self-management tools: it's not just patients who can benefit eleanor davidson, md tanya...
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Self-Management Tools: It's Not Just Patients Who Can Benefit
Eleanor Davidson, MDTanya Massey, CNPMaryann McGlenn PhDCase Western Reserve University
Objectives
1. Introduce the National College Depression Partnership and discuss how it led to our focus on self-management
2. Describe 3 self-management tools used for patients with depression
3. Describe 3 self-management tools used for clinicians
4. Describe a teaching process for clinicians learning to use self-management
5. Describe how clinician self-management tools can be entered into the medical record
Our model
So why screen for depression in primary care?
US Preventative Services Task Force Recommendation:
Adult primary care practice settings should screen for depression—but only within the context of a “prepared practice.”
http://www.uspreventiveservicestaskforce.org/
Background: Phase I NCDP
College Breakthrough Series-Depression: 2006-07NYU, Princeton, Cornell, CUNY (Hunter & Baruch), CWRU, St Lawrence
Gap Strategy
Under-detection of students with depression & suicidal ideation
Maximize existing medical & mental health resources to identify and treat depression
All studies show that follow up after initiation of treatment (in any setting) is a critical factor for successful outcomes
Create a safety net for identified depressed students including systematic planned follow up, treatment monitoring & coordinated referrals to community links.
Phase I (CBS-D): challenges
● How would students react to depression screening in the health service?
● Could the health service achieve an 80% rate of screening all patients once during a school year?
● How would clinicians react to screening for depression in primary care?
-Use of Plan-Do-Study-Act cycles
-Start small and grow.
Some of us imagined that our biggest challenge was identification of depressed students who would then be referred to the counseling service for treatment.
Successes and challenges (our model)
We could achieve 80-90 % screening of all students in primary care (throughout—all visit types).
We could achieve simple self-management goals with a majority of patients (30 min of exercise 2-3 times per week was most common).
Successes & challenges (our model)
The majority of our patients were entered from primary care; we had a disproportionate number who did not want either counseling or medication.
Identification was the easy part. The challenge became what do after depression was identified.
In other words, if a student did not want to go to counseling, we wanted to initiate treatment without feeling forced to
start medication.
We needed another way to start and self-management seemed like a plausible option
What Is Self-Management?
Self-management - Goal directed patient behaviors that enhance clinical & functional outcomes:
– Medication management and adherence– Self-monitoring of symptoms, treatment status
– Managing effects of illness on social role function– Reducing health risks (alcohol misuse, smoking)
– Preventive maintenance (e.g., exercise,
screening check-ups)– Working with health care professionals
NCDP Operational Definition
The engagement of patients in a collaborative partnership with clinicians to achieve goal-directed behavioral change and patient activation.
Why Self-Management?
We know it is evidence based
It is simple
Fits well in a college setting. It focuses on a developmental model. For them everything is a self-management tool.
Phase II (NCDP) 20 schools 2008-09
Refined the concept of a prepared practice
Expanded self-management tools to a treatment goal:
- Exercise
- Harm reduction (e.g. alcohol, marijuana)
- Sleep hygiene
- Full session with dietitian: concern for eating
disorder
- Assessment in career services
- Positive activity: spending time with friends
- Medication follow through
- Mindfulness/Stress Management: Friday group
therapy sessions
Phase III (NCDP-CAN) 17 schools 2010-11
Further refine/expand self-management:
-Collaborative treatment planning (educate
about treatment options, elicit feedback,
encourage behavioral activation) by four
weeks
- Personalized self-management
(personalized goal, frequency, duration,
confidence rating, reassessment of goal)
by 8 weeks
Findings
N = 42
Baseline 4 weeks 4-8 weeks 8 weeks 12 weeks
PHQ-9 100% 48% 20% n/a n/a
Functional recovery n/a n/a n/a n/a 33%
Treatment initiated - 84% - - -
Self-management goal set and reviewed by 8 weeks
n/a n/a n/a 0% n/a
What Happened?
Self-Management goals/measurement criteria were high
Not enough time to accomplish this in one visit
After obtaining PHQ-9, history, and addressing the patient’s medical concern, we were lucky to have enough time for a self-management goal let alone elicit duration, frequency, and student confidence.
Is time the biggest impediment?
We’ll return to something we invented as a bridge to counseling that involved encouraging patient activation, exploring self-management options, and chart documentation of these steps.
One of the psychology post docs created this in consultation with our NCDP team.
[The BRIDGES Program]
What if time is not the biggest impediment:The patient’s perspective
May disagree on diagnosis• Believe there is a physiologic etiology such as
fatigue due to anemia or thyroid problem
May disagree on treatment plan• May not be ready for counseling• May not be ready for medication• May not be ready for the self-management
tools we have in mind.
We need to step back and figure out where the patient is. Is the patient ready to make changes?
Transtheoretical Model of Change
Transtheoretical Model of Change
Where are the CWRU students?
Although many are in pre-contemplation or contemplation, the model does not necessarily describe every student
Where are our clinicians?
