Transcript Slides F2 - Collaborative Family Healthcare Association

Track #4 F2
There’s an App for that: Treatments for Medically
Unexplained Symptoms in Primary Care Associated
with Cost Savings and Return on Investment
David Clarke, MD, Clinical Assistant Professor Emeritus, Oregon Health & Science University
Ronald R. O’Donnell, Ph.D., Clinical Professor, Arizona State University
Jana Svoboda, LCSW, Clinical Social Worker, Samaritan Family Medicine Resident Clinic
CFHA 18th Annual Conference
October 13-15, 2016  Charlotte, NC U.S.A.
Faculty Disclosure
The presenters of this session have NOT had any relevant financial relationships
during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Understand treatment options for Psychophysiologic
Disorders (PPD)
• Understand new models of healthcare payment in the
ACO model and how population-based treatment of PPD
can thrive in that environment.
• Calculate cost savings and return on investment for
population-based treatment of PPD
Psychophysiologic Disorders
(PPD)
Illness caused by past or present
psycho-social stress.
(Recently linked to altered
neuroanatomy).
4
Cause of Presenting
Symptoms
Landa, Psychosomatic Medicine, 2012.
Outpatient Primary Care
15%
30%
PPD
Organic
Psychiatric
55%
5
PPD: Financial Impact
10-20 cents of every health care dollar
Increased disability and distress in patients due to medication SE,
unnecessary procedures, lost productivity time
High Utilization that results in frustration and unnecessary cost
and risk
Spectrum disorder: from mild, transient discomfort to long-term
disability, thus interventions range from reassurance to complex
team support.
NIMNUAN, C. ET AL (2001) MUS: AN EPIDEMIOLOGICAL
STUDY IN SEVEN SPECIALTIES. JOURNAL OF
PSYCHOSOMATIC RESEARCH, 51: 361-7
A Wide Range of
Presentations
7
Stress Evaluation Part I
The Illness
Chronology
8
Stress Evaluation Part II
Current
Stress
9
Stress Evaluation Part II - a
Insufficient
Personal
Time
10
Stress Evaluation Part III
Childhood
Stress
11
Asking, Listening, Accepting:
A Sequence of Questions
Did you experience stress as a child?
How much? (0-10 scale)
Why that number?
What if it was your child?
12
Chronic Unpredictable
Toxic Stress
•Abuse or Observing abuse
•Parental Substance Abuse or Mental Illness
•Losing a Parent
•Community Violence & Racist Abuse
•Poverty
•Bullying at school (afflicts 25%)
•Arguments/Tension in Family
•Lack of Affection/Communication in Family
•Early Medical Trauma
•Family Secrets
13
Stress Evaluation Part IV
Depression
14
Stress Evaluation Part V
PostTraumatic
Stress
15
Stress Evaluation Part VI
Anxiety
Disorders
16
Treatment of Current Stress
Listing
Your
Stresses
17
Treatment of Current Stress
Self-Care
Time
18
Treatment of Current Stress
1. Relaxation
Technique
2. Meditation
3. Mindfulness
4. Yoga
19
Treatment of
Childhood Stress
Acknowledge
Their Heroism
20
Treatment of Childhood
Stress
Writing
21
Treatment of
Childhood Stress
Do You Like to Read?
Self-Help Books
22
What if there was a
blood test for PPD?
23
Transition
JANA - TREATMENT APPROACHES:
EXAMPLES AND APPS
Effectively Addressing MUS
With the patient:
1. Connect
2. Listen
3. Validate
4. Educate
Make sure they leave with
a new tool
What to do? Interventions
START HERE
Treatment of symptoms and function can work as well as treating
underlying psychosocial issues.
Assess social connectivity and sense of purpose/meaning
Reassure that the negative diagnostic evaluation makes
organic/structural problems unlikely.
Educate.
Offer a benign or evidenced-based tool/intervention. Don’t over
treat.
Schedule follow-up.
