In this issue:
Preparing Healthcare Practices to Promote Tobacco Cessation
CHAD MORRIS, Ph.D., Director
In late 2015, our program received funding for our Build a Clinic project, an innovative educational model, training primary care providers to integrate tobacco cessation services and supports into their regular clinical workflow and daily practice. The Build a Clinic program consists of six webinars, six live collaborative video-conference learning sessions for practices across the nation, and individual technical assistance and consultation. The program was piloted with a cohort of primary care providers between February and August 2016 and the second cohort is set to launch fall 2016. Jim Pavlik, program manager of the Build a Clinic program, asked me some questions and provided an opportunity to describe this unique program and how practices may benefit from participation.
Jim: Given the many competing demands that healthcare practices face, is adding tobacco cessation screening and services yet one more task that may have limited utility in really changing patient behaviors?
Chad: There is strong evidence that addressing patients’ tobacco use and encouraging quit attempts may be the single most important intervention clinicians can make to improve their patients’ health. When practices provide brief interventions, such as asking about tobacco use, advising patients to stop their tobacco use, prescribing cessation medications, and providing referrals to counseling, they can as much as double or triple quit rates. When these daily practices are integrated into existing workflows, the impact on practitioners’ limited time and resources is minimal. Brief interventions also support the need of most practices to demonstrate that they are screening for tobacco use and making appropriate referrals to meet uniform data reporting expectations or meaningful use criteria. The Build a Clinic program was created to assist clinics to meet both patient and agency reporting needs.
Jim: Through learning communities, BHWP hosts monthly technical assistance calls, in person trainings, and webinars for agencies, interdisciplinary providers, and peer specialists who are integrating wellness into their programming and services. What attracts you to the learning community model and what separates Build a Clinic from other learning communities BHWP has been a part of?
Chad: Having done a great amount of national training, the BHWP team is aware of the limits of many training modalities. We feel strongly that peer-based learning is a needed complement to other training efforts. It is a far more powerful way to shift practice cultures and norms. Build a Clinic participants have the opportunity, in real time, to suppport each other’s change efforts. Practices hold each other accountable and offer creative solutions to typical, as well as unexpected, practice barriers. While learning communities generally include peer interactions, Build a Clinic offers an innovative advantage in several key ways. Through ECHO Colorado distance technology, we are able to bring geographically dispersed practices together to use case-based learning to support one another. Using this structure, Build a Clinic also helps practices move through a series of topics that have been strategically organized to assist clinics to implement and sustain change. In this way, we take a team-based approach to not only cover evidence-based cessation practices, but also the infrastructure, workflow, and billing issues that must be addressed to offer sustainable and scalable services.
Jim: BHWP has helped over 400 organizations including schools, community behavioral health organizations, substance abuse treatment facilities, and private corporations add tobacco cessation services for clients and staff, but this is your first full scale learning community focusing on primary care providers. What was most surprising to you as you implemented the pilot program earlier this year?
Chad: I was fully aware of the many competing demands primary care practices face, but this project really brought home how precious each minute is for a primary care practice. Based on this, the BHWP team continues to refine the program to make the Build a Clinic training commitment as brief as possible and offer archived materials that practices can review on their own schedule. I also continue to be surprised by how anxiety provoking it is for practices to integrate tobacco services into treatment. There is often “analysis paralysis” among practices that are unsure where to start. On the other hand, I have also been surprised by how quickly tobacco cessation can be integrated when practices set short-term achievable goals and use the support of peer agencies.
Jim: Is the Build a Clinic Program a one-size-fits all experience and right for all primary care practices?
Chad: The program was designed to meet a broad range of practices where they are at in terms of implementing tobacco cessation strategies. The common denominator is that the Build a Clinic program is built on evidence-based medicine as well as proven infrastructure redesign and continuous quality improvement processes. While the program would not be appropriate for practices that have no desire for change, Build a Clinic is a good match for practices across the spectrum—from those just starting an implementation plan to others that have implemented many strategies and are looking to maintain these gains. Importantly, there must be at least one staff member who truly wants to champion this initiative in their practice.
Jim: If you could offer one piece of advice to organizations curious about adding these services and you knew they would follow it, what would it be?
Chad: Don’t wait to start. Using proven rapid improvement practices, such as Plan-Do-Study-Act cycles, set your first realistic 3- to 6-month goal. Through participation in Build a Clinic, practices are able to match their goals to their unique culture, clinic structure, training, and resources. Small wins help practices to quickly gain momentum toward comprehensive tobacco cessation programming.
