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How can front-line pro­fes­sion­als incor­po­rate the emerg­ing brain health toolkit to their practices?


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(Session held at the 2014 SharpBrains Virtual Summit; October 28-30th, 2014)

12:30-2pm. How can front-line pro­fes­sion­als incor­po­rate the emerg­ing brain health toolkit to their practices?

- Eliz­a­beth Frates, Direc­tor of Med­ical Stu­dent Edu­ca­tion at the Insti­tute of Lifestyle Medicine
- Dr. Cather­ine Madi­son, Direc­tor of the Ray Dolby Brain Health Cen­ter at Cal­i­for­nia Pacific Med­ical Center
- Bar­bara Van Amburg, Chief Nurs­ing Offi­cer at Kaiser Per­ma­nente Red­wood City
- Dr. Wendy Law, Clin­i­cal Neu­ropsy­chol­o­gist at Wal­ter Reed National Mil­i­tary Med­ical Center
- Chair: Dr. Michael O’Donnell, Editor-In-Chief of the Amer­i­can Jour­nal of Health Promotion

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How can front-line pro­fes­sion­als incor­po­rate the emerg­ing brain health toolkit to their practices?

  1. 1. How can front-line professionals incorporate the emerging brain health toolkit into their practices?
  2. 2. Sponsors Welcome!
  3. 3. How can front-line professionals incorporate the emerging brain health toolkit into their practices? Chaired by: Dr. Michael O’Donnell, Editor-in-Chief of the American Journal of Health Promotion Dr. Elizabeth Frates, Director of Medical Student Education at the Institute of Lifestyle Medicine Dr. Catherine Madison, Director of the Ray Dolby Brain Health Center at California Pacific Medical Center Barbara Van Amburg, Chief Nursing Officer at Kaiser Permanente Redwood City Dr. Wendy Law, Clinical Neuropsychologists at Walter Reed National Military Medical Center
  4. 4. SharpBrains Virtual Summit 2014 Elizabeth Pegg Frates, MD Director of Medical Student Education at the Institute of Lifestyle Medicine Assistant Professor, Part Time Harvard Medical School Lifestyle Medicine Specialist Wellness Synergy, LLC
  5. 5. Lifestyle Medicine • Lifestyle Medicine (LM) is the use of lifestyle interventions in the treatment and management of disease. Such interventions include: • Diet (nutrition) • Exercise • Stress Management
  6. 6. The Foundation for Lifestyle Medicine • “If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” • Hippocrates • 460 B.C. – 370 B.C. images/scientists/s4hippocrates_big.jpg
  7. 7. Our Lifestyle Are Killing Us.
  8. 8. Institute of Lifestyle Medicine • Director of Medical Student Education – Faculty Advisor, Lifestyle Medicine Interest Group • Co-Director of Tools for Promoting Healthy Change, live CME course at HMS • Assistant Director of Active Lives, live CME course at HMS • Co-Author of online HMS CME Exercise Prescription, Nutrition, Back Pain in lifestyle medicine suite of online courses
  9. 9. Content • Exercise prescription • Nutrition prescription • Stress Management • Connection/Social Networks • Behavior Change • Empowering people to adopt healthy habits
  10. 10. Invited to Teach at Harvard Extension School • Dr. Stephanie Peabody • Cluster of courses on applied coaching and applied health and wellness • Introduction to Lifestyle Medicine – 74 students form Boston, CT, NY, NJ, CA, TX, Canada, India, Russia, Singapore, China
  11. 11. Text books • Lifestyle Medicine • The SharpBrains Guide to Brain Fitness • Chapters are relevant to our weekly topics
  12. 12. Specifically • Chapter 2- Be a Coach, Not a Patient • Chapter 3- Mens Sana in Corpore Sano • Chapter 4- You Are What You Eat and Drink • Chapter 6- Oh the People You’ll Meet • Chapter 7- Manage Stress, Build Resilience • Chapter 9- How To Be Your Own Brain Fitness Coach
  13. 13. Benefits • Students like to hear about the brain and behavior, not just the body (heart, liver, pancreas) • Disease management is important, but they want to know about the brain and how to increase their brain power. • The research studies mentioned allow for a deep dive into the medical literature and the studies that support the recommendations • The interview make the material come alive, as the student gets a chance to “meet” the researcher/author/expert.
