Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care.

Although primary care is an ideal setting in which to address behavioral influences on health, clinicians spend little time discussing preventive care, including lifestyle counseling. There is a dearth of comprehensive training and evidence-based resources to educate clinicians in how to effectively engage with patients about these topics. This study describes and evaluates the acceptability of Change that Matters: Promoting Healthy Behaviors, a ten-module curriculum to train clinicians in brief, evidence-based interventions. Each module includes three parts: interactive patient handouts, didactic training, and electronic health record templates to guide the discussion and after visit summary. A two-part, mixed-methods pilot study was used to evaluate the acceptability of the curriculum in a family medicine residency clinic. In Study 1, external family medicine faculty experts (N = 11) provided written feedback on the patient handouts. In Study 2, 20 residents and 20 patients completed qualitative interviews regarding their experience with curricular materials. Content analysis was used to extract qualitative themes. Experts rated the patient handouts as highly understandable and actionable. Resident themes indicated that the curriculum provided concrete tools to address health behavior change, helped structure patient discussions, and increased confidence. Patients felt empowered to make behavior changes. This new curriculum addresses a gap in existing resources, and is available for free download online which can facilitate dissemination ( https://changethatmatters.umn.edu/ ). Research has found the curriculum to be acceptable to experts, residents, and patients. Future studies need to explore its impact on the behavior of both clinicians and patients.

Psychosocial Needs of Parents Engaged in Treatment for Opioid Use Disorder.

Background: Little research has examined the needs of parents with opioid use disorder (OUD) who are receiving medications for OUD (MOUDs), which is striking given growing rates of OUD among parents. Objective: The current study expands the literature by examining psychiatric, psychosocial, and parenting-related functioning, as well as 12-month MOUD treatment retention among parents versus non-parents participating in a buprenorphine program at an academic family medicine residency clinic. Methods: Patients (N = 144; 61 parents) completed measures of psychiatric and psychosocial functioning at the first MOUD visit; parents also completed measures of parental functioning. Results: Parents endorsed less anxiety and loneliness, as well as greater social connection, life satisfaction, and life meaning. Parents were also older, more likely to be female, of a race other than white, married, employed, and had higher incomes. Although parents endorsed high levels of parental self-agency and strong bonds with children, many also reported elevated parental shame. Among parents, higher levels of shame were also associated with higher depression, anxiety, anger, stress, and loneliness. Over 25% of parents reported that a child lived with friends/relatives over 3 months, and 11% noted a child having been removed from the home by child protective services. Finally, parents were more likely to be retained in treatment at 12 months, although this finding was non-significant after controlling for covariates. Conclusions/Importance: These findings illustrate the needs experienced by parents engaged in MOUD treatment, which may prove valuable in informing policy, program development, and treatment approaches for parents with OUD.

Family medicine physicians' confidence and perceived effectiveness in delivering health behaviour change interventions.

BACKGROUND: Approximately 40% of deaths in the USA are attributable to modifiable health behaviours. Despite clear recommendations and practice guidelines, primary care physicians (PCPs) generally do not dedicate much time to addressing health behaviours, thereby missing opportunities to improve patient well-being. OBJECTIVE(S): To examine what health behaviour change techniques PCPs use with their patients, including frequency of use, confidence in and perceived effectiveness of those interventions. METHODS: Using a cross-sectional study design, family medicine resident and faculty physicians (n = 68) from three residency training programs completed an anonymous online survey. Questions explored their use of, confidence in and perceived effectiveness of health behaviour change interventions for six domains: physical activity, healthy eating, medication adherence, smoking cessation, sleep and alcohol reduction. Qualitative responses to open-ended questions were double coded by two independent raters. PCPs' open-ended responses to questions regarding specific intervention techniques were coded using an evidence-based behaviour change taxonomy. RESULTS: Although PCPs indicated that they address health behaviour topics quite frequently with their patients, they reported only moderate confidence and low-to-moderate perceived effectiveness with their interventions. The most frequently cited technique was providing instruction (telling patients what to do). PCPs reported lowest frequency of addressing, lowest confidence and lowest effectiveness regarding helping patients decrease their use of alcohol. Insufficient time and perceived low patient motivation were commonly cited barriers. CONCLUSION: These findings highlight the need for the development and evaluation of educational curricula to teach physicians brief, evidence-based approaches to helping patients make these changes in their health-related behaviours.

