Author: Scott Endsley, M.D., Associate Medical Director, Quality

As often defined, polypharmacy is the prescription of greater than 5 to 9 medications. Continue reading →

Part II: Implementing Trauma-Informed Care into Organizational Culture and Practice (Ken Epstein PhD LCSW, SF Department of Public Health and Rahil Briggs, PsyD, Montefiore Medical Group)

Link to audio of entire webinar session: https://www.youtube.com/watch?v=XrKL9ov4ddw#action=share

Chronic Stressors and Collective Trauma In an Organization Are Caused by:

• Not enough time for collaboration or supervision
• Staff and budget cuts
• Client needs vs. services offered
• Technology and paperwork demands
• Task-driven vs. relational reforms
• Feeling unsafe with co-workers
• Staff turnover
• Traumatic events in the workplace

Characteristics of a TRAUMA ORGANIZED system:

• Reactive
• Organizational Hyperarousal
• Reliving/retelling
• Us vs. Them
• Interpersonal Conflict
• Avoiding
• Authoritarian leadership
• Dissociation/Amnesia

Characteristics of a TRAUMA INFORMED system:

• Shared language
• Understanding of trauma and healing
• Understanding racial disparities and insidious trauma

Characteristics of a HEALING system:

• Reflective
• Collaborative
• Culture of learning/curiosity
• Making meaning of the past
• Growth and prevention oriented (conflict OK)
• Relational leadership

Understanding the traumatic beliefs or TRIGGERS for those who have experienced trauma:

• Event: Door to examining room is closed even when patient asks for it to be open.
  • Traumatic belief: I am not safe.
• Event: Patient told she must undergo a certain procedure regardless of her anxiety.
  • Traumatic belief: People want to hurt me.
• Event: Patient is told she cannot be seen because she arrived late for appointment.
  • Traumatic Belief: If I am in trouble, no one will help
• Event: Waiting room is filled to overflowing with patients allowed to be disruptive.
  • Traumatic Belief: The world is dangerous

Negative roles providers/staff can take with patients who have had traumatic experiences:

• The Avoider (moving away): Withdrawing, dis-enrolling or referring patient elsewhere, silence with patients/colleagues, using inappropriate humor
• The Superhero (moving toward): Exaggerated sense of responsibility, excessive advocacy, over-sharing
• The Critic (moving against): Anger and irritability, heated arguments, sarcastic remarks

Trauma-informed reactions to the traumatized patient (PEARLS)

• Partnership: Let’s work together
• Empathy: That sounds frustrating (when patient complains)
• Apology: I am sorry that happened (when untoward event occurs with patient)
• Respect: You have gone through a lot
• Legitimization: I understand why you are so upset
• Support: Let’s see what we can do

Secondary trauma or compassion fatigue:

• A gradual erosion of all the things that keep us connected to others in our caregiver role.
• You didn’t experience the trauma but hear about it second-hand from a patient or a colleague
• Symptoms are similar to those of patients who have trauma experiences including PTSD

Online MINDFULNESS/RELAXATION RESOURCES for patients or staff dealing with past or current trauma:

• PHC at-home resources in English, in Spanish, in Russian, in Tagalog.
• Non-PHC resource for mindfulness/relaxation resources from webinar presenter in English, Spanish, and Arabic

Additional resources to create trauma informed clinics:

Examples of trauma-informed and non-trauma-informed office waiting rooms

Creating Safe, Trauma-Informed Agencies (North Carolina Division of Social Services)

Developing a Trauma Informed Agency (Alameda County CA)

By Karen Stephen, Ph.D., PHC Mental Health Clinical Director

Part I:  Implementing Trauma-Informed Care in Pediatric and Adult Primary Care Settings  (Nadine Burke-Harris MD Center for Youth Wellness and Edward Machtinger MD, Women’s HIV Program UCSF)

Link to audio of entire webinar session: https://www.youtube.com/watch?v=VbqwJ1h1Qy8&feature=youtu.be

Definition of trauma: Event or series of events, or set of circumstances that are experienced by the individual as physically or emotionally harmful or life threatening that can have lasting effects on the individual’s mental, physical, social, emotional, or spiritual well-being.

