One other thing that made this meeting memorable was the appearance of T-shirts that express loyalty to a model of integrated care. It started with the PCBH T-shirts, but by the end of the conference I was seeing CoCM T-shirts as well. This made literal the process that I have been thinking about for several years. I’ve been describing metaphorically the process of “wearing the T-shirt” for a model to indicate people wanting to affiliate with it, to be fans of it.

Wearing the T-shirt

The notion first came to me while I was sitting in a meeting of the AHRQ Integration Academy. I used to like to sit next to Jurgen Unutzer, the founder of the AIMS Center at the University of Washington. He was on the Academy Council from the beginning, but had to drop off when he became Chair of Psychiatry at U.W. Jurgen is a person of broad knowledge and intense intellectual rigor. It was always delightful to discuss things with him. We were usually taking different tacks on integration. I took the “horizontal” tack, the “behavioral health as practice infrastructure” approach. He took the “vertical”, an integrated team for collaborative care of one clearly defined population within a practice.

I think he was interested in me as well, because we took such different approaches to thinking about integration. He was always one to collaborate across “models” rather than to set up opposing camps. He even cited me in an opinion piece he wrote on the “Flavors of Integration”. So, it was a moment of trust one morning when he leaned over and gave me an authoritative insight into real world model fidelity. He said, “You know, there’s a 400% variation in outcomes within the practices in the Northwest that say they are doing collaborative care.” He added that all these folks think they’re doing the model and see themselves as great supporters of the model that they think they are doing.

Model Driven Practices

That was when the metaphorical idea of “wearing the t-shirt” started in my head. Since that time, I have heard a couple of the people who are recognized as leaders in PCBH say essentially the same thing. When they first consult to a “PCBH site,” they are never sure what they will find being done. The same is true among the model-driven practices whose BH leaders have taken my Leadership course.

Sometimes a model can be an irritant in a practices’ collegiality and culture. In the Primary Care Behavioral Health Leadership course some participants follow the CoCM model, more follow PCBH, while others don’t think of themselves as following either model. The pattern that I have seen in perhaps 10 to 20% of the of the settings consists of a leader who is leading a program that by a reasonable assessment of its development is doing well. The behavioral health clinicians, the patients, and the medical providers are all reporting being more satisfied with the program than the BH leader.

When this happens, it is usually around issues of fidelity to a model. I have often in these cases suggested to the BH leader that they stop worrying about pushing the model and push a more inclusive process of defining the next step in BH care for their site. If you are constantly dissatisfied with your program and your colleagues because your site is not as evolved toward your understanding of a particular model as some of the well-known exemplars are, the model becomes a burden.

Working from a “North Star”

One more thing I have learned from my course participants is that folks who are needed to support the implementation of integration, particularly top leadership, tend not to be willing to support a difficult change in clinical routines because “it is the model.” To energize practice transformation, “better care for patients” is a much more convincing “north star,” than a particular model. When the folks in the site agree to be committed to better access, for example, or more evidence-based care, a model can become an acceptable tool to get to the goal of better care that people are agreed on.

If we spend our energy looking at what the strengths of the program are and what sort of culture we want to develop, we may find that rather than focusing on adherence to the model, we should focus on the next challenges that the needs of our patients or colleagues present. Models can offer useful approaches, but each site will have different needs, and each will find different programmatic adaptations more useful than others. Working from a “north star” of commitment to our patients, problems and opportunities will show themselves, and then a model will be one good source for ideas and routines that can help us move forward, wearing whatever t-shirt is most fun that day.

Share a thought, leave a comment!