Behavioral Medicine at JoslinBehavioral Medicine at JoslinResources and Expectations for Affiliated

Programs

October 2009

Joslin Care = Team Care

• Endocrinologist• Nurse educator, CDE• Dietitian educator, CDE• Exercise physiologist

(or related degree)

• Mental health provider– Social worker– Psychologist– Psychiatrist

The Joslin Mental Health Provider’s

Orientation:

•Policy AO-20

•Come to Boston for training

•Use Psychosocial Manual (Tab A)

October 2009

How is behavioral medicine integrated at Joslin?

• People– Large staff (social worker, psychologist, psychiatrist)

• Materials– Assessment tools– Handouts (stress management, emotions)

• Classes / Support groups– Usually begin with discussions related to feelings, common

misunderstandings – You Did It – a specific class on goal setting– Blood Glucose Awareness Training (BGAT)– Support groups

• Counseling Approaches– A focus on behavioral goal setting – Understanding barriers– Patient directed action steps

• Participate in team meetings – discuss cases

October 2009

Expectations for Affiliates

• Identify, orient and use your Mental Health Provider (MHP)• Clarify roles and responsibilities:

– Attend periodic staff meetings– Attend annual Affiliate Site Visit– Conduct classes for patients/training for Joslin staff– Participate in team clinical case conferences– Conduct support groups and/or other classes – See patients individually by appointment

• Identify someone on the Affiliate staff who will be the primary link to the MHP (to forward Joslin related materials, updates, etc)

October 2009

Joslin Resources for Behavioral Medicine

• Psychosocial Manual• Integrated into forms, classes, materials, etc• Joslin/Boston experts

– Readings– Consultation

• Discuss your needs with your Affiliate Site Coordinator

October 2009

Psychosocial Manual – TOC (2006)

• Mental Health Unit Structure– Job descriptions– Sample marketing materials

• Curriculum and resources– Relaxation strategies

• Group Treatment• Recommended Reading

– HCP– Patients

• Geriatric Assessment

• Structured Assessments– PAID– D QOL– R-BPRS– PHQ-2/9– DDS

October 2009

PAIDProblem Areas in Diabetes

• Questionnaire (20 items) to identify areas that may be barriers / problem areas

• Can be used for type 1 or type 2 • Valid and reliable; (First published in 1995)• 5 point scale: Not a problem Serious problem• Available in Spanish• Can be scored (0 – 100)• At Joslin Clinic – completed by all new patients

October 2009

Sample PAID questions

• Not having clear and concrete goals for your diabetes care?

• Feeling discouraged with your diabetes treatment plan?

• Feeling scared when you think about living with your diabetes?

• Uncomfortable social situations related to your diabetes care? (e.g., people telling you what to eat)

• Feelings of deprivation regarding food and meals

Which of the following diabetes issues are currently a problem for you?

October 2009

Basic Screening Assessment Questions

PHQ-2 (Personal Health Questionnaire):• Over the past two weeks, how often have you been

bothered by:– Little interest or pleasure in doing things?– Feeling down, depressed or hopeless?

If an anxiety disorder is suspected:• Over the past four weeks, how often have you been

bothered by:– Feeling nervous, anxious, on edge?– Worrying a lot about different things?

October 2009

Joslin Assessment FormsHow are psychosocial concerns addressed?

• Medical:– General feeling about having diabetes– Review of systems – PSYCH– Follow-up: mental health

• Education– Assess needs: Feeling less blue or depressed– Who helps with your diabetes?– PHQ-2 questions– What gets in the way? (emotions, stress, feeling

depressed)

October 2009

What can you do to enhance this service?

• Ways to enhance your relationship• Strengthening the role of the mental health

provider

October 2009

Joslin’s Behavioral Team:Areas of Interest

• John Zrebiec, MSW– Groups, BGAT

• Ann Goebel-Fabbri, PhD– Eating Disorders, Insulin omission, Wt mngmt

• Ann Butler, PhD– Psychopharmacology

• Katie Weinger, RN, EdD– Barriers to change, driving and hypoglycemia

• Marilyn Ritholtz, PhD– Adult and adolescent therapy, depression

October 2009

Depression and Anxiety Disorders

• Depression is common– 2-3 times more common than in general population– 19% met criteria for major depressive disorder

• Twice as likely to miss medication doses– About 70% type 2 report some depression symptoms

• Linked with poorer adherence to diet, exercise, meds and higher A1C levels

October 2009

Eating and Related Disorders

• Eating disorders more common in type 1 women– 2.4 times higher risk for developing eating disorder than

age matched women without diabetes

• Insulin restriction common in type 1– 30% insulin restrictors at baseline– Higher rates morbidity and mortality– Screening question: I take less insulin than I should

(often – sometimes – never)

Goebel-Fabbri, D.Care March 31(3):415-9, 2008

October 2009

Diabetes is a Self-Management Condition

Findings from DAWN

Adherence rates to all aspects of prescribed regimens• 19% - type 1• 16% - type 2

Identified link between BG and HCP relationships• 53% linked better BG control to good relationship• 37% linked poor control to one that wasn’t good

enough

October 2009

Relationship, Control and Distress DAWN - Diabetes Attitudes, Wishes and Needs

People with Diabetes Reporting Good Diabetes Control

53%

37%

Re

lati

on

sh

ip

Good Poor

People with Diabetes Reporting Diabetes Distress

25%

37%Re

lati

on

sh

ip

Good Poor

October 2009

• Insulin adherence estimates: 20-80%• Meal plan adherence: 65%• Blood glucose monitoring: 57-70%• Exercise adherence: 19-30%

• Global adherence in diabetes: 7%

Defining non-compliance in real terms

October 2009

• Clear communication counts– Patients who rated

communication as poor had an A1C 1% higher than those who assessed communication as good

– Demonstrate empathy and understanding

– The 3 important qualities of a constructive clinical relationship

Importance of the Pt-Provider Relationship

October 2009

• Communications is less about speaking than it is about listening and observing.– Barbara Anderson, PhD Former Joslin Psychologist

October 2009

Counseling Skills

• Listen! Observe.• Pay attention to your skills

– Open ended inquiry• “Tell me….” (not why)• Avoid questions requiring “yes” or “no” answers

– Reflective listening• “So, you are saying…..”• “It sounds like…..”

– Demonstrate empathy• “You seem….”• “Most people would find that hard…”

• Be positive– Focus on what can be done– Help patient set a specific goal

October 2009

Solving Problems – the Collaborative Way

• What does not work– Tell patient what to do– Provide solutions

• What does work– Let patient describe plan– Provide choices– Recognize you are both

“experts”

October 2009

Favorite Resources

• Educating Your Patient with Diabetes– Chapter by Marilyn Ritholtz

• The Art of Empowerment, 2nd Edition– Anderson, R and Funnell

• AADE Art and Science Text– Chapter 4

• Practical Psychology for Diabetes Clinicians– Anderson, B and Rubin

• 1000 Years of Wisdom– Lessons clinicians have learned from their patients