Collaborative Documentation: New National Council Webinar

If you have read this blog for a while, you are no doubt aware that I am a webinar junkie. There are loads of free webinars available and they provide lots of very useful information. I am especially fond of the webinars presented by The National Council and have written several articles based on their webinars on topics such as Health Information Exchange and behavioral health, integrating behavioral healthcare into the healthcare home, compliance requirements, and the impacts of healthcare reform on behavioral health providers.

These presentations have usually been packed with information, quick-moving, presented by very well informed individuals or panels, and a pleasure to attend. The webinar I attended today was no exception.

Collaborative Documentation Promotes Efficient Services for Children & Youth was presented by Katherine Hirsch, MSW, LCSW, Consultant, MTM Services, LLC. Ms. Hirsch did an excellent job of explaining just what collaborative documentation is, how to do it, how to engage the client in the process, and what the benefits are. She covered an impressive quantity of high quality information in 90 minutes.

If you are looking for ways to more effectively use psychotherapeutic time, improve the accountability of your staff, and assure that records are completed in a timely fashion, you need to see this webinar. In about 48 hours, the recording of the webinar will be available for viewing at the National Council website.

Behavioral healthcare faces many challenges in these rapidly changing times. Finding the time to provide services well and effectively while accurately and carefully documenting those services is a real challenge. Learning how to utilize collaborative documentation can increase your chances of success.

Are you already using this methodology? How is it working for you? for your staff? Please share your experiences in the comments below.


Change in Healthcare is Upon Us…Law or not

In 1992, when Bill Clinton was elected President of the United States for the first time, I was a member of the Committee for the Advancement of Professional Practice (CAPP) of the American Psychological Association. CAPP is charged with general governance oversight of the Practice Directorate, the part of APA responsible for promoting “the practice of psychology and the availability and accessibility of psychological services, providing resources and services to practicing psychologists in all settings and to the public.”

Our first meeting immediately after the election was highly charged. Staff had been studying President Clinton’s healthcare proposals, and the notion of controlling cost through “managed care.”

President Clinton’s healthcare proposals did not fly, but the industry picked up the notion of controlling costs by managing the care provided to consumers, and psychological practice has never been the same. For private practitioners, “managed care” continues to be a primary obstacle to the practice of psychology. Costs might have been suppressed by managing care, but some would argue that the primary effect of the managed care revolution was the creation of a new industry that made money as the middle-men at the cost of providers. Indeed, after a few years of leveling of the costs of care, the rise has been renewed and expanded.

In mid-November, the Supreme Court of the U.S. agreed to hear an appeal of the Affordable Care Act, our nation’s most recent effort to reform our healthcare system.

The Supreme Court agreed to hear appeals from the United States Court of Appeals for the 11th Circuit in Atlanta, which is the only court to have struck down the individual mandate because it overstepped Congressional authority and wasn’t justified by the constitutional power “to regulate commerce” or “to lay and collect taxes.” FierceHealthPayer, November 18, 2011

According to editor Dina Overland of FierceHealthPayer newsletter, even a complete overturn of the law would have little significant impact. She believes that consumers like the changes the law is mandating and there is no stopping this train.

Mercom Capital Group, in their HIT Report of November 21, 2011, says the same thing about the massive changes in the healthcare arena at large. Basing their conclusions on a report by PwC (PricewaterhouseCoopers, LLC), Mercom reports that health organizations will continue to move forward with changes to their health technology and other innovations because the multiple drivers in the marketplace have finally come to a head. No matter the political or the financial uncertainties, PwC believes this movement will continue. These are changes consumers like, and the movement will continue no matter which market forces might change.

In their HIT Report of November 28, 2011, Mercom reports that Harvard and Aetna will ally to work to improve healthcare costs and quality. The two have formed a research collaborative focused on improving the quality and cost of healthcare. They will use bioinformatics, the interface of computer science and information technology with the fields of biology and medicine, to analyze healthcare data in innovative ways. They will focus on outcomes of various treatments considering quality and cost, factors that predict adherence to medical and drug treatments for chronic diseases, examining how claims and clinical data can be best used to predict disease and follow outcomes, as well as other treatments of data that will emerge over time.

Where is your organization in the midst of this dramatic change in how we manage healthcare? How do you see yourself participating in the sea change that is under way? Where does behavioral healthcare fit into this picture?

Just type in your thoughts below. Thanks for commenting.

Creativity: Running out of ideas…

I have been struggling with a topic for this week’s blog. The only thing that has come across my path that feels compelling is the hummingbird who showed up at our coral honeysuckle on Sunday. Unfortunately, integrating that ruby throat into my article does not seem like an easy task.

Sometimes, I feel like I have run out of ideas. When that happens, I am reminded of feelings I experienced as a child and young adult. I knew I was not an artist and felt myself also to be not creative.

It took many years before I learned that my creativity takes forms different than that of artistic individuals. At some point in the process of doing psychotherapy with some very difficult clients, I realized that most of my creativity takes the form of what I will call creative alternativism. Generating possibilities…especially possibilities for different types of behavior and different kinds of thinking…was the primary manifestation of that creativity. Helping my clients find different ways to be in the world in order to overcome their pain and problems was the most important way I expressed that creative urge.

I have since realized that I often apply that process to myself as well. Since I can be a pretty rigid person when it comes to my own thinking and behavior, I have found that I need to make systematic efforts to implement the alternatives I generate for myself. I may well come up with many ideas about how to change my behavior, but I need structure to implement those changes.

Three years ago, I knew that adding yoga into my fitness efforts would benefit my arthritic joints and relieve some of my stress. Signing up for a yoga class was the structure that allowed me to make that a regular part of my activities. After three years, I have found other structures to help me extend that one class to two and now into a daily practice. I need and use structure to implement the possible changes I creatively generate for myself.

I had an email this week from a colleague I have not seen in years. I was delighted to learn that for the past year, she has been painting! At age 60, she took a pastels class at her local community college. She was hooked on the medium and has found a new outlet for her creativity. In my experience, she has always been creative. She has been a psychologist and psychotherapist for her entire professional life. She has researched and written and published…an aspect of her professional creativity; and now, she paints!

I am delighted to know that a new aspect of creative expression can manifest itself at any age, as long as we are open to it.

How do you express your creativity? Do you manage to do this within your professional life? Does the place you work benefit from your creative endeavors, or is it just for you?

Please share your thoughts about creativity, regenerating it, and keeping our lives…and blog topics…fresh.

