Engaging the Sick Patient: Using Hospitalization to Establish Care in an Outpatient Clinic

1. Session #B3b October 17, 2014 Engaging the Sick Patient: Using Hospitalization to Establish Care in an Outpatient Clinic Lane DiFlavis, LSW, Behavioral Health Consultant Nicholas Madsen, LCSW, Behavioral Health Consultant Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

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

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Explore how trauma-informed interventions are especially useful when working with HIV+ patients • Discuss how behavioral health consultants can engage patients while hospitalized • Describe the benefits of establishing care during hospitalization • Identify potential areas of concern with this integration

4. Bibliography / Reference Amodio, Rachel D., “Predicting Initial Mental Health/Substance Abuse Treatment Attendance in HIV/AIDS Patients: An Exploration of Risk Factors” (2013). PCOM Psychology Dissertations. Paper 267. Harding, Richard, Lampe, Fiona C., Norwood, Sally, et al. “Symptoms are highly prevalent among HIV outpatients and associated with poor adherence and unprotected sexual intercourse” (2010). Sexually Transmitted Infections. June 2010, 86, 520–24. Lucas, Gregory M., “Substance Abuse, Adherence with Antiretroviral Therapy, and Clinical Outcomes Among HIV-Infected Individuals” (2011). Life Science. May 2011, 88(21-22), 948-952. Merlin, Jessica S., Westfall, Andrew O., et al, “Pain, Mood, and Substance Abuse in HIV: Implications for Clinic Visit Utilization, Antiretroviral Therapy Adherence, and Virologic Failure” (2010). JAIDS Journal of Acquired Immune Deficiency Syndromes. October 2012, 61(2): 164-170. Mugavero, Michael J., Davila, Jessica A., Nevin, Christa R., and Giordano, Thomas P., “From Access to Engagement: Measuring Retention in Outpatient HIV Clinical Care” (2010). AIDS Patient Care and STDs. October 2010, 24(10): 607-613. Mugavero, Michael J. et al. “Missed Visits and Mortality in Patients Establishing Initial Outpatient HIV Treatment” (2009). Clinical Infectious Disease. January 2009, 48(2), 248-256.

5. Additional References www.ptsd.va.gov www.instituteforsafefamilies.org/philadelphia-urban-ace-study www.phila.gov/health/aaco www.sanctuaryweb.com Briere, J., & Scott, C. (2006). Principles of Trauma Therapy: a Guide to Symptoms, Evaluation, and Treatment . California: Sage Publications. Herman, J. (1997). Trauma and Recovery: The Aftermath of Violence. NY: Basic Books Miller, W., & Rollnic, S. (2013), Motivational Interviewing; Third Edition: Helping People Change. New York: Guilford Press. Rollnic, S., Miller, W. & Butler, C. (2008), Motivational Interviewing in Healthcare: Helping Patients Change Behavior. New York: Guilford Press. Bloom, S. (2013), Creating Sanctuary; towards the evolution of sane societies; revised edition. New York: Routledge. Bloom, S. (2013), Restoring Sanctuary: a new operating system for trauma-informed systems of care. New York: Routledge.

6. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

7. First, some background about our project…

8. SAMHSA Funded Project • Part of Twelve Cities Inter-Agency Program • Concentrating services for HIV+ patients in cities with largest numbers of patients • Funded in part by all three SAMHSA Centers • Grant awarded to Philadelphia Department of Public Health, AIDS Activities Coordinating Office • Collaboration of Department of Psychiatry, Drexel College of Medicine, Mental Health Association of Southeastern Pennsylvania, and Health Federation of Philadelphia • And six HIV care clinics in the city

9. Participating Clinics • Partnership Comprehensive Care Practice, Drexel College of Medicine • MacGregor Clinic, University of Pennsylvania Medical Center • Infectious Disease Clinic, Penn Presbyterian Medical Center • HIV Comprehensive Care Clinic, Temple University Medical Center • Immunodeficiency Clinic, Albert Einstein Medical Center • Ambulatory Health Centers, Philadelphia Department of Public Health (four clinics)

10. The BHC Model • Consultation on patient “behavioral health” needs with medical providers as requested • Brief, focused visits with patients • Typically in medical examination rooms • 15-20 minute sessions in cycle with medical providers • Typically 1 to 4 sessions per patient • Focused progress notes in the medical record or EMR • “Low threshold” access to behavioral health care • Eschewing the “therapist” model • Interventions for a wide variety of needs • Depression, anxiety, trauma, substance abuse, smoking cessation, support for exercise, good diet, etc. • Help with medication adherence, disclosure of HIV+ status to various others, prevention of HIV transmission, etc.

