[Yellow Cohort] Module 6

[Leslie Kao]

Please submit your SOAPs for Module 6 below:

[Jie Chi]

psychosocial and behavioral determinants of health
S: We find quite often even we spent a lot of time to educate patients and thought we improved pt’s compliance and knowledge to help them avoid repeated hospitalization. However, often times, pt will high risk like mental disorders, poor educational resources have a hard time digesting the knowledge we gave, therefore they still didn’t benefit from what we are trying to do. Just like in the article. When working with high-risk patients, such as this individual with extremely low income and evidence of possible psychiatric disorder, clinical care must incorporate understanding of their social determinants of health. Particularly in homeless or uninsured/underinsured populations, it is important to consider socioeconomic status, environment, behavioral factors, and access to the health system
O: I had a patient on HD who came to hospital repeatedly due to high potassium and fluid overload. I found him non compliant with diet and tried to educate him on diet. However, after a few times of back and forth, pt finally told he didn’t know what’s sodium, he only eats microwavable food because he can’t afford fresh food. He didn’t have anyone who takes care of him and no one would cook for him and tells him what’s good and not good for him.
A: Recent findings often show a robust relationship in which social and emotional support from others can be protective for health. Positive social support (family or friends) plays an important role in one’s ability to make healthier choices. Social support means being able to access people that a person can rely upon if needed. In terms of chronic disease, the support of family or friends has been shown to lessen the chance that one will become sick or die from complications of ESRD.
P: Adopting and implementing policies and programs that support relationships between individuals and across entire communities can benefit health. The greatest health improvements may be made by emphasizing efforts to support disadvantaged families and neighborhoods, where small improvements can have the greatest impacts.

[shahram]

This weeks discussion mainly focused on how often we get to ask about the psychosocial aspect of pts care. Most of us get to ask this question one the first visit to clinic or when they are admitted to hospital for some reason. There is a room for improvement in getting to know these aspects of pts care on every visit. Discussed some of the barriers and how to overcome those barriers.
We as physicians sometimes feel reluctant to ask the questions we know that we will not be able to help with. Its still important to ask those questions because from a pts perspective, the fact that you asked these questions tells the pt that you care about them.

[Deya Obaidat]

S: as a physician I always learnt to think about things in a pure scientific way, I’ve always looked at patients as some who needs help where you look into their lab values and you need to fix them to make them look better, but in a lot of time things don’t go the way it supposed to be going although you are pretty sure that they are supposed to be right, then we will start to explore the problem, and will start to question whether or not the medical treatment that you give for the patient is being taken the way it’s actually prescribed, and then you will start to explore why is the patient has a non-compliance issue and you will start to ask him about his social history and you’ll figure out that he is having social problems and that he doesn’t have enough encouragement and social support to continue with the treatment.

O: I was taking care of one patient on the floor who has a history of ESRD where she used to come to the hospital on monthly basis where she misses her dialysis and come with a fluid overload picture, she will get dialyzed and will go back home after lecturing her about how important the dialysis session is for her health. after recurrent discharges where i took care of the patient personally i started to question why the patient is not complaint with her dialysis where she turned out to have a trouble to get to the dialysis unit as she doesn’t always have a ride and there is no one around to give her a ride, after that we arranged along with the social work for a ride from dialysis to back home.

A: social history is something that we really need to spend more time exploring with hte patients, giving the fact that the most important factor of failure of medical therapy is non compliance and the most important factor of the non-compliance are the sociopsychological issues.

P: I’m gonna start from now on to explore the social history to my patients from the first encounter, will talk to them about their social support, will get an idea about their economical status and will try to be more efficient in my work by exploring these areas of defects.

[Brandon Twardy]

Social determinants of health: Behavior aspects

Different personality disorders, when unrecognized, can have an impact on the quality of care and doctor physician relationship. For instance they can produce a disconnect between the patients expectations and what the physician feels is appropriate in terms of treatment. Patients that exhibit splitting personality may have many complaints about a previous physician while praising a new one on the first visit with underlying expectations. This can make adequate and appropriate care difficult and can potentially lead to excessive use of resources if not recognized. Best approach to working with such patients is to work on a strong physician/patient relationship – frequent visits if needed.

[Syed Umer Mohsin]

S: We have always been taught that we should treat the patient as a whole and not just their illness. We often focus on diagnosing and treating their present illness and not paying attention to patient’s social issues. These social issues have a deep impact on patient’s health decisions.

O: I recently saw a patient in the clinic who came in for her lab results. She was a known hypertensive but had stopped taking her meds for 6 months. This was my first encounter with her. I tried counselling her to start her medications as her BP was uncontrolled. She just told me that she does not want to and was not willing to maintain a conversation. When I came with my preceptor, patient opened up after seeing a familiar face. It turns out that her sister kicked her out 6 months back and she didn’t get a chance to pick her medication before leaving. After a bit of counselling, she agreed to start taking her meds.

A: Social history is a component that is neglected on regular bases. Patient’s complainant to medication and even keeping future appointments are linked to their social issues. It is important to identify these issues and be mindful of them before offering treatment options to patients.