Patient loneliness in an urban, underserved family medicine residency clinic: prevalence and relationship to health care utilization.

BACKGROUND: Mounting evidence suggests that loneliness increases the risk of poor health outcomes, including cardiovascular disease and premature mortality.Objective: This study examined the prevalence of loneliness in an urban, underserved family medicine residency clinic and the association of loneliness with health care utilization. METHODS: Adult patients (N = 330; M age = 42.1 years, SD = 14.9; 63% female; 58% African American) completed the 3-item UCLA Loneliness screener at their primary care visits between November 2018 and January 2019. A retrospective case-control study design was used to compare health care utilization [hospitalizations, emergency department (ED) visits, primary care visits, no-shows and referrals] in the prior 2 years between patients who identified as lonely versus those who did not. Covariates included demographics and clinical characteristics. RESULTS: Nearly half (44%) of patients exceeded the cut-off for loneliness. Patients who were lonely were more likely to identify as African American, have depression and have a substance use disorder. Patients in the lonely group had significantly longer hospital stays and more primary care visits, no-shows and referrals than patients in the non-lonely group; there were no differences in number of hospitalizations or ED visits. CONCLUSIONS: The prevalence of loneliness in an urban, underserved primary care clinic was much higher than prior prevalence estimates in primary care. Patients who are lonely may use more health care resources than patients who are not lonely. Primary care may be an ideal setting in which to identify patients who are lonely to further understand the impact of loneliness on health care outcomes.

Values-Based Behavioral Activation for Chronic Pain in Primary Care: A Pilot Study.

Chronic pain is prevalent and can be complex to manage in primary care. Encouraging patients with chronic pain to engage in valued activities has been associated with reduced disability and distress. This single-arm, mixed methods pilot study examined whether adding a values-based behavioral activation intervention to a chronic pain protocol is feasible and acceptable in an urban, underserved family medicine residency clinic. Patients (N = 30) living with chronic pain completed a values assessment and co-created a plan with a psychologist to engage in values-based activities. Patients completed self-report measures of psychological health and functioning pre- and post-intervention and a qualitative interview at the follow-up visit. The intervention was considered feasible and acceptable. Patients reported high levels of satisfaction and enjoyment of the intervention and significantly less pain interference at follow-up compared to baseline. Values-based behavioral activation for chronic pain may be implemented as part of behavioral health practice in primary care.

Supporting families managing parental mental illness: Challenges and resources.

Over five million children in the United States have a parent living with a serious mental illness. These offspring are at higher risk for developing mental health problems themselves due to a complex interplay of biological, psychological, and psychosocial factors. Life with a parent with psychiatric symptoms can be scary, confusing, overwhelming, and sad; children often blame themselves for their parent's problems, find their parent's behavior embarrassing, and struggle to explain the illness to their friends. Unfortunately, these children's needs and experiences are often ignored by overwhelmed parents, worried family members and relatives, separate mental health systems of care for adults and children that often fail to coordinate care, and even well-intentioned health-care providers. Family medicine teams have an opportunity to detect and support these families in unique ways. We offer four recommendations for family medicine teams to help families managing parental mental illness including assessing functioning, treatment needs, and impacts on each family member; educating all family members about mental illness; instilling hope, noting the range of effective treatments for mental illness; and encouraging the use of supports and referral options. Providers can leverage family members' strengths, work with community-based resources, and offer continuity to these families, as they struggle with an oftentimes chronic, relapsing disease that has ripple effects throughout the family system.