Prevention and Pain: A major way to save money

This morning I read an editorial (An ounce of prevention could heal a pound of pain) by Dina Overland of the FierceHealthPayer newsletter. She decided to use her platform as the editor of a newsletter that is aimed at insurance payers to directly address those payers about prevention of healthcare problems and diminishing future costs. She focused on an area that behavioral health and substance abuse professionals work in often . . . pain.

Ms. Overland’s review of the Institute of Medicine’s (IOM) report on pain and prevention cited some facts I had not heard.

Chronic pain affects 116 million Americans–that’s more people than affected by heart disease, cancer, and diabetes combined–and costs the United States
$635 billion each year. That’s what the Institute of Medicine (IOM) found in its report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.

If that’s not jarring enough, here are some more staggering facts: The United States spends $2 trillion on healthcare, but only 4 cents of every dollar goes to prevention and public health, despite being among the best tools to reduce spending. For every $1 invested in prevention, we save $6 in projected healthcare costs, says Sen. Tom Harkin (D-Iowa), who participated in the Department of Health and Human Services (HHS)’s announcement
of its guidelines to incorporating prevention throughout the healthcare industry.



I could not help but think about the number of people who would never have become substance abusers if their chronic pain had been addressed and treated at an early stage. How many behavioral health clients have you treated for depression after years of experiencing intractable pain?

The IOM and HHS see the coordination of care among primary care providers and specialists as the best way to address early intervention and prevention of pain. What role should mental health and substance abuse providers play in this coordination? How many of your patients also experience chronic pain? Where do behavioral health providers fit in?

Please share your thoughts and comments below. What role do you want to play in diminishing healthcare costs? Who should we see when it hurts?


APA and Public Education in Behavioral Health

In a previous life, when I was actively involved in the American Psychological Association (APA), I was for three years a member of and one year the chair of the Public Information Committee of the APA. Prior to that, I hosted a live, call-in television show for two years. Frankly Speaking with Dr. Kathy Peres was entirely focused on educating the public about psychological matters. I believe that public education about how mental health issues affect our day-to-day lives is a significant responsibility of all professionals and organizations that provide services in the behavioral health arena.

Given that belief, I was very pleased today to receive an email from the APA announcing a new series of videos and podcasts by APA CEO, Norman B. Anderson, Ph.D. You can view the introduction and the first two installations in the series This is Psychology, one on bullying and another on children’s mental health.

APA invites you to place these links on your own professional web sites and to share them and the information they contain as broadly as possible.

Last week, I wrote about potential problems with use of social media in your organization. Public education of this sort. . .including sharing of the information created on Twitter and FaceBook is one arena in which I think social media has the potential for more power than in any other area of our professional lives.

How does your organization participate in education of the public about behavioral health issues? Please share your initiatives and activities here so others can communicate them more broadly for you.

Electronic Claim Filing for Secondary Insurance

Our technical support and customer service staff regularly discuss questions our customers commonly ask. They often answers these questions in emails—repeatedly. For a long time, we have tried to answer some of these questions in documents to make it easier for our customers to succeed in their jobs. The Document Library page on our web site has always aimed to achieve that goal. This year, we implemented new and additional documents in a blog format on our web site as another way for our customers to get answers to their questions quickly.

Electronic claims filing is one of those areas where questions abound. No matter how many times we answer the same questions, we always need to come up with new and different ways to communicate information that is very familiar to us but not so apparent to our customers. This is the same kind of task psychotherapists and others who work with people in any capacity have to accomplish—coming up with different language and presentation of an idea so it can be heard and understood by the person being addressed.

Our lead technical support rep, Manon Faucher, recently wrote an article about how to file claims for secondary insurance carriers electronically. I have borrowed heavily from her article to address the issues that are crucial in successfully filing electronic claims for secondary insurance payers, assuming that the clearinghouse or site through which you send your electronic claims allows submission of secondaries and the payer to whom you are sending can receive secondary claims electronically.

In order to successfully submit secondary insurance claims, it is essential that you include the information about how the claim was adjudicated by the primary insurer. Doing so requires specific data in certain loops and segments of the 837P. If you are an SOS Software user, you should read Manon’s document. She created detailed instructions with screen shots for our product. If you use a different software product, you will need to find out from your vendor whether you can enter and they can report the necessary information to file the secondary claims.

  • Primary payer– You must be able to indicate the order of liability for payers. Make sure you have the Primary set as such for this claim.
  • Secondary payer– You must be able to designate this payer as Secondary for this claim. You must also be able to enter the “Amount received from other insurance”, information that would go in box 29 on the CMS 1500. This should go into the 2320 loop, segment AMT 02.
  • Verify the Claim Adjustment Reason (CAR) amount– If you have received an Electronic Remittance Advice (ERA) that automatically posted your payment from the Primary payer, you will need to determine that the total of the CARs matches the amount of the date of service Fee minus the payment from the primary insurance. Examples:

Denial – no payment by Primary

Fee for service $200
– Primary insurance did not pay for the service so $0 payment is entered for a Denial
CARs must equal the entire fee, $200.00

Partial Payment and Adjustment

Fee for service $200.00
– Primary insurance paid $120.00 and an adjustment of $30.00 was required from the payer
Amount of your CARs will have to equal to $80.00 ($200-$120)

The information from the CARs must be entered in the appropriate segment in the 2430 loop.

  • Adjudication or payment date: Make sure you have entered the payment date in the appropriate place so it will show up in loop 2330B segment DTP 03.
  • Generate and submit the secondary claim.

If your organization is not yet filing insurance claims electronically, it is certainly a service you should investigate. At some point in the future, it will certainly be required that all claims are filed electronically. In the meantime, it is a major convenience and financial savings for providers and organizations.

Maybe it is time for you to get rid of the paper!

Got any observations, opinions, reservations, cheers about filing claims electronically? Please share in the Comments section below. Thanks for reading!




Medicaid Shrinkage: Innovation or reaction?

Just one year ago, after passage of the Affordable Care Act (ACA), The National Council highlighted the expansion of Medicaid that would occur as a result of the ACA. To meet the law’s requirements to provide insurance coverage to the working poor who are generally not insured through their employment, do not have access to insurance groups, and cannot afford individual coverage, the Medicaid program would need to expand to provide the legally required coverage.

In November, the American electorate hired new Congressional representatives who are dead set on rolling back what they call “entitlement” programs (Social Security, Medicare and Medicaid) and returning the Federal government to what they see as its proper role: funder of national security and protector of free markets (code words for defense and corporations). In this new/old world view, individual rights consist of the right to pursue happiness and to bear arms; communal responsibility for one another appears to be non-existent.

Where does that leave those with serious behavioral health issues and the people who treat them?