P: I will pay more attention to patient’s social issues. I will try to spare initial few minutes of the patient encounter to talk about the patient before talking about the problem that brought him in. This will be a good way to know my patient and his social issues before we talk about his illness.

[Lea monday]

I had a patient this week who I was seeing for an asthma follow up. A young AA male. On the first visit I thought he was a little tangential and for example was asking for full std testing so he could take the results to California and join the porn industry. I noted his PHQ9 was 0 and we focused on asthma and std. well when he came for follow up I checked CIS and noticed he had been in psych crisis unit for suicidal ideation and also had had a prior suicide attempt as teen via belt hanging. Keep in mind I saw this the same day that we discussed the need to ask every patient specifically if they’ve ever had a mental health admission. This entire situation really hit home for me what a huge chunk of his life and history I had missed. I used the visit this week to talk about his support system (his sister) and offer strategies for staying away from his toxic family members (father).

[Shivani Agrawal]

The five domains of the psychosocial model including social support, resources, behavioral and substance use disorders, psychiatric disorders and biomedical conditions and medications. In the social support domain, I asked who lived with them to find out who can help them with their healthcare. In the resources domain, I asked people where they were living to find out their home situation. In the substance abuse domain, I typically ask people about alcohol / drug use. For psychiatric disorders, I did ask two patients who their mental health provider was to help coordinate care this week. In regards to biomedical conditions/medications, I review the EMR medication reconciliation. I then ask patient what medicines /supplements they are taking. I have called pharmacies in the past to obtain a more complete list. I also attempted this week to obtain records from systems outside of DMC to coordinate care.

A patient this week told me how the cost of the evaluation /testing we are doing for him in our clinic is getting expensive due to his fixed income. Therefore, we decided to space out his clinic visits and not order any more tests at this time. I did encourage him to seek out a specific specialist whenever he had the time/money/resources as I am concerned about a specific chronic condition which can have high morbidity/mortality. I am glad he was forthcoming about his concerns due to cost. I do practice cost conscious care but I appreciate him sharing his financial situation with us. We all want what is best for the patient.

[Kalyna Jakibchuk]

The 5 domains of the psychosocial model of care are support, resources, behavioral, psychiatric, biomedical. Questions that I asked my patients this week were:
Support: Who lives with you? Do you have friends or family that help you out when you need it?
Resources: how did you get to your appointment today? Are you having any trouble paying for your medications?
Behavioral: when asking how much alcohol my new patients drink, I also ask was there a time where you were drinking more than that or where you had problems drinking alcohol.
Psychiatric: have you ever been diagnosed with a mental health disorder? Do you see a mental health team?
Biomedical: Who helps you remember to take your medications?

The most revealing answer I got from a patient was after he said he does not drink alcohol asking if he had a previous problem with drinking too much. He said yes and the patient was actually depressed. When he was an alcoholic he had attempted suicide and so it was a very relevant time to encourage his decision to stop drinking as alcohol can worsen depression.

[Marc]

One of my patient’s regularly comes for blood pressure check ups. Overall, compared to my other patients, he is doing pretty well but he is obese and has been struggling to lose weight. He seems happy and likes to chat about the work he does outside as a parking lot attendant for sports events. I don’t really use a checklist of “5 domains of the psychosocial model of care” to talk to my patients but I try to actually get to know them as human beings and let the story flow where it will. Sometimes these stories can fit within such a rubric. In this gentleman, a deeper conversation revealed that he was anxious about his living situation because he lived near the stadiums in some of the cheaper housing and was worried that his place would get bought out from under him to get developed, and he would have to find a new place without warning. This would present a big problem to him because he needed to live close to the stadiums to do his work. Consequently, he has a habit of drinking a couple of 24 ounce bud lights whenever he has extra spending money and smoke a couple of cigarettes to deal with his anxiety. Despite frequent coaching from me (and he hasn’t gotten to annoyed not to show up to his repeat health visits) he continues to drink his beer. He knows he needs to lose weight. He knows that the drinking and smoking aren’t good for his blood pressure. He has been given resources to follow up on to help cut down on the drinking, but he still continues to drink a little too much because he is alone, the world is uncertain, and this is his one release at the end of a long day.

[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.

Support can be assessed with simple and quick questions such as where do you live, who is there with you, do you feel safe, who do you talk to about your health issues apart from your doctor. These can allow for fast assessment of support and provide greater insight into why a patient may be having greater difficulty than others in adherence. One such example this week was asking the brother of a patient who accompanies the patient to clinic visits how he was doing. The brother was scheduled to undergo a knee replacement later this week; given that the patient is reliant on the brother for completion of his ADLs we needed to have a discussion about who will fill this role while he recovers. This raised a serious concern for this patient’s wellbeing in the near future and these arrangements are important in order to provide the best plan of care over this time.

Resources can include a wide variety of items including access to housing, money, food, insurance, transportation. Our patients often are lacking one or many of these resources and require our assistance in accessing them through state or charitable programs. Although we often complain about our patient arriving late to clinic, often times they are reliant on transportation services to get here and are at their wim. A patient of