Behavioral health coaching for diabetes: But when it happens to yourself!

Angela A’s story:
     In the last 3 – 4  years, I had some issues about walking without difficulty, and some acceptance issues with my health, and the decline in my health.  I went into the doctor’s office to get a checkup, and ended up in the hospital for three weeks.  It was kind of scary!  Every time, they found something else!  I didn’t realize how despondent and depressed I was becoming. I work full-time at home, though I hadn’t wanted to do that initially.  I’m pretty sedentary, so going to work was the social thing I did that gave me a sense of camaraderie.

     It felt like things weren’t worth it.  I was having issues with depression and my newest diagnosis, diabetes.  And I had other things going on with my hospitalization, bing, bing, bing, boom!  There were too many other very emotional things going on then.

     I’m a nurse, so I know you can help others.  I do that all day long in their journey to get healthy again.  I know all about diabetes, but when it happens to yourself!  You can’t help yourself—I found that out.

     My health issues triggered a call from AbleTo.  A nurse would call me every three months, so I got to talking with them.    We could do it over the phone, which was very convenient.  They connected me with a social worker, JoAnna, and a nurse, Marta.  They do an assessment the first time, and the two of them collaborate.

     They had an eight-week course so we could dig in, and teach mindfulness and other strategies to get myself in a better place.  Now I talk to each of them once a week:  the social worker on Monday, and the nurse on Wednesday.  The social worker looks at the social aspects.  The nurse is a teacher.  She was fundamental in giving me online places to read about the mindfulness technique, relaxation, and learning to eat in a different way, with the diabetes.

     I can’t do all the things I used to be able to do, but I can look forward to things I can do.  I lost quite a bit of weight.  I had lost some, but then I lost 46 pounds, which was easier with help on the phone.  They motivated me.  I didn’t realize how badly I had not taken care of myself emotionally.  I’d been avoiding getting out and seeing my friends and family outside the house, having them come to mine.  Marta and JoAnna encouraged me to schedule times and to set goals like to at least go out once a month, like attending a function with friends a couple of times a year to meet up with old nurses I used to work with, which I do now.

     I got tons of grandchildren.  I’m on oxygen, with a walker.  I’m not vain, I’m just not used to people seeing me outside the home.  My son and daughter-in-law moved in with me, and assist me with a lot of things.  There gets to be conflict with that, with communication, for example, so I’m setting goals with that too.  Now I’m able to communicate better with my son.

     Life is better now.  I’m more active.  I go out to birthday parties.  The last one was for three of my grandchildren, ages 4, 7 and 17.  The best thing was the fact that I went and enjoyed myself.  I had so much fun!  I went by myself for the first time.  That was kind of daunting because I have oxygen and a walker, and it was 25-30 miles away at my oldest son’s house.  The biggest problem for me was in asking for help, for me to realize, Hey, if you can’t assist me, I’ll do it myself.  I did!  I’m taking back my life a little bit, at a level that I can.  I’m meeting up with friends, and I have a better social life.

Dr. Reena Pande’s comments:
     I’m the Chief Medical Officer at AbleTo. As a cardiologist, I spent a lot of time with my patients focused on lifestyle and behavior change. But I also quickly recognized that as physicians we are really quite good at telling people what to do, but not as good at helping them figure out how to do it, or at helping them identify and overcome the barriers that are standing in their way! And for so many people, it became clear that that barrier was in fact a real mental health challenge like depression or anxiety.

     So at AbleTo, a national behavioral health provider, we do just that. We pair each patient with a therapist and a coach who they meet with weekly by phone or video.  The treatment program uses protocols and is tailored around a specific clinical condition and uses Cognitive Behavioral Therapy (CBT) at its core.  The coach really helps the patient translate what they’ve learned in the therapy sessions into something actionable.

     A lot of my work is focused on measuring outcomes and proving the benefits of our treatment for patients and our partners. For example, we’ve found a consistent decrease in depression in the range of 50 – 65%, fewer admissions to the hospital and better diabetes management as shown in our articles in AJMC and Telemedicine and e-Health.

     I sometimes joke that the care isn’t rocket science; what's rocket science is finding the right people at the right time, keeping them engaged, and ensuring the treatment is easy to access and very high quality.  For example, we have a proactive outbound screening program, since so many people aren’t identified otherwise.  We use our clinical algorithms based on claims data, pharmacy data, and other health-related information to identify who’s at risk. Our engagement specialists  are trained to reach out to people in a very empathic and destigmatized way. We make it ok to accept the help they might need. It's very satisfying to know we are making a difference.

Ken’s note:  The journal article describes a study that looked back at 466 people with diabetes who had gone through the AbleTo program.  Among people who had had highly severe depression, anxiety, and stress beforehand, they had major reductions in depression (67%), anxiety (59%),and stress (70%). More of them started measuring their morning glucose levels.  The people who had had the highest morning blood sugar levels had the greatest reductions in them.

     Read a story of another innovative approach for a person with diabetes.  Thanks to John Pelle of AbleTo for connecting us. 