We noticed that clinicians could quickly figure out a student was likely depressed but the student was nowhere near that conclusion.
We wondered if our team member from mental health could help us understand more about where we might lose patients in the journey.
NCDP Team
A group made up of clinicians, a care manager, a women’s health advocate, and a representative from counseling services.
Meet every 2 weeks to discuss patient cases.
Mental Health Professional as Team Member
Focus on:
Biopsychosocial/Mind-Body perspective and viewing the person as a whole
Relationship as an important change factor
Interaction between provider and patient can be a help or hindrance towards change
Self care tools – Providers also need them
PRECURSORS MODEL OF CHANGE
Adapted from Hanna, F. J. (2001)
Therapy With Difficult Clients: Using the Precursor Model to Awaken Change.
Seven Elements Necessary for Therapeutic Change
CLIENT CLINICIAN
1. Sense of necessity => Sense of necessity to help the client change
2. Willingness to experience anxiety => Willingness to experience the anxiety or difficulty inherent within the client
3 . Awareness of the problem => Awareness of the client’s issues and one’s own corresponding issues
4. Confronting the problem => Confronting the client’s issues
5. Effort or will toward change => Effort or will to work through issues with the client
6. Hope for change => Hope for client change
7. Social support for change => A therapist’s social support for facilitating change
Comparing Models of Change
Transtheoretical Model of Change
Precursors Model of Change
Looks at: Stages of change occurring within the individual client
Looks at: Both the client and the clinician and the interaction between them
Emphasizes 7 Contextual Factors necessary for change to occur . Factors which must be present for advancement along the stages
Regression occurs because the precursors have waned
Difficult Client or Difficult Therapist?
One-sided View of a Difficult Client
One who is defiant, unruly, stubborn, undermining, ambivalent, apathetic, deceptive (pejorative)
One who fails to make satisfactory progress in treatment
Shared Perspective (of a difficult client)
One for whom change is not forthcoming in spite of therapist and client efforts to achieve it
Rating the Clinician on the Precursor Scale
It’s important to examine the clinician’s disposition and reactions to “difficult” clients (aka countertransference)
“Resistance” viewed as client or therapist interference in the change process
Therapist Effectiveness is enhanced by
Building the Relationship and Reducing Interference
Relationship Building: Strategies and Techniques
1. View empathy as a duty not a suggestion
2. Attend to the unspoken conversation that the client may be having with the therapist (metalog)
3. Set (mutual) boundaries including asking permission and taking time to reflect before responding
4. Leave the ego at the door
5. Work from a strength based approach and validate the client’s abilities and positive qualities
6. Reframe Negative Behaviors and Attitudes
Reducing Therapist Interference
1. Detach from one’s own agenda
2. Confront with curiosity, empathy, serenity and the intention to help
3. Be aware of becoming too rigid, flexible, distant or long-winded
4. Meet hostility with equanimity and humor and avoid power struggles
5. Attend to differences in culture and socioeconomic status
6. Use consultation to regain focus and a sense of control
Self Survey for Clinicians(adapted from Kottler, 1992)
1. What am I doing to exacerbate the situation?
2. What buttons is this client pushing in me?
3. Who does this client remind me of from my past?
4. In what ways am I acting out my impatience?
5. What are my expectations for this client?
6. Which of my needs are not being met by this client?
So we’ve looked at factors that influence both the patient and the clinician in this change process.
Now let’s examine 3 cases which illustrate how this might apply in the clinical setting.
Case Example: Patient M.
27 y/o Asian male MD/PhD student
Presents with chief complaint of fatigue and headache
Also reports sleeping more, decreased appetite, less energy, trouble focusing, and hand weakness
14
3
21
3
32
3
0
0
0
941
Case Example: Patient M.
• Rejects possibility of depression as the initial diagnosis• Requests blood work to rule out the physiologic first
• BMP, CBC, and TSH are all normal• Again discussed counseling. Said he would consider it
after exams
3
Case Example: Patient M.
• One month later made an appointment for ADHD testing
• Canceled appointment and rescheduled with counseling
• Attended an initial intake evaluation and then one full counseling session
• Two weeks after that met with psychiatry. Wellbutrin prescribed initially. Klonopin added later
• On and off meds for the next year.
• Never returned for counseling sessions. “Not a talker”
Case Example: Patient M.
Returned to UHS sporadically, seeing a different provider each time, often when off meds
• Fatigue—concerned with sleep apnea, enlarged tonsils
• HA—began one week after stopping antidepressants
Last saw psychiatry Oct 2012. Did not keep 3 month follow up
Last seen at UHS Feb 2013 for travel visit (on med)
Case Example: Patient M.
What would we do differently now?•Assign a primary care clinician•Schedule routine follow up at UHS (even if it seemed like he was going to UCS)•Send periodic messages via secure e-mail•Work on relationship and self-management
Case Example: Patient M.
We might also be kind to ourselves and realize someone that is not only getting an MD but also a PhD in the sciences might be more focused on identifying a ‘molecular” cause of his distress.
How would this help?
We don’t need to berate ourselves in the process.