What is success in treatment for opioid use disorder? Perspectives of physicians and patients in primary care settings.

INTRODUCTION: Clinicians and researchers have traditionally relied on treatment retention and opioid abstinence as the primary measures of treatment success for people with opioid use disorder (OUD). However, these measures may not capture the range of clinically important treatment outcomes. The study sought to identify indicators of success in primary care-based medication for OUD (MOUD) treatment from the perspectives of patients with OUD and the physicians who treat them. METHODS: The study recruited patients (N = 18; M age = 38.1 years, SD = 11.5; 44% female) and physicians (N = 14; M age = 34.6, SD = 6.8 years; 57% female) from two academic family medicine residency clinics in the upper Midwest to participate in semi-structured qualitative interviews. Participants reflected on signs of progress and success in primary care MOUD treatment. Interviews were recorded, transcribed, and analyzed using an inductive thematic analysis approach. RESULTS: Seven themes of success emerged: (1) staying sober; (2) tapering off buprenorphine; (3) taking steps to improve physical and mental health; (4) improved psychological well-being; (5) improved relationships; (6) improved role functioning; and (7) decreased stigma and shame. Interviews with both patients and physicians supported five of the seven themes, with patients also describing themes of tapering off buprenorphine and reduced stigma and shame. CONCLUSIONS: Themes suggest that a wider view of success, in addition to maintaining sobriety, is needed when considering outcomes for MOUD programs delivered in primary care settings. Future work should identify appropriate outcome measures and potential adjunctive treatments.

Providing Psychotherapy in an Urban, Underserved Community during the COVID-19 Pandemic.

Psychologists housed in two family medicine residency clinics located in underserved communities quickly transitioned their mode of psychotherapy from in-person to completely virtual at the beginning of the COVID-19 pandemic. We share numerous successes and advantages of a telehealth model in serving our community and describe challenges we have encountered.

Longitudinal assessment of mental health and well-being in patients being treated with medications for opioid use disorder in primary care.

Opioid use disorder (OUD) continues to be a significant problem in the United States, contributing to overdose and death. Recent efforts to expand access to treatment of OUD in primary care have increased the availability of medications for OUD (MOUDs). However, OUD is often accompanied by poor mental health and well-being, and it is not known if treatment with MOUDs alone is associated with improved psychological well-being. This study's purpose was to examine changes in mental health and well-being in the first 6 months of treatment with MOUDs in a family medicine residency clinic. Patients (N = 126; M age = 34.6 years, SD = 10.6; 54.8% male; 71.4% white) completed validated screeners of mental health and well-being (depression, anxiety, anger, loneliness, perceived stress, meaning in life, and life satisfaction) at baseline (induction visit for buprenorphine), 1-month, and 6-months. Results indicated that the mental health and well-being indices did not significantly change over the first 6 months of treatment on MOUDs. There were initial decreases in depression and anxiety at 1-month; however, both increased and were equivalent to baseline levels at 6-months. These results suggest that MOUD treatment alone does not significantly impact mental health or well-being in patients with OUD. Additional treatments or supports are clearly needed to address the comorbid mental health and well-being challenges in this population, as these factors can be both antecedents and consequences of substance misuse.

Awareness of Meaning in Life is Protective Against Burnout Among Family Physicians: A CERA Study.

