Bringing Family Back into the Medical Home

1. Session #A3 October 28, 20113:30 AM Bringing Family Back into the Medical Home Barry J. Jacobs, PsyD, Crozer-Keystone Family Medicine Residency Program Maureen P. Davey, PhD, LMFT, Drexel University Jennifer L. Hodgson, PhD, East Carolina University David B. Seaburn, PhD, LMFT, Private Practice 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 What is the scientific basis for this talk? --Review of empirical literature on efficacy of family-based interventions on patient clinical outcomes --Observations of clinician-educators, as well as outcome studies, of specific family-based healthcare programs in North Carolina and Philadelphia

4. Objectives --Cite 3 key empirical studies that demonstrate the importance of family involvement to patient clinical outcomes --Describe 2 models for involving family members in the collaborative healthcare team --Identify core skills, derived from Medical Family Therapy, for healthcare and social service professionals to establish collaborative relationships with family members --Describe how family systems concepts can improve the functioning of collaborative healthcare teams

5. Expected Outcome What do you plan for this talk to change in the participant’s practice? --Participants will learn about the importance of involving patients’ family members in the collaborative healthcare team. --They will learn specific models and skills for integrating family members into that team.

6. 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.

7. TODAY’S TALK • Introduction on importance of family involvement in the Medical Home • Research highlights on family-based interventions • Key concepts of family-centered healthcare • A model of family-centered care for HIV-infected children • A family-centered, primary care model • Comments and discussion

8. INTRODUCTION • Why do we say “back into the Medical Home?” • Because the hottest trend in American healthcare delivery during the past 5 years—the “Patient-Centered Medical Home”—placed little emphasis on engaging family members in patients’ healthcare, despite a long tradition of family-oriented approaches to health, especially in primary care

9. THE HOME THAT WAS BUILT • In 2007, American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, American Osteopathic Association released Joint Principles of Patient-Centered Medical Home (PCMH) • Cited 7 key principles—personal physician, physician-directed practice, whole person orientation, coordinated/integrated care, enhanced quality, access and payment • Scant mention of patients’ families

10. HOME (cont.) • On basis of these principles, the National Committee for Quality Assurance (NCQA) began accrediting medical practices as “medical homes” • In many regions, these practices received increased insurance reimbursement for their innovations • Few of these practices have family-centered care or clinicians with family systems training

11. THE PENDULUM SWINGS • The PCMH seemed a rebuff to long tradition of family-centered care • Within family medicine: • 1977--Geyman: “It is axiomatic that family is the basic unit of care in family practice…” • 1983--Doherty & Baird: “therapeutic triangle”: patient-family-physician • 1983—Bloch founds Family Systems Medicine

12. PENDULUM (cont.) • 1990—Publication of Family-Oriented Primary Care by McDaniel, Campbell & Seaburn • 2003—AAFP practice monograph by McBride on 6 principles of family-oriented medical practice • None of their conceptual frameworks or clinical practices were incorporated into the PCMH

13. SWINGING BACK? • 2010—Stille et al—Medical Home in pediatrics should be “family-centered” • Same emphasis on “family-centered” care in geriatrics (e.g., Gaugler, 2005; NAC, 2009) • Information systems advances: Patient and family portals—adopted by many healthcare systems in last 2 years—offers new opportunities for involving family members in patients’ care

15. JACOBS (2010)--FCMH • Valuing family member’s expertise and engaging them in process of improving quality • Including family members as full-fledged or quasi-treatment team members • Family access to information and secure emailing through EMR patient portal • Family advisory councils, family educator groups, family caregiver mentoring groups

16. PLACE IN THE HOME? • Will family-oriented approaches to healthcare regain traction? • Will depend on evidence-based practices and demonstrated clinical outcomes • We have to show that involving family improves patient clinical outcomes • Also show it decreases family member morbidity (e.g., reduce caregiver depression)

17. SOME OF OUR FAVORITE RESEARCH • Little research on families and Medical Home • Recent studies from variety of disciplines on family impact on health and illness: • Having family member present during medical visit increases patient’s satisfaction with physician (Wolff, Roter, 2008) • Involving a spouse in care for a chronically ill patient decreases patient’s depression and, in some cases, decreased mortality (Martire et al, 2004)

18. RESEARCH (cont.) • Involving family members in an adult’s diabetic care increases family supportive behaviors, improves patient’s knowledge about and attitude toward diabetes (Kang et al, 2010) • Supporting family caregivers can delay an Alzheimer’s patient’s nursing home placement for nearly 2 years (Mittelman et al, 2006) • Please see bibliography for more

19. A FAMILY FRAMEWORK • Family Social Context • Family Context of Illness Meaning • Family Contributor to Problem • Family Partner in Care

