano. “Having a behavioral health consultant right there is a more culturally appropriate way to deliver care for folks who are more comfortable with primary care.”
[box type=”bio”] Integrated Care can offer older adults a safe place to get help with behavioral health issues.[/box]
Initial research trials among the elderly combined psychiatric therapy with primary care, and proved to be very successful, said Dr. Serrano. For example, cardiovascular health, a common concern for the elderly, can improve by treating depression. “There are clear links between heart health and depression,” said Dr. Serrano.
Another advantage of integrated care is the free flow of patient information. The patient’s medical history is on hand, and can better inform the behavioral therapist, instead of having to start from the beginning with every patient.
Integrated care can also help primary care physicians make better assessments for their patients. For example, depression is often masked by physical health issues. Patients with vague pain may be suffering from isolation or loneliness.
“Oftentimes primary care doctors will do a whole lot of work to address the physical problems but fail to address the root issues,” said Dr. Serrano.
There is also a certain threshold a patient must meet for referral to a mental health therapist. Many people that need behavioral health assistance may not have acute behavioral health issues, but would benefit from the input of a therapist in their primary care office.
Dr. Serrano said it will take a lot of broad training across specializations to prepare the medical profession for an older population. Mental health professionals in particular, according to Dr. Serrano, will need to reconfigure their mindset and work-flow. “Mental health professionals are more accustomed to sitting in an office by themselves than working on a team,” he said.
The Center of Excellence for Integrated Care (COE), a program of the Foundation, helps providers make this adjustment. They have practical training programs on all aspects of integrating the silos of behavioral health and primary care in any setting where health care is delivered. COE is also dedicated to reducing the stigma associated with behavioral health issues. Accessing therapy through a primary care doctor can help reduce any discomfort of feeling of shame about needing help. The integrated approach to elderly care is important to recognize and replicate as our population continues to age.
The Center of Excellence for Integrated Care adds another level of expertise by welcoming Neftali Serrano as Associate Director. The Center of Excellence aims to integrate patients’ physical and behavioral health across health care settings. Serrano has years of experience doing just that, and we asked him a few questions to get to know him better:
What attracted you to the Center of Excellence? After 14 years as a clinician and program developer I was looking for an opportunity to train a behavioral health workforce in primary care in a more efficient, scaled fashion. The Center of Excellence provides this opportunity to engage an entire state in developing an integrated care workforce. This is a really exciting opportunity.
Where were you before accepting this position? Before coming to the Center of Excellence I was the director of behavioral health at Access Community Health Centers in Madison, Wisconsin where I developed a primary care behavioral health program that is one of the most mature and successful programs in the country. The team there is great and one of my proudest accomplishments professionally is that when I left the program was a strong as it ever was and will continue on in perpetuity as a result.
What are your hopes for the position? I hope that in five years or so we are all able to look back and reflect how we were able to train hundreds of behavioral health professionals to provide integrated care to thousands of patients across the state of North Carolina and set a model for how to do so in a sustainable fashion for other states to follow.
In your experience, what’s been the best strategy for successful behavioral health integration? The keys to successful integration are actually pretty simple. First, it is essential to have a relatively healthy organization. No project of any kind thrives in a dysfunctional organization. Second, it is essential to have clear that one of the main goals of integration is to support the day-to-day work of primary care clinicians. In other words, whatever you do should make life easier for the main cogs of your workforce. Third, you need behavioral health professionals who are truly able and willing to adopt a new professional identity related to primary care. Mental health professionals who work in primary care become a new breed or type of professional and embracing this is core to working through all the inter professional issues that will arise. And of course it is essential the mental professionals remember the first key, which is the primary care clinician is their first customer.
Most healthcare providers agree that mental health affects physical health and vice versa. However, integrating the two is not easy. Providers aren’t trained to address both the mind and the body in one setting. As we transition towards value-based reimbursement, there’s a greater incentive to improve quality for patients. The Center of Excellence for Integrated Care (COE) is an example of a creative approach to improving patient outcomes.
The imminent changes to our healthcare system will result in a workforce that operates differently—and that’s where COE steps in. Housed in the NCFAHP, this small team provides the tools and training for integrating mental and physical health. “And we have our eyes on oral health specialists and pharmacists too.” says Associate Director Christine Borst.
The COE team works in a broad range of settings, and not just traditional healthcare sites. “North Carolina is one of the most diverse states in the nation when it comes to putting teams together to meet the patient where they seek services,” says Director Cathy Hudgins, “This can be a school-based clinic, a mental health or substance abuse clinic, homeless shelters, migrant worker camps and church basements.”
COE breaks down the cultural and educational barriers between health sectors. This type of workforce development, dubbed cross-training, is crucial to better patient outcomes. “It’s been exciting to work with universities,” said Borst, “Conducting trainings early on is really helpful for developing that multidisciplinary lens.”
In a healthcare practice with established workflows, cross-training requires a colossal team effort. “We work with everyone in the office, from the front desk ‘eyes and ears’ of the clinic, to the physicians and therapists in the back,” said Borst, “Regardless of what kind of specialist you are, it’s essential to work together as a team and develop a mindset of integration.”
Every care site is different. Some have a behavioral health therapist in-house; others have close connections to one. Some have no partnerships or experience with behavioral health. Borst gave the example of smoking cessation or diabetes diagnosis. “These issues really require a behavioral health intervention,” she said, “And not every clinic has the resources to provide that.” Tailoring training to meet the needs of a care setting is part of COE’s work. Every practice and every community has its assets, and COE works to create partnerships around those assets.
The biggest hurdle for integrating care is payment reform. “Everyone wants to know how to pay for it,” said Borst. COE provides some direction on navigating the billing process, but it will take policy reform to dictate how behavioral health integration will be properly reimbursed.
Effective workforce training to integrate the siloes of care is an important step towards fully implementing value-based care. “There’s a method to our madness,” Borst said, “Laying a strong foundation for a multidisciplinary approach is the first step.”