Promoting Provider Resiliency in the Primary Care Medical Home

1. Session #: Period 3, Track H3 October 27, 20114:15-5PM Promoting Provider Resiliency in the Primary Care Medical Home Debra A. Gould MD, MPH deb.gould@commhealthcw.org Central Washington Family Medicine Residency Program, Yakima, Washington Associate Clinical Professor, University of Washington, Seattle Patricia J. Robinson PhD patti1510@msn.com Mountainview Consulting Group, Inc. patriciarobinsonphd.com Healthcare Consultant and Trainer, Yakima, WA Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure • We currently have the following relevant financial relationships during the past 12 months: • New Harbinger Publications – Co-Authors

3. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? • Burnout in Primary Care Clinicians is a current reality Working conditions in primary care: physician reactions and care quality. Linzer M, et. Al. MEMO (Minimizing Error, Maximizing Outcome) Investigators. Ann Intern Med. 2009 Jul 7;151(1):28-36, W6-9. • PCMH requires “Adaptive Reserve” for successful practice transformation Journey to the Patient- Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration project. Nutting P, et. Al. Ann Fam Med 2010;8(Supp 1):S45-S55.

4. Need/Practice Gap & Supporting Resources What is the scientific basis for this talk? • Resiliency is a dynamic, evolving process of positive attitudes and effective strategies Building Physician Resilience. Jensen PM, Trollope-Kumar K, Waters H, Everson J.Can Fam Physician. 2008 May;54(5):722-9. • Resilient clinicians are needed for primary care practice who: value the their role, are self-aware, can balance and prioritize, manage a practice and, support relationships

5. Objectives • Provide a summary of research concerning resiliency and burnout in primary care providers and primary care residents • Use the Primary Care Provider Stress Checklist to determine sources and magnitude of stress • Use the Primary Care Provider Acceptance and Action Questionnaire to obtain an estimate of psychological flexibility • Identify Core Processes that support Provider Flexibility in responding the to stresses of practice in today's primary care medical home

6. Expected Outcome “By using self-assessment tools and learning about the core processes of psychological flexibility, primary care clinicians and trainees will become more self-aware and flexible in dealing with the personal and professional stresses of primary care and practice transformation.”

7. Learning Assessment A learning assessment is required for CE credit. • Based on your PCP-SC scoring, what specific stress area do you want to work on? • Of the six core processes of psychological flexibility, which one would you like to learn more about to help you cope with your specific stress area?

8. Burnout - Definition “Insidious changes in attitudes, moods and behaviors that have consequences on personal and professional life.” • Emotional exhaustion • Depersonalization • Personal Accomplishment (Maslach Burnout Inventory)

9. Burnout Rates • Medical Students – 45% • Residents – 27% FP to 75% OB-GYN • Attendings – 20% - 65% Limitations of studies – poor response rates, definition of burn-out (EE, DP, PA).

10. Burnout – Factors/Consequences Adverse workflow Low MD satisfaction Low control High Stress/Burnout Unfavorable culture Intent to leave Some work conditions associated with lower quality & more errors but findings inconsistent across work condition & diagnosis. MD stress/burn-out Quality of care errors • Linzer et.al, Working Conditions in Primary Care: Physician Reactions and Care Quality. Ann Inter Med 2009;151:28-36.

11. Burnout in Primary Care – Why Care? • Substance abuse • Over-eating, over-drinking, over-working • Depression/isolation • Suicide • Leave profession • Leave current position/job • Relationship problems work • Relationship problems at home .

12. PCMH- “A Relationship Centered Approach” • “Adaptive Reserve” for successful practice transformation - dealing with Constant Change ! • Healthy Relationship Structure • Effective Communication • Trust • Principles for establishing Common Values • Aligned Management Model • Facilitative Leadership – empower staff, respect for all staff, shared responsibility Journey to the Patient- Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration project. Nutting P, et. Al. Ann Fam Med 2010;8 (Supp1):S45-S55.

13. Primary Care Provider – Stress Checklist (PCP-SC)* Where are your areas of heaviest stress? I. Interactions with patients II. Practice Management III. Administrative Issues IV. Education/Learning V. Relationships with Colleagues VI. Balance between Work and Life Available on-line http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html

14. PCP Stress (PCPs A, B, C, D, E)

15. PCP Stress: Interactions with Patients Top 3: Chronic Pain, Angry Demanding, Alc / Drugs

16. Physician Resiliency • Attitudes and Perspectives – valuing physician role, maintaining interest, developing self-awareness, accepting personal limitation • Balance and Prioritization – setting limits, taking effective approaches to CME, honoring thyself • Practice management - sound business mngmt, good staff, effective practice arrangements • Supportive relations – positive personal relationships, effective professional relationships and good communication Building Physician Resilience. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Can Fam Physician. 2008 May;54(5):722-9.

17. Psychological Flexibility(Model of Acceptance and Commitment Therapy) Pain is inevitable, suffering isn’t!

18. Psychological Flexibility Learning to be aware and accepting of the pain that comes into our lives while continuing to pursue what we value. Primary Care Provider – Action & Acceptance Questionnaire (PCP-AAQ)

19. What Can I do to become more Psychologically Flexible?

20. TEAMS (Our Private Experience) Emotions Associations Memories Thoughts Sensations

21. Experience Present Moment Accept TEAMS Connection with Values Step back from Value Consistent TEAMS (Defusion) Action Use Observer Self To See Limiting Self-stories Core Processes – Psychological Flexibility Flexibility

22. Resident “Self- Management Workshops” - Schedule Beginning of Academic Year: • R1 - Introduction to Burnout, ACT model with focus on Values exercises • self assessment - MBI, AAQII/PCP-AAQ • local resources • R2/3 – Reminder about Burnout, ACT model with focus on Sources of Stress, Mindfulness & Values exercises • self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL • local resources Mid-Year: • R1/R2/R3 – Reminder about Burnout, ACT model with focus on Sources of Stress, Mindfulness exercises • self assessment - MBI, AAQII/PCP-AAQ, PCP-SCL • local resources

23. Resident Resources CHCW • Employee Assistant Program • Athletic Club corporate membership • Peers • Advisor • Dr. Strosahl – Behavioralist Faculty • Health insurance – health risk assessment, • - Gift certificate for healthy lifestyle choices; massage therapist. Hospital – Physician Wellness Committees Washington StatePhysicians Health Program - http://www.wphp.org/services Community – family, faith community, social interests, Farmer’s Market, Sparkpeople.com – diet & exercise (free)

24. ACT Resources New Harbinger Publications http://www.newharbinger.com “Association for Contextual Behavioral Science” http://www.contextualpsychology.org/ http://www.newharbingeronline.com/real-behavior-change-in-primary-care.html

25. Learning Assessment A learning assessment is required for CE credit. • Based on your PCP-SC scoring, what specific stress area do you want to work on? • Of the six core processes of psychological flexibility, which one would you like to learn more about to help you cope with your specific stress area?

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