The National Council works to represent community behavioral health organizations and the people they serve. They view Medicare and Medicaid as crucial to the treatment and therefore to the survival of the seriously mentally ill since “Medicaid is the single largest source of funding for America’s public mental health system.” Since early March, The Council has reported regularly on the threatened slashing of the Medicaid and Medicare systems.

In early March, The Council reported that a group of governors testified about their need for greater “flexibility” in their Medicaid programs. This group especially wanted to be exempted from the maintenance of effort (MOE) requirement under ACA that prohibits the states from rolling back Medicaid eligibility. President Obama said he would support allowing states to opt out of the law’s requirements if they could guarantee an alternative method of providing universal coverage.

On April 4, Representative Paul Ryan (R-WI) released his committee’s plan for the 2012 budget that includes a dramatic restructuring and slashing of both Medicaid and Medicare. On April 7, the National Council released a fact sheet on the potential impact of the funding decreases promised by the budget blueprint. Under Congressman Ryan’s proposal, Medicaid would be converted to a block grant program beginning in 2013 and Medicare would be converted to a privatized voucher system starting in 2022. The House of Representatives voted to adopt this framework. While it is highly unlikely the Senate will accept the blueprint, they will need to come up with one of their own and then work to reconcile it with the House’s plan.

In a Health IT newsletter by Mercom Capital Group, it was reported that on April 14, 2011, The U.S. Department of Health and Human Services (HHS) “announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families.” In Florida which has been providing some Medicaid services through managed care contracts, the legislature is close to mandating managed care for the entire program in spite of poor reviews for the pilot programs. “At the workshop in Hollywood, a succession of doctors, care providers, advocates and Medicaid patients all had the same message: Managed care has been a disaster.”

As a small business owner who buys health insurance in the private marketplace for a very small group of employees, these proposals are extremely frightening. My health insurance premium at age 60 is already more than the proposed Medicare plan would pay once I become eligible at age 65, and my premiums will certainly not get any lower if I need to buy insurance in the private marketplace. If I, as a pretty healthy 60 year old, am so concerned about these changes to Medicare, I can only imagine the panicky reactions being experienced by those persons represented by the National Alliance on Mental Illness (NAMI) who are dependent upon Medicaid and Medicare to pay for their treatment.

How do you see these proposed changes impacting you and your organization? Do you agree with this method of limiting spending? What ideas do you have for controlling the growth of costs of Medicaid and Medicare? How do you propose that we proceed?

Please share your comments below.

Sleep Deprivation: The cost

Two nights ago I woke up at 1:30 a.m. and did not fall back to sleep until 3:30 a.m. The room was too hot to sleep comfortably and I was awakened by a night sweat. I got up and cooled the room, but before I could fall back to sleep I was experiencing painful flushing caused by the niacin I take. Yikes! Today I am struggling with staying awake and trying to be productive.

According to surveys done between 1999 and 2004 by the National Sleep Foundation, 60% of adults report having difficulties sleeping a few nights a week. According to WebMD, some of the consequences of sleep deprivation can be:

  • Decreased performance and alertness
  • Memory and cognitive impairment
  • Stress on relationships
  • Poor quality of life
  • Occupational injury
  • Automobile injury

For many of us, irritability, poor decision making and decreased performance are the main problems. Yep, I have now started this article for the second time…my first try did not save properly.

According to sleep researchers, cognitive behavioral therapy can be as or more effective than the use of popular medications to solve sleep issues. Some of the recommendations for improved sleep include this list from the APA web site:

  • Keep a regular sleep/wake schedule
  • Don’t drink or eat caffeine four to six hours before bed and minimize daytime use
  • Don’t smoke, especially near bedtime or if you awake in the night
  • Avoid alcohol and heavy meals before sleep
  • Get regular exercise
  • Minimize noise, light and excessive hot and cold temperatures where you sleep
  • Develop a regular bed time and go to bed at the same time each night
  • Try and wake up without an alarm clock
  • Attempt to go to bed earlier every night for certain period; this will ensure that you’re getting enough sleep

I will definitely be heading to bed early tonight. I already do many of the other recommendations and usually sleep pretty well. Maybe that is why I am so discombobulated when my sleep is disturbed.

How often is sleep deprivation a problem for you? Has it become chronic insomnia? What do you do about it? How can we prevent this epidemic of sleep deprivation from undermining our lives?

Please share your experiences, your comments, your yawns 😉 below.

Integrating Behavioral Health into the Healthcare Home

One of the many provisions included in the Patient Protection and Affordable Care Act (health care reform law) was the creation of pilot programs to integrate all health care services into a Health Home. The development of the ‘medical home‘ concept will be most important among those with complicated health concerns and in vulnerable populations. Those with significant health issues in addition to behavioral health disorders will be in special focus.

This attempt to integrate care will likely have major impacts on how behavioral health care services are provided to the seriously mentally ill and chemically dependent populations. The National Council has been actively involved in this movement and has received funds to found the Center for Integrated Health Solutions.

The National Council for Community Behavioral Healthcare has won a competitive cooperative agreement from the U.S. Department of Health and Human Services (HHS) to establish the Center for Integrated Health Solutions. The Center will address the comprehensive health needs of clients with mental illnesses and/or substance use disorders by improving the coordination of healthcare services in publicly funded community settings. The Center is funded jointly by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources Services Administration (HRSA).

In that role, on January 19, 2011, the National Council participated in an extremely informative webinar on current integration projects initiated by community behavioral health organizations. Each of the organizations that participated came to their ‘Health Home’ program in a different way and developed programs using different models. The presentation made clear that there are likely to be as many ways to accomplish the purpose of integrating health care for the most vulnerable populations as there are organizations that will provide that care. Even so, there are significant issues to be considered, challenges to be met, and goals to be accomplished for the establishment of a successful program.

A recording of this webinar is to be posted at at an indefinite date. Information about Co-Occurring Disorders Integration & Innovation can be obtained at

The hope that these programs can provide more effective health care at a lower cost is high. I am sure we will all be watching carefully to see how these and other initiatives progress.

I invite those  of you who have interest and experience with integrated care to share your perspectives. Your input will be valuable to your colleagues.

Implementing Evidence Based Practices

Last week I attended the semiannual member meeting of the Software and Technology Vendor Association (SATVA), the trade association I have mentioned in the past. At lunch, I sat at a table with Don Hevey, the President/CEO of MHCA, described as “an alliance of select organizations that provide behavioral health services.” Their members are some of the largest community mental health centers in the country. We were talking about accountability and evidence based practices and Don mentioned a statistic from the American Medical Informatics Association and quoted in the American Psychological Association’s Monitor on Psychology

that it takes as long as 17 years for research findings to enter medical or mental health practice, and even then, only a fraction makes it in.

