[Yellow Cohort] Module 5 2018-2019 – Psychosocial and Behavioral Determinants of

[Nabil Al-Kourainy]

Please submit your SOAPs for Module 5 below:

[Nabil Al-Kourainy]

With the 5 domains of the psychosocial model of care for change in mind, I am reminded of a patient encounter with Ms. C, a 54-year-old female who had recently been evicted from her daughter’s house due to a long-standing addiction to crack-cocaine. After receiving cocaine cessation counseling, Ms. C stated that she was open to quitting, and wanted to get her life on track so that she could be able to spend time with her daughter and granddaughter. With the knowledge that this was indeed a tall order, given her long-standing use of cocaine, and her moderate major depressive disorder, I made efforts to delve into her social support system. She told me that up until a couple days prior to our encounter, she had been living in a duplex owned by her daughter. She had access to social security, disability benefits due to her ESRD on iHD, food stamps, and a vehicle. Despite those resources, she had been evicted by her daughter by court order for lack of payment of rent. She confided in me that her drug dealer often allowed her to purchase cocaine on credit and then charged her interest on the drugs in addition to charging her exorbitant fees for the crack-cocaine. To assess her Community and Environmental Resources, I asked her how she pays for medical care and how she gets to medical visits. She stated that she had Medicaid/Medicare and transportation provided to and from iHD thrice weekly. To assess Behavioral and Substance Use Disorders, I asked her more about her substance use history. She stated she was chronic 30+ 2-3 times weekly user of crack-cocaine but was interested in quitting. We set a quit date for the following Monday, and I provided her with resources for substance use disorder clinics and treatment facilities. I congratulated Ms. C on her willingness to strive for a healthier life and the hope of rekindling her relationship with her daughter and in turn her granddaughter. These seemed to be her main motivations to “get clean” Overall, I was encouraged that Ms. C was committed to make efforts to better her health. I also put her in touch with Detroit Central City for mental health and substance use disorder management, as the pt’s depression was contributing to her desire to self-medicate with crack-cocaine. We also decided on a trial of SSRIs together I encouraged Ms. C to continue to improve her life and offered her support in this endeavor.

[John Dawdy]

The 5 domains of the psychosocial model of care are support, resources, behavioral, psychiatric, biomedical. Both screening and in-depth questions are important to best assess these domains with your patient. Insight regarding a patient’s support systems helps better understand the barriers that they face to receiving optimal care. One patient interaction that emphasizes this point was somebody that I had met in the ED this past week, where they presented to the ED each day during the week for minimal complaints. Given the severely cold weather, this was their way of getting out of the cold. It didn’t take much questioning to discover they had little social support to find alternate shelter or assistance in making other arrangements. Moving to the second aspect, this patient had few resources available to him in order to assist with finding an alternate solution to returning to the ED when cold. Resources can mean a variety of different things including housing, money, food, insurance, transportation, etc. Our patients often are lacking one or many of these resources and require our assistance in accessing them through state or charitable programs. This lack of resources can impact our patients in many ways, whether it be a lack of transportation to appointments or ability to obtain prescription medications. Behavioral/Substance use disorders are common and often difficult to both identify and treat. At times these can be tied into psychiatric issues that our patients may be struggling with. In the case of the gentleman in the ED, he likely had a personality disorder that has hindered his social interactions throughout his life, making it difficult for him to interact with those in his life, including those trying to assist him during his ED visits. He is often resistant to this assistance and has a poor insight into why his current solution was not ideal to continue. This can also work in another way, in that being labeled with a psychiatric disorder can often carry over between medical system encounters, predisposing health care providers to jumping to conclusions about a patient’s ability to carry through with care plans and at times impact the care that they receive. Finally, biomedical can involve all of the above pillars and how they impact the underlying pathology that the patient may have. These can manifest overall through a patient functional status. Asking about activities of daily living, how they are accomplished and who is there to help can provide a good overall picture of the patient’s well being and support system. Overall, understanding these domains for each of our patients allows us to better treat the patient as a whole and not just as a disease process. It is crucial that we take these into account when we are delivering care regardless of the setting, but continuity clinic provides a particular opportunity to build rapport with our patients over multiple visits in order to gain greater insight than might be gleaned from a hospital admission or ED visit.