20. No organism can be understood apart from the context in which it was shaped. The family is the first and often the most lasting influence on its members. FAMILY AS SOCIAL CONTEXT

21. We create meaning through dialogue in the context of relationships. Family is the first shaper of illness meanings. FAMILY AS CONTEXT OF MEANING

22. Illness in a family member can be maintained by family dynamics. FAMILY AS CONTRIBUTOR TO THE PROBLEM

23. Partnership with the family is essential when working with chronic and terminal illness. FAMILY AS PARTNER IN CARE

24. The Dorothy Mann Center for Pediatric & Adolescent HIV at St. Christopher's Hospital for Children/Drexel University College of Medicine: A Model of Family-Centered CareDr. Jill Foster, MD, Director Maureen Davey, PhD, LMFT Drexel UniversityDepartment of Couple and Family Therapy

25. HIV Affects Families in the US CDC estimates that more than one million people are living with HIV in the United States (www.cdc.gov). One in five (21%) of those people living with HIV is unaware of their infection. In tens of thousands of families, Parents will need to tell their children that they have HIV In thousands of families, Parents will need to tell their children that they too have HIV

26. Model of Family-Centered Care:The Dorothy Mann Center for Pediatric & Adolescent HIV at St. Chrisopher’s Hospital for Children

27. Demographics of North Philadelphia 44% African American, 9% Latino/a, and 5% Asian. A quarter of the cities’ families live below the federal poverty level. 1 in 16 households receive public assistance. Minority families in Philadelphia with HIV face the associated co-morbidities of substance abuse, domestic violence, low literacy, and mental health issues The median rate of new AIDS cases in Philadelphia is approximately 1,000 per year. For Philadelphia, the epidemic is primarily heterosexual and black—44% of the population is black, but 70% of AIDS cases are black.

28. History of Services at St. Chris

29. Current Services at St. Chris • “One Stop Shopping Model” for 160 HIV+ positive children/youth, 60 HIV + adults, and 300 families affected by HIV: • Medical Care • Case Management • Nutritional Counseling • Family Therapy (75% patients and increasing) • Psycho-educational Support Groups • Patchwork of Funding (Ryan White Title I and Medicaid)

30. Multidisciplinary Collaboration • Multidisciplinary Clinic Comprised of: • Physicians and a Part-time Psychiatrist • Midlevel practitioners (e.g., Nurses, Physician Assistants) • Social Workers • Child life specialist • 2 Family Therapists and Family Therapy Interns • Community Based Case Mangers/Action AIDS • Family-centered Collaborative Model: • One Medical Record and integrative treatment plan • Weekly team meetings and meetings as needed to coordinate care • Leveling of hierarchy (providers ‘speak’ same language) • Co-provision of services • Family support and ongoing psychological assessments to target treatment

31. Current Clinical Services

32. Benefits of family-centered care for children/youth coping with HIV Wiener et al., 2007 Higher self-esteem Better coping skills Helps garner sources of social support Less depression/anxiety Improved treatment retention & adherence Better long-term health and emotional well-being

33. Benefits of family-centered care for families coping with HIV • Recent studies1 demonstrate that other family members’ anxiety, depression, and paranoid thoughts impact on the health of HIV positive family members • Less depression/anxiety among caregivers • Improved trust/attachment with child/youth • facilitating open family communication • Improving treatment adherence • Increasing family closeness and social support • decreasing feelings of isolation and stigma 1Alexander et al., APHA 2008

34. GIVEN THAT THERE ARE SO MANY BENEFITS… Collaborative Family-centered care is the exception rather than the rule for patients coping with HIV Barriers: Funding for family-centered care Successful collaborative models Davey et al, 2008

35. Getting Started • Assessment of patient and family • Biopsychosocial Assessment (1-3 sessions) • Combination of parent/youth individual sessions • Genogram • Assessing for Family Support • Has the parent/youth disclosed HIV status to anyone? • Do other people in the household know about the child’s/youth’s diagnosis • Is the living situation stable? • May need to involve another caregiver to support teen, parent (e.g., fictive kin, aunt, grandmother)

36. Helping People with HIV • Disclosure & Psychological impact of HIV • Decrease anxiety, depression • Increase coping skills • Compliance with medical regimes • Compliance is related to positive affect, adaptive coping, and social support • Increasing family support • Reduce stigma, fear, blame • Reduce rejection by others - Palliative Care Johnson, et al. (2009)

37. CASE DISCUSSION:

38. Case: Donna and Family • 30 year old mom (Donna) who has HIV is parenting 2 school-age children • Donna recently developed resistance to her HIV medications from prior poor adherence and is now progressing to chronic renal failure and dialysis • Donna has a long trauma history • Infected in her mid-teens through sexual abuse and had an HIV+ baby from that assault who was placed in foster care and eventually adopted by another family • In her mid-20’s Donna had 2 HIV- children and was a wonderful parent • Donna was never able to take her HIV meds without experiencing them as a result of the sexual abuse