One of the others at the table (MHCA chair Tony Kopera, Ph.D.) indicated that part of the problem in mental health is that treatment protocols are often designed for and tested on those with a unitary diagnosis and relatively stable lives. This does not match the real world, community behavioral health center situation where many of the seriously mentally ill carry multiple diagnoses and may bounce from group home to the street to jail to hospital and back again.

The American Psychological Association has begun a science/practice collaboration for the purpose of creating treatment guidelines. Since the U.S. healthcare system has begun a significant focus on accountability, “providers need to show insurers and policymakers that their treatments provide good outcomes for patients” according to Katherine Nordal, Ph.D., executive director of APA’s Practice Directorate.

A treatment guideline won’t be a one-size-fits-all cookbook approach, she emphasized. Instead, a guideline will serve as a decision-making aid to help a practitioner decide the best possible course of care for a particular patient, combining clinical judgment, the best available research, and the patient’s individual characteristics and preferences. Longterm, clinical treatment guidelines can help improve patient care by identifying gaps in research and treatment where more work is needed to develop effective interventions.

I was interested to see that only one of the members of the APA treatment guidelines committee is a private practitioner; another member is with the VA. All others are academician/researchers. While this composition favors quality science, it runs the risk of overlooking real-world needs.

There are researchers who focus their attention on dissemination as well as implementation of the science that already exists. The APA has recently run multiple articles on this new field.

Until we figure out effective strategies to get evidence-based practices integrated so they can help people, they’re not much better than a nice publication,” says the National Institute of Mental Health’s David Chambers, DPhil, who directs the institute’s dissemination and implementation research arm.

Getting research into the real world, by Tori Deangelis, is an excellent examination of the resources and the challenges. DeAngelis quotes Dr. Gregory Aarons:

“Our job isn’t just to create new knowledge, it’s to improve the health-care delivery system,” he says. “Sometimes that means proceeding with the best available information and learning from experience, even though we’d prefer to wait for something a lot more definitive.”

While dissemination and implementation science are multidisciplinary by nature, psychologists with strong research backgrounds and an interest in systems change have much to contribute, adds psychologist Gregory Aarons, PhD, an implementation researcher and associate professor at the University of California, San Diego.

And in Evidence-based psychology in action, DeAngelis reports on an implementation of evidence-based practice in a community program utilizing a structured framework for this implementation.

The challenges of incorporating evidence-based practices (EBPs) into clinical practice has resulted in a whole field called implementation science. The National Implementation Research Network has as its goal “to close the gap between science and service by improving the science and practice of implementation in relation to evidence-based programs and practices. I can imagine this discipline becoming a major field as we attempt to control the costs of health care.

Resources abound. The US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) maintains web resources aimed at dissemination of evidence-based practices, including those for mental health. The Substance Abuse & Mental Health Services Administration (SAMHSA) has long provided access to research and protocols for EBPs.

One of my biggest concerns about possible future mandates for the use of evidence-based practices is the challenge of getting treatments from paper to practice. Implementation science may help.

How is your organization proceding in adopting EBPs? Do you see a role for behavioral health specialists in implementation? What do you think about how we will get there? Please enter your comments below.

How’s Your Compliance Program Coming Along?

Last week I attended a webinar sponsored by The National Council: Healthcare Reform Expands Compliance Requirements: Prepare Now.  There is a recording of the presentation at the link above.

I attend lots of webinars to try to stay informed about what is happening in our industry. As indicated by the fact that I often write about those webinars, I am often stimulated by them. I am rarely alarmed, but this presentation by attorney Adam Falk was almost frightening. I found myself thinking that, if I were still in private practice of psychology, I would stop accepting Medicare patients. Since I just turned 60 and will become one of those Medicare patients in only five years, that thought was most distressing.

According to Mr. Falk, the Patient Protection and Affordable Care Act of 2010, as part of the attempt to save money by eliminating fraud, has placed new requirements on providers of service large and small, to demonstrate compliance with the law. It is not enough to comply; one must also be able to prove that compliance, hence the need for a formal Compliance Program.

The regulations have not yet been written to determine what must be included in such a Compliance Program, but Mr. Falk strongly suggests the need to be proactive rather than reactive regarding this matter. While compliance programs are to be ‘scalable’ based on the size of the organization and the amount of service provided as part of the Medicare or Medicaid systems, there are certain aspects that are essential.

The biggest danger to provider organizations is that the Affordable Care Act classifies much irregular activity as making a false claim. The penalties for false claims are significant. Fraud is rampant and HHS is tasked with eliminating as much of it as possible to protect the taxpayer’s dollar. The attempts to prevent this fraudulent activity provide the Secretary of HHS with broad authority.

Additionally, providers are required to identify, report and return overpayment by Medicare or Medicaid within 60 days of the provider’s recognition that an overpayment has been received. That recognition applies to the clerk in your accounts receivable department who mentioned the overpayment to a supervisor or to someone in authority. Training staff and providing formal procedures to follow will be an essential part of any compliance program.

I would suggest that you take an hour and listen to Mr. Falk’s webinar. Then start to research what might be required at your organization’s level to comply with the requirements of the law.


I received an email notification today from the Office of Civil Rights indicating that HHS has scheduled a second public discussion on Confidentiality and Privacy Issues Related to Psychological Testing Data. The meeting will be held in Los Angeles on November 18, 2010.

Please share your comments below. Thanks for reading!

Primary and Behavioral Healthcare Integration

On Monday the National Council announced that they have won a competitive grant to provide training and technical assistance to move forward the process of integrating primary and behavioral health care services. They will provide support services and assistance to organizations that have received grants to develop integrated care within their organizations, as well as to other organizations seeking to move in this direction.

 One of the pushes in the ARRA stimulus funding and in the health care reform law (Patient Protection and Affordable Care Act) was more efficient and cost effective provision of health services. One possible way to accomplish this for those who experience mental health and addiction problems is to integrate the care they receive for all illnesses, physical and behavioral. The National Council has been at the forefront of this movement. Their snagging of this grant demonstrates their commitment to the cause of integrating primary and behavioral health care for vulnerable populations. The press release indicates the following:

The Center will provide training and technical assistance to 56 organizations that have collectively been awarded more than $26.2 million in grants as well as to community health centers and other primary care and behavioral health organizations. According to HHS Secretary Kathleen Sebelius, these grants are part of an unprecedented push by the Patient Protection and Affordable Care Act to help prevent and reduce chronic disease and promote wellness by treating behavioral health needs on an equal footing with other health conditions.