[Jane]

Practical support from family and friends — such as help with reading labels, filling pill boxes and transportation — can be a simple and cost-effective way to improve medication adherence and chronic disease management for patients, concluded the study. Assistance and support from families, friends, and other individuals have been connected with promoting patients’ adherence by encouraging optimism and self-esteem, buffering the stresses of being ill, reducing patient depression, and improving sick-role behavior.
We had a guy in VA who was very much addicted and had some severe mental health issues. we worked with him on his meds. We tried everything to educate him but still not compliant. It was the family suggested and we finally found out that the first thing he did every morning was put on his dentures. So we put his pills just beside his dentures and family set an alarm to call him in the morning to remind him to take his pills. It comes down to relationship and figuring out if you’re speaking in a way that patients can understand.
Particularly in homeless or uninsured/underinsured populations, it is important to consider socioeconomic status, environment, behavioral factors, and access to the health system. The patient’s personal support network of friends and family is closely integrated with these social determinants and can be essential to achievement and maintenance of health. Indeed, family and social support have been found to have stronger influence on care plan adherence than biomedical factors, even for discrete interventions such as cardiac rehabilitation
Leveraging a patient’s existing social contacts and networks to help them with the practical aspects of being adherent, such as providing transportation to the pharmacy or picking up medications for the patient, could be both an effective and cost-effective way to help improve adherence. However of course, Clinicians should continue to promote social and family support, they cannot assume that such support would necessarily include and result in support for, and promotion of, future and continued medication adherence. Active interventions in support of patient’s adherence to medication may need to be incorporated in interactions, even with patients who have relatively more supportive families.

[Shivani Agrawal]

With the extreme cold weather we have had recently, I think it has affected our patients’ ability to get care. I just finished NF – I had far fewer admissions during those super cold days. However, once our weather improved, it seems like people waited to get care and then arrived sicker once the weather cleared up. I know the weather was an inconvenience for all of us but for many of our patients, it likely lead to extreme hardships. For example, I turned down my heat after getting the warning from the energy company. However, I have enough extra clothing/blankets to make sure I was warm. This may not be available to everyone, there were deaths reported across the midwest due to the weather.

Now during clinic week, many patients reported due to the weather – they have missed other appointments/ tests. I am sure others missed medications since they could not get to the pharmacy. When reviewing the module, social support and access to resources in an important part of healthcare.

[Muhammad Usama]

The roots of ‘psychosocial health’ lie in the World Health Organization’s (WHO) definition of health as ‘a state of complete physical mental and social well-being, and not merely the absence of disease and infirmity’. Personally, I find this definition beautiful because it incorporates psychosocial factors in health. We often downplay this fact but social structural factors mediate effects on individual health outcomes. I recently cared for a patient who unfortunately had an ACS after being evicted from his home. This clinic week to have an impact on patients’ risk of chronic disease, I dedicated time in my patient encounters to intervene in the four prominent health behaviors influencing chronic disease: alcohol and other substance abuse, cigarette smoking, dietary patterns, and physical activity patterns which turned out to be very fruitful. By being mindful of behavioral and psychosocial factors and addressing them, I believe, we will be able to make a positive impact on our patients’ lives.

[Marvin Kajy]

When a healthcare professional is asked to figure out what is wrong with the patient, the first step in assessing the patient broadly is using the biopsychosocial model. The psychosocial component looks at the patient in the context of the combined influence that psychological factors and the surrounding environment have on their physical and mental wellness and their ability to function in their daily lives. As we were having our group discussions, I could not help but think about the patients that I care for on a daily basis. One patient is Ms D who is a 65 yo gentleman with a past medical history of schizophrenia, type 2 diabetes and hypertension who follows up with my at GMAP clinic. I initially took care of the patient at the end of my first year. At that time, he was homeless and was not taking any medications. It was very difficult to communicate with him because he was very tangential in speech and his thoughts were not clear. Often times I felt like he was not understanding or I could not understand him. Initial hbA1c measured in the clinic was >15% and BP was 160/100. We setup the patient appropriate mental health services and started him on appropriate hypoglycemic and antihypertensive regimen. I analyzed the patient from a biopsychosocal standpoint. In terms of support, he had no family but had some friends that he had met at his neighborhood shelter. The patient had little to no resources as he has lost most of his money during the 2008 economic collapse when he lost his job in car manufacturing plant. In terms of substance use, the patient did use heroin initially to “escape” the stressors of life after he lost his job. However, he now smokes marijuana socially. From a psychiatric standpoint, the patient has a history of schizophrenia and has been off medications for many years. Lastly from a biomedical standpoint, the patient had comorbidities of diabetes and hypertension. When I think about Mr D, the theory of the drift hypothesis comes to mind. This hypothesis states that illness causes one’s downward spiral in social class. It accounts for the disproportionately high rate of schizophrenia among the low- income population which is the concern. To illustrate, Mr D had a well paying job at a car manufacturing plant and had no comorbidities. He lost his job during the 2008 economic crisis. I believe that this stress was a trigger for him to develop schizophrenia and set off the chain of events that led to him to develop diabetes, hypertension, substance abuse and losing his house.
I have been following Mr D for a several months now. With each visit, we had to make several adjustmens to his medications to try to simplify it for him and to reiterate the importance of taking his medications. The last time I saw him was in January 2019 and he still resides at a local shelter. He currently on appropriate antipsychotic medications and his diabetes and hypertension are under well control. One can see the health disparity that is closely linked with social or economic disadvantage in this case. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health and my patient was a perfect example of that. Takeling one problem at a time and have frequent follow ups allowed me to take care of the patient appropriately and control his comorbidities.

