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Session # October __, 2011 0:00 AM. Robert A. DiTomasso , Ph.D., ABPP Professor and Chairman, Department of Psychology Barbara A. Golden, Psy.D ., ABPP Professor and Director of Clinical Services, Department of Psychology Deborah A. Chiumento , Psy.D . - PowerPoint PPT Presentation
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Interprofessional Collaboration and Empirically-Based Strategies for Underserved Chronically Ill Vulnerable Adults: Barriers, Strategies and Outcomes
Robert A. DiTomasso, Ph.D., ABPPProfessor and Chairman, Department of Psychology
Barbara A. Golden, Psy.D., ABPPProfessor and Director of Clinical Services, Department of Psychology
Deborah A. Chiumento, Psy.D.Behavioral Health Consultant, Family Medicine Healthcare CenterPhiladelphia College of Osteopathic Medicine, Phila., Pa. 19131
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #October __, 20110:00 AM
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
Need/Practice Gap & Supporting ResourcesThe existing needs, practice gap, and scientific basis for this talk
are thoroughly outlined in the following sources:
DiTomasso, R.A., Golden, B.A., & Morris, H.J. (Eds.) (2010). Handbook of Cognitive Behavioral Approaches in Primary Care.
New York: Springer Publishing Company. Section I. General Considerations
Section II. Cognitive Behavioral Techniques: Empirical Basis and FindingsSection III. Clinical Problems I: Common Behavioral Problems in Primary CareSection IV. Clinical Problems II: Common Medical Problems in Primary Care
Section V. Conclusions and Future Directions
DiTomasso, R.A., Golden, B.A., Cahn, S.C., & Gradwell, A. Primary care psychology. In A. Nezu, C. M. Nezu & P. Geller (in
press),HealthPsychology(volume #9) of I. WeinerHandbook of Psychology, New York: Wiley.
Expected Outcome 1. Learn how to integrate empirically-based
psychological and behavioral medicine services into a healthcare system serving chronically ill underserved adults.
2. Identify and address common challenges and barriers to delivering integrated healthcare to this population.
3. Employ strategies for facilitating interprofessional collaboration among professional psychologists, family physicians, and social workers at the level of the patient, family, setting and community.
4. Utilize a variety of psychological and physical outcome parameters demonstrating the impact of integrating healthcare services in the underserved population.
Objectives Describe the characteristics of an integrated healthcare
program for delivering empirically-based psychological and behavioral medicine services to chronically ill underserved adults.
Describe common challenges and barriers to delivering integrated healthcare to this population.
Describe strategies for facilitating interprofessional collaboration among professional psychologists, family physicians, and social workers at the level of the patient, family, setting and community and overcoming challenges.
List the benefits of integrating healthcare services in the underserved population in terms of demonstrated psychological and physical outcome parameters.
Learning Objective #1 Describe the characteristics of an integrated healthcare program for delivering empirically-based psychological and behavioral medicine services to chronically ill underserved adults.
PCOM’s Mission and HistoryPresent in community for over 50
yearsServing the underserved
Pilot study (2003) indicated: Confirmed presence of several chronic illnesses
co-morbid with depression and anxiety Outcomes included improvement of quality of
life Decreased depression and anxiety Increased adherence to medical regimens
Serving in an urban setting Collaboration between Family Medicine and
Psychology -10 year history Focus on Chronic Medical Illnesses
PEW Charitable Trusts Grant“To enable vulnerable adults who
face significant social, behavioral and health problems to become independent and productive members of their community.”
“To expand innovative models that integrate behavioral health services with other supports for vulnerable adults.”
Integration of Psychologists with Primary Care PhysiciansModel for successful management of
both mental health and physical problems
Most successful collaborations occur when PCPs and psychologists are “in house”
Same-Site Collaboration: AdvantagesRemoves stigma of an outside
referral Immediate availability-”warm
handoff”Convenient and efficientEnhanced compliance
Integrated Healthcare and Population Needs“Vulnerable Adult” population:
Underserved minorities Urban residents Low socioeconomic status Suffer from medical disparities such as:▪ Social issues▪ Behavioral issues▪ Health problems▪ Limited access to healthcare
Chronic IllnessesDiabetesHypertensionCoronary artery diseaseAsthmaCOPD Irritable bowel syndromeFibromyalgiaChronic pain
Health Risk Behaviors
Nicotine useSubstance abusePoor nutritionObesitySedentary lifestyle
Additional Specific ServicesCognitive-behavioral therapyStress managementWeight reductionDiabetes self-managementCoping with chronic illness and
chronic painSmoking cessationVarious lifestyle health
promotion/disease prevention strategies
Free seminars on nutrition and wellness education
Learning Assessment: Audience Questions
What are the critical characteristics of an integrated healthcare program for delivering empirically-based psychological and behavioral medicine services to chronically ill underserved adults? In house collaboration and referral on-site Availability and Immediate Access Holistic Mind-Body (Biopsychosocial) Approach Close, ongoing communication between Psychologist and
PCP Consultative model Team Approach
Learning Objective #2
Identify/Describe means for overcoming common challenges and barriers to delivering integrated healthcare to this population.
