1 Upstream Medicine Stephanie Benson, MD Ivan de la Rosa, Ph.D. Stephen Colmant, Ph.D. February 20, 2016
2 Objectives Define Upstream Medicine and discuss why this concept is important Describe a multidisciplinary approach to addressing social barriers to health Discuss the concept of wellness and how it can be addressed in a primary care office
8 Prevention Ramano &Hage, Stops (prevents) a problem behavior from ever occurring. 2. Delays the onset of a problem behavior. 3. Reduces the impact of an existing problem behavior. 4. Strengthens knowledge, attitudes, and behaviors that promote emotional and physical well-being. 5. Supports institutional, community, and government policies that promote physical and emotional well-being.
9 The Problem Poverty is the single largest determinant of health Some Americans will die 20 years earlier than others who live just a few miles away because of differences in education, income, race, ethnicity and where and how they live. Your zip code may be a bigger determinant of your health than your genetic code!
11 Mental Health & Primary Care are Inseparable 43-60% of all MH care is provided by PCP. Up to 30% of primary care Pts have a mental disorder. Identification & Treatment is poor Pharmacology is the most common treatment. The provision of primary care and MH Tx is mostly segregated.
16 The problem in New Mexico New Mexico ranks 33 rd in overall health status among U.S. states Health indicators demonstrate significant health disparities related to social determinants of health Need for better training of medical residents to address social determinants of health in primary care setting
17 What we know Life expectancy for Latinos US: 82.8 NM: 78.8 Teen death rate (per 100,000 residents) US: 49 NM: 62
18 What we know Diabetes death rate (per 100,000 residents) US: 21.2 NM: 27.6 Percent of Native Americans with overweight/obesity US: 68.1% NM: 77.5%
19 Basic conditions necessary for health include: access to and quality of health care education income the environment employment housing safety
20 Project Activities 1. Develop integrated multidisciplinary team 2. Develop a social and behavioral determinants of health screening tool 3. Develop social/behavioral determinants of health curriculum in family medicine residency in line with Beyond Flexner developments 4. https://drive.google.com/file/d/0b5pbu2ze2t4kskduzv FtNG94b0U/view?usp=sharing
21 Project Activities 4. Develop operating procedures to utilize the screening tool to identify the upstream health needs of patients 5. Train NMSU undergraduate and graduate students to work in multidisciplinary teams to address health disparities
22 Social/behavioral health surveillance system Conducted literature review of social/behavioral determinants of health Surveyed rapid assessment instruments used in other medical facilities across the country Conducted power analyses to sample current patient population
23 Social/behavioral health surveillance system I was able to follow the treatment plan my provider and I agreed on at my last appointment. I take all of my medications the way I am told to take them. I need to increase my exercise. I need to change my eating habits. I use illegal drugs (or drugs prescribed for others) so I need to cut down or stop. In the past 30 days, I had to cut the size of my meals or skip meals because there wasn t enough money or food. There is someone in my life I m afraid of or who hurts me. I m having trouble paying for gas or electricity bills. There are legal issues that I am having trouble addressing. I want to talk with someone today about the change I need to make.
26 The part can never be well unless the whole is well. -Plato, 400 BC
27 World Health Organization, 1946 Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.
29 1957 Macleod, A. W., Silverman, B. and Poland, Phyllis. (1957). The well- Being Clinic: A study of the effectiveness of an attempt to provide routine mental health check-ups for community groups. The American Journal of Psychiatry, 113, pp A Well-Being Clinic has been in operation for the past 2 years at McGill University. This preliminary report furnishes details about its development and its manner of operation and summarizes results to date and discusses basic assumptions underlying its conception. (PsycINFO Database Record).
30 DEFINING WELL-BEING Flourishing, Self-Actualization, Subjective Well-Being, Wellness, Quality of Life, Happiness, and Life Satisfaction are often used interchangeably. WB Life Satisfaction, Emotional Vitality, & Optimism. Wellness refers to diverse and interconnected dimensions of physical, mental, and social well-being that extend beyond the traditional definition of health. It includes choices and activities aimed at achieving physical vitality, mental alacrity, social satisfaction, a sense of accomplishment, and personal fulfillment, (Huseyin & Ioannidis, 2015).