  14. 14. Feedback • It is accessible. • It is enjoyable to read. • It has powerful information. • It ties in nicely with the themes and topics in the class.
  15. 15. Starting Line • Professional students coming to learn about Lifestyle Medicine
  16. 16. Finish Line • After 14 weeks of the class: • They have the latest literature and recommendations. • The understand the way to empower people to mount lasting change. • They themselves have experienced a transformation.
  17. 17. Lifestyle Medicine
  18. 18. Ray Dolby Brain Health Center SharpBrains Summit, October 29, 2014 Catherine Madison MD Director, Ray Dolby Brain Health Center California Pacific Medical Center 45 Castro Street, #220 San Francisco, California 94114
  19. 19. The Problem with Alzheimer’s • Many are impacted, we’re all at risk • Under recognized, and it’s a scary disease • Healthcare system unprepared • Physicians unsure about how to diagnose & treat • Few services in the community, lack of awareness & information • Families delay seeking help • Expensive, with limited financial support of research
  20. 20. $100 on research vs. $28,000 on care spent in 2012
  21. 21. With Alzheimer’s, it is not just those with the disease who suffer. It’s also their caregivers • In 2013, 15.5 million family and friends provided 17.7 billion hours of unpaid care to those with Alzheimer’s and other dementias • The economic value of the unpaid care provided to those with Alzheimer’s and other dementias totaled $220.2 billion in 2013 • The average per-person Medicaid spending for seniors with Alzheimer's and other dementias is 19 times higher than average per-person Medicaid spending for all other seniors.
  22. 22. Doctors and Philanthropy • Philanthropic support no longer simply a bonus • ‘How can I thank you?’ • ‘I would like to help others facing this problem’ • Varying sources • Bill and Melinda Gates Foundation • Robert Wood Johnson Foundation • Atlantic Philanthropies • Centers for Medicare and Medicaid Services • Local connections
  23. 23. Developing a Partnership
  24. 24. Donor’s Vision awareness • Increased awareness of the epidemic • Recognition of signs of dementia & reduce stigma • Public outcry for more funding & support access • Support & care for Alzheimer’s patients & families • Knowledgeable physicians and providers • Early detection & treatment research • Better ways to identify Alzheimer’s • Effective treatment… eventual cure
  25. 25. 25 CPMC Brain Health Center: Mission and Vision Patient Care - Neurologists, Mental Health Providers, Psychiatrists and Internists - Neuropsychologists - Access to therapists: PT, OT, Social work, Nutrition - Case management, Counseling and Planning Education - Partnership with Alzheimer’s Association - Information and resources for patient and family - Training of social workers and therapists in the community - Family-oriented public awareness initiatives Mission: The Brain Health Center provides leading-edge diagnosis, treatment, research, technology, and psychosocial support for persons to maintain cognitive strength and deal positively with changes to maintain independence and harmony. Vision: To achieve our mission the CPMC Brain Health Center: • Uses accurate diagnosis along with multi-faceted, medical and holistic interventions •Ensures each patient has access to our multidisciplinary team of health professionals who provide comprehensive, individualized treatment plans •Provides patients and their caregivers with ongoing psychological and emotional support •Works closely with the Alzheimer’s Association to educate other professionals and the community for earlier diagnosis and better directed intervention •Conducts patient and family oriented research to evaluate treatments, works with local technology companies to integrate the latest technologies into patient care and safety, and collaborates with regional basic science groups. Research -- Chair with strong clinical focus -- Research Fellowships for PhD, MD, LCSW, or RN - Partnerships with NIH, Alzheimer’s Association, and regional basic science research organizations Patient and Family
  26. 26. Ray Dolby Brain Health Center: Development in Three Steps Patient Care Program Current Step 1: Step 2: Step 3: Timeframe: 1 year 18 months – 2 years 2 years Location: 2100 Webster 2100 Webster Davies Davies Market: • Silent Generation • Baby Boomers • Silent Generation • Baby Boomers • Generation X • Entire at-risk population Patient Care • Neurologist focused on diagnosis and treatment • Part-time neuropsychologist for diagnostic testing • Part-time LCSW for counseling, planning and case management • Limited PT and OT for consultation with balance, walking and safety issues in the home • Part-time RN to assist with patient/family questions, medication and management issues • Social work student to provide education and assistance • Focus continues on diagnosis and treatment with