When I have mentioned this topic in previous blog articles, the response has been disbelief that such integration will occur any time soon. After all, behavioral health private practitioners of our generation are not likely to dramatically change the way in which they practice, and now they mostly practice independently of medical settings.

In fact, it is even the case that many of our community-based behavioral health  organizations have a hard time seeing themselves moving toward providing primary care services for their consumers. At least one of our customers tried establishing a primary care facility as part of their organization a couple of years ago. The service did not take hold and they closed it. Perhaps they were too far ahead of the curve to be successful.

According to the National Council, the motivation to integrate general and behavioral health care among the chronically and seriously mentally ill is the significantly shorter lifespan experienced by those with serious mental illnesses.

According to a 2006 national survey, persons with schizophrenia, bipolar disorder and major depression have lower than average life expectancy and die, on average, at the age of 53 — often from untreated and preventable chronic illnesses like hypertension, diabetes, obesity and cardiovascular disease. Lack of access to primary care and specialty medicine is a critical factor in these tragic outcomes. . . .

The average life expectancy of the population at large in the U.S. in 2006 reached an all time high of 78.1 years. This 25 year difference is unconscionable. It is believed by many in the public health and behavioral health communities that integrating health care services for the seriously mentally ill and chemically dependent populations will encourage treatment regimens that will benefit both physical and mental health.

Most of the organizations active in this integration movement are considered ‘safety net’ providers. Although part of an endangered system,  ‘safety net providers are providers that deliver a significant level of health care to uninsured, Medicaid, and other vulnerable patients.’ They are the health care safety net that is intended to keep vulnerable populations from falling through the cracks in our costly and difficult to navigate health care system.

Are any of our readers among the 56 organizations that have received grant funding to develop integrated physical and behavioral health services? Do you see this as a possible and worthwhile goal for private practitioners to move toward? What changes in training models and practice models would need to occur to integrate primary and behavioral health care?

Let us know your thoughts about these issues. Please enter your comments below.

OpenNotes Project: Where does mental health fit in?

On Monday of this week, Seth asked me if I had a topic for my current blog. As I had none at hand, he pointed me to last week’s episode of the podcast/NPR show, Science Friday. Seth is a regular subscriber to this series and I listen when I find the time. That effort is always rewarded by fascinating discussions of current science issues. For the science professional, wanna-be-scientist or interested layperson, this show is a ready source of truly valuable information.

On Friday, July 30, 2010 the discussion topic was a medical records project called OpenNotes. With the advent of electronic medical records (EMRs) and patient portals into the medical records system, it is only reasonable to begin to consider the nature of the records that physicians keep on their patients. The OpenNotes project is an attempt to allow some 25,000 patients direct access to what 100 participating primary care physicians write in their notes after seeing them.

The project will study the experiences of both the physicians and patients, the impact on work flow of such note taking/sharing, the possible increase in communications between patient and physician, and the reactions of both sets of participants to their experiences. The details of the study are published in an Annals of Internal Medicine article, Open Notes: Doctors and Patients Signing On.

The Science Friday discussion included concerns about sharing sensitive information with the patient and the ability of the patient to understand and process the information included in the note. It has especially been argued that the mental health patient might be too fragile to be exposed to the psychotherapist’s or the psychiatrist’s true evaluation of their status as stated in the progress note.

On the other hand, Concurrent (Collaborative) Documentation has been touted by some community behavioral health specialists as an essential tool for increasing both quality and efficiency of client interactions while simultaneously increasing client buy-in to the treatment plan. The New York State Office of Mental Health writes:

It has been suggested that Concurrent Collaborative Progress Notes were the ‘way to go’. What about uninterrupted direct face to face contact as the best way to achieve high rates of engagement and retention in our clinics?

Concurrent documentation does not require the clinician to take notes during a session or to detach themselves from the recipient. Rather it is advised that at the end of the session, a brief review of the session takes place and the recipient and clinician collaboratively record the progress note. This process supports the delivery of person centered services and often provides the clinician with important feedback about the recipient’s perspective and information obtained from the session.

The process of creating this record concurrent with the meeting and collaboratively with the client is the epitome of an open record. While the OpenNotes project does not go quite this far, it certainly opens the door in this direction. Since the patient owns the record, it seems only fair that they should have easy access to that record and even participate in its creation.

My background as a Feminist Therapist has long given me a strong leaning in this direction. In the view of Feminist Therapy, the treating professional is a consultant having special expertise who is hired by the client to assist them in solving their “problem”. This is certainly also the case in the medical office. The physician has expertise the patient is seeking in their efforts to treat illness and to live healthier lives. This collaborative relationship is more a meeting of equals working together for the patient’s benefit than a dictation of treatment by an authority-figure intent on successful treatment and risk management.

What do you think about opening progress notes to your patients and consumers of service? How would that change the work done by the provider of services? How do you imagine it would change the experience of the consumer?

Please share your comments below.

Managed Care Organizations Oppose Parity

An organization called the Coalition for Parity, Inc. comprised of managed behavioral health organizations (MBHOs) has filed suit to halt the implementation of the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act. This group has as some of its members Value Options, Magellan Health Services Inc., and Beacon Health Strategies Inc.

As reported by Open Minds and American Psychological Association Practice Organization, the lawsuit challenges the rulemaking process and has requested a temporary restraining order to stop the rulemaking process from moving forward. They argue that the Departments of Health and Human Services, Labor and Treasury overstepped their rulemaking authority in how they interpreted the statutory language and violated federal rulemaking procedure in publishing the rule as they did. While the judge denied the temporary restraining order because the law will not be enforced until July 1, 2010, the court will hear the case as presented by the parties to the action.

On May 9, 2010, the NY Times reported that insurance companies and employer groups are also objecting to the rules.

In a suit over the rules, Magellan and other companies said the concept of nonquantitative limits was “boundless and ill defined” and would reach virtually every policy and procedure used to manage mental health benefits.

As most mental health providers can readily attest, the procedures used by insurers and managed care organizations to limit costs and usage of behavioral health services have themselves been “boundless and ill defined”; after all, a treatment plan certainly could not be a valid treatment plan if it is printed on the wrong form. The MBHOs have been innovative in their development of “every policy and procedure used to manage mental health benefits.” Unfortunately, most of that management has consisted of denying or limiting the amount of service provided and placing onerous requirements on providers.

The NYTimes article states that:

One premise of the law is that mental illnesses often have a biological basis and can be treated as effectively as many physical ailments. But insurers say it is impossible to use the same techniques in managing the treatment of colon cancer and schizophrenia, or heart failure and major depression.

What do you think? Is it reasonable to assume that mental illness and addiction can be managed using the same techniques as are used to manage the treatment of cancer or heart disease?

