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

1. Session # October __, 20110:00 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. Behavioral Health Consultant, Family Medicine Healthcare Center Philadelphia College of Osteopathic Medicine, Phila., Pa. 19131 Interprofessional Collaboration and Empirically-Based Strategies for Underserved Chronically Ill Vulnerable Adults: Barriers, Strategies and Outcomes Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. Need/Practice Gap & Supporting Resources The 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 Findings Section III. Clinical Problems I: Common Behavioral Problems in Primary Care Section 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.

4. 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.

5. 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.

6. Describe the characteristics of an integrated healthcare program for delivering empirically-based psychological and behavioral medicine services to chronically ill underserved adults. Learning Objective #1

7. PCOM’s Mission and History • Present in community for over 50 years • Serving the underserved

8. 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

9. 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.”

10. Integration of Psychologists with Primary Care Physicians • Model for successful management of both mental health and physical problems • Most successful collaborations occur when PCPs and psychologists are “in house”

11. Same-Site Collaboration: Advantages • Removes stigma of an outside referral • Immediate availability-”warm handoff” • Convenient and efficient • Enhanced compliance

12. 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

13. Chronic Illnesses • Diabetes • Hypertension • Coronary artery disease • Asthma • COPD • Irritable bowel syndrome • Fibromyalgia • Chronic pain

14. Health Risk Behaviors • Nicotine use • Substance abuse • Poor nutrition • Obesity • Sedentary lifestyle

15. Additional Specific Services • Cognitive-behavioral therapy • Stress management • Weight reduction • Diabetes self-management • Coping with chronic illness and chronic pain • Smoking cessation • Various lifestyle health promotion/disease prevention strategies • Free seminars on nutrition and wellness education

16. 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

17. Learning Objective #2 • Identify/Describe means for overcoming common challenges and barriers to delivering integrated healthcare to this population.

18. Challenges • Patient challenges • Physician challenges and Administrative challenges

19. Patient Challenges • Developing rapport • Adherence • Logistical challenges • Scheduling and safety • Weather/time of year varies • Unfamiliarity with Model • Assessment process (lengthy)-unique

20. Physician and Administrative Challenges • Initial “buy in” issues and orientation to model-early stages • Obtaining ongoing referrals • meetings, reminders, education • Issue of appropriate vs. non-appropriate referrals • Difficulty obtaining physiological data

21. Physician/Administrative Challenges (cont’d) • Limited time and magnitude of patient load • Balancing multiple priorities simultaneously • Psychological sophistication • Personality issues and unrealistic expectations • Completing forms for documentation of outcomes

22. Benefits • Unique opportunity • Multi-disciplinary approach to treatment • Satisfaction of patients with model • Satisfaction of physicians with model • Sustainability Plan

23. Learning Assessment: Audience Questions • What 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,

24. Learning Objective 3 • Describe strategies for facilitating interprofessional collaboration and overcoming common challenges and barriers to integrated healthcare?

25. Interprofessional Collaboration • Paradigm shift- all as critical members of the team • Statistics support need for collaboration • Benefits of collaboration • Biopsychosocial Assessment and treatment

26. Models of Collaboration • Minimal collaboration • Basic collaboration – distance/on-site • Close collaboration- distance/on-site • Close collaboration- partly integrated/fully integrated • Routine and intensive collaboration

27. Barriers, Myths and Stereotypes • Confidentiality • Time-pressures • Inexperience • Lack of interest • Lack of training • Relationship differences

28. Avoiding “big black hole” • Post-referral/intake letter • Expectations and means • Termination letter • Questions for conversation

29. Recommendations for Effective Practice • Expand clinical skill set • Networking and Location • Health and billing codes • Medical Home……

30. Learning Assessment: Audience Questions • What are several possible strategies for facilitating interprofessional collaboration and overcoming common challenges and barriers? • Respect relationships and differences • Learning mode • Communication and follow-up

31. Learning Objective 4 • List the benefits of integrating healthcare services in the underserved population in terms of demonstrated psychological and physical outcome parameters.

32. 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.

33. 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

34. 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.

35. 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.

36. 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

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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;

43. 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.

44. 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

45. 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.

46. 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. 

47. Learning Assessment: Audience Questions • What 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

48. 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.

49. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!