TBI and Other Healthcare Professionals

1. TBI and Other Healthcare Professionals R. Jeffrey Goldsmith MD Cincinnati VA PTSD & Anxiety Disorders Program Professor of Clinical Psychiatry, UCCOM

2. TBI Epidemiology • Hoge et al. 2008, NEJM, military N=2525 • 4.9% loss of consciousness • 44% PTSD, significant major dep • 10% altered mental status • 27% PTSD • 17% other injuries • 16% PTSD • mTBI associated with more physical c/o

3. Chronic Pain • Nampiaparampil, 2008, 23 studies • Civilians: chronic pain mTBI 75% v. 32% • Headaches common, variable initiation • mTBI 89% headaches, 18% severe TBI

4. Collaboration Multidisciplinary Definition 1978 • Sharing responsibility for care • Each role must be defined • Each professional has standards of care • Patient must know of each role

5. Definitions • Collaboration • Consultation • Supervision • Team work

6. Guidelines for Collaboration • Talk to each collaborator • Ahead of time? • How many can you handle? • Define roles • Define communication technology • HIPPA issues? • Cross-coverage issues • Billing issues • Forensic issues

7. Models of Collaboration by Lorenz et al 1999 • Collaboration is an attitude and an interpersonal process that embodies cooperation and a spirit of working together. Professionals with divergent training work within a convergent framework. Competition and turf battles are left behind as professionals rise above power struggles and petty status competition. • Collaboration is a way for professionals to provide quality, comprehensive, and efficient care. Collaboration recognizes each party’s presence, expertise, and special talents. It is not leaderless, amorphous, inefficient group process. The team leader varies depending on the situation. … • This spirit of collaboration applies equally well to patients, families, and communities. If professionals can work together, the next logical step is to include the patients and those who care about them.

8. Key Ingredients for Effective Collaboration by Lorenz et al • Good working relationships: take time, mutual respect and shared responsibility • Common purpose: general patient welfare • Paradigms: shared or blended • Communication: clear, no jargon, continual, HIPPA issues • Location: co-location can simplify some issues • Business management and payment methods

9. VA Integrated Care • One goal of the VA’s Mental Health Strategic Plan is to “develop a collaborative care model for mental health disorders that elevates mental health care to the same level of urgency/intervention as medical health care.” Program funding commenced during fiscal year 2007 after a request for proposals for new programs to promote the effective treatment of common mental health and substance use disorders in the primary care environment. • It recognizes under-diagnosis in PC, patient comfort in PC, and ease of referral on site.

10. British PCMH Collaboration, 2007 by Nolan et al, 2008 • Assumptions of “better working together” without defining process of success • Clarity of goals is important • Differing opinions and paradigms are barriers • Local v. national models of quality • Little consumer involvement in policy decision-making

11. British Collaboration, 2007 part II • Do we develop new professionals or more of the traditional ones with their departments? • Drive towards information technology ignores richness of face-to-face communication • Equality of information access • Co-creating a peer community of inquiry, developmental learning process for all

12. Collaboration Research • Inconsistent definitions of collaboration • Discreptant attitudes between Dr’s and Nurses • Comparable with aviation findings • Elimination of measurable deficits in safety • Medicine is more interrupted • Some unexpected critical events • ICU must respond ASAP • Some redundancy in roles capture mistakes

13. Other Healthcare Professionals • Neuropsychologist • Speech Therapist • Physical Therapist • Occupational Therapist • Pain Specialist • PTSD Therapist • Physiatrist/PM&R

14. Speech Therapist • Unawareness: intellectual awareness, emergent awareness and anticipatory awareness, not psychological denial • Working with mTBI: early phases and later phases, might work on environment changes and family assistance • Attention, time pressure management, specific memory interventions, self-management and self-efficacy, CBT

15. My Results • Not always match the Neuropsychology testing • Not many CT scans abnormal • many not done if far from injury • PTSD anxiety interferes with concentration and attention

16. Pitfalls for Many Collaborators • Overvaluation of pharmacotherapy and/or psychiatrists • Overvaluation of psychotherapy or physicians • Each professional works independently • Only the doctor knows about pharmacology • Ignore the psychology of medications

17. Pitfalls part II • The doctor will try to take over • The patient is too sick for psychotherapy • My collaborator always agrees and is comfortable discussing things with me • The psychiatrist takes over if the patient worsens • The psychiatrist covers when the therapist leaves town/vacations • Physicians are only interested in medication

18. Pitfalls part III • The patient worries the doctor will force hospitalization • The patient worries the doctor will stop meds • All uncomfortable feelings are side effects • Keeping secrets damages collaboration • Splitting (projective identification) means good guys and bad guys on a teetertotter

19. Final Thought • Let us live by their example. We can acknowledge that oppression will always be with us, and still strive for justice. We can admit the intractability of depravation, and still strive for dignity. We can understand that there will be war, and still strive for peace. We can do that--for that is the story of human progress; that is the hope of all the world; and at this moment of challenge, that must be our work here on Earth. • Barack Obama, Nobel Peace Prize, 2009