Please share your comments below.

Resources for Behavioral Health Providers

I read lots of articles online…or I download the articles and read them in .pdf format. Seth found a free tool that is going to make this whole reading and organizing process easier for me. It is called PDF-XChange Viewer and it can be downloaded for FREE! If you like to highlight and make notes as you go, this is a great tool.

That resource is really just a lead-in. In case you have not already collected some of the following sources from my references to them in other articles, I am going to put them all in one place. These are newsletters and web sites that are chock full of information that can help you stay informed about changes in the health care and regulatory world.

  1. My favorite by far is The National Council (NCCBH). This organization produces regular newsletters on varied topics, but I find their Public Policy Update to be an invaluable source of information on laws and regulations, policy trends and how you can address them. I have also greatly enjoyed their Webinars. Ordinarily, I would have already registered for the program coming up on Friday, May 14, What is an Accountable Care Organization and Why Should I Care? Since I will be out of town, I won’t be able to attend when it is broadcast; instead, I will watch it at a later date from the web site. The best part is that these programs are free and you do not need to be a member to participate in them. They are provided as a service to the behavioral health community.
  2. Every Monday, I receive a free multi-paged newsletter from the Mercom Capital Group, LLC of Austin, TX and Bangalore, India. This newsletter pulls capsules of information from a large variety of sources providing a quick overview of events in the domain of health care technology and health care policy. If you are interested in trying it out, send your email address to Raj at
  3. Open Minds is a longstanding and thorough source of industry information and strategy specifically for behavioral health provider organizations. While there are an abundance of workshops, webinars and premium programs, the Open Minds Circle is a free-for-the-registering newsletter from founder Monica Oss and others at Open Minds.
  4. Behavioral Healthcare and Healthcare Informatics (products of the Vendome Group), the U.S. Department of Health and Human Services, and the Office of the National Coordinator for Health Information Technology all have mass quantities of information to offer you, all available online.

The amazing thing to me is that this is just a small list. If you were to add in blogs, the amount of free, high-quality information available to you on the web is overwhelming. Choose wisely…and use that free .pdf markup tool to make it easier!

Please share with the rest of our readers sources of behavioral health industry information upon which you rely. Just enter your comments in the box below.

License to……

Every two years around this time I am busy completing my Continuing Education Units (CEUs) so I can renew my license as a psychologist. I have done this every biennium since 1980, even though I retired from practice 17 years ago. In Florida, the license is both a practice and title act…to represent myself to the public as a psychologist, I need to be licensed. This was the first year I have even vaguely questioned why I continue to do so.

The decision to renew has usually been an easy one for me to make even though I do not practice and have no plan to return to work as a psychologist. I have a strong identification as a psychologist. I knew since early high school that I wanted a Ph.D. in clinical psychology; I always wanted to practice independently.

Even when we decided to relocate to central Florida and I took the opportunity to close my practice and work with SOS full time, I never considered dropping my license. After all, we have always told you that we provide software by psychologists for psychologists (and all other behavioral health providers). And anyway, who knows what time and politics will bring!

Usually my reading is a way to meet my CEU requirements and keep up with the clinical side of psychology. This year I was surprised; two of the articles I read this weekend were actually quite interesting to me; they were articles on personal or life coaching and Positive Psychology. Both of these areas have roots in the personal growth and Humanistic Psychology movements of the 1970’s, but are 21st century, mainstream ways of implementing growth-oriented interventions.

As the healthcare arena changes over the course of the next few years, it is highly likely that some organizations will seek to provide pure healthcare services. Others will choose to diversify their services in a variety of ways…and even to provide their services in unique fashion. Open Minds recently discussed both telehealth delivery of services and the use of virtual reality interventions to treat certain problems.

What new kinds of therapy has your organization considered? Do you continue to provide the same services you have always performed, or are you on the lookout for ways to diversify? What criteria do you use to decide if a particular service or technique should be added to your bag of tricks?

Please share your comments. We would love to know how you expand the services your organization provides. Just enter your comment in the box below. If you do not see a box, click on the title of the article and scroll down to the comment box. Thanks for reading!

Stress: APA’s 2009 Survey

In early November 2009, the American Psychological Association released the results of their 2009 Stress in America Survey. The executive summary is an excellent way to review the results of the survey in 20 pages. The survey was conducted by Harris Interactive and included 1,568 adults aged 18 and older who reside in the United States. The report also includes the results of a YouthQuery survey conducted among 1,206 youths aged 8-17 years of age. Those who provide mental health services to either or both adults and children should take a look at the outcome of this survey. The data are distressing and worrisome to those of us with interest in the effects of stress on our physical health.

According to the survey, parents think their own stress does not affect their children and that their children are not stessed. It appears that parents do not see the worries and stress-related symptoms of their children accurately; and while three-quarters of young people say they can talk to their parents about things they worry about, they also indicate that worry is a real problem for them. Either they are not telling their parents about their stress or worry, or their parents are not hearing them when they communicate. As a result, children may not be getting the family support they need to manage stress. Parents also seem to underestimate the severity of the stress teens and tweens experience.

42% of adults indicate that their stress has increased in 2009. This is 7% fewer than those reporting an increase in stress during 2008 (49%) but is still almost half of the adults surveyed. While it is somewhat comforting to know that only 42% of adults said that their stress has increased in the past year, it is difficult to tell from this report whether the 49% who reported an increase last year are now experiencing less stress or whether it is merely the same as in 2008. The summary indicates that “this could be a precursor to serious health consequesces related to chronic stress.”

While 44% indicate they exercise or walk to manage their stress, 49% indicate they rely on sedentary means of managing stress. 43% reported eating too much or eating unhealthy foods because of stress. Only 4% indicate that they see a mental health professional to deal with stress.

Money, work and the economy are still the most important sources of stress for adults.

Two-thirds of U.S. adults have been told by a health care provider that they have chronic health condition(s) and 70% have received recommendations for lifestyle and behavior changes….exercise more (48%), lose weight (38%) and eat healthier (36%). Few were offered or received support to make these changes; half did not even get an explanation for the recommendation. Women seem to be bearing the brunt of the stress…or are more likely to report it. They are also more likely to report physical symptoms along with the stress.

The potential physical effects of stress has long been studied by mental health and medical professionals. Back in 1967 Holmes and Rahe developed their Life Changes questionnaire also known at the Social Readjustment Rating Scale. This simple questionnaire has been used in a multitude of studies and scores correlated with the occurrence of serious physical illness within the next year. Let’s hope that those who become ill following these two years of significant stress will have access to the health care services they need.