39. Donna and Family (Cont’d) • Family Therapy was critical to help Donna make a decision about whether or not to continue on dialysis or go to hospice and to make a plan for her 2 children. • Home visits with the family therapist began after consulting with multidisciplinary team, as it became too hard for Donna to come to the clinic • Donna eventually chose hospice • Family Therapy continued with Donna, 2 children and her estranged mom (maternal grandmother) • Reconciliation between Donna and her mom • 2 Children moved in with maternal grandmother • Donna died and family therapist continues to work with children and Donna’s mother on grief counseling and adjustment as a newly formed family

40. Case Discussion: Palliative Care Team had many discussions about how to ‘push’ family therapy on someone who was clearly dying without taking her medication, primarily because of psychological reasons (triggering of childhood trauma) How to know when it was time to move to more of a hospice/palliative care model How to help Donna choose and plan for her children, knowing she is dying How to help Donna say goodbye to her children and help them remember her Family-centered care in this case made a tough situation better for the family/children and easier for the staff to work through Continuity of care possible with family-model

41. Greene County Health Care, Inc Snow Hill Medical Center Kate B. Reynolds Medical Center Bernstein Medical Center Walstonburg Medical Center Migrant Farm Outreach Clinic Pamlico Medical Center (NEW!)

42. OUR POPULATION…

43. Demographics 30,235 patients Age Breakdown: 1-19 = 4,256 (male); 4,083 (female) 20-64 = 12,044 (male); 8,891 (female) 65 and over = 415 (male); 546 (female) Hispanic/Latino = 21,032 Income as % of poverty level: 100% and below = 12,744 101-150% = 1,030 151-200% = 248 Over 200% = 78 Unknown = 16,135 Uninsured = 25,093 Migrant or seasonal = 17,751

44. SPECIFICS OF “UNDERSERVED” All people who face barriers in accessing services because they have difficulty paying for services, because they have language or cultural differences, or because there is an insufficient number of health professionals/resources available in their community. Underserved populations also include people who have disparities in their health status. Health Resources and Services Administration’s Policy Information Notice 98-23: Health Center Programs Expectations (1998) United States Department of Health and Human Services, ¶ 2.

45. GCHC’s Integrated Care Program Medical Family Therapy Services integrated with Primary Health Care: • Utilize 3 Option Model • Screening • Assessment • Brief Therapy • Traditional Therapy • Lifestyle Change Consultation • Medication monitoring • Coordinated team care

46. Three Option Model Consult before provider visit Psychosocial screening (PHQ-9) SBIRT screening Coordinate Care Resume Interaction and Finalize Plan Assess and Screen Patient Together BH provider exit room for physical exam Coordinate Care Resume Interaction and Finalize Plan Consult during provider visit Consult after provider visit Provider communicates psychosocial concerns and focus for care Screen, Treat, Coordinate, and Finalize

47. Core Skills: Therapists Learning to “Insert” Themselves Focus on building relationships with staff, providers, and patients/families Provide the level of care they are ready to provide and patient/family ready to receive Review medical provider schedules for the day—anticipate patients with more mental health needs Approach providers before the start of clinics about patient panel that day Remain visible in clinic, even when documenting Use referral list if patient may require more than 4-6 sessions so available for IC services Connect with the nursing staff on a regular basis Work with Promoturas or local liaisons with minority groups in community

48. Core Skills: Engaging Family/Support Persons in Primary Care • Attend to Family Life Cycle Stages & Normative Stressors • Engage patients’ support persons ethically • Balance voices in room respectfully • Promote cultural sensitivity and competency in working with families • Screen and assess for couple and relational issues (i.e., family, social, occupational, community) • Make eye contact and acknowledge each person at beginning, middle, and end • Encourage patients to bring support person(s) in to each visit

49. Core Skills: Sample Interventions Speaker-Listener Technique (Markman, Stanley, Blumberg, 2010) Circular Questioning (Wright & Leahey, 1994) Role Play Motivational Interviewing (Miller & Rollnick, 2002) Scaling Question (Solution Focused) Thought Stopping and Thought Insertion Mindfulness Strategies * Want to have family leave with some change/thoughts about change with regard to their cognitions, behavior, and/or emotional states individually and/or relationally

50. Advances in billing for IC “Incident to” billing – Services rendered by a behavioral health provider (BHP) as a physician extender. MD’s NPI number is utilized. Traditional therapy billing codes by BHP using their National Provider Number (NPI)