[James Bathe]

The five domains of the biopsychosocial model represent five major areas of focus we have to have as practitioners for a patient’s health. It’s frequently difficult to always cover all five points though we must strive to keep them all in mind. Support systems and resources are two areas that can be straightforward to identify but difficult to address. If someone has no family or supportive friends, they become completely reliant on a support system which is outdated and is frankly broken in many ways. While we have some dedicated people and services, it’s always better to have some personal support, something that a solid number of our patients lack. Same with resources. If someone is homeless and broke, there is not much that can be done beyond charity programs. Again, good concept, but in reality, there isn’t enough to cover everyone in our current system.
Behavior and substance abuse fits together as a lot of the obstacles require similar methods of intervention. Active cognitive behavioral therapy and other intensive methods are needed to improve this angle. However, dealing with these features is important for treatment success. One doesn’t have to fix everything to improve overall health though that should be the goal. Psychiatric disorders being the second to last is more addressable with our standard toolbox and the final dimension of biomedical is our main area of focus in our training.
Basically, we have to advocate for change and promote ways to support our patients for the other dimensions. We should be promoting a healthy social safety net to help even the most destitute get the support they need. Resources and support are things that we can push for improvement all the time. Working close with social workers and community members, we can make differences in these areas while keeping the truth of each patient’s situation in mind. Working close with behavioral health and psychiatry also can improve the impact of our care. Everyone of our patients needs to be fully addressed and we can only do that by reaching outside of ourselves.

[Lea monday]

We talked about pyschosocial determinants this week and dr nnodim brought us pizza 🙂
One aspect that we discussed was support people in a patient’s life. I asked my patient mr B about his sister who is a nurse and helps him when needed for a ride or other help. He is a recovering alcoholic at a halfway house I met last year. He said she is doing well. I also asked about his kids which he said is a sore subject. Dr nnodim and I discussed how that’s ok to ask about support both positive and negative and that even bringing up negative feelings is part of getting to know our patient.

[Leslie Kao]

There are five domains of the psychosocial and behavioral determinants of health that we should try to address when taking care of our patients: support, resources, behavioral, psychiatric, biomedical. The ability to address all these domains successfully brings to mind one of my long-time patients. When I had first met him, he had been lost of follow-up for decades and his Charcot-Marie Tooth disease was slowly taking a toll on his life. The patient had recently moved back to Detroit from Los Angeles and was recently reconnecting with friends that he had not seen in decades. Initiating the appropriate care with this patient was a step-wise exercise that reached a huge setback when his girlfriend passed away suddenly right in front of him. Each time I brought the patient back for follow-up we would slowly address his issues with issues as simple as getting him a cane/orthotics and home health care [resources], to convincing him to go to a psychiatrist [psychiatric/behavioral] to finally getting him to agree on PMR [biomedical]. Despite an understanding of his disease, the patient still struggled with compliance due to lack of support. His “people” were all out West. Finally, as the patient grew more comfortable and re-settled into Detroit, the patient’s support group grew. As his support grew, his confidence and compliance grew. As I watched my the patient’s care evolve, I was also reminded that these five domains also apply to us are residents as well. We have all been displaced and are placed in an arduous situation to navigate in residency. We all too must have a wide net of support, be able to find study resources, display professional behavior, get psychological resilience and support (which is often ignored) and grow our basic medical knowledge.

[Syed Umer Mohsin]

This week’s topic was psychosocial determinants. One of the domains of psychosocial is resources on which we had a good discussion. It reminded me of one of the patients I saw in the hospital. She was admitted with PAD. Post-angioplasty, she being discharged on CV medications along with prophylactic antibiotics (for small uninfected leg wound). I was doing medication reconciliation before handing her the discharge paper when she told me that she won’t be able to afford all the medications due to her limited income. We went over her medication list and categorize her medicines based on the necessity of those medications.

