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How can front-line professionals incorporate the 
emerging brain health toolkit into their practices?
Sponsors 
Welcome!
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
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
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 
www.lifestylemedicine.org/define
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. 
http://www.ssvisuals.com/http://www.brainyquote.com/quotes/authors/h/hippocrates.html images/scientists/s4hippocrates_big.jpg
Our Lifestyle Are Killing Us.
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
Content 
• Exercise prescription 
• Nutrition prescription 
• Stress Management 
• Connection/Social 
Networks 
• Behavior Change 
• Empowering people to 
adopt healthy habits 
http://www.lifespanfitness.com/workplacesolutions-treadmill-desk-and-bike-desk.html
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
Text books 
• Lifestyle Medicine 
• The SharpBrains Guide 
to Brain Fitness 
• Chapters are relevant to 
our weekly topics
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
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.
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.
Starting Line 
• Professional students 
coming to learn about 
Lifestyle Medicine 
http://soshable.com/getting-started-the-hardest-part-about-running-a-facebook-page/starting-line/
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.
Lifestyle Medicine 
http://www.extension.harvard.edu/courses/introduction-lifestyle-medicine
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
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
$100 on research vs. $28,000 on care spent in 2012
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.
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
Developing a Partnership
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 
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
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
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
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
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
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
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.
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
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
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
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
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
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)
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 
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 
% 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 
© 2011 HeartMath LLC Creating an Optimal Healing Environment 
41
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 
% 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 
© 2011 HeartMath LLC Creating an Optimal Healing Environment 
44
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.
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
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.
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
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
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
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
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.
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?
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
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.)
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
Office of the Surgeon General Brain Health Consortium 
Performance Triad Roll Out April 2014 
http://armymedicine.mil/Pages/performa 
nce-triad.aspx
Questions 
Wendy Law 
wendy.a.law.civ@mail.mil 
Kate Sullivan 
Katherine.w.sullivan.ctr@mail.mil
 To learn more, visit SharpBrains.com

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

  • 1. How can front-line professionals incorporate the emerging brain health toolkit into their practices?
  • 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. 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. 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 www.lifestylemedicine.org/define
  • 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. http://www.ssvisuals.com/http://www.brainyquote.com/quotes/authors/h/hippocrates.html images/scientists/s4hippocrates_big.jpg
  • 7. Our Lifestyle Are Killing Us.
  • 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. Content • Exercise prescription • Nutrition prescription • Stress Management • Connection/Social Networks • Behavior Change • Empowering people to adopt healthy habits http://www.lifespanfitness.com/workplacesolutions-treadmill-desk-and-bike-desk.html
  • 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. Text books • Lifestyle Medicine • The SharpBrains Guide to Brain Fitness • Chapters are relevant to our weekly topics
  • 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. 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. 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. Starting Line • Professional students coming to learn about Lifestyle Medicine http://soshable.com/getting-started-the-hardest-part-about-running-a-facebook-page/starting-line/
  • 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.
  • 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. 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. $100 on research vs. $28,000 on care spent in 2012
  • 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. 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
  • 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 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 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 % 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 © 2011 HeartMath LLC Creating an Optimal Healing Environment 41
  • 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 % 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 © 2011 HeartMath LLC Creating an Optimal Healing Environment 44
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Office of the Surgeon General Brain Health Consortium Performance Triad Roll Out April 2014 http://armymedicine.mil/Pages/performa nce-triad.aspx
  • 58. Questions Wendy Law wendy.a.law.civ@mail.mil Kate Sullivan Katherine.w.sullivan.ctr@mail.mil
  • 59.  To learn more, visit SharpBrains.com