A state-led framework for value-based purchasing to incent integration.

Addressing healthcare costs requires incenting providers to address both physical and behavioral health conditions, as well as social determinants of health. The most complex, and expensive, patients are often those with comorbid mental illness and/or addiction, who are at higher risk for exposure to violence, food insecurity, unstable housing and other adversities that negatively affect health. Yet today's value-based payment models and associated quality measures do not incent providers to address patients' behavioral and social needs. We propose a state-led framework for moving towards fully integrated accountability through improved value-based payment and measurement.

Coping and resiliency enhancement program (CARE): a pilot study for interpreters in cancer care.

OBJECTIVE: There is a growing demand for interpreters in the cancer setting. Interpreters, the link to quality care for limited English proficiency patients, face many psychosocial stressors in their work. This project assessed interpreters' experiences of stress and piloted a resiliency program to help interpreters cope with stressors. METHODS: From 2013 to 2014, we pilot tested a targeted resiliency program with interpreters from three Boston-based hospitals. In Phase 1, we conducted five focus groups (n = 31) to identify interpreters' psychosocial needs. In Phase 2, we developed and tested a 4-h group program with 29 interpreters (response rate = 90%; 69% female, 54% Hispanic, 85% born outside of the U.S.). RESULTS: Phase 1. Stressors were patient-based (seeing young patients decline), interactions with medical team (unsure of role), and systems-based (appointment unpredictability). Phase 2. At baseline interpreters reported low abilities to cope with stress (measured by the Measure of Current Status (MOCS-A)). At 4-week follow-up we found improvements in job satisfaction (p = .02; Cohen's d = .41) and declines in sick days (p = .08; Cohen's d = .38). Stress reactivity (MOCS-A) improved; specifically participants reported feeling more assertive about their needs (p = .10; Cohen's d = .30) and more able to relax at will (p = .10; Cohen's d = .35)-important mechanisms to lower distress. CONCLUSIONS: We piloted a resiliency program for medical interpreters in cancer care. We found that interpreters experience distress and have low coping skills. This program resulted in improved work factors and stress reactivity. Future research should include further implementation and testing in a larger, randomized trial.Copyright © 2016 John Wiley & Sons, Ltd.

Building Resiliency in a Palliative Care Team: A Pilot Study.

CONTEXT: Palliative care clinicians (PCCs) are vulnerable to burnout as a result of chronic stress related to working with seriously ill patients. Burnout can lead to absenteeism, ineffective communication, medical errors, and job turnover. Interventions that promote better coping with stress are needed in this population. OBJECTIVES: This pilot study tested the feasibility of the Relaxation Response Resiliency Program for Palliative Care Clinicians, a program targeted to decrease stress and increase resiliency, in a multidisciplinary cohort of PCCs (N = 16) at a major academic medical center. METHODS: A physician delivered the intervention over two months in five sessions (12 hours total). Data were collected the week before the program start and two months after completion. The main outcome was feasibility of the program. Changes in perceived stress, positive and negative affect, perspective taking, optimism, satisfaction with life, and self-efficacy were examined using nonparametric statistical tests. Effect size was quantified using Cohen's d. RESULTS: The intervention was feasible; all participants attended at least four of the five sessions, and there was no attrition. After the intervention, participants showed reductions in perceived stress and improvements in perspective taking. CONCLUSION: Our findings suggest that a novel team-based resiliency intervention based on elicitation of the relaxation response was feasible and may help promote resiliency and protect against the negative consequences of stress for PCCs.

Clinician considerations when selecting high-risk patients for care management.

OBJECTIVES: Hybrid approaches to case finding show promise as a method to increase the success of care management programs (CMPs). A large healthcare system implemented a hybrid approach in which clinicians review algorithm-generated lists of potential high-risk patients within their practice and select the patients most appropriate for the CMP. We sought to understand the criteria clinicians used when selecting patients. STUDY DESIGN: We conducted 20 semi-structured interviews with a convenience sample of primary care clinicians and their care managers from a diverse set of practices. METHODS: Two independent reviewers thematically coded interview responses through an iterative process. RESULTS: In addition to clinical need (eg, disease severity or multiple comorbidities), interviewees considered a number of nonclinical patient characteristics that they felt placed patients at risk for suboptimal healthcare utilization and poor adherence. These include patients' predisposing (eg, health literacy or navigation challenges, physical vulnerabilities, insight regarding their health) and enabling characteristics (eg, social and home environment, coping skills, financial resources). Interviewees also considered patients' existing linkages with the health system and whether other clinicians were already meeting a patient's care needs. CONCLUSIONS: In selecting patients for a CMP, clinicians considered patient characteristics that are not easily captured in standard clinical and administrative data. A hybrid approach to case finding concentrates clinician review on patients who meet standard clinical and healthcare utilization criteria, and allows clinicians to incorporate knowledge of patients' predisposing and enabling characteristics that are not readily maintained in clinical data.