Types of Adverse Childhood Experiences (ACEs)

• Abuse: Physical, emotional, and sexual
• Neglect: Physical, emotional
• Household Dysfunction: Mental illness, mother treated violently, divorce, incarcerated relative, substance abuse

Increasing number of ACEs experienced increases impact on all aspects of physical and mental health, behavioral outcomes (e.g., smoking, addiction, alcoholism), and life potential (school and work success).

SAMSA data on ACE outcomes.  The landmark Kaiser study on ACEs.

The biology of adversity:

• Neurologic:
  • Dysregulation of HPA and SAM Axes
  • Activation of the amygdala
  • Inhibition of the prefrontal cortex
  • Hippocampal neurotoxicity
  • VTA and reward center dysregulation
• Immunologic:
  • Increased inflammatory mediators and markers of inflammation such as interleukins, TNG alpha, IFN-y
  • Inhibition of anti-inflammatory pathways
  • Impaired cell-mediated acquired immunity
• Endocine:
  • Long term endocrine changes in ACTH, cortisol, adrenaline and other hormones
  • Inhibition of thyroid function
  • Alterations in Growth Hormone and pubertal hormones
• Cardiovascular:
  • Increased plasma endothelin 1, total peripheral resistance, DBP and pulse wave velocity
• Epigenetic:
  • Altered epigenetic regulation leads to differential gene expression
  • Changes in way DNA is read and expressed lead to changes in the way brain and organ systems respond to stress
  • Telomere erosion leads to premature cell death and altered cell replication

What is trauma-informed care in a nutshell?

• Take the person’s experience into account
• Don’t ask “What’s wrong with you? Ask, “What happened to you?”
• Needs to be addressed at clinical and organizational level.

Core principles of trauma-informed care:

• Empower patients—use their strengths to develop treatment plans
• Provide options, let patients choose
• Maximize collaboration—patients, family members, staff
• Ensure physical and emotional safety
• Create trust through clear expectations regarding who, what, and how’s of treatment

Tools to screen for ACEs:

Adults

Teens

Children

ACE score 0-3 without symptoms = Provide Anticipatory guidance

ACE score 1-3 with symptoms or 4 or more ACEs = Counsel and refer

Basics to Institute Trauma-Informed Primary Care:

Foundation: Train ALL staff, use clinic champions, support providers, ongoing evaluation

Screen:  Inquire about current and lifelong abuse, PTSD, depression, substance use

Create Environment:  Calm, safe, empowering for patients AND staff

Respond:  Use onsite and community based programs that promote safety and healing

What can you do tomorrow!

Realize that a lot of who we are and what we do is because of what happened to us.

Embrace trauma-informed values.

Distribute literature about impact of trauma on health

Get training for staff

Assemble a team to support the process

It has been predicted that the 2017-2018 influenza season may be severe.  It is starting early – having shown up in Southern California earlier than usual.  It causes or is a part of the cause of death in thousands of people in the US every year – mostly small children/ babies and the elderly.  The Centers for Disease Control and Prevention (CDC) has published guidance for preventing seasonal influenza in the workplace.