increasing growth of patients/families served • Add full-time RN • Add full-time neuropsychologist to expand testing and diagnosis of memory disorders • Expand counseling and case management by social work • Add part-time Patient Navigator for follow-up and coordination of care • Focus expands to include people concerned about “healthy aging." • Increase Neuropsychology and mental health staffing to expand therapy and testing. • Expand PT/OT and offer personalized exercise plans (potential partnership with IHH). • Add dietician services • Addition of part-time psychiatrist to further improve patient management and care • Focus expands to managing patients at risk identified in hospital and outpatient setting with addition of a Geriatrician • Add nurse practitioner to increase patient access to medical intervention and assessment
  27. 27. Ray Dolby Brain Health Center: Development in Three Steps Research Program Current Step 1: Step 2: Step 3: Timeframe: 1 year 18 months – 2 years 2 years Location: 2100 Webster 2100 Webster Davies Davies Market: • Silent Generation • Baby Boomers • Silent Generation • Baby Boomers • Generation X • Entire at-risk population Research • Research on the use of relaxation guided imagery to reduce caregiver burden • Referral of patients interested in clinical trials to appropriate regional centers • Begin recruitment for research chair • Add chair in research on early diagnosis of cognitive dysfunction, optimum care and delivery • Emphasis on patient and family education, interventions and therapeutic strategies for individuals at risk for or suffering from memory loss • Research Chair develops multi-disciplinary research program partnering with NIH, American Academy of Neurology, National Institute of Neurological Disorders • Add 1- 2 Clinician investigators
  28. 28. Ray Dolby Brain Health Center: Development in Three Steps Education Program Current Step 1: Step 2: Step 3: Timeframe: 1 year 18 months – 2 years 2 years Location: 2100 Webster 2100 Webster Davies Davies Market: • Silent Generation • Baby Boomers • Silent Generation • Baby Boomers • Generation X • Entire at-risk population Education • Training of medical residents at CPMC involved in geriatric rotation • Limited support groups offered for family members • Limited amount of individualized therapy and coaching for patients and their families • Part-time social work student • Increase support groups • Increase involvement with Alzheimer’s Association with offering education classes at CPMC and more involvement in outside events • Increase social work student to year round for improved continuity of care • Increase patient navigator to full-time (working with Brain Health Center and Alzheimer’s Association) • Add PT/OT evaluations in center or home • Add nutrition evaluations and individualized instruction • Further integrate classes with Alzheimer’s Association in new space • Implement training fellowship • Increase presence in the community
  29. 29. Ray Dolby Brain Health Center October 2014 • Two neurologists and one Nurse Practitioner with over 2,000 patients seen since opening in October 2012 • Care Navigation Team consisting of 3 social workers, one MFT and a SW student • Part-time pharmacist and dietician for patient consultation and education. • Four dedicated staff members and several volunteers • Adding a research division with greater expansion planned 2015
  30. 30. Ray Dolby Brain Health Center Reimbursement Out Patient Hospital Base Clinic Description CPT/HCPCS Clinic Price Actual Reimbursement Level 1 Established patient 99211 $168 $25.32 Level 2 Established patient 99212 $195 $53.65 Level 3 Establiched patient 99213 $222 $87.83 Level 4 Established patient 99214 $369 $128.96 Level 5 Established patient 99215 $397 $171.70 Actual Patient Revenue for 2013 is $764,803
  31. 31. Integrated Care Initiative Study (ICI Project) • Patient and family interested in improving care for individuals with cognitive impairment. • Development of a proposal to address the fact that most patients with dementia and other causes of cognitive impairment are cared for by family Caregivers at home, often with little or no background/training in how to manage the issues that they face. • Identified issues Caregivers face and developed an Educational Curriculum – Over 50 individual educational resources that cover behavioral and psychological symptom management, Activities of Daily Living (ADLs), nutrition, medication management, advance care directives, and the burden and stress on Caregivers themselves. • Representative examples of topics include: “How to Handle Suspicions, Delusions, and Paranoia”, “Making Dressing and Grooming Easier,” “How to Talk about the Issue of Driving,” and “How to Maintain a Social Life While Being a Caregiver.” • Partnering to develop technology plan (in progress) - provides caregivers with resources they select in primary care setting.
