Robert A. DiTomasso , Ph.D., ABPP Professor and Chairman, Department of Psychology

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!