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

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

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

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

Three Steps
Research Program
• Baby Boomers
• Baby Boomers
• Generation X
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

Three Steps
Education Program
• Baby Boomers
• Baby Boomers
• Generation X
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 3 Establiched patient 99213 $222 $87.83
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

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
N = 553
Kaiser Aggregate Stress Data Highlights

41
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%
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.
N = 34
Medical/Surgical Unit, CA

44
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
Wendy A. Law, Ph.D.
Clinical Neuropsychologist
Traumatic Brain Injury Service
Katherine W. Sullivan M.S., CCC-SLP, CBIS
Director, Brain Fitness Center
Defense and Veterans Brain Injury 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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