A Study in Wellness
Innovations in Healthcare Through Evolving Technologies
JAMIE PFAHL, B.A., Community Liaison
Every morning on my hour-long bus ride to work, I flip casually through my RSS feed to catch the latest news in health, science, technology, and economics. Some of the news is unsurprising (“Longer Commutes May Add Calories and Hurt Your Health”; “Marijuana-Using Rats Are Lazy”) but the really eye-catching headlines are the ones that feature innovative research at the intersection of health and technology.
A few days ago I read an article featuring the use of virtual reality as a more controlled form of exposure therapy to treat phobias. This led me down the rabbit hole to discover that virtual reality (VR) has been shown to be as effective as cognitive behavioral therapy for social phobia1 and that the use of VR has tremendous potential to help people suffering from PTSD or chronic pain.2
While most of us don’t have easy access to virtual reality, an estimated 68% of Americans have smartphones, and 1 in 5 Americans use a wearable device to track their physical activity.3,4 With the increasing popularity of wearable technology, social media, smartphones, and mobile apps, there are new opportunities to improve health and healthcare delivery almost every day. We now have the ability to gather massive amounts of information from social networks, online behavior, tracking devices like Fitbits, and GPS-enabled smartphones. This has opened up a huge source of data for researchers as well as raising concerns about privacy and data security.
Some scientists are looking for a correlation between low-saturation Instagram filter use and depression, which is probably not the best or most reliable use of technology, and others are exploring the ability to use GPS and other smartphone data to determine behaviors that might signal depression.5 While it’s fascinating that your movement can provide clues to your mental health, there is also something inherently unsettling about the idea that your phone is constantly collecting data points that could be used to profile you.
In a slightly less unsettling application of mobile technology, hospitals are now working with transportation services like Uber and Lyft to improve access to care. For the 10-51% of patients who report lack of access to transportation to medical appointments, new Medicaid and hospital partnerships with transportation services can help reduce missed appointments and improve access to care.6
These are just a few examples of the exciting – and sometimes disquieting – prospects that technology holds for health and healthcare improvement. With so much innovation, I can’t wait to see what shows up in tomorrow’s RSS feed.
1 Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I., & Nugues, P. (2005). Virtual reality therapy versus cognitive behavior therapy for social phobia: A preliminary controlled study. Cyber Psychology & Behavior, 8(1), 76-88.
2 Li, A., Montaño, Z., Chen, V. J., & Gold, J. I. (2011). Virtual reality and pain management: Current trends and future directions. Pain Management, 1(2), 147–157.
Wellness in Practice
CINDY MORRIS, Psy.D., Clinical Director
For a few silent moments, I sit quietly at my desk. Arms in a relaxed, open position. Eyes closed. I breathe in deeply. Then exhale. My shoulders drop. In my mind’s eye, I reach for my emotions. How do I feel right now? Nothing—I’m drawing a blank. Not high or low, just meh. Or maybe not even meh.
I’m in my focused, busy, productive mode. Thinking about what needs to be done. Setting my priorities. Doing what needs to be done. There’s not a lot of room for emotions in this space. To be honest, holding space for and attending to my emotions takes effort. I’m good at being the stable, responsible, and reliable one. I can create a holding space for other people’s emotions all day long. But creating one for myself can be challenging.
And so each day, I stop from time to time. Check-in with myself. Some days are easier than others. Sometimes, like today, I draw a blank. But then, I begin by focusing on my bodily sensations, drawing on my environment—the gentle breeze from my open window, the cooling weather of fall, the ease I feel in my body. And I begin to feel a surge of pleasure, the joy of being alive in this moment. With no judgment or consideration about what is going right or wrong. A spontaneous smile of happiness moves across my lips. I guess I’m feeling happy right now.
Made to Move
DEREK NOLAND, M.A., Community Liaison
Over the last few months I’ve been increasingly ramping up my distance running in an attempt to realize my dream of qualifying for the Boston Marathon. Not only do I find running to be one of my preferred forms of exercise, but it has become a powerful tool in preserving my emotional wellness over the years. Generally speaking, nothing helps me to feel less stressed, mentally clearer, and as uplifted to the same degree. However, with the pressure to strive for better and better times mounting as my qualification run approaches, I’ve begun to realize that I am simultaneously experiencing a competing challenge to my wellness as a result.
Namely, when things go awry with my running, I have noticed that I’m actually experiencing increased stress, among other negative outcomes. Whether it be having to keep off my feet for a few days due to injury, struggling to find the time to squeeze in all of my runs, or balancing being a good host to visiting family without losing momentum, the complications and stressors have grown as the deadline nears. Having recognized this unintended result, it’s time to take a step back, and think about the fine line between pushing the limits and overreaching. Regardless of whether a goal is work-related or athletically inspired, making a change in your personal life or habits and working toward and achieving that goal can be a great source of emotional wellness. But, as I have discovered, if we’re not cognizant of how striving for a goal may impact us, doing so may actually take on a negative form.