BACKGROUND AND OBJECTIVES: Burnout is considered a public health crisis among physicians and is related to poor quality of life, increased medical errors, and lower patient satisfaction. A recent literature review and conceptual model suggest that awareness of life meaning, or meaning salience, is related to improved stress and coping, and may also reduce experience of burnout. This study examined associations among meaning salience, burnout, fatigue, and quality of life among family medicine residency program directors. METHODS: Data were collected via an online survey administered by the Council of Academic Family Medicine (CAFM) Educational Research Alliance (CERA; n=268, response rate of 45.4%) in December 2018. Program directors completed measures of meaning salience, burnout, fatigue, and quality of life. Data were analyzed using Spearman correlations and path analysis. RESULTS: Program directors who reported greater experienced meaning salience also reported significantly less burnout (ß=-.40, P<.001) and less fatigue (ß=-.38, P<.001), which were then both significantly associated with greater quality of life (Ps<.001). Program directors who reported greater meaning salience also reported greater quality of life (ß=.21, P<.001). Additionally, there were significant indirect associations between meaning salience and quality of life through less burnout and fatigue (ß=.26, P<.001). CONCLUSIONS: The potential for increasing physicians' awareness of their sense of meaning as a means to prevent or decrease burnout is underresearched and warrants further study. Both preventive measures (eg, wellness curricula) and interventions with already-distressed physicians may encourage regular reflection on meaning in life, especially during busy workdays.

Predictors of Family Medicine Patient Retention in Opioid Medication-Assisted Treatment.

PURPOSE: Opioid use disorder is a prevalent and chronic condition that can lead to adverse outcomes if untreated. Medication-assisted treatment (MAT) with buprenorphine in a primary care setting has the potential to increase availability of treatment and reduce harm; however, retention in MAT is key for patient success. This study's purpose was to examine predictors of retention in a MAT program for OUD in a family medicine residency clinic. METHODS: A retrospective chart review was conducted for 238 patients diagnosed with OUD and receiving MAT at a family medicine residency clinic between 2015 to 2017, with visit and prescription data collected through December 2018. Cox-proportional hazards models were used to examine the length of time in treatment. RESULTS: Over three-fourths of our patients were retained for at least 3 months, 69% for at least 6 months, and 48% retained for at least 1 year. Physician continuity of care and having insurance coverage significantly predicted retention and longer duration of treatment. CONCLUSIONS: Continuity of care and having health insurance were key predictors of patient retention in MAT care. Our findings emphasize the clinical significance of maintaining physician continuity of care to improve retention of patients with OUD in MAT programs. Future research could explore what aspects of continuity of care lead to retention in OUD treatment.

Mental Health and Psychosocial Needs of Patients Being Treated for Opioid Use Disorder in a Primary Care Residency Clinic.

Purpose: Primary care is an ideal setting to deliver efficacious treatments for opioid use disorder (OUD). Primary care providers need to be aware of other concerns patients with OUD might have in order to provide comprehensive care. This study describes the prevalence of mental health, comorbid substance use, and psychosocial concerns of patients seeking treatment for OUD in primary care and their relation to 6-month treatment retention. Methods: Patients (N = 100; M age = 34.9 years (SD = 10.8), 74% white, 46% female) with OUD who were starting treatment with buprenorphine at an academic family medicine residency clinic completed surveys of mental health concerns (depression, anxiety, trauma), psychosocial needs (food insecurity, income, transportation, employment), and demographic variables. Chart reviews were conducted to gather information on comorbid substance use, mental health diagnoses, and 6-month treatment retention. Results: Mental health symptoms were highly prevalent in this sample (44% screened positive for anxiety, 31% for depression, and 52% for posttraumatic stress disorder). Three-quarters reported use of illicit substances other than opioids. Many patients also had significant psychosocial concerns, including unemployment (54%), low income (75%), food insecurity (51%), and lacking reliable transportation (64%). Two-thirds (67%) of the sample were retained at 6 months; patients who previously used intravenous opioids were more likely to discontinue treatment (P = .003). Conclusions: Many patients receiving treatment for OUD have significant mental health problems, comorbid substance use, and psychosocial concerns; interestingly, none of these factors predicted treatment retention at 6 months. Primary care clinics would benefit from having appropriate resources, interventions, and referrals for these comorbid issues in order to enhance overall patient well-being and promote recovery.

Violence between therapy-seeking veterans and their partners: prevalence and characteristics of nonviolent, mutually violent, and one-sided violent couples.