11. Some Interpretations • The BHCs have achieved very high rates of penetration of their clinics • In FQHCs, 25% penetration is viewed as strong and showing effectiveness of the service • The BHCs have higher numbers of repeat visits with patients than BHCs at FQHCs • Some patients have 10 or more visits • Due to complexity of needs • Due to challenges keeping them from engaging in formal therapy • The high penetration rates relate to the complex behavioral health needs of the patients

12. Prominence of Support for Medical Treatment • Although BHCs also engage patients for classical behavioral health issues (depression, anxiety, trauma, relationship difficulties), a major focus of their care is on supporting patients in engaging in medical treatment: • Attendance at appointments with medical providers • Adherence to medications • Regularity in attendance and adherence • Modifying conduct to prevent transmission of HIV • Disclosing HIV status to appropriate others • And not disclosing when perhaps inappropriate • Disclosure – esp. to partners and family - often relates to treatment engagement

13. Who are these patients? How trauma-informed care helps us better engage with these patients…

14. The Impact of Trauma on Health Outcomes Adverse Childhood Experience (ACE) Study Emotional Abuse Physical Abuse Sexual Abuse Emotional Neglect Physical Neglect Mother treated violently Household Substance Abuse Parental Separation / Divorce Incarcerated household member (Acestudy.org)

15. Cumulative Impact of Trauma: Health Risks Behaviors: • School tardiness/ truancy • Dysregulated eating • Smoking • Suicide Attempts • Substance use • Multiple Sexual Partners • Self-Injurious Behaviors Outcomes • Autoimmune disorders • Obesity • Substance Abuse Disorders • COPD • Depression • Anxiety • PTSD • Liver Disease • Risk for IPV • STI’s / HIV • Unintended pregnancies

16. Sequelae of Adverse Childhood Experiences

17. Urban Aces: Philadelphia Added ACES: Experiencing Racism Witnessing Violence Living in an unsafe neighborhood Experiencing bullying

18. Prevalence of Population with 4 / + ACE’s

19. Prevalence of People living with HIV / AIDS

20. Similarities

21. Trauma and HIV Risk Behaviors • Disrupted relationships • Psychological distress • Substance Abuse • Exchanging Sex for money, shelter, substance • Experiencing retraumatization • Difficulty navigating boundaries and condom usage

22. Being Diagnosed with HIV is a Traumatic Event Can trigger feelings of: Betrayal Victimization Powerlessness Mortality Loss Shame

23. The “Difficult Patient” Avoidance of triggers: Medication and appointment adherence Challenges in participating in care: organizing narrative material, attentiveness and memory difficulties Protective behaviors that can be perceived as character flaw rather than survival strategies Difficulty with affect regulation and self soothing (disproportionate reactions) Aggression / Defiance Poor boundaries Avoidance, denial, or deflection Difficulty taking another’s perspective

24. Patients with PTSD and/or histories of trauma are likely to present to primary care with some (or many of these characteristics. Their behavior can interfere with patient-provider communication, impede compliance with treatment regimens, and generally frustrate the practitioner. These patients are at high risk for deteriorating health. ** Most trauma victims do not seek mental health services. Instead they look for assistance and care in the primary care setting (www.ptsd.va.gov)

25. To Engage the Sick Patient we Must understand Complex Problems Technical Problems • Easy to identify • Cut and dry repetitive solutions • Can be implemented quickly • Requires relatively little change • Provides immediate relief from anxiety Adaptive Problems • Hard to define • Every case is different • Often requires considerable time and resources • May require significant and uncomfortable change • Requires ability to tolerate uncertainty and risk

26. Humans are Adaptive When faced with adaptive problems, practitioners may experience anxiety, a desire to “fix” what’s “wrong,” and are more likely to treat the problem as technical which minimizes the complexity of our patients experience and decreases the likelihood of their success

27. When Working with The Sick Patient: Keep in Mind… Educate yourself on the impact of trauma Be aware that trauma may be involved in our patients history Be non-judgmental Do not take the patients reactions, accusations, and commentary personally– Though it may be designed to hurt you. Offer consistency in the way that you treat them Stay calm, attuned, present, predictable, and do not escalate. Help Patients to identify personal triggers and plan for safety. Support patients in identifying their own needs and utilizing appropriate resources to address their trauma histories Reflect on our own practice and work settings; evaluate for ways to increase patients sense of safety and incorporate trauma informed considerations.

28. Case Study Claire is a 40 year old HIV+ African American female who had been referred to the BHC due to recurrent hospitalizations (Pneumocystis pneumonia) as a result of her compromised immune system and non-adherence. Her lab work indicated a CD4 count of 37 and a viral load of 87,400. Claire had been linked to our care but had missed all 11 of her scheduled appointments. She had been diagnosed with HIV since 2004 and had maintained adherence to HAART until the death of her mother in 2008, whom she identified as her only support. Claire has a history of childhood sexual assault, witnessing violence / household IPV, living in an unsafe neighborhood/chronic poverty, incarcerated family member, history of substance abuse, and experiencing racism.

29. Initial contact BHC made contact with Claire during one of her inpatient hospitalizations after having missed 11 scheduled appointments to the clinic. She presented initially as agitated and defensive and reported that her primary barrier to attending her medical appointments was lack of car fare. Upon further assessment, Claire was able to open up about her struggle with her HIV diagnosis and the onset of depression following the loss of her mother– who used to take her to her medical appointments. Claire attended her following medical appointment.

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