• Promote influenza vaccine: “The single best way to protect against the flu is to get vaccinated each year.”   There are several types of vaccine that can be used depending on your particular health situation.  It is recommended for everyone 6 months and older.   Otherwise there are few people for whom the vaccine is not appropriate.  Vaccination during preganancy can help protect your newborn who is particularly at risk if the baby catches influenza.
  • Unfortunately, as the vaccines are prepared early in the year in anticipation of the major predicted strains of influenza in the fall, this year the vaccine was off the target from the prevalent strain causing influenza this year. However, protection against the 2 or 3 other strains involved in causing influenza remains.   It is still highly recommended.  I got mine – even during the fires!
  • The influenza vaccine is given at a time of the year when common colds show up in the population (kids back in school) – so many people have said they thought that the vaccination gave them the illness. THIS DOES NOT HAPPEN.
• Hygiene
  • We have become familiar with cover your cough (either with your elbow or a tissue) and dispose of the tissue properly – stand away – it doesn’t take much distance to reduce exposure.
  • Wash your hands – transmission from hands can be prevented by washing. I do frequently during the day and when I arrive home from work.  Don’t be nuts about it but have common sense.
• Know the signs and symptoms of influenza – influenza is NOT the common cold (people do come to work with colds – kinda unavoidable and a nuisance).  I consider influenza with the following symptoms that can often develop quickly:
  • Fever – almost always (or chills)
  • Cough – influenza is a respiratory illness
  • Body aches – yeah, this is part of the misery – ache all over
  • Headache – another typical part of the misery.

So you can see how influenza is different from the run of the mill cold or stomach ailment.  You can have sniffles, sore throat, stomach complaints, fatigue too, but I pay attention to the top four.

• If you think you have influenza – GO HOME – STAY HOME– WATCH NETFLIX! (although you may want only to sleep) – Check in with your health care provider if you are at high risk or take a turn for the worse.   Don’t be a part of the spread of influenza in the workplace.

I practice these measures for five reasons

• I don’t want to get sick – influenza – not the common cold – is miserable
• I don’t want to use my valuable PTO time being ill! (hmm vacation or home feeling like I’ve been run over)
• I don’t want to bring it home to my family (what a way to spoil the holidays and new year – and they will get mad at you)
• I don’t want to bring it to work – “IT WAS YOU!”
• AND I’m a doctor – walk the walk – I’m a believer

If you have influenza – stay home, rest, take fluids, medications like ibuprofen to feel better (don’t give aspirin to kids or adolescents).  If you worsen seek medical advice or help.   Don’t return to work until your fever is gone for 24 hours – you’ll know, the relief is remarkable.

Vaccine, cover, wash, recognize, stay home.

By Jeff Ribordy M.D., Regional Medical Director

As medical directors at Partnership HealthPlan of California, we are honored to review an array of medical records, treatment authorization requests and sundry other medical documentation on a daily basis. Every so often we encounter documentation that makes us scratch our heads and entices a chuckle. Here are some of the best-

Before the current “Golden Age” where everyone has an EHR and now loves charting endlessly (sarcasm intended) there were these things called “medical errors”. I know it’s hard to fathom, doctors making mistakes, but it’s not just fake news. Most of the “errors” were typically related to undecipherable hieroglyphics known as “doctors’ handwriting” leading to medication mistakes or other orders either being ignored or completed incorrectly.

While typed or dictated notes now allow legibility, comprehension can still be a struggle. Whether from stream of consciousness HPIs, dictation errors or excessive reliance on standard templates without reviewing, errors still are found. In our review of submitted medical records we have found a few mistakes that make us chuckle or even laugh out loud. I’m going to share some of these here – not to point fingers but with the understanding we all have made similar mistakes.

Sometimes we have to take a patient’s history with a grain of salt…

From the category of “How Do You Find The Time To Do Anything Else”:

 From the Physical Exam:

Family history can be…very revealing:

And from the Catch-All category of “Huh?”:

And good advice for everyone:

The Case for Advance Care Planning. Advance care planning is a series of conversations that a patient and you, their care provider, have about end of life wishes. Continue reading →

Written by: Scott Endsley, MD, MSc., Associate Medical Director for Quality

Dementia is a terminal illness, like cancer or advanced heart disease. Dementia is rapidly increasing in the U.S. and worldwide. In 2012, there were over 5.2 million Americans with Alzheimer’s Disease (AD). By 2025, the number is expected to grow by almost 30% to 6.7 million.[1] Along with the prevalence expanding at epidemic proportions, mortality also continues to increase. It is the 5^th leading cause of death in the U.S.[2]