Among male veterans and their female partners seeking therapy for relationship issues, three violence profiles were identified based on self-reports of physical violence: nonviolent, in which neither partner reported perpetrating physical violence (44%); one-sided violent, in which one partner reported perpetrating violence (30%); and mutually violent, in which both partners reported perpetrating physical violence (26%). Profiles were distinguished based on the veteran's psychiatric diagnosis, woman's age, and both partners' reports of the frequency and severity of violence. Men and women in mutually violent couples reported more verbal and physical aggression than did men or women in any other group. The three groups reported comparable rates of sexual aggression. Appraisals of marital satisfaction and intimacy were not different based on violence profile. No gender differences emerged in the self-reports of frequency and severity of verbal, physical, and sexual aggression.

Implicit Bias Training in a Residency Program: Aiming for Enduring Effects.

BACKGROUND AND OBJECTIVES: Implicit bias often affects patient care in insidious ways, and has the potential for significant damage. Several educational interventions regarding implicit bias have been developed for health care professionals, many of which foster reflection on individual biases and encourage personal awareness. In an attempt to address racism and other implicit biases at a more systemic level in our family medicine residency training program, our objectives were to offer and evaluate parallel trainings for residents and faculty by a national expert. METHODS: The trainings addressed how both personal biases and institutional inequities contribute to structural racism, and taught skills for managing instances of implicit biases in one's professional interactions. The training was deliberately designed to increase institutional capacity to engage in crucial conversations regarding implicit bias. Six months after the trainings, an external evaluator conducted two separate 1-hour focus groups, one with residents (n=18) and one with program faculty and leadership (n=13). RESULTS: Four themes emerged in the focus groups: increased awareness of and commitment to addressing racial bias; appreciation of a safe forum for sharing concerns; new ways of addressing and managing bias; and institutional capacity building for continued vigilance and training regarding implicit bias. CONCLUSIONS: Both residents and faculty found this training to be important and empowering. All participants desired an ongoing programmatic commitment to the topic.

The family forum: directions for the implementation of family psychoeducation for severe mental illness.

It is well documented that family psychoeducation decreases relapse rates of individuals with schizophrenia. Despite the evidence, surveys indicate that families have minimal contact with their relative's treatment team, let alone participate in the evidence-based practice of family psychoeducation. The Department of Veterans Affairs (VA) sponsored a conference, the Family Forum, to assess the state of the art regarding family psychoeducation and to form a consensus regarding the next steps to increase family involvement. The forum reached consensus on these issues: family psychoeducation treatment models should be optimized by efforts to identify the factors mediating their success in order to maximize dissemination; leadership support, training in family psychoeducation models for managers and clinicians, and adequate resources are necessary to successfully implement family psychoeducation; because family psychoeducation may not be appropriate, indicated, or acceptable for all families, additional complementary strategies are needed that involve families in the mental health care of the patient; and work is required to develop and validate instruments that appropriately assess the intervention process and consumer and family outcomes. A treatment heuristic for working with families of persons with severe mental illness is also offered and provides a match of interventions at varying levels of intensity, tailored to family and consumer needs and circumstances. The article describes opportunities for the research and clinical communities to expand the proportion of families served.

Family-focused interventions and resources for veterans and their families.

Accelerated by the decreasing military presence in Iraq and Afghanistan, many military members are currently transitioning out of active duty into civilian life. Many of these new veterans have recently experienced combat deployment(s), and some are struggling with the aftermath of combat exposure, separation from family, and reintegration stressors. These challenges often follow these military families as they enter the civilian world, a time with its own major life changes vocationally, socially, and interpersonally. Although numerous resources have been developed to assist service members during their transition to the civilian world, relatively fewer exist for partners, children, and broader family systems. Family psychoeducation is a nonpathologizing, strengths-focused model of care that has documented benefits in the arena of mental illness. This article describes some manualized family psychoeducational programs and online and phone-based resources that may be useful to veteran families during this time of change. The programs and resources described herein are all available for free, primarily online. Because of a wide variety of barriers and limitations for family based care in the Veterans Affairs health care system, veteran families are and will continue to seek mental health care in public sector settings. Community providers can enhance their military culture competence by familiarizing themselves with these resources and drawing upon them in working with transitioning military families. (PsycINFO Database Record

Video Review Process: Enhancing Impact and Resident/Faculty Satisfaction.

