eccu survivor workshop: serber
TRANSCRIPT
Optimizing Patient Outcomes:Role of the Healthcare Professional
Eva R. Serber, Ph.D.Centers for Behavioral & Preventive Medicine,
The Miriam HospitalDepartment of Psychiatry & Human Behavior,
Warren Alpert Brown Medical School
ΨΨ© 2010 Serber
Disclosures
• Medtronic, Inc – Speaker Honoraria
• NIH/NHLBI – R21 HL092340 (CARE-E Trial)
ΨΨ© 2010 Serber
The healthcare professional hasmany roles:
• Support• Education• Coping skills training• Symptom management• Transition and recovery• Addressing family needs
…to name a few
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Communication
Patient OutcomesPatient Outcomes
SupportSupport
EducationEducation
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Predictors of Improved Outcomes
• Understanding of disease and treatment• Social support• Self-efficacy• Self-management• Positive outlook and expectations• Shared decision-making
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Social Support
• Encouragement• Facilitating activities• Seeking meaningful information• Sharing experiences, concerns, feelings• Forming relationships
– With peers– Health care providers
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Common SCA/ICD PatientConcerns
• Preventive care• Health care providers• Partner relationships• Activities of daily living• Physical changes• Emotional challenges• Coping with shocks
Dougherty et al., Adv Nurs Pract 2001
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Effective Education
• Find out what works• Find out what is needed• Let the patient play• Encourage planning and prep• Be patient• Model problem-solving
Boyd et al., 1997; Lorig, 2001; Overgaard, Nurs Crit Care 2010
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Patient’s Preferences
• Support – psychosocial or adjustment needs– Office visit or call with device nurse (23-25%)– Support group (15%)
• Education – content of dx, ICD, coping strategies– Written materials (48%)– Office visit with cardiologist or nurse (42%, 40%)
• Interest in attending Supportive and EducationalICD meeting (68%)
Serber et al., PACE 2009
ΨΨ© 2010 Serber
Disparities in Preferences
• African-Americans – written materials and phonecontact with cardiologist
• Women – Support from ICD peers, device nurse,professional counselor
• Young Age (< 67 yo) – Internet and e-communication for support and education
Serber et al., PACE 2009
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Benefits of Communication
Without intervention:• No change in uncertainty and adjustment 1- to 8-
wks post ICDWith intervention:• Psychoeducation: ↓ s/o depression, anxiety, ↓
healthcare utilization and sick days• Recall counseling: ↓ worry and uncertainty
Dunbar et al., PACE 2009 Fisher et al., PACE 2009 Mauro, Int J Nurs Stud 2010
ΨΨ© 2010 Serber
• Weight loss• Healthcare utilization• Mortality• Quality of life• Psychosocial outcomes
• Blood pressure• Lipids• Physical activity• Smoking• Dietary intake
Intervention Outcomes
Allen & Dennison, JCN 2010; Stolic et al., Euro J Cardiovasc Nurs, 2010
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Support Groups
Benefits:• ↑ coping• ↑ adjustment to device• ↑ life satisfaction• ↑ connection to others• ↑ health
Dickerson et al., Heart Lung 2000, Clin Nurse Spec 2006
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Support Groups
Nurse facilitator:• Fosters individual participation• Encourages group cohesion• Provides medical and technical expertise• Maintains topic relevance• Addresses distress and provides referrals
Dickerson et al., Heart Lung 2000, Clin Nurse Spec 2006
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Therapeutic Connection & Themes
• Information and education• Interaction and stories• Benefiting each other• Support and friendship• Importance of a facilitator• Accessibility (for online)
Dickerson et al., Heart Lung 2000a & b; Serber et al., Heart Lung 2010
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“Informed Consent”
• Process – ongoing conversation• Communication and comprehension
– Description, explanation, trajectory– Risks or discomforts– Benefits– Appropriate alternatives
• Current status and future options
Always comes down to communication –providing support and education
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The 5 A’s1. Ask: about concerns and wellbeing2. Advise: provide education about psychosocial
impact3. Assess: emotional and behavioral sx4. Assist: be practical; educate; support5. Arrange: follow-up and refer as neededTake the time and listen to the person who is your
patient.Interact with the patient and family in dialogFiore et al., 2000; Sotile & Sears, You Can Make a Difference, 1999
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Screening for PsychologicalDistress
Ask questions that help identify:• Emotional factors• Chronic Stressors• Somatic complaints
Rozanski et al., J Am Coll Cardiol 2005;45:637-651
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Screening for PsychologicalDistress
Possible screening questions:• How has your mood been recently?• How would you describe your energy level?• How have you been sleeping?• What kind of pressure have you been under at
work/home?• How do you unwind at the end of the day?Rozanski et al., J Am Coll Cardiol 2005;45:637-651
ΨΨ© 2010 Serber
Specific Areas For Intervention
• Relaxation and shock-anxiety management– Breathing exercises– Imagery– Positive self-talk
• Education– Cardiac dx, course, and tx– Relationship between emotions, behaviors, and cardiac
events• Family involvement
– Pt-focused– Caregiver strain
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Specific Areas For Intervention
• Activity planning and pacing• Physical activity• Thought management
– ↓ Negative– ↑ Positive
• Goal Setting and problem-solving– Long- and short-term– Are they realistic?
• Finding meaning and purpose
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Know When to Refer & GetConsult
• Most common times:– After SCA– Time of ICD implantation– Status Post ICD shock
• Other times:– Pt benefit from more 1-on-1 time than can be provided
during clinic visits– Treatment adherence issues– Increase in medical care utilization– Change in patient temperament, interactions, or loved
ones voicing concerns– Recognizing own limitations with
psychosocial issues
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Thank you!
Questions?
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Validated Screening Surveys
• Patient Health Questionnaire– 2-item, 9-item, or 4 pg comprehensive versions
• Hospital Anxiety and Depression Scale• Beck Depression Inventory• Center for Epidemiological Survey Depression
Scale
• Florida Patient Acceptance Scale• Florida Shock Anxiety Scale