Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings

1. Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings Barbara Walker, Ph.D. Clinical Professor, Department of Psychology Professor, Department of Family Medicine University of Colorado, Denver Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHS Assistant Professor of Family Medicine Uniformed Services University of the Health Sciences Bethesda, MD Helen L. Coons, Ph.D., ABPP President and Clinical Director, Women’s Mental Health Associates Philadelphia, PA Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure Drs. Walker, Coons and Goodie have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? In this symposium, we will define evidence-based practice (EBP), introduce participants to the associated skill-set, tools and new resources for doing EBP, and illustrate how it can be translated it into both primary and specialty collaborative care settings.

4. Objectives • Describe how evidence-based practice is used for clinical decision-making and the 5 steps associated with this process. •  Describe why it is necessary to adapt evidence-based methods for use in primary care. • List examples of evidenced based assessment and intervention strategies to improve physical and psychosocial outcomes among women seen in collaborative ob/gyn and oncology practices. • Describe how several interventions have been adapted to be effective in a primary care environment.

5. Expected Outcome What do you plan for this talk to change in the participant’s practice? • Be familiar with and be better able to use evidence-based practice skills for clinical decision-making in collaborative care settings. • Increased ability to apply gender-specific research to improve outcomes in collaborative ob/gyn and oncology settings. • Increased use of evidence-based practice strategies that have been adapted for use in primary care, specifically with regard to insomnia, weight management, and PTSD.

6. Learning Assessment A learning assessment is required for CE credit. • List the 5 specific steps associated with clinical decision-making in evidence-based practice. • Name and explain how to access and search at least 2 databases that contain synthesized evidence-based research. • Give at least one example of how evidence based care can improve health and psychosocial outcomes. • Describe how evidence-based treatment has been adapted and found to be effective in primary care for treating insomnia, weight, and/or PTSD.

7. Session # October __, 20110:00 AM Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings Fundamentals of Evidence-Based Practice: It’s more than applying evidence-based treatments (Barbara Walker) Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD (Jeffrey Goodie) Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes (Helen Coons) Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

8. EVIDENCE BASED MEDICINE Sackett et. al 1997 Straus et. al, 2011 (4th ed.) What should I do for this particular patient in front of me?

9. Best available research evidence Patient’s values Clinical Expertise CD

10. Psychology introduces EBPP in 2005 Best research available Clinical Expertise CD Patient characteristics, culture and preferences “The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (became policy of the American Psychological Association in August, 2005)

11. The framework OPERATIONALIZATION : 5 STEPS Best research available CD Patient characteristics, culture, preferences Clinical Expertise CLINICIAN PATIENT RESEARCH 1. ASK 1st 2. ACQUIRE 3. APPRAISE 4. APPLY 5. ASSESS CD

12. Evidence-based Practice • TOP DOWN: • What is the most effective intervention for this particular disorder? • (ESTs, EB guidelines) • BOTTOM UP: • What should I do for this particular patient in front of me? • (Clinical Decision Making) EBIDM: Eddy, D. Health Affairs, 24, no.1 (2005):9-17 Evidence-Based Medicine: A Unified Approach

13. ASK:Questions are formulated in a specific way Therapy Diagnosis Background Foreground By Content By Format • Harm • Etiology • Prognosis • Cost-effectiveness THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY LIBRARY

14. Why bother?

15. THIS SERIES COURTESY OF SUE LONDON IUPUI LIBRARY

16. High Sensitivity

17. High Specificity WHAT: Scientifically synthesized literature WHERE: Specialized databases HOW: Specialized search strategies/filters

18. Step 2. Acquire Evidence that has already been (scientifically) synthesized for us: Syntheses Summaries Systems

19. HOW? Start at the top

20. What is EBP and why is it so important in collaborative care? • EBP has two sides: Top-down and Bottom up (a set of clinical decision-making resources and tools) • Common language • Setting / Context matters • Need for primary and secondary literature studies in collaborative care • Ultimate goal is to improve outcomes

21. To learn more… Norcross, Hagan & Koocher, 2008 • www.ebbp.org has training modules

22. Jeffrey L. Goodie, Ph.D., ABPP LCDR, USPHS Assistant Professor, Dept of Family Medicine Uniformed Services University Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD

23. Outline • Three examples • Weight • Insomnia • PTSD • Medical or Behavioral health providers • Outcomes • Challenges

24. Weight Goodie, J. L., Hunter, C., Hunter, C., McKnight, T., LeRoy, K., & Peterson, A. (2005, March). Comparison of weight loss interventions in a primary care setting: A pilot investigation. Paper presented at the 26th Annual Meeting of the Society of Behavioral Medicine, Boston, MA.

25. Specialty Care Evidence • Identification • Setting realistic goals • Self-monitoring • Stimulus control • Exercise to maintain weight loss "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.“ (1998). National Heart, Lung, and Blood Institute, NIH.