INTRODUCTION: Although video review (VR) is a common component of family medicine (FM) resident education, levels of faculty and resident satisfaction and the perceived impact of the VR process are unknown. Our FM residency program made several changes to our VR process, including a new feedback form highlighting strengths and areas for growth, a post-VR email to the resident including a tip sheet on an identified skill, and follow-up shadowing by a behavioral health clinician to increase VR impact and reinforce skill development. METHODS: FM residency faculty (n=11) and residents (n=34) completed an anonymous 20-item online survey. The survey was administered twice, first at baseline and then 9 months after the changes were instituted. Survey questions targeted the preceding 9 months and assessed satisfaction with VRs and perceived value and impact of the VR process. RESULTS: At baseline, both faculty and residents reported low levels of satisfaction and perceived impact and value of the VR process. Among both residents and faculty, significant improvements emerged in ratings of satisfaction and perceived value of the VR process. At postsurvey, significantly more residents reported feeling equipped with specific tips on how to improve their communication skills after VR than at baseline. CONCLUSION: Our evaluation documented significant improvements in satisfaction and perceived value in our VR process following the changes in our procedures. Future research could develop measures to assess communication skills that are more sensitive to change, thereby strengthening this line of research by supplementing self-report data with more objective observational data.

Promoting Documentation of Suicidality in a Family Medicine Residency Clinic.

BACKGROUND AND OBJECTIVES: Careful assessment of depression and suicidality are important given their prevalence and consequences for quality of life. Our study evaluated the impact of an educational intervention in a family medicine residency clinic on rates of provider documentation regarding suicidality. METHODS: We offered two brief workshops to our clinic staff and created two standardized charting templates to empower and educate providers. One template used with the patient during the clinic visit elicited key factors (eg, plan, intent, barriers) and offered treatment plan options. The second template included supportive text and resources to include in the after-visit summary. A chart review was completed, examining 350 patient records in which the patient reported thoughts of death or suicide in the preceding 2 weeks on the Patient Health Questionnaire-9 ([PHQ-9], 150 over a 5-month baseline period, 150 in months 1 through 4 immediately following the workshops and template development, and 50 at follow-up months 7 through 8 following the intervention). We examined use of the templates and changes in rates of documentation of suicidality. RESULTS: Rates of provider documentation of suicidality for patients who had expressed suicidal ideation on the PHQ-9 increased significantly from 57% at baseline to 78% in the postintervention phase; the rise persisted at follow-up. Rates of use of the assessment template were 58% (postintervention) and 49% (follow-up). Anecdotal provider feedback reflected appreciation of the templates for assessing and documenting challenging issues. CONCLUSIONS: Brief educational interventions were associated with improved rates of provider documentation of suicidality. The longer-term impact of the workshops and templates warrant further investigation.

Domestic violence in veterans with posttraumatic stress disorder who seek couples therapy.

Domestic violence rates among veterans with posttraumatic stress disorder (PTSD) are higher than those of the general population. Individuals who have been diagnosed with PTSD who seek couples therapy with their partners constitute an understudied population. Self-report measures of domestic violence, relationship satisfaction, and intimacy were administered at intake to 179 couples seeking relationship therapy at a Veterans Affairs clinic. Couples in which the veteran was diagnosed with combat-related PTSD were compared with two other groups based on the veteran's primary diagnosis (depression, adjustment disorder/V-code). Both the PTSD- and depression-diagnosed veterans perpetrated more violence than did those with adjustment/V-code diagnoses. Domestic violence rates among depressed and PTSD-diagnosed veterans were much higher than those found in previous research. Implications for assessment and treatment are discussed.