We might get a bit more therapeutic distance to help us make observations.
Case Example: Patient N.
19 year old undergraduate studying piano performance seen for women’s health annual physical exam Routine PHQ-2 = 1.
PHQ-9 = 7. Functional score = 1 somewhat difficult.
Counseling information given and also referred to Dr. Davidson. Declined scheduling follow up appointment.
Case Example: Patient N.
Seen 5 months later for Depo-Provera shot.
PHQ 9 = 9 with yes to question 9 (suicidal ideation)
Functional score = 2 very difficult
More thorough history taken
Realized she was depressed but admitted to coming from an ethnic background that did not accept mental health treatment--it was looked down upon in her culture.
Had discussed counseling with her parents in high school and was told that counselors would just “mess with her”
Case Example: Patient N.
States on the one hand she is interested in counseling but on the other and it is “unnecessary and for the weak”.
Not interested in medication or therapy but interested in other options.
Assessed that she was not in acute danger to herself or others and scheduled a one week follow up appointment
Self-management: safety, enjoyable activity, spend time with friends
Case Example: Patient N.
In the next two years, I saw her periodically for sick visits, Depo-Provera shots and annual exams.
During that time I continued to work on the relationship, getting a thorough history, encouraging treatment and working on self-management.
Eventually, she did start counseling at CWRU, started on medication through a home psychiatrist. The last time I had seen her she was on medication and going to counseling.
What did we learn?
Removing barriers to treatment• Multiculturalism—she knew she needed treatment but did not
have family or cultural support to back her up
Keeping patients in the women’s clinic• Many women would prefer all of their care in one place.
Forget about seeing a provider in a different side of campus. We learned they wanted to “stay within the product line” they chose originally.
Benefits of our Women’s Health Advocate• She could do full PHQ-9 if time was an issue• Clinicians felt more comfortable raising these issues if the
health advocate was there for back up.
Case Example: Patient D.
19 year old sophomore with chief complaint of chest discomfort/tightness, heart palpitations, and body aches.
Came in realizing that all her symptoms were linked to anxiety provoking situations.
Had been attending counseling weekly for the last 2 months but felt uncertain about returning. Wanted to switch counselors
PHQ-9 = 18
Functional score = 2 very difficult
Case Example: Patient D.
She had already been making changes by going to counseling
She was ready to start medication (Zoloft) and work on her issues
We worked on self management
Finding a counselor that was the right fit for her
Putting herself in situations to work on her social anxiety
Case Example: Patient D.
She has stayed on the medication
Has kept regularly scheduled appointments with me
She found a new therapist that she is happy with and sees regularly
PHQ-9 started at 18 and decreased to 6
Functional score: Very difficult initially to somewhat difficult four months later
Time will be the test
Real World Use
Rule out the physiologic• physical exam, lab work, etc
Work on relationship--build rapport, trust• taking the time to listen to their concerns• acknowledging these concerns but also offering
alternative diagnoses
Obtain a more thorough psychosocial history• where they were born, grew up, current major, why they
came to this school. • family history—health, parent’s occupation, marital status • relationship with family, friends, significant other
Real World Use
Work on self-management
• working on the relationship and learning more about the patient helps the provider guide the patient to determine their own self-management goals
Schedule follow up with same provider
• must establish a relationship for this to be successful long-term
Maintain follow-up until successfully transitioned
• But remember that may not be what the patient may choose
What else can we do? BRIDGES program
Invented as an intermediary type of visit when a student did not see counseling as an option.
Our post-doc (Sasha Ribic PsyD) worked on creating this alternative.
Behaviors
Relationships
Interests
Development
Growth
Emotion
Success
BRIDGES
Documentation
We wanted to put this in electronic record where it could be seen both by counseling and health services.
After this was completed at a visit, the paper copied would be scanned into the chart.
Summary
Describe three self-management tools used for patients with depression
1. Exercise
2. Spending time with friends
3. Regular sleep schedule
But we also learned sometimes self-management needs to be more basic than that
1. Think about what we discussed at this visit
2. Keep one week follow up appointment
Summary
Describe 3 self-management tools used for clinicians:
1.Reframing – work from a strength-based approach, check your ego
2.Detach – from your own agenda; check your posture with the client (too rigid, flexible, long-winded)
3.Consult – form a team, do a self-survey
Questions or Comments?
Thanks for listening!
Resources
Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. The Guilford Press.
Barlow, et. al. (2002) Patient Education Counseling. 48,177.
Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K. (2002). Patient self-management of chronic disease in primary care. JAMA, 288(19), 2469-2475.
Hanna, F. J. (2001). Therapy With Difficult Clients: Using the Precursors Model to Awaken Change. American Psychological Association.
Katon, W., Ludman, E., & Simon, G. (2008). The Depression Helpbook. Bull Publishing Co.
Kottler, J.A. (1992). Compassionate therapy: Working with difficult clients. San Francisco: Jossey-Bass.
Rollnick, S., Miller, W.R., Butler, C.C. (2008) Motivational Interviewing in Health Care. The Guilford Press.
ACHA Boston
May 30, 2013