Challenges
Patient challengesPhysician challenges and
Administrative challenges
Patient ChallengesDeveloping rapportAdherenceLogistical challengesScheduling and safetyWeather/time of year variesUnfamiliarity with ModelAssessment process (lengthy)-
unique
Physician and Administrative Challenges Initial “buy in” issues and orientation
to model-early stagesObtaining ongoing referrals
meetings, reminders, education Issue of appropriate vs. non-
appropriate referralsDifficulty obtaining physiological
data
Physician/Administrative Challenges (cont’d)Limited time and magnitude of
patient loadBalancing multiple priorities
simultaneouslyPsychological sophisticationPersonality issues and unrealistic
expectationsCompleting forms for documentation
of outcomes
Benefits
Unique opportunity Multi-disciplinary approach to
treatmentSatisfaction of patients with modelSatisfaction of physicians with modelSustainability Plan
Learning Assessment: Audience QuestionsWhat are some common challenges
and barriers to delivering integrated healthcare to this population? Patients-Lack of Adherence, Logistical Issues, Environmental
Issues, Unfamiliarity with model, Suspiciousness, Skepticism Physician and Administrative Challenges-Obtaining
initial “buy in”, limited time, multiple priorities, personalities, completion of documentation forms, appropriate versus non-appropriate referrals,
Learning Objective 3
Describe strategies for facilitating interprofessional collaboration and overcoming common challenges and barriers to integrated healthcare?
Interprofessional Collaboration Paradigm shift- all as critical
members of the teamStatistics support need for
collaborationBenefits of collaborationBiopsychosocial Assessment and
treatment
Models of Collaboration
Minimal collaborationBasic collaboration – distance/on-siteClose collaboration- distance/on-siteClose collaboration- partly
integrated/fully integratedRoutine and intensive collaboration
Barriers, Myths and StereotypesConfidentialityTime-pressures InexperienceLack of interestLack of trainingRelationship differences
Avoiding “big black hole”Post-referral/intake letterExpectations and meansTermination letterQuestions for conversation
Recommendations for Effective PracticeExpand clinical skill setNetworking and LocationHealth and billing codesMedical Home……
Learning Assessment: Audience QuestionsWhat are several possible strategies
for facilitating interprofessional collaboration and overcoming common challenges and barriers? Respect relationships and differences Learning mode Communication and follow-up
Learning Objective 4
List the benefits of integrating healthcare services in the underserved population in terms of demonstrated psychological and physical outcome parameters.
Characteristics of Patients All patients served in this program were chronically ill,
underserved adults. About 77% of participants were African American and 2% were
Hispanic; the remaining 9% were Caucasians. Almost 87% of these patients were female. About 80% of those served had a high school education or less. Ages ranged from 20 to 78 years. The majority of patients had multiple primary medical
diagnoses. Most significantly, obesity (46%) and hypertension (26%)
were the most frequent problems encountered. The most frequent co-morbid medical diagnoses were
arthritis and diabetes. The most frequent primary psychiatric diagnoses were
anxiety and depressive disorders.
Treatment Protocols
Patients received one of a variety of treatments, including the LEARN Program , pain management, and smoking cessation. The majority attended an average of 12
sessions A healthy lifestyle program focused on
lifestyles, exercise, attitudes, relationships and nutrition
Clinical Outcomes
At program onset, over 99% of patients served were significantly overweight.
At program completion: Approximately 68% lost weight. There was an average decrease of 10
mmHg in systolic blood pressure. About 63% of patients also had a
decrease in diastolic blood pressure.
Total cholesterol levels decreased in 40% of patients, with an
average 11-point decrease. 54 % of patients had a decrease in LDL
level 36% had an increase in HDL. 40% of patients served had decreases in
triglyceride levels. Hemoglobin A1C 60% had improvements.
