1. Behavioral Medicine at Joslin Behavioral Medicine at Joslin Resources and Expectations for Affiliated Programs

2. 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)

3. 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

4. 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)

5. 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

6. 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 –DQOL –R-BPRS –PHQ-2/9 –DDS

7. October 2009 PAID Problem 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

8. 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?

9. 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?

10. October 2009 Joslin Assessment Forms How 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)

11. October 2009 What can you do to enhance this service? Ways to enhance your relationship Strengthening the role of the mental health provider

12. 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

13. 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

14. 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

15. 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

16. October 2009 Relationship, Control and Distress DAWN - Diabetes Attitudes, Wishes and Needs

17. 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

18. 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

19. October 2009 Communications is less about speaking than it is about listening and observing. –Barbara Anderson, PhD Former Joslin Psychologist

20. 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

21. 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”

22. October 2009 Favorite Resources Educating Your Patient with Diabetes –Chapter by Marilyn Ritholtz The Art of Empowerment, 2 nd 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