26. Does primary care provider delivered evidence-based behavioral interventions for weight result in more weight loss?

27. Procedures Enhanced Care Group • Appointment 1 • Set 10% weight loss goal for first 6 months • Maintenance goal for second 6 months • Discuss motivators and barriers • Provided w/ calorie book • Food diary for 12 days • Appointment 2 (2 – 4 weeks later) • Review food diary and C.A.M.E.S. • Review barriers and motivators

28. ProceduresEnhanced Care Group, Cont’d • Appointment 3 (2 – 4 weeks later) • Discuss physical activity • Provided w/ pedometer • Set baseline and increase by 10% • Appointment 4 – 5 • Review progress. Again, discuss barriers and motivators • Appointment 6 • Set maintenance goals • 1 year follow-up

29. ProceduresMinimal Contact Group • Appointment 1 • Discuss cutting calories and increased exercise • No specific tools or training provided for PCP • PCP could recommend any weight loss strategy • Appointment 2 -5 • Discuss any problems • Appointment 6 • Plan for 6 month maintenance • 1 Year follow-up

30. Results

31. Insomnia Goodie, J. L., Isler, W., Hunter, C. L., & Peterson, A. L. (2009).Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65, 294-304.

32. Specialty Care Evidence • Stimulus control • Sleep restriction • Sleep hygiene • Relaxation Schutte-Rodin et al. (2008). J Clin Sleep Med.  Morin et al., (1989). Sleep Research; Morin et al., (1994), American Journal of Psychiatry.

33. Do CBT evidence-based treatments for insomnia decrease insomnia symptoms when delivered by a BHC in primary care?

34. Methods • Case Control Series (Goodie et al. 2009) • 29 physician referred Primary Insomnia patients • Limited exclusion criteria • Intervention delivered by BHC • Attend four appointments • Assessment (30 mins) • 1-2 intervention appointments (15-30 mins) • Sleep hygiene, stimulus control, sleep restriction • Relaxation • Supplemental book • Follow-up

35. Outcomes *Significant compared to α=.008;Goodie et al. (2009)

36. PTSD Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A. Peterson, A. L., and the STRONG STAR Consortium. (2011). Treatment of active-duty military with PTSD in primary care: Early findings. Psychological Services 8(2), 104-113.

37. Specialty Care Evidence • PTSD Treatment • Prolonged exposure • Cognitive processing therapy Powers et al. (2010). Clinical Psychology Review 30(6): 635-641.; Cloitre, M. (2009). CNS Spectr 14(1 Suppl 1): 32-43.

38. Do CBT evidence-based treatments for PTSD decrease PTSD symptoms when delivered by a BHC in primary care?

39. Intervention • Adapted forms of prolonged exposure and cognitive processing therapy • Assessed and treated by BHC • After initial assessment, • 1 to 4 (up to 6) < 30 min appointments • Weekly • Homework between meetings

40. Procedures Pt referred to BHC Appointment 0 Testing Appointment 1 Appointments 2-4 6 & 12 month Testing

41. Appointment 0 • Duration: thirty-minute appts • Brief Assessment (PCL-M) • Education • Normal recovery curve; “getting stuck” • Role of avoidance in maintaining symptoms • Evidence for exposure-based treatments • Presentation of treatment options • Primary care vs Specialty care vs Self-care

42. Appointment 1 • “Confronting Uncomfortable Memories” workbook • Write narrative of traumatic experience • Answer cognitive/emotional processing questions • Prescribe as homework • Goal: 30 minutes write/review daily • Self-monitor SUD’s • Problem-solve homework implementation • When/where of homework • Barriers to completion

43. Appointments Two to Four(optional 5, 6) • Discuss homework completion • Review SUD’s • Read narrative out loud (at least once) • Read answers to processing questions out loud • Socratic dialogue on problematic beliefs • Re-assign writing assignment as homework • BHC has option of other CP questions • Encourage opportunities for in vivo exposure

44. % with PTSD Diagnosis (PSS-I) N=24 N=17 N=16 N=11 Overall Χ2=8.95, p=0.03; All time points different from baseline (p < .01)

45. PCL-M N=24 N=17 N=17 N=10 Overall F=6.51, p=0.002; All time points different from baseline (p < .003)

46. Overall considerations • What determines evidence-based care? • What outcomes should we expect? • Who can provide the evidence-based care? • Challenges with research in primary care

47. Questions • Jeffrey L. Goodie, LCDR, USPHS Uniformed Services University (301) 295-9461 jgoodie@usuhs.mil

48. Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes Session # October __, 20110:00 AM HELEN L. COONS, PH.D., ABPP PRESIDENT AND CLINICAL DIRECTOR WOMEN’S MENTAL HEALTH ASSOCIATES PHILADELPHIA, PA 19103 Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

49. Faculty Disclosure I have not had any relevant financial relationships during the past 12 months.

50. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? The presentation provides examples of evidenced based care in collaborative obstetrics and gynecology and oncology settings to improve physical and psychosocial outcomes. Research on depression in women; preparing them for diagnostic and treatment procedures; and the important benefits of exercise will be translated.