The effectiveness of a brief mind-body intervention for treating depression in community health center patients.

OBJECTIVE: The objective of this pilot study was to examine the effects of a brief, 6-week, 1.5-hour mind-body intervention for depression (MBID) in patients being treated for depression in 2 community health centers. DESIGN: The MBID taught techniques such as meditation that elicit the relaxation response (RR) in combination with additional resiliency-enhancing components. Clinical outcomes of 24 depressed patients were measured pre-MBID, at completion of MBID, and 3 months post-MBID, using the Center for Epidemiological Studies Depression Scale (CES-D 10), Quality of Life Scale (QoL5), SF-12 Health Survey (SF-12), and Health-Promoting Lifestyle Profile-II (HPLP-II). RESULTS: Significant post-treatment improvements were shown in depressive symptoms, spiritual growth, mental health, and quality of life, with a median CES-D 10 change from 17.5 (interquartile ratio [IQR] 13.3-22) to 12 (IQR 10-17.5; P<.001); a median HPLP-II Spiritual Growth subscale change from 2.0 (IQR 1.8-2.3) to 2.3 (IQR 2.0-3.0; P=.002) and a median HPLP-II Stress Management subscale change from 2.0 (IQR 1.8-2.4) to 2.4 (IQR 2.0-2.9; P=.027); significant improvement in median score on the QoL-5 from 53.3 (IQR 47.5-62.5) at baseline to 63.3 at endpoint (IQR 50-70; P=.008). Three-month follow-up data suggest that the improvement in outcomes were sustained 3 months after the intervention. CONCLUSIONS: Participation in a 6-week RR-based MBID is associated with an improvement in depression, spiritual growth, and mental health among depressed community health center patients.

Promoting resiliency among palliative care clinicians: stressors, coping strategies, and training needs.

BACKGROUND: Palliative care clinicians (PCCs) are susceptible to burnout, as they regularly witness immense patient and family suffering; however, little is known about their specific challenges and training needs to enhance their long-term sustainability. OBJECTIVE: The purpose of this qualitative study was to explore common stressors, coping strategies, and training needs among PCCs in efforts to inform the development of a targeted Resiliency Program. METHODS: Utilizing a semistructured interview guide, we conducted a series of in-depth interviews with 15 PCCs at the Massachusetts General Hospital. RESULTS: Content analysis highlighted three main areas of stressors: (1) systematic challenges related to managing large, emotionally demanding caseloads within time constraints; (2) patient factors, such as addressing patients' mutable needs, managing family dynamics, and meeting patient and family demands and expectations; and (3) personal challenges of delineating emotional and professional boundaries. Engaging in healthy behaviors and hobbies and seeking emotional support from colleagues and friends were among the most common methods of coping with stressors. In terms of programmatic topics, PCCs desired training in mind-body skills (e.g., breathing, yoga, meditation), health education about the effects of stress, and cognitive strategies to help reduce ruminative thoughts and negative self-talk. A majority of clinicians stressed the need for brief strategies that could be readily integrated in the workplace. CONCLUSIONS: These results suggest that an intervention aimed to enhance PCC sustainability should focus on utilizing a skill-building approach to stress reduction that imparts strategies that can be readily utilized during work hours.

A healthy aging program for older adults: effects on self-efficacy and morale.

