A few years ago, I went to a Festschrift for Steve Zyzanski, one of my revered mentors, on the occasion of his retirement. A large group of us gathered to celebrate his life, his contributions, to collectively tell his story and celebrate the greatness of his life’s work. So after all our hot air and bloviation, Steve got up and damn if he didn’t spend an hour talking about all the next great things in his field that were coming up over the horizon, that we had to look forward to, that we needed to get to work on. I didn’t know what we has talking about, but I understood one thing: we’re not at the end of anything! Ever! We’re in the middle of a neverending story.
Now, there’s nothing more satisfying, more inspiring and instructive, than a true story told well. And what we’ve just heard is a good true story: the heroes, the problems, the struggle, the crisis, the resolution. Inspiring, instructive, true. But move over an inch and you’ll see a completely new, heretofore hidden, path through the tangle. Raise up to treetop level, and you see a whole new set of pathways home. Raise up to the mountaintop, and you can see where the whole continent breaks, east and west, leading to completely different futures. Look through your long lens, and you have a new definition of your destination—”I thought we would come into a safe high plain in a few miles, or years, but look!—in a mere 50 miles, there’s a riverside, a safe harbor, a much better place for us to stop and rest.” I have a million metaphors for the stunning difference just the slightest change in context or viewpoint can make, this shift in context that can completely change one’s reality—that changes the work you have right in front of your nose. (Pecan orchards. GoPros and drones following skiers.) Stories of success have to start somewhere in their telling, but just move over an inch, or raise up to just above the treetops, and stories start somewhere else, or further back, or go on longer, just keep going. So I hope you feel inspired, and have gotten a few ideas and made a few connections, but mostly I hope you feel motivated to forge ahead, break your own trail, make your own story, greater and more valuable than this.
Let’s stop and remember why we’re doing this. To help people become a little healthier. In order to do this in our own particular way, which is through the rendering of advanced, team-based care (in my case, advanced, team-based primary care), it’s only proper to remember who got us here. I’m not going to drive this back to your birth, or the privilege you might have enjoyed along the way—but to a different notion of how we get and give help. I’m going to drive this back to the notion that we live in a gift economy, right alongside the economy based on exchange of money and services. So people work to figure something out. You take what we already know, put it together in an new way, sweat your way through a trial or experiment or program, and do some good, and learn something, and come here and tell me about it, or publish it and I read it. All free and clear for me to use as I wish. I collect that stuff together, sort through it, use the pieces that fit my particular problem, and then try something. I work to do all of this, and then I give it to you, free and clear, to use as you see fit. A gift economy.
So. Here in Colorado, we have not only borrowed freely from your work, your ideas, your mistakes, your findings, but we have also borrowed people. Did you notice that Larry is not from Colorado? He’s not. Ben’s not from Colorado. I’m not from Colorado. Nobody’s from Colorado! We borrowed all these beautiful people. It’s what we do, and you should too.
I love this state, and I love the work that has happened here, but I want to emphasize that there are points of light all over this nation, and this planet. My best ideas about how to shape integrated care in a state have come from somewhere else. Susan McDaniel has built these exquisite training programs that embed behavioral clinicians in every corner of her health system. That’s Rochester New York. I have learned from Parinda Khatri and Cherokee Health Systems more than I could learn from years of reading how to operate a complex adaptive system in such a way that you flex your care to your community’s needs, no matter how those needs change, no matter how out of left field those needs are, no matter whether you have the money to do it or not. That’s not Colorado. That’s East Tennessee. AHRQ has built an Integration Academy that offers you, free of charge, a playbook, a step-by-step manual for how to get started with this, a description of exemplar integrated practices, maps of where integrated practices are located, a lexicon of definitions and concepts, an inventory of tools, a library of the world’s English-language literature on integration, and more. It’s yours for the taking. Most of the people who did that work are not from Colorado.
We lucked into a permissive context out here, a context that makes certain things possible, and context is everything. If you’re the kind of person, or program, or department, that generates opportunities, that attracts ideas, and especially that keeps looking for your way through the forest, shifting the frame of reference, you’ll do more good for more people than we have ever dreamed of.
Did you notice how the nature of the problems these folks faced changed over time? Larry came out and started working in a clinic, figuring out how to do this stuff one patient at a time, eating peaches and hiking in the mountains. Barbara Martin was wrangling 300 practices into some sort of shape. If you solve a problem or make progress it only brings the next problems into view. When I started advocating for integrated care thirty-five years ago, the most common question people asked was “Why?” There was a small band of us out there in the wilderness busy falling on deaf ears. As evidence slowly accumulated, and the rationale became more evident, the question changed from “Why?” to “How.” That “success” was hard for me, because I had gotten pretty good at answering Why. I had to almost start over and learn how to design a successful integrated clinic under all kinds of weird circumstances. Now the How question has taken on a different complexion. We have models of integration aplenty—we need to understand what the different flavors of integration are for different settings, how to finance it, what kind of local, statewide, and national policies it takes to sustain it, and how to take things to scale in a new way. There’s a guy in the audience, Jay Voight—where are you, Jay?—who works deep in the leadership structure of my partner hospital system. UCHealth has just committed $100M, and another $25M if someone will match it—$150M total—to integrate behavioral health into every clinical corner of their system—every primary care clinic, every specialty clinic, every inpatient service. And I just came from Vail a couple of weeks ago—Vail Valley Hospital System has just committed $60M to do the same thing. So this year’s question is not Why, or How, but Holy Shit! Are there any grownups in the room? Now we won’t be flying under the radar, posing as outsiders, making mistakes that nobody will notice—this takes a whole different order of expertise, organization, metrics.
You just heard a sweet, inspiring story. But it’s just one chapter. And the next chapter? I don’t know—we cannot know. It might be a simple explosion, a wholesale adoption of models we’re familiar with. I doubt it. I think we can count on the next big move maybe coming unexpectedly out of left field to take us completely by surprise. It’ll be you who surprises, and educates us, and inspires us, next.
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