In order to avoid the undesirable elements of goal setting, I believe that a mindful approach is best, with our emotional wellness firmly in focus. If goals become overly demanding and damaging, the smartest strategy might be to amend them—thereby not abandoning the goal, but assuring that the process of obtaining it does not become detrimental. Ultimately, if working overly hard toward one goal begins to have negative ramifications in other aspects of our lives, we’re probably missing the point.
Whatever goals you may be pursuing in your life, consider giving some thought to whether or not you are doing so in a manner which best supports your own emotional wellness. While I wholeheartedly believe in goal setting and stretching oneself in pursuit of those goals, it’s equally important to recognize that a healthy approach is critical. As for my own goal, I plan to fully apply myself toward qualifying, but the next time stress enters the equation, I intend to allow myself some more room to tinker with the steps I am taking toward achieving my goal and to focus on controlling the things that I can realistically control. At the end of the day, I believe this approach will not only support goal achievement, but will preserve my emotional wellness along the way.
Resolutions in Harmony
MARY MANCUSO, M.A., Clinical Associate
There is a battle currently waging at home. Looks of accusation, disappointment, and indignation meet my every glance. I know relationships are a delicate balance of give and take, and communication and compromise are essential components. Right now, I feel like I’m failing. No one is happy. We are miserable and desperately struggling to find emotional harmony.
I pull back the bed covers and seek escape. I crawl under the fluffy white comforter and exhale exhaustion, anxiety, and guilt. I feel hopeless and not at all confident that we will make the right decision, but something has to change. It’s just too painful.
We have a new addition to our home: an 85-pound Lab/Newfoundland named Bear who is wreaking havoc. Two short months ago, we lost our sweet 14-year-old doggie, Kody, and have been contemplating the notion of a new pup. It’s an emotional decision. We still miss him every day. His collar has a position of honor in our garden. No one can replace our beloved Kody, but maybe we can give another dog a good home, lots of love, and receive just as much, and more, in return.
We go to the shelter on a whim one night after work. For one reason or another all five of the dogs we consider taking home are unavailable. “Maybe tonight isn’t the night,” we say, and turn to leave. “I do have another dog you might like,” a young man with a leash slung over his shoulder calls out to us as we head toward the exit. “We just got him in.” We look at each other and nod, “Of course, we want to meet him.”
We love him right away. He enters the room with enough enthusiasm and energy to power a train. It doesn’t take much of an introduction before he puts his paws on my shoulders and gives me a hug—all 85 pounds of him. He is in desperate need of a bath, but that doesn’t squelch our enthusiasm. We feel elated and optimistic as we drive away with Bear drooling on our shoulders from his perch in the back seat. Life is grand! We now have a new partner for our daytime adventures and a new cuddle buddy for nighttime snuggles.
As soon as we enter our yard, however, we know we’re in trouble. Our black cat, Boo, is perched on the table tranquilly grooming herself. Bear fixates on her immediately and bolts toward her, pursues her off the porch, across the deck, and out of the yard altogether. We don’t see her again for 3 days. The situation plays out much the same inside the house, only it involves a 2am chase of our other cat, Tyche, down the stairs, around the living room, and out of the house altogether. Or so Bear is led to believe. Unbeknownst to Bear, Tyche darts behind the couch. But Bear later caught up with him and holds him precariously by his neck.
Hence the looks of accusation. The cats are certainly not amused and most definitely traumatized. We feel guilty for bringing this upon them but hopeful that Bear is trainable and will grow accustomed to them. There are some other new discoveries: Bear has a habit of jumping on people. This is fine if you are stable on your feet, but it’s very different if you are my 77-year-old mother who hasn’t exactly kept up with her leg and core strengthening exercises. And Bear has some unexpected medical issues.
We are driving home one rainy night. The heavy darkened sky reflects our mood. Bear is happy, but the kitties aren’t. I am distraught that Boo is not to be seen. I call to her and hear her cry, but she won’t come near the yard when Bear is there. No matter what we choose, we feel wretched. We can’t keep him and force misery and distress on the cats. And we don’t want to take him back. He’s so sweet and loving.
In the end, we decide that Bear is just not the right dog for us. Now I think about him and hope all is well. Finding harmony often involves difficult decisions, possibly weighing one value against another as well as compromise. It entails listening to your inner voice and expressing it. At the same time, it’s important to listen to what others say and feel, even the furry others.
Bear, if this gets back to you, take heart and be well. We felt your love, albeit briefly. May you seek and find your own emotional harmony.
The mission of the Behavioral Health and Wellness Program is to improve quality of life by facilitating evidence-based health behavior change for communities, organizations, and individuals.