Social Rhythm Therapy
Help the patient synchronize with their circadian rhythm
Chief components: sleep, wake, eat, exercise, take meds if
prescribed,
Add ons: scheduled focus on improving social connections,
sense of meaning and purpose (creativity, hobbies, volunteer
work), and time in nature
Stress Medicine
Group Appointment
Teaching patients about the real effects of stress on the body and
ways to intervene in a group educational class has many benefits:
Low stigma: everybody has stress; ed format doesn’t have the
psych connotation
Low barrier: free or low cost, no insurance referral needed
Increases patient buy-in to understanding the physical expression
of stress in the body and implications for disease and disease
prevention
Group atmosphere and plain language reduces feeling of isolation
and marginalization
Psychological Interventions
CBT
Trauma informed therapies
Problem solving brief strategic therapies
Group using any/all of the above
Mind/body therapies
Yoga
Massage
Mindfulness Meditation
OMT
Hakomi
EMDR
Acupuncture
Nia
Tai Chi, Qi Gong
Quick In-Office Intervention
Duchenne Smile
Mountain Pose
Get Big/posture correction
3 minute body scan
Diaphragm breathing
Reframing and goal alignment
Handouts and homework
Have patient listen to podcast or watch vid in office/patient area
and discuss after
Handouts and homework
TED talks: Happiness series, B. Brown on vulnerability, K.
McGonigal and D. Levintin on stress, N. Burke Harris on trauma
and health, A. Cuddy on body posture and mood
Apps
Tip sheet for stress management
Prescribed nature walks
Journaling: out of the body and onto the page
Tracking sheets: mood, sleep, social rhythm
“Rejection therapy” podcast and related assignment
Handouts and homework
Exercise– set a LOW bar, but remind patient that when stressed,
whether physical or emotional, the body doesn’t like to feel
trapped.
3 minute workouts: YouTube dance or exercise
3 minute mindfulness: YouTube or handout
Tapping exercises
 Safe touch: massage, work with animals (ex: equine therapy)
OTHER: Set challenges for your patient
Volunteer work, community classes, learn something new
Gratitude journals
APPS FOR THAT
Something for everything
Apps for meditation, depression
•Headspace
•Omvana
Apps for anxiety and stress
•Self Help for Anxiety
Management
•Bhuddify
•Stop Panic and Anxiety Self
Help
•Calm
•What’s Up
•PTSD Coach
•Worry Watch
•Live OCD free
•Worry Box
•Pacifica (mood/anxiety)
•Panic Relief
•MoodKit, MoodGYM
•Breathe to Relax
The Evidence for cost savings
– what works AND saves $$$
REDUCING OVERUSE OF MEDICAL
UTILIZATION
Mindfulness for Somatizers
Functional somatic syndromes:
◦
◦
◦
◦
5% Danish population
10-20% of total healthcare costs
20-30% of all consultations
5th most expensive category (higher than stroke, cancer)
N = 119 Mindfulness vs Enhanced TAU
N = 5,950 matched controls
10 year pre-data, 15 month follow-up
Fjorback et. Al. Mindfulness therapy for somatization disorder and
functional somatic syndromes: Analysis of economic
consequences alongside a randomized trial. J Psychosomatic
Research. 2013. 41-48 (Denmark)
Mindfulness for Somatizers:
Results at 15 month follow-up
Mindfulness disability pension lower (25%) than enhanced TAU
treatment group (45%)
Total healthcare utilization/cost reduced in both groups from 1
year pre-treatment mean $5,325 vs. $3,644
Somatizers more weeks of unemployment and sickness 5 and 10
years pre-treatment than controls
Costly Patients with
Medical Symptoms
Setting
◦ PCP, nurse, social worker plus specialty consultants, lab and imaging
Treatment
◦
◦
◦
◦
Short-term family therapy in primary care
Clinical interview
Lifestyle changes
Basic psychotherapy (empathy, defense mechanisms)
Margalit and El-Ad, Costly patients with medical symptoms: A
high-risk population. Patient Education and Counseling. 2008.