  32. 32. Summary • Alzheimer’s Disease is a growing problem • Many individuals affected with ideas on how to improve care • Collaborate • Within your community • With businesses and hospitals • With care organizations • With philanthropically inclined persons • Advocate and be part of the change needed in our culture
  33. 33. How can front-line professionals incorporate the emerging brain health toolkit into their practices? Barbara Van Amburg, Chief Nursing Officer at Kaiser Permanente Redwood City
  34. 34. Why Coherence & HeartMath at Kaiser? • The Kaiser Permanente Nursing Vision:  Kaiser Permanente nurses advance the art and science of nursing in a patient-centered healing environment through our professional practice and leadership. • Redwood City Initiatives: • Commitment to highly reliable, exceptional quality and patient/family centered care • Commitment to caring, compassionate, and relationship-based care • Engaged workforce
  35. 35. Hospital Pace • Nurses face a highly stressed, fast-paced work environment • Multi-tasking frenzy • Lack of alignment around common goal or purpose and organized silos result in lack of support for each other • Teams invest in multiple time activities that ultimately don’t fulfill the goals of engaged employees to assist them in making improvements for our members • Top down leadership pushes work down and delivers one way communication
  36. 36. Redwood City’s Journey  “Employee Wellness Program” in place since 2009  Goal: to improve the physical, emotional, social, and spiritual health of our staff  Mindfulness training at work – “At Kaiser Permanente, we have a key audience to focus on – our customers, members, patients, our teams, and ourselves. When we are unfocused or stressed, we are not at our best and we are not interacting with our patients and co-workers in a way that we should.” ~ Diane Gage Lofgren, Chief Communication Officer & Sr. Vice President  2011 Jean Watson’s Caring Science introduced throughout Northern California o Caritas Coaches Model introduced o In conjunction with Caring Science, frontline staff were introduced to HeartMath
  37. 37. Emotions and Heart Rhythms Incoherence: Impairs performance, amplifies energy drain Coherence: Promotes optimal performance, builds resilience © 2014 Copyright Institute of HeartMath Inhibits Brain Function (Incoherence) Facilitates Brain Function (Coherence)
  38. 38. Coherence Practice − Outcomes • Enhances ability to maintain composure during challenges • Improves family and social harmony • Reduces fatigue and exhaustion • Promotes the body’s natural regenerative processes • Improves coordination and reaction times • Enhances ability to think clearly and find better solutions • Improves ability to learn and achieve higher test scores • Increases access to intuitive intelligence © 2014 Copyright Institute of HeartMath
  39. 39. 39 Published Research Antioch Fremont Hayward Fresno Ø American Journal of Cardiology Redwood City San Rafael Santa Clara Santa Rosa South Sacramento South San Francisco Ø Journal of Stress Medicine Ø American College of Cardiology Ø Modern Healthcare Ø Harvard Business Review Vacaville Ø Wall Street Journal Continuum of Care Southern CA, Oregon and Maryland/D.C. N = 1,848 © 2011 HeartMath LLC Creating an Optimal Healing Environment
  40. 40. 40 % of responses: often – always: Pre Post (2 weeks) Tired 40% 24% Fatigued 39% 20% Exhausted 30% 17% Worried 29% 18% Annoyed 21% 10% Body aches (join pain, backaches, etc) 33% 19% Muscle tension 34% 20% Rapid heartbeats 8% 5% How stressed you have been in past month 41 28 © 2011 HeartMath LLC Creating an Optimal Healing Environment N = 553 Kaiser Aggregate Stress Data Highlights
  41. 41. 41 © 2011 HeartMath LLC Creating an Optimal Healing Environment 41
  42. 42. 42 % of responses: often – always: Pre Post (2 weeks) I feel optimistic about the future 76% 97% My life is deeply fulfilling 62% 85% Grateful 74% 88% Dynamic 55% 76% Peaceful 41% 68% Relaxed 29% 47% Tired 53% 12% Fatigued 41% 9% Anxious 18% 6% Worried 35% 6% Unhappy 18% 3% Annoyed 24% 6% I get upset easily 21% 3% © 2011 HeartMath LLC Creating an Optimal Healing Environment N = 34 Medical/Surgical Unit, CA