A 2008 study detailed a physiological explanation, and an article in Gizmag does a nice, brief discussion, of how stress affects the immune system. Under stress, the body produces cortisol to facilitate the “fight or flight” response. Under chronic stress, there is an overabundance of cortisol, so the body remains on alert long after that is necessary and the immune system is affected. The mechanism at work seems to be the shortening of chromosomal end caps called telomeres which produce telomerase, an enzyme that keeps immune cells “young”. Cortisol diminishes the production of telomerase thus shortening the healthy life of protective T lymphocytes.

Of course, there is a perfect opportunity for development of a drug to reduce cortisol or increase telomerase. As specialists in behavioral change, I would think it incumbent upon mental health professionals to be doing more education about stress management rather than waiting for yet another drug to make us healthy. There are certainly online resources to facilitate such education. If only 4% of adults indicate that they consult with a mental health professional to help them manage stress, it would appear that the opportunities in this area are wide open.

What does your organization do to help your clients and your community better manage stress? Do you believe there are ways that behavioral health providers might more effectively attract the severely stressed into treatment? Should the practice of psychotherapy also include community education in stress inoculation techniques? How do you manage your own stress?

Please enter your comments by clicking on the title of this article and making your entry in the box below.


I try to keep informed about Electronic Medical records (EMRs), certification of those products, and funding for them provided through the economic stimulus bill (ARRA). After all, as a developer and vendor of a behavioral health EMR, I really should know some of this stuff. This week, I was struck by the number of acronyms that have come into common parlance in the past six months. I find the amount of information being generated about healthcare information technology (HIT) overwhelming. I am sure it feels even worse to someone who has not been trying to keep up with this information. After all, who can possibly know what all of these shorthands stand for and mean? 

So what would any good technology hound do? Well, of course, I googled ‘Health Information Technology acronyms‘ to see who out there has started to organize this information for the public. To my pleasant surprise, several documents attempt to do just that.

To start with, our federal department of Health and Human Services has a whole web site dedicated to HIT. On the left side of the page, there is a list of tabs. Under Resources there is a page called Acronyms. And that is just what it is. A list of the letters used as the shorthand referents for 112 terms ranging alphabetically from AHIC (American Health Information Community) to WW (Wounded Warrior). You can then cut and paste a name into the Search box on the top right of the page to find documents on the site that reference this “term”. When I do this for American Health Information Community, I get a list of 601 documents linked to this site that refer to AHIC in some fashion. If I do this same search on Google, I get about 129,000,000 hits. Be careful what you search for!

The Rural Health Resource Center, a not-for-profit located in Duluth, Minnesota has a document containing a list of 53 acronyms including brief definitions or descriptions of the terms or organizations listed as well as links to the sites of some of the organizations described.

Likewise, the Department of Health Services of the state of Wisconsin has published a list of acronyms and what they stand for. This list relates to eHealth rather than just health information technology, so it is bound to have some different entries.

A web site created by Pivotal Solution Group called HITECH Answers has their own list of acronyms and definitions. Pivotal Solution Group is a coaching and consultancy organization…a private group as opposed to the government sources listed above.

And finally, the Software and Technology Vendor Association (SATVA), a trade association of behavioral health software vendors to which we belong, has developed a section on their web site to monitor information regarding behavioral health EMR certification. Behavioral Health Certification Watch will be updated as new information is received. 

While some of you have probably clicked on the links above, I think it highly unlikely that you will spend much time reviewing this information. After all, who has the time to go looking into the masses of information that are being created about HIT, certification of products and paying for those products. Most behavioral health organizations are likely to just continue doing what they do until someone finally tells them they must move to an electronic medical record (EMR) by a certain date or they will not get paid for the services they provide. Oh wait, that is what has happened…at least, for Medicare and Medicaid payments.

Is that enough to start movement toward an EMR in your organization? Is your practice beginning to consider the possibilities? What do you believe it will take to move mental health providers into EMRs?

Death and EMRs: Disruptive events?

The deaths of the past week have set me to thinking. The mother of a friend passed away early in the week followed by the wife of a family friend. Then, news of the death of cultural icon, Michael Jackson, was everywhere.

I come from a family and culture (New Orleans-based) where death is an intrinsic part of life. It very much affects those who are touched most directly by the loss, but it is also integrated into day-to-day life in such a fashion that life moves on with barely a ripple. The deceased is celebrated and mourned in one or multiple events ranging from wake to jazz funeral. Burial in above-ground graves and mausoleums (the water table in New Orleans is very high) caps off the events, and the cemeteries are daily reminders of the short-term nature of life. As with everything else in New Orleans, after death there is a party, but there is real disruption only for those immediately touched by the death. Life goes on.

I married into a family that shares the more traditional views of death held by most of American culture. It is not to be talked about too openly, lest it be invited to approach. And, as for most people in our culture, death is definitely considered to be a disruptive event, dislocating those related to the deceased from the ordinary course of life for an extended period of time. In fact, the disruption is frequently so severe that it is no surprise to those around the survivors that they are forever changed.

The term disruptive technology was introduced by Clayton M. Christensen in 1995 and together with his modification disruptive innovation has become a catch-phrase for technological change that is so radical that it dramatically alters the course of events that follow. If you read any articles about technology, you will come across the terms.

On the way to an event yesterday, we were listening to a podcast of The Week in Technology (TWIT) in which Twitter was discussed as a disruptive technology…disruptive to the field of journalism and to our whole way of communicating and thinking about news events. The techno-nerds who are the mainstay of TWIT are convinced that the immediacy of communication enabled by Twitter is and will continue to radically alter the way in which we receive information, likely becoming the jumping off point for even newer innovations in the realm of communication and information sharing.

I find myself wondering if Electronic Medical Records (EMRs) will not become the same kind of disruptive technology for our current healthcare system. Since EMRs have been around  for a while now, many would argue that they will certainly change healthcare, but do not reach the level of disruptive technology. But when I think about many of our customers in the behavioral health community and the radical changes to their organizations that will be required to move to EMRs and to use them in a meaningful way, I can imagine few more disruptive events.

Some would say that managed care had the potential to be just as disruptive…it certainly changed the way in which private mental health practices have conducted themselves over the last twenty years…but it did not intrinsically change the way in which the provider interacts with the recipient of healthcare services. The consumer may be seen less frequently and for a shorter total length of treatment, the managed care organization may refuse to pay for certain types of care (which the patient can then purchase with their own dollars), but the provider still sees the patient, assesses the problem at hand and provides treatment.