CONTEXT: As of 2012, 810 million people worldwide were older than 60 y, accounting for 11% of the population. That number is expected to rise to 2 billion by 2050 or to 22% of the overall population. As a result, a growing need exists to understand the factors that promote mental and physical health in older populations. OBJECTIVES: The purpose of this study was to develop a healthy aging program for older adults and to measure the changes from baseline to the end of the program in participants' relevant psychosocial outcomes (ie, self-efficacy and morale). DESIGN: The study's healthy aging mind-body intervention (MBI) was adapted from the Relaxation Response Resiliency Program (3RP) at the Benson-Henry Institute for Mind Body Medicine, which incorporates elements from the fields of stress management, cognitive behavioral therapy, and positive psychology. That program was modified with examples and exercises targeted to an older population and evaluated in the current single-arm pilot study. SETTING: The program took place at the Massachusetts General Hospital (MGH). PARTICIPANTS: The 9-wk healthy aging MBI was developed for participants aged 65 y and older. Fifty-one older adults from the surrounding community participated in the study's groups. INTERVENTION: A new intervention group began the program every 3 mo, with a maximum of 12 individuals per group. For each group, the MBI consisted of weekly 90-min sessions for 9 consecutive wk, directed by a psychologist. The program included sessions that taught participants (1) a variety of methods to elicit the relaxation response (RR), (2) the practice of adaptive coping and cognitions, (3) behaviors necessary to create a healthy lifestyle, and (4) methods of building social support. OUTCOME MEASURES: The research team chose to focus on 2 psychological variables of interest for aging populations: morale and self-efficacy. The study used 2 questionnaires to measure those outcomes, the Philadelphia Geriatric Center Morale Scale (PGCMS), a multidimensional measure of the psychological state of older people, and the Coping Self-efficacy Scale (CSES), a measure that addresses the multiple dimensions of self-efficacy. RESULTS: Data from 5 intervention groups were combined for the current analysis. Forty-six participants enrolled and completed questionnaires. Of those participants, 41 attended at least 7 of the 9 sessions. Significant increases in self-efficacy and morale were observed for program completers. After a highly conservative sensitivity analysis, the change for the measure of self-efficacy remained significant, and the change for the measure of morale trended toward significance. CONCLUSIONS: The study's healthy aging program appears to be a feasible intervention for older adults, with the potential to increase levels of self-efficacy and morale in participants. Further research is warranted to determine its effects on other psychosocial outcomes and health care utilization in aging populations.

The effectiveness of a community-based, mind-body group for symptoms of depression and anxiety.

CONTEXT: The prevalence of depression and other mental health conditions is on the rise, with an estimated 350 million people affected. Populations with lower socioeconomic status are at higher risk for mental health problems, including depression and anxiety. Community health centers (CHCs) often have wait lists for individual counseling. Group mind-body interventions (MBIs) that are based on the relaxation response (RR) are plausible options for treating mental health conditions at CHCs. OBJECTIVE: The study examined the feasibility and effectiveness of an 8-wk MBI developed at the Benson-Henry Institute for Mind Body Medicine (BHI) for treatment of symptoms of depression and anxiety in a community-based population. DESIGN: The research team designed a retrospective, open-label study of 124 patients with symptoms of depression or anxiety enrolled in an MBI as a group. SETTING: The setting for the study was 2 CHCs at Massachusetts General Hospital (MGH) in Boston, MA, USA. PARTICIPANTS: Participants were adult patients at MGH with symptoms of depression and/or anxiety. The program was billed as treatment related to behavioral health and accessible to people with all levels of education. INTERVENTION: The MBI for depression and/or anxiety in the current study teaches techniques that elicit a relaxation response (RR), in combination with additional resiliencyenhancing components. OUTCOME MEASURES: To examine effects of the program, self-report clinical measures were administered pre- and postintervention: (1) for depression, the Center for Epidemiologic Studies Depression Scale (CES-D10); (2) for anxiety, the State-Trait Anxiety Inventory-State Subscale (STAI-State); and (3) for perceived stress, the Perceived Stress Scale (PSS-10). RESULTS: The intervention was associated with a significant decrease in depressive symptoms: 95% CI, -6.0 to -2.6 (P < .001); anxiety--95% CI -12.6 to -2.2 (P = .007); and perceived stress--95% CI -7.6 to -2.0 (P = .001). Approximately 52.4% of the participants completed at least 75% of the 8 sessions, with 5 sessions attended on average. CONCLUSIONS: Participation in this MBI was associated with an improvement in symptoms of depression and anxiety as well as decreases in perceived stress among CHC patients.