To Australia and Back!
By Dr. Cara English, CGI CEO
 
In November 2017, I traveled to Brisbane, Australia to attend APIC: the first International Foundation of Integrated Care (IFIC) conference in the southern hemisphere, resulting from a partnership between the International Foundation of Integrated Care (IFIC), Children’s Health Queensland (CHQ), and Queensland Health’s Clinical Excellence Division.
 
This conference brought together researchers, clinicians and managers from the Asia Pacific region and around the world who are engaged in the design and delivery of integrated health and care services. They shared experiences and the latest evidence generated around the following key conference themes: New Models of Care Delivery; Child and Youth Health; Rural and Remote Health; Mental Health; and Engaging and Empowering Communities.
 
As I was the only American in attendance at the conference, I thought I’d share 5 takeaways from APIC 2017 with my state-side colleagues:
 
1. Patient engagement from start to finish drives innovation and population health improvements. Rather than designing care for patients the way we believe it will help the most, the evidence is clear that when community members have a voice at the table from design, through implementation, and into evaluation and quality improvement activities, significant health improvements are the result. This is a paradoxical approach to the way healthcare is designed and delivered primarily in the U.S., and a model I believe will be critical for us to embrace and utilize to achieve change in our country. It just makes sense! The Logan Together community effort in Australia is an example of the exciting outcomes of this work.  
 
2. Regional and cultural perspectives and influences on health deserve to be honored. Each presenter began their session with the following acknowledgment in Brisbane: “I’d like to take a moment to acknowledge the Traditional Custodians of the land, and pay respect to Elders past, present, and future.” Respect for the wealth of indigenous and regional knowledge and guidance, wherever we happen to be working to improve the health of communities, was a value that was consistently present at the conference and in hospital and community visits in Australia and New Zealand, and this is leading to gains in public health. Take a look at Manaia Health PHO of New Zealand to see this work in action.
 
3. Integration efforts need to focus on transitions for patients and their families across sectors. Children’s Health Queensland Hospital and Health Service facilitated discussions between providers, policy makers, and caregivers for children with chronic and complex healthcare needs. These discussions shed light on how healthcare can transform and better support families through stressful transitions, including becoming an adolescent or the transition to adult services, changing schools, surviving childhood illness, and coordination of care between primary, secondary, and tertiary services. We must work together with families to identify their pain points, which are often celebrated as “graduation” milestones for hospital providers.
 
4. Linkages between public and private service providers and communities are critical to make the maximize efficient use of funding and resources. Integration was defined differently by Children’s Health Queensland. There, the foundations of integration include child and family centered care, joint planning and governance, as well as shared values and culture. In our efforts in the U.S. to pursue the Triple/Quadruple Aim, we tend to overly focus on data information and sharing, clinical integration, and interprofessional workgroups, which are all important – but a broader perspective on integration is needed here, too, to accomplish the change we all wish to see in our health system. 
 
5. Integrated care needs EVERYONE. Everyone from every sector and community is needed at the table to help our broken system find the path forward we all want. A diverse group of Australian specialists, general practice physicians, community health workers, government, and non-government organization workers, and health consumer representatives have partnered with the International Foundation of Integrated Care (IFIC) to drive integrated care efforts forward. Now, more than ever, we need similar collaboration in the U.S. to reclaim sovereignty of our health, and to overcome the political, financial, and systemic cultural barriers that plague our healthcare system. 
 
Cummings Graduate Institute’s students, faculty, staff, and governing board are dedicated to achieving our vision of improving the way the world experiences healthcare, and we are honored and proud to be working alongside our partner, the International Foundation of Integrated Care (IFIC), and our colleagues and champions in the southern hemisphere as well as colleagues and communities in the U.S. as we pursue better health for all. Join us at our Integrated Care Conference on March 8-10 in Phoenix, AZ as we continue to learn together how we’ll make a difference.

Bridging the Gap
By Liliane Deaguiar-Rocha, DBH Candidate

In 2017, the World Health Organization (WHO) estimated that 1 in 160 children worldwide has autism. While this estimate is an average, the prevalence of autism in many developing countries is unknown.