70:173-178
Costly Patients with
Medical Symptoms
Results: Significant reductions in:
◦
◦
◦
◦
Annual # visits to PCP from 31.8 to 12.6
Annual hospital ED visits from 33.5 to 4.1
Hospital days from 112.7 to 19
Reduced mortality rates (6/21 vs. 17/21)
Margalit and El-Ad, Costly patients with medical symptoms: A
high-risk population. Patient Education and Counseling. 2008.
70:173-178
The Opportunity and the
Challenge
Opportunity:
Health care reform transition from fee for service to Value-Based
payments
Incentives for improved quality and reduced costs
PPD population is the low-hanging fruit to demonstrate costsavings for behavioral treatments in primary care
Challenge:
How do you identify all of the PPD patients in your practice?
How do you approach treating all of the PPD patients once
identified?
Solution: Population Health
Management
Population Identification
Health Risk Assessment
Risk Stratification
Low Risk
• Prevention
• Education
• Self-help
Moderate Risk
• Health Risk
Management
• Coaching
• Apps
High Risk
• Disease
Management
• Psychotherapy
Identification and Screening
PPD diagnosis
Medical diagnoses
PHQ-9/GAD-7
Somatic Symptom Scale
PHM for PPD based on
Stress Evaluation I - V
Low Risk
• Stress
• Insufficient
personal
time
Moderate Risk
• Depression
• Anxiety
• PTSD
High Risk
• Chronic
depression,
anxiety
• Severe
PTSD
Stepped Care for PPD
Self –Help
Internet
Apps
Stress class Mindbody In-office
quick tx
Handouts and
homework
Psychological
Intervention
Trauma informed
treatment
Pharmacotherapy
Cost savings and Return
On Investment (ROI)
1.
Measure cost of intervention
2.
Measure medical utilization (pcp visits, hospital visits, etc.)
and related cost for one year or more before treatment and
then measure again for post-treatment period
3.
Cost savings = cost of treatment year before treatment minus
cost year after intervention
ROI Calculation
Net savings from changes in utilization
ROI =
__________________________________
Program Costs
Session Evaluation
Please complete and return the evaluation form before leaving
this session.
Thank you!
Bibliography / Reference
•
Budtz-Lilly, A., Vestergaard, M., Fink, P., Carlsen, A., and Rosendal,
M.,2015, The prognosis of bodily distress syndrome: a cohort study in
primary care. Gen Hosp Psychiatry, Nov-Dec;37(6):560-6
•
Chitnis, A, Dowrick, C., Byng,Turner, P. and Shiers, D. 2011. Guidance for
health professionals on medically unexplained symptoms (MUS). Retrieved
from:http://www.rcpsych.ac.uk/pdf/CHECKED%20MUS%20Guidance_A4_4
pp_6.pdf
•
Creed, F. and Hennington, P. and Fink, P. 2011. Medically Unexplained
Symptoms, Somatisation and Bodily Distress : Developing Better Clinical
Service, Cambridge University Press, Cambridge, UK, 268 p.
•
Levine, P., 2015, Trauma and Memory: Brain and Body in a Search for the
Practical Guide for Understanding and Working with Traumatic Memory ,
North Atlantic Books, Berkeley, CA, 206 p.
Bibliography / Reference

Mate’, G. , 2011, When the Body Says No: The Cost of Hidden Stress,
Wiley, New York, 360 p.

Skovenborg, E.L., and Schroder, A., 2014, Is physical disease missed in
patients with medically unexplained symptoms? A long-term follow-up of
120 patients diagnosed with bodily distress syndrome, Gen Hosp
Psychiatry, Jan/Feb 2014, p. 38-45

van der Kork, Bessel, 2014, The Body Keeps the Score: Brain, Mind, and
Body in the Healing of Trauma, Penguin, New York, 2014, 464 p.