We as physicians have to be mindful of the patient’s socioeconomic situations when treating them. The above-mentioned event is a good example of how socioeconomic factors can even effect patients and their wellbeing. Another great point that was brought up during our meeting was that when we are prescribing patients insulin, we should always ask about their living situations and enquire if they have fridge and electricity at home for storing insulin. This may seem very insignificant but can have a big impact on the patient’s adherence to treatment.

[Brandon Twardy]

This weeks topic covered the 5 aspects of psychosocial health; Social support, resources, behavior and substance abuse disorders, psychiatric illness, and biomedical conditions. Social support represents the patients social interactions at home and the people they encounter, whether good or bad, and the overall impact they have on the patients health. The available resources to the patient will affect their overall access to health care and ability to provide for themselves. Psychiatric illness and substance abuse disorders will impede the patients ability to take part in their own care and alter their insight. Finally, medical conditions will dictate the amount of resources and involvement required by the patient. Without assessing each of these areas we cannot ensure that our patients will get and maintain the care they need.

[Salina Faidhalla]

this week topic is the psychosocial determinant of health, in our practice we face a lot of challenges related to patient care that are defined by those psychosocial, and one of the major issues that we encounter almost everyday is homelessness. unfortunately most of the times there is no solutions for that and the only thing social workers can do is provide the patient with a list of shelters to call to find a bed. Just today I had a patient in the clinic who is currently living in a shelter, he doesn’t have any health problems, his issue started after he was evicted from his apartment and then had to stay with a friend where he started experiencing itching!!!! very severe, preventing him from sleeping, he went to the ED and was diagnosed with scabies, given treatment for that which he has been using as prescribed with no resolution of symptoms.
that made me think, if this patient really has scabies, no matter how much we treat him, try to dis-infect him, recommending daily bathing and washing all clothes and sheets (which seems easy to us maybe), but he will mostly continue to fail therapy as along us he is still living in that shelter.
many times our management fails or at least achieve suboptimal results due to these social determinants of health.

[Deya Obaidat]

When you treat, you don’t treat a medical condition, when you treat you treat a patient, yes anti-biotics can treat an infection, but without knowing and diving deep into what caused the infection to begin with, you’ll never be able to put an end to the repeated risk of the patient to get sick and requiring medical attention, and here where the psychosocial and behavioral determinants of health come in place, as identifying those factors play a major roll in treating the patient as a whole rather than a medical condition, those areas are social support where patients who have family support they are more likely to seek medical attention and be adherent to the medications regimen, resources is the second component and it is about identifying potential resources that the patient can benefit from to achieve the medical goal, third one being substance use disorder, identifying patients who has this issue and seeking help for it will improve the overall condition of the patient physically, mentally and financially, psychiatric illness is also one of the determinants of health as people with depression for example they are more likely to be non-adherent to their medication regimen, and last comes the biomedical component, as patient with chronic diseases seem to have more issues with non-adherence.
those aspects are inseparable and you can’t talk about one of them without talking about the others, but overall achieving an understanding about hte patient situation in these aspects will help achieve optimum care to all of the patient’s medical needs

[Aliza Rizwan]

Out of all the pillars in our medical practice, one important pillar to be considerate of is psychosocial and behavioral determinant of health. Sometimes we as physician gets so much focused on treating our patients disease that we overlook our patients psychosocial aspect. Linking social position to health can only be assessed if these two pathways are modeled simultaneously. Not too long ago, I provided my patient instruction for screening colonoscopy and gave him the prescription of screening prep, when he looked at the prescription he didn’t say anything, so I assumed he was ok with it. But when he returned back for his next appointment he hadn’t completed his colonoscopy. On asking him why he didn’t follow through with it, that’s when he reveled that he has been living in a homeless shelter and didn’t feel comfortable doing a colon prep. I felt really bad inside, although I was trying to help him by giving him a screening tool to avoid any future malignant condition, but at the same time with this act I might have put him in tough spot. Only if I could be more considerate regarding his psychosocial condition earlier, I could have avoided him going through the difficult situation and could have found a plan that worked for him in his current situation better. I really thought to myself that the importance of being mentally, socially, emotionally and spiritually sound is somewhere faded in medicine we practice. Sometimes we take things so casually and later regret why our patient population is not compliant and not where we want to see them, answer is not just limited to them. A pill is not supposed to solve everything! Its a collaborative effort, at least we on our end can make sure that we don’t miss the important and key aspect of our patient. By not just focusing on their presenting complain, but to take into account their psychosocial, emotional, behavioral,financial condition, in order to provide them better and well round healthcare.