Many factors may account for the uncertain reporting in developing countries, for example, lack of awareness about autism, lack of training in diagnostic tools, infrequent screening, and public policies

that do not support services for persons with autism.

In December of 2012, the Law 12.764 granted a person with autism the same rights as any other person with special needs in Brazil, which meant they could now attend regular schools, and request special aides to accompany the students with autism to school. While the law is in place, the reality is far different. In an interview, Dr. Márcia de Aguiar, a psychiatrist from the state of Bahia in Brazil, described a convoluted process, where parents take their child to several specialists before obtaining a diagnosis.  The pediatrician or neuro-pediatrician will make a referral to other providers, such as a speech pathologist and an occupational therapist. Usually there is no care coordination, unless the child’s parents are from the upper class and can afford a clinic with multidisciplinary providers. Many times, when the children go to school, the teachers are not prepared to do any work with them, and they may just spend the day, without much structure, in the company of the aide (M.C.M. de Aguiar, personal communication, April 13, 2017).

In a recent review, Paula, Fombonne, Gadia, Tuchman, and Rosanoff (2011) identified reasons why there are so many deficits in the treatment of autism in Brazil, they attributed the scarcity of robust research

and its presence being limited to two main states to the lack of funding, and suggested that a consequence of this lack of funding was the lack of specialized providers and poor services to the families and children affected by autism. Paula et. al collected data during the first Brazilian Meeting for Autism Research (April 2010) to identify challenges and barriers to autism services and research. Among the identified barriers were a lack of trained clinicians and a lack of campaigns to improve autism awareness and understanding in the public and amongst professionals.

Autism Speaks stated that “behavioral therapies are the foundation of treatment for most children on the autism spectrum” (Autism Speaks, n.d.). The New York State Department of Health (NYSDOH) lists ABA as one of the most effective approaches to treating individuals with autism, and recommends behavioral interventions based in Applied Behavior Analysis (ABA) as a treatment of choice (NYSDOH, n.d.). The Center for Disease Control and Prevention (CDC) also lists ABA as a recommended treatment for people with autism, and describes several ABA techniques that are effective in supporting individuals with autism become more independent and gain behavioral control (CDC, n.d.). However, in Brazil, psychology practice is dominated by psychodynamic approaches, and ABA is not widely utilized. In order to address the lack of clinicians trained in ABA, CGI student, Lili Rocha offered two main services, in Portuguese:

1. Group Supervision and Professional Networking: a group of recent graduates or professionals who have recently started practicing ABA meet weekly to discuss challenges in their cases and brainstorm interventions that may lead to more adaptive functioning if the clients.
 

2. Training in Behavior Analysis and its application: Lili offered an online course on the basic principles of behavioral analysis and its application. This course offered a recorded lecture and a live session where students had the opportunity to discuss cases and application scenarios.

CGI takes pride in the diversity of our student expertise in many fields. The DBH program originally set out to meet the needs of having mental health providers in a medical setting, but since the inception of the program, we have seen a need for diversity and inclusion of various providers other than specialty mental health providers in healthcare settings. Lili is a perfect example of how a non-mental health provider can make a powerful impact in a global healthcare system, and we are proud of her accomplishments!

References:
 

Autism Speaks (n.d.) Autism therapies and supports. Retrieved from:  https://www.autismspeaks.org/what-autism/learn-more-autism/autism-therapies-supports

Centers for Disease Control and Prevention (n.d.) Autism Spectrum Disorders: Treatment. Retrieved from:
https://www.cdc.gov/ncbddd/autism/treatment.html

New York State Department of Health (n.d.). Retrieved from:

https://www.health.ny.gov/community/infants_children/early_intervention/disorders/autism/ch4_pt2.htm

Paula, C. S., Fombonne, E., Gadia, C., Tuchman, R., & Rosanoff, M. (2011). Autism in Brazil: perspectives from science and society. Revista Da Associação Médica Brasileira (1992), 57(1), 2-5.

The World Health Organization (April 2017). Autism Spectrum Disorders. Retrieved from:

http://www.who.int/mediacentre/factsheets/autism-spectrum-disorders/en/