31 PERMA Seligman, 2011 Positive Emotions Engagement Relationships Meaning Accomplishment
32 The Wheel of Wellness Myers et al.
35 SEVEN REASONS TO INVEST IN WELL-BEING 1. Well-Being is a Natural Motivator 2. Well-Being Improves Physical Health and Longevity 3. Well-Being is Good for the Economy 4. Well-Being Promotes Positive Relationships 5. Well-Being Can Be Enhanced in Relatively Easy and Inexpensive Ways 6. Improving Well-Being May Catalyze the Success of Other Interventions 7. Well-Being Interventions May Elicit a Population- Level Shift in Mental Health.
36 Perception of QUALITY OF LIFE Health Self-Esteem Goals and Values Money Work Play Learning Creativity Helping Love Friends Children Relatives Home Neighborhood Community
37 PROCEDURE 1. Patient completes intake paperwork and questionnaires. 2. Examination by Physician and Behavioral Health Provider. 3. Physician and Behavioral Health Provider consult with one another on the patient s strengths, needs, and recommendations. 4. The two health providers provide the patient feedback.
38 TOOLS CHILDREN Psychological Symptoms Achenbach Connors ADULT Brief Symptom Inventory Published by Pearson. $5 per assessment Well-Being CHILDREN Check on parent wellness Behavioral and Emotional Rating Scale Ages 5-18, admin time 10 min, $198 for 25 admins ADULT Wellness Evaluation of Lifestyles Quality of Life Inventory Age 17 and up, 5 min to admin, $120 for 50
39 WBCU Protocols Children Ages Observation of interaction. Quality of Life Inventory for caregiver(s) Consider the Coparenting Relationship Scale Use BSI with primary caregiver(s) if indicated. Children Ages Achenbach Pre-school Parenting Scale (ages 1.5-5) Consider Alabama Parenting Questionnaire (ages 3-18). Quality of Life Inventory for caregiver(s) The Coparenting Relationship Scale BSI with primary caregiver(s) if indicated Children Ages 6 12 Connors CBRS o Ages 6 18 BERS o Ages 5-18, admin time 10 min. Consider Alabama Parenting Questionnaire (ages 3-18). Quality of Life Inventory for caregiver(s) The Coparenting Relationship Scale BSI with primary caregiver(s) if indicated Youth Ages The BSI o Ages 13 and older, $5.50 per admin., BERS Ages 5-18, admin time 10 min, $198 for 25 admins. Consider Alabama Parenting Questionnaire (ages 3-18). Quality of Life Inventory for caregiver(s) The Coparenting Relationship Scale BSI with primary caregiver(s) if indicated Adults 19 and up BSI Quality of Life Inventory (QOLI) - Age 17 and up, 5 min to admin, $120 for 50.
42 REFERENCES & RESOURCES 1. Huseyin, N. and Loannidis, J.P.A. (2015). Evaluation of Wellness Determinants and Interventions by Citizen Scientists. The Journal of the American Medical Association, 314, (2) Mental Health Screening and Assessment Tools for Primary Care. (2010). In Addressing Mental Health Concerns in Primary Care: A Clinician s Toolkit. American Academy of Pediatrics. 3. SAMHSA Screening Tools: 4. Hage, S.M., Romano, J.L., Conyne, R.K., Kenny, M., Mathews, Connie, M. Schwartz, J.P., and Waldo, M. Best Practice Guidelines on Prevention Practice, Research, Training, and Social Advocacy for Psychologists. (2007). The Counseling Psychologist 35, 4, Myers, J.E., Sweeney, T.J. and J.M. Witmer. (2000). The Wheel of Wellness Couneling for Wellness: A holistic model for treatment planning. Journal of Counseling & Development 78, Howell, Fosco, Nelson, Coffey, Kracke, Grych, and Rothman. (2016). Seven Reasons to Invest in Well-Being. Psychology of Violence 6, (1) Lambert, L., Passmore, H., Holder, M. (2015). Foundational Frameworks of Positive Psychology: Mapping Well-Being Orientations. Canadian Psychology 56, (3)
44 Conclusions Upstream Medicine refers to a complete view of prevention A multidisciplinary team that includes the social sciences can be used to address social barriers to health A holistic approach to wellness can be integrated into a primary care office as an important component of prevention
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