EMRs have the potential for changing that sequence of events. If used in a “meaningful” way, if decision support tools and treatment protocols that are based on scientifically assessed methods (evidence-based treatment) are incorporated into the EMR products and utilized by providers at the point of care in the way envisioned by the framers of HITECH, we will have a new healthcare system….or maybe not.

What do you think? Will widespread adoption of EMR systems be a disruptive innovation for healthcare? Do behavioral health EMRs have the potential to be disruptive technology for the mental health community?

Please add your comment by clicking on the title of this article and typing your thoughts in the comment box at the bottom of the page.

Personal vs. Professional: Social Networking Sites

I checked my email on Sunday night to find two new requests for “friend” status on my Facebook page…one was from a customer, the other was from my mother-in-law. The juxtaposition of requests brought directly home the conflict and confusion that some folks are having about use of the social media sites. Is your use personal or professional? Is it acceptable to mix the two? Would you and your contacts be better served if you have two separate online identities, a personal one and a professional one?

I am a firm believer in synchronicity. I think of Carl Jung and his notion of synchronicity (an acausal connection of events in time) often as I experience the unexpected confluence of events. This weekend was no exception.

  1. On Friday, I had time (for the first time in weeks) to tune in to HubSpot TV, a podcast done by staff members of the Internet Marketing firm whose products and services I use. They mentioned this issue of social media utilization and the possible need to keep one’s “identities” separate. One of their blogs addressed the issue on Friday and the author lays out some considerations.
  2. On Friday evening, my partner, Seth Krieger, suggested that I write a blog on social media and professional vs. personal concerns.
  3. On Sunday I got the Friend requests I mentioned above.
  4. This morning I looked at two print newspapers I receive: The New England Psychologist ran an article featuring input from Thierry Guedj, Ph.D., “Psychologists navigate use of online social networking sites“; and The National Psychologist included John Grohol, Psy.D.’s article “How ‘tweet’ it is: Social networking using Twitter”. Both of these psychologists explore some of the concerns unique to providers in the behavioral health community.

This confluence of events was impossible for me to ignore. I have found myself thinking about these issues often over the past several months. Since I began use of social networking as a way to spread our business presence more broadly on the Internet, the differences between personal and professional presence have been playing around the periphery of my mind.

While I have not seen clients for the last 16 years, I was trained as a psychologist and saw patients in a private practice and in a CD program setting from 1978 to 1993. I am well aware that boundary issues are confronted regularly by psychotherapists charged with providing a safe space in which consumers of their services can deal with issues ranging from relatively minor personal problems to serious chronic mental health issues. Protecting that ‘space’ is part of building trust and of maintaining the privacy of the client.

The sanctity of that space is challenged regularly, sometimes by the spill-over of the therapist’s life into the therapy. Personal illness and family deaths are regular intruders, but many others exist. I hosted a live, call-in television show on psychology topics from 1981 to 1983. Some of my clients were proud of the public education work I was doing; others felt that they lost a part of me that they owned and were not happy to share me with the public. As a feminist psychologist treating lots of women, it was not unusual to cross paths with a client in the ‘real’ world. Prior agreements about how or whether to greet in public aside, face-to-face interaction outside the therapy space was often a cause for discomfort for me and for the client.

Those challenges to privacy are part of the physical community in which we live. Now we add the complication of a virtual world in which massive quantities of information, both personal and professional, are available to anyone who bothers to Google us. Factor into that the fact that we have no idea which information the client has. Each form of social media provides different challenges.

1. blog: A weblog, or blog, can be an excellent way for you to provide useful information to your own clients and to many others who see your blog articles. But if you go out there into the blogosphere and take a look at the material available, you will find that the writing styles are much less formal than other published documents, especially journal articles. Because of that informality, there can be a tendency to slip into personal revelation.

Potential benefits:
Great way to become more known in your community, to educate and share valuable information with your clients, and to provide a community service through public education.
Potential risks: Informal style of blogs can lead you to share more personal information than you would usually do in journals or in direct contact with your clients.

2. Facebook: When I started to use Facebook, I intended that use to be purely personal. My nephew’s wife invited me to join first. I resisted. When an age-mate with whom I share a book club and a social sphere invited me, I joined. Facebook has been great fun! I have connected with classmates, friends and family members. As with many people in my age group, my postings are rather tame. They do reveal personal relationships and history. I was a little conflicted when business associates asked for ‘friend’ status, but decided that I do not live a wild and crazy life and there is little about me on Facebook that I am not comfortable sharing with customers and other business associates.

Potential benefits:Facebook is a great way to keep up with new family photos and to stay in more frequent contact with friends and family members who are far away.
Potential risks: If you do live a wild and crazy life and do not want your clients to know that, do not give ‘friend’ status to those clients.

3. LinkedIn: LinkedIn is the only one of the social networking sites I use that is designed for professional purposes. It is professional networking, par excellence. If you want to connect with other colleagues, this is the place to do it. If you are looking for a job, this is certainly the place I would start. There are headhunters who frequent the site looking for the most qualified individuals for their position postings. You can join groups that meet your interests and connect there with other folks who have like concerns. 

Potential benefits: LinkedIn is a great place to network with other professionals. It is designed for peer-to-peer connections.
Potential risks: If your clients/patients are other professionals, you might run into them here and need to make some decisions about who your network should include or exclude.

4. Twitter: Twitter is something else. I am still not sure about Twitter. I use it in a purely professional way. In fact, the name under which I tweet is @SOS_Software. The people I follow are other professionals who have similar interests. Those other folks are great sources of information. The tweets I find most useful are about articles, blogs and news that is relevant to my professional world. Most of the people who follow me are also interested in healthcare and software. Sometimes, I get a follow from someone who seems totally unrelated to anything in which I am interested. I blocked the clearly pornographic Follow that appeared last week.
     The way I use Twitter is totally contrary to the way most young people use it. To folks who are used to text messaging for everything, Twitter is a way to disperse text messages much more broadly. You can let everyone in your network know your status all at one time. To me, this is useless. To many others it is an essential part of staying connected.

Potential benefits: This is an excellent way to disperse a communication to a large group of people at one time. You could use Twitter to communicate educational information to all of your clients at once.
Potential risks: Twitter is like Facebook. Everybody who follows you sees everything. If you intersperse personal messages with your professional ones, everybody who follows you still sees all of it.

What do you think about these social networking sites? Do you use them? Does your organization use them to keep in touch with consumers? What do you see as the potential benefits or glaring weaknesses of being connected 24/7?

One last word of advice: If you decide to jump into the sphere of social networking, decide whether you are going to do so as a professional or for your personal needs. Once you decide, choose your networking sites accordingly. If you want to do both, you might be best served by having two different social networking identities.