Dementia is a progressive disease with seven stages (figure 1). Alzheimer’s Disease may last for decades, though the mean in eight years. The Global Deterioration Scale[3] is a validated instrument that is helpful in staging the patient along the progression timeline. Memory and function loss proceeds inexorably across the stages until Stage 7 in which the patient has very limited words, incontinence, severe function loss requiring assistance for ADLs, and total disorientation. Median survival in Stage 7 is 1.3 years. Over 80% of patients in this stage have significant eating problems, often requiring assistance. Resultant weight loss is common. Infections, primarily pneumonia and urinary tract infections, are common and carry a high risk of mortality (40% or greater in the CASCADE study[4])

Palliative care is appropriate at any point after diagnosis and may be provided along with symptom management as early as Stage 2. Caregivers and providers are often confronted with the agonizing decision of anticipating death and entering the patient into hospice. Prognostication in advanced dementia is a problematic endeavor. The ADEPT tool has been developed to assist in predicting survival based upon eleven variables in demographics, cognitive status, functional status, active diagnoses. Risk scores greater than 16 (scale 1-32) suggests a six month probability of dying of > 50%. The Medicare Hospice guidelines requires the patient to have significant functional limitation (Stage 7 or beyond of Functional Assessment Staging (FAST) scale) AND at least one of six medical complications in the preceding year including aspiration pneumonia, pyelonephritis, septicemia, multiple decubitus ulcer, recurrent fevers after antibiotics, or inadequate hydration and caloric intake with 10% body weight during previous 6 months (or serum albumin less than 2.5 g/dl). When compared to the ADEPT prognostic tool, the Medicare Hospice guidelines perform less reliability in predicting 6 month mortality.

Recommendations. As your patients with dementia of any type (Alzheimer, vascular, Lewy body) progress through the seven stages, consider the following:

• Educate caregivers on the nature of dementia as a progressive and ultimately fatal disease
• Initiate advance care planning conversations early (stage 1 or 2)
• Ensure that a surrogate has been identified to medical decision making
• Start palliative care in addition to other medical care early or at least by Stage 5 or 6.
• Manage symptoms (neuropsychiatric, incontinence, insomnia) appropriately
• Recommend caregiver assistance early to avoid burn-out and depression
• Consider hospice evaluation at Stage 7

Resources. Many dementia management resources are available. Consult these as needed.

Alzheimer Association: www.alz.org

National Institute for Aging: www.nia.nih.gov/health/alzheimers-dementia-resources-for-professionals

National Hospice and Palliative Care Organization:  www.nhpco.org/resources-access-outreach/dementia-resources

[1] Alzheimer’s Association. 2012 Alzheimer’s disease facts and figures, accessed at: www.alz.org/downloads/facts_figures_20122.pdf

[2] Tejada-Vera B. “Mortality from Alzheimer’s disease in the United States. NCHS Data Brief. National Center for Health Statistics, Hyattsville, MD 2013

[3] Reisberg B, Ferris SH, de Leon JJ, Crook T. “The Global Deterioration Scale for assessment of primary degenerative dementia”. Am  J. Psychiatry (1982), 139: 1136

[4] Mitchell SL, Teno JM, Kiely DK et al. “The Clinical Course of Advanced Dementia”, NEJM, (2009), 361:1529

CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.

Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:

• Memory loss that affects daily living or work
• Difficulty performing familiar tasks
• Problems with language
• Disorientation in time and space
• Poor or decreased judgement
• Problems with abstract thinking
• Misplacing things
• Changes in mood or behavior
• Changes in personality
• Loss of initiative

Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment.  This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.

Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.

If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:

• Behavioral modifications (scheduled toileting)
• Music especially during meals and bathing
• Walking or light exercise
• Pet therapy (yes with animals, not electrons)
• Cognitive exercise

Last year, approximately 33% of two year old members of Partnership Healthplan were not fully immunized. Continue reading →

In examining how to improve patient outcomes we turn to population medicine to develop treatment strategies. Continue reading →