  43. 43. 43 % of responses: often – always: Pre Post My sleep is inadequate 41% 21% Body aches (joint pain, backaches, etc.) 38% 12% Muscle Tension 33% 6% Headaches 9% 3% % who agree or strongly agree: Pre Post A strong rapport with my supervisor 36% 56% Tension b/w management and staff 41% 26% I feel very useful in my job 74% 94% I am creative and innovative 53% 74% Conflict b/w work & personal priorities 29% 15% We have great confidence about being successful 72% 91% in the future. © 2011 HeartMath LLC Creating an Optimal Healing Environment N = 34 Medical/Surgical Unit, CA
  44. 44. 44 © 2011 HeartMath LLC Creating an Optimal Healing Environment 44
  45. 45. Training Outcome Coherence building skills which are core to HeartMath has: • helped staff to improve coping mechanism to stress factors • assisted in creating positive and healing patient and family experiences • improved communication among leaders through using “Quick Coherence” techniques Coherence is central to quality, safety, positive patient outcomes, and the exceptional patient experience.
  46. 46. INTEGRATING BRAIN HEALTH TOOLS INTO MILITARY REHABILITATION Update from the Brain Fitness Center at Walter Reed National Military Medical Center Wendy A. Law, Ph.D. Clinical Neuropsychologist Traumatic Brain Injury Service Walter Reed National Military Medical Center Katherine W. Sullivan M.S., CCC-SLP, CBIS Director, Brain Fitness Center Defense and Veterans Brain Injury Center Walter Reed National Military Medical Center
  47. 47. Disclaimer The views, opinions, and/or findings contained in this article are those of the authors and should not be construed as an official Department of Defense position, policy or decision unless so designated by other official documentation.
  48. 48. How WRNMMC incorporates brain health tools into rehabilitation • Varied tools for what appears to be a homogeneous population • 6+ available options to integrate • Open door policy • Independent use, self-determined schedule • Outcome measures include objective, subjective, and compliance tracking • BFC in patient notes, patient rounds, and rehabilitation goals
  49. 49. BFC Patient Population • 50% of pts seen >1 year TPO • Average BFC visits per mo. (2013): 187 • Average 23.4 sessions per patient • Average stay 96.0 days per patient • 62% currently in SLP, OT or both TBI DX 48% Neurological PSYC DX 16% Comorbid Patients with PSYC & TBI DX 19% Origin 13% Chemobrain 2% Physical Trauma 2% BFC DX % Overall Breakdown 70 60 50 40 30 20 10 0 Brain Fitness Center Patient Dx Trends 2006 2008 2010 2012 2014 2016 Number of Patients Year TBI DX PSYC DX Comorbid Patients with PSYC & TBI DX Neurological Chemobrain Physical Trauma
  50. 50. Becoming a Resource A resource for providers: A resource for patients: 26% 18% 2014 Referrals 15% 10% 11% 6% TBI CM BH IOP Audiology OT SLP Neuropsych Other 4% 10% Patient Visits (2013 vs. 2014) 212 253 199 139 220 240 156 193 110 186 1200 1000 800 600 400 200 0 WRNMMC 2013 WRNMMC 2014 May April March February January
  51. 51. Front-line Professional • Provide education and be an advocate for tools that may benefit your specific population • Inform users and referring providers of the benefits and limitations of the programs • Be prepared to provide data and research updates • Coaching for patients • Help pts select tools • Encourage use • Encourage feedback from patients • Provide feedback for patients
  52. 52. Research Updates CURRENT • BRAVE trial: Posit Science, CDMRP • Multi-site, prospective, parallel arm, double-blind, randomized, controlled clinical trial to assess the safety and efficacy of plasticity-based, adaptive, computerized cognitive remediation treatment • Orrb trial: Environment: Health & Performance International, Biofeedback: emWave/Heartmath, and Neurofeedback: Evoke Neuroscience • To determine whether BCI-HRV treatment, performed in an optimized environment, improves the effectiveness of mTBI treatment over current WRNMMC and FBCH standards of care or BCI-HRV outside the optimized environment • Database • The data collected will provide the foundation for the development of hypothesis-driven protocols, and will ultimately advance our understanding of characteristics of treatment responders and non-responders, aspects of cognitive change, and self-perceived symptom change following Brain Fitness Center participation.