Among patients who were smokers 50% learned to control their smoking ▪ by decreasing the number of cigarettes
smoked per day. For those consuming alcoholic
beverages on a weekly basis, nearly one quarter were successful in
decreasing their alcohol consumption
92% of patients increased their hours of exercise engaged in per week.
About 95% of patients decreased their daily caloric intake.
significant increase in the number of health adherent behaviors between pretest and posttest. The average patient increased their
health adherence by 7 health promoting behaviors.
On psychiatric indicators On the BDI, patients served had a
significant decrease in depressive symptomatology,
significant increases were observed in the quality of life indicator (WHOQOL –BREF/Psychological).
40% of patients demonstrated increases in self-efficacy,
47% exhibited decreases in hopelessness.
almost 75% of patients at pretest displayed possible to likely problems in physical inactivity only 26% displayed such problems at the end of the
program.
Prior to treatment the incidence of problematic smoking behavior was displayed in about 13% of the patients by the end of the program only 3% of
the patients continued to show problematic smoking.
for problematic caffeine consumption, 11% of patients initially demonstrated problems with caffeine use by the end of the program only 3%
displayed these problems.
Coping Styles significant decrease in Denigration [MBMD]
meaning that patients were less likely to believe they deserved to suffer by the end of the program.
improved functional capacity, significant increase in their belief in their abilities to
carry out vocational roles and responsibilities in daily living.
significant increases in spirituality beliefs that they possessed the spiritual resources for
coping with stressors in their daily lives. decrease in their risk for abusing medication.
Quality of Life
1) As Quality of Life–Physical increased, depression and anxiety decreased;
2) As Quality of Life–Psychological increased, depression decreased;
3) As Quality of Life–Social increased, depression decreased; 4) As Quality of Life –Environmental increased, depression
decreased; 5) As Quality of Life–Physical increased, Quality of Life–
Psychological increased; 6) As Quality of Life–Social increased, Quality of Life–Physical
increased; 7) As Quality of Life–Environmental increased, depression
decreased 8) As Quality of Life–Physical increased, Quality of Life–
Environmental increased;
10) As Quality of Life–Environmental increased, Quality of Life–Psychological increased;
11) Weight loss at the end of the program was negatively correlated with HDL;
12) As adherence to healthy behaviors increased overall, the number of cigarettes smoked per day decreased;
13) As hours of exercise per week increased, overall adherence increased;
14) As adherence to healthy behaviors increased, depression decreased.
Overall, the average participant who completed the program lost 10.02 pounds; decreased systolic blood pressure by 10
mmHg ; decreased their daily caloric intake by
1,099 calories; acquired seven additional health
adherent habits; and showed decreases on measures of
depression and anxiety
Qualitative Data qualitative data also support the positive impact of
the program. Based on patient preprogram and post-program self-
reports, we observed themes of ongoing trust and confidence in the physician-patient
relationship; increases in participation in community, social, and spiritual
activities; increases in patients’ reported abilities to successfully cope
and to handle problems in daily living (e.g., thinking through problems more clearly, solving problems more easily, and making healthy choices in their lives).
Some of these outcomes may also be related to referrals made to our Social Worker.
Summary of Outcomes After participation in the program,
patients exhibited fewer negative health habits, fewer psychiatric indications, enhanced positive coping styles, and improved physical prognostic indicators; improved quality of life; an increase in adherence behaviors that promote health and well-being; decreased levels of depression and anxiety; enhanced patient trust in their physician and satisfaction with medical services; physician reports of perceived increased patient trust, patient quality of life, and
patient satisfaction with medical services; decreased limitations related to health issues; decreased levels of hopelessness; increased levels of self-efficacy; and evidence of improvements on qualitative
behavioral indices of independence, self-sufficiency, and productivity, as shown by quality of life indicators and qualitative measures.
Overall, the preceding measures provide encouraging evidence of movement toward recovery, as evidenced by patients’ ability to live more wholesome lives.
Learning Assessment: Audience QuestionsWhat are the potential benefits of
integrating healthcare services in the underserved population in terms of demonstrated psychological and physical outcome parameters? Weight loss; Decreased Daily Caloric Intake; Improved Blood
Pressure; Improved Cholesterol; Controlled Smoking; Decreased Alcohol Consumption;Increased Exercise; Increased Health Adherence Behaviors; Decreases in Depression, Hopelessness , and Anxiety; Increase in Quality of Life
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters:Please incorporate audience interaction through a
brief Question & Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based on your learning
objectives to satisfy accreditation requirements.
Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.Thank you!