[Sahrish Ilyas]

The focus of our discussion this week was the bio-psycho social domains of care which include biomedical conditions and medications, social support, resources, behavioral and substance use disorders, and psychiatric disorders.
Our discussion focused on how key screening questions we can utilize to ask patients to uncover any issues that exist within any of these domains. Also we discussed how the individual domains are interlinked in playing a role in a patient’s overall health. Serving the population of Detroit has made many physicians realize how crucial addressing social support and resources are with each of our patients as often times these are great barriers for patients in accessing healthcare (I.e transportation related issues preventing some from making it to scheduled appointments or financial constraints preventing some patients from paying for their essential medications). We also become need to be more vigilant and wary of the underlying psychiatric and behavioral disorders that afflict many patients which largely occur due to social issues but biomedical conditions and medications can contribute (for example dealing with overwhelming chronic medical problems leading to depression or medication induced side effects). An example of this is all the time spent on dialysis for an ESRD patient and how spending half the week in a dialysis unit can have a tolling effect on one’s mental health and this is something that we should be aware of in our patients.

[Hammad Ali]

Biopsychosocial models of health contribute towards a communities general well being. The five pillars of the psycosocial model are Social support, Resources, Behaviour and substance abuse disorders, Psychiatric illness, and Biomedical conditions. The patient population we have here in Detroit have many of these issues which all contributes towards a cumulative detrimental effect on their health. For example many of the patients we see in DCC come there with the Salvation Army. So they are living at half way houses and keep moving frequently from place to place hence they do not get continuity of health care at any one place, because of the constant uncertainty of where they will be they do not have social support. Resources are limited generally for our patient population. And these people either have substance abuse that they are trying to shake off or end up getting involved in it as a result of their situation and coming in contact with people who can provide them with recreational drugs. In the setting of these pressures and substance abuse people end up manifesting psychiatric illnesses. Hence the burden from psychosocial factors is huge in the patient population we are treating and this leads to increased burden on our community and then on us who have to provide care whilst keeping all these issues n mind.

[Dana Kabbani]

The biopsychosocial model considers individuals as well as their health problem and the social context; it ultimately recognizes that health, disease, illness and disability result from complex interaction of biological, emotional, cognitive, social, and environmental factors, and considers how these factors can impact the patient’s perceptions and actions, and their overall illness. Understanding the complexities of the psychosocial contributions to patient care is important because no two patients are alike. These determinants not only play a role but sometimes serve as hurdles when providing patient care in regards both treatment and patient compliance. This is not to say that these are the only two issue, but rather the ones that impact my interaction this week with an HIV patient attempting to quit smoking. This patient is struggling with smoking cessation, due to external stressors not limited to but including anxieties secondary a lack of family support. This patient’s daughter had recently had a charge for DUI, which subsequently introduced a new variable and ultimately an unexpected hurdle towards her health care. Understanding the psychosocial mechanisms playing a role in disrupting the treatment allows for us as practitioners to help the patient learn positive coping mechanisms in scenarios such as this particular patient. In doing so, we allow the patient to utilize these new tools, rather than rely on cigarettes as an anxiolytic, and move forward in the assistance with smoking cessation.

[Justin Gatt]

Psychosocial and behavioral determinants of health are critical factors in care of all patients, but are particularly essential to consider with the specific patient population we treat here in Detroit. I think it is safe to say that the majority of doctors in our program did not grow up in the type of environment most of our patients come from. Because of this, it is imperative we have a keen grasp on psychosocial processes and how they influence the health of our patients. A person’s “health behavior” is a reflection of that specific point in time and can change many times throughout his/her life. Understanding the broader context of why a patient is presenting to the hospital that day will make treating and caring for the patient much more effective. For example, if someone has recently lost their job and all sources of income and is now stuck living on the street, they probably aren’t as concerned with taking their blood pressure medications as the person living safely inside a private home. One thing that has particularly stuck in my mind is a patient Mr. J who I have cared for multiple times over my 7+ months of residency. Mr J is homeless and oftentimes finds himself kicked out of shelters because of his drug habits. On top of this, he developed severe heart failure from untreated HTN and crack cocaine use. Each time he has been admitted, we have worked with social work to obtain him a bed at a shelter before discharge. However, he still has to deal with the fact that shelters are overcrowded (esp. in Detroit where there is a shortage), undermanned, and ill-equipped to handle the large population of homeless people on a daily basis. This puts a tremendous pressure on Mr J that few of us have actually experienced. Working with the patient and understanding his motivations, home and social life will help keep the patient from requiring hospital admission in the near future.

[wsumed]

Street Zen: The Life and Work of Issan Dorsey by David Schneider ~ 9781611808476

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