Milford Regional’s PFAC Story, as told by Beverly Swymer [Part 1]

In June of 2012, as members of the Milford Regional Medical Center’s Patient/Family Advisory Council (PFAC), we were searching for a direction to go.  Dr. Jeff Hopkins, Chief of the Emergency Department, gave a presentation to us about the care of behavioral health patients in the Emergency Department and how the volume impacted the E. R. The patients who came to the E.R. needed follow-up care but the resources for staff to refer them to were very limited. With the deinstitutionalization (of mentally ill patients), the use of antipsychotic drugs can help to control the behavior of this patient population but this often results in homelessness and the revolving door syndrome. Patients with drug addiction and/or mental health issues and subsequent problems need active intervention and follow-up care.  They are a growing number of E.R. patients, often seen on an emergent basis.  These people are devastated; they do not know where to turn, so they seek out care and support in the E. R. and often arrive in a crisis state. The staff, not being trained in psychiatric care, aim to keep the patients safe, maintain their medicine regime and actively seek out appropriate behavioral health care support…essentially custodial supportive care while in the E.R. The result was long-term stays in the E.R. (sometimes this meant many hours or even days), which was troubling. It was especially difficult to place patients who’d been violent, children and those patients who had complex medical problems in addition to their behavioral issues as well as the difficulty of placement of behavioral health patients on the weekends.

As the PFAC Co-Chair at the time, I met with Dr. Hopkins to discuss how the PFAC could realistically have an impact on this issue.  We discussed ways to educate the community about the Behavioral Health Care crisis, and to identify ways to short-circuit the crisis step by connecting the E.R. patients to community services in a more timely fashion. This was our initial approach to define the role of the PFAC Subcommittee within the hospital: to define “better care”. We on the PFAC had a couple of meetings to discuss how to accomplish this effort. By September 2012, we started meeting on a monthly basis.

I became the head of the Behavioral Health Subcommittee of the PFAC at that time because I believed the PFAC, through collaboration with other healthcare providers, could make a difference in behavioral health care in the E.R.  I felt this issue impacts us all because it impacts health care in general as well as care in the E.R.  If ten of 30 beds are occupied with behavioral health patients, especially if occupied for extended periods of time, this impacts bed availability for all other patients. The goal of the PFAC Subcommittee was to find ways to improve care with better resources in the community and thus ultimately alleviate the impact on the E.R.

Assuming responsibility as Chairperson, my role through all of this was to get this challenging endeavor on track. Monthly meetings were and continue to be held. To develop a more comprehensive approach to this issue, we reached out to others who dealt with this patient care population. For example, we invited representatives from Case Management, Social Service, Nursing and Riverside Counseling Services to join the subcommittee in an effort to improve care of the behavioral health patient. It took a real strong collaborative approach and the PFAC was part of all of those discussions. As the PFAC Subcommittee chair, I worked with the E.R. behavioral health team to incorporate everyone’s input, obtain feedback from others and evaluated how it was all working.  I, along with other members of the PFAC Subcommittee, presented the PFAC and ED Behavioral Health Program at the Health Care for All PFAC State Conference at Holy Cross, the Massachusetts Coalition for the Prevention of Medical Errors, the Juvenile Advocacy Group (JAG) Community Breakfast and at a webinar hosted by Health Care for All.

We formed a diverse group with Dr. Hopkins, Chief of the Emergency Department, community caregivers, a child psychiatrist, Riverside Emergency Services, Nursing, Case Management, Social Service and a family member who dealt first hand with the issues of trying to find care for her son in crisis, etc

We reached out to the E.R. staff for their input and perspective on Behavioral Health Care in the E.R., asking for their suggestions on how to improve care of the behavioral health patient while in the E.R. The nurses developed a list of very helpful suggestions to enhance the care of the behavioral health patient while under their care. Some creative but simple suggested improvements included: a predictable schedule, showers, attention to proper nutrition, an opportunity to take a walk, exercise, music, etc., since some of these patients were in the E.R. for days. This effort showed the staff we were willing to listen and we valued their input.

As a result of this collaborative effort between the PFAC, Emergency Department, Case Management and Community Benefits, we received a grant from the EOHHS (Executive Office of Health and Human Services). This grant enabled us to provide an educational program for the E.R. nurses interested in Behavioral Health and to provide initial funding for Behavioral Health nursing positions. The first group of behavioral health nurses became mentors for their colleagues in the E. R.  This initiative was very well received by the nursing staff.

An integrated team was developed comprising Case Management, ED front line staff, Riverside, and other mental health care workers. Patients are evaluated during daily rounds in the E.R. Therefore they all know where each patient is in their care management and what follow-up resources could be identified. At one time, for those patients on behavioral watch or at risk of suicide, we had security guards watching over them. A program was developed to train people as Patient Safety Advisors. These people are specifically trained to interact with the behavioral health care patient in the E. R. while they waited for individualized plans of care.

Next we looked into the community for resources available to provide timely care and counseling to the behavioral health patient population. Our thinking was if we could provide opportunity for timely care and support we could short circuit the need for crisis intervention in the E.R. at 3 am.  Information was presented to our PFAC Behavioral Health Subcommittee about the Interface Referral Service of the Massachusetts School of Professional Psychology (MSPP). This service provides information about services available in and around the community and guidance in how to navigate the mental health system.  I, as well as others on the team, reached out and spoke with other communities who had successfully utilized this service. This was the first time this organization would be working in a hospital broad based outreach. In February of 2013, we signed a contract with Interface. In addition to making the information about this service available in our E.R, we notified (via letter) the schools, pediatricians’ offices, Counseling Services, Youth Groups in town, Library’s Youth Department, etc., all in an effort to make the public aware of this referral service.  This was one more step in our effort to make Behavioral Health Care better and available to our community when needed.  We’re trying to meet the patients’ needs for medication, personal needs, etc., with active intervention, not just custodial care in a hospital setting with a broad-based community outreach.

Stay tuned for Part 2.  In the meantime, read a story about other innovations by Patient/Family Advisory Councils at Milford and Beth Israel Deaconess Medical Center.