  53. 53. Database • 170 total data points • Pilot information to justify larger-scale studies • Allowing other in-house researches access • Communication? Tinnitus? Self Esteem? Self awareness? Gender, Education Differences? Co-morbidities and compliance? • Clinical information on responders and non-responders, initial research question: • What is the relationship between objective performance and subjective symptoms?
  54. 54. Cognitive efficiency and neurobehavioral symptoms of Military patients seeking treatment Wendy A Law, Katherine W. Sullivan, Alanna M. Covington, Laura Loyola, Angela M. Perta, Louis M. French 122nd Annual Convention of the American Psychological Association, August 7-10, 2014, Washington, D.C. What is the relationship between objective performance and subjective symptoms? • Within a Military patient population, subjectively reported neurobehavioral symptoms are associated with objective cognitive functioning in a general mixed clinical sample but are unclearly related in patients with mTBI/concussion as the primary diagnosis • For mTBI patients reporting neurobehavioral symptoms, factors other than neurocognitive functioning play a role in symptom persistence • Cognitive retraining outcomes related to such patient factors are unknown at this time and require further investigation. Patients without clear associations between objective performance and subjective symptoms may be less likely to benefit from cognitive retraining or may show improved cognitive functioning without reduced symptom report. Limitations: retrospective chart review
  55. 55. Database Research Findings PRIOR/CURRENT FINDINGS • BFC Retrospective study results– Significantly improved Mayo and NBSI scores and suggested improvement in SWL in a mixed clinical sample following cognitive retraining exercises (Sullivan KW, Quinn JE, Pramuka M, Sharkey LA, French LM. Outcomes from a pilot study using computer-based rehabilitative tools in a military population. Studies in Health Technology and Informatics. 2012; 181: 71-7.) • BFC Exploratory study results– ANAM performance efficiency is related to NBSI symptoms in a mixed clinical sample overall and in the subgroup that did not have mTBI but are not clearly related in the mTBI subgroup. (Law, W., Sullivan, K., Covington, A., Loyola, L., Perta, A., & French, L.(2014, August). Cognitive efficiency and neurobehavioral symptoms of Military patients seeking treatment. Poster presented at the American Psychological Association Annual Convention, Washington, D.C.)
  56. 56. Future Directions NEXT STEPS • BFC Descriptive study – Examine the role of performance validity on symptom improvement following cognitive retraining exercises • Examine pre/post changes in MAYO, NBSI and SWL for the mixed clinical patient sample overall and in each of the two subsamples (mTBI and NOT mTBI) in relation to valid ANAM performances at both visits • Identify predictors of improvement in relation to patient demographics, program use, and participation rate
  57. 57. Office of the Surgeon General Brain Health Consortium Performance Triad Roll Out April 2014 nce-triad.aspx
  58. 58. Questions Wendy Law Kate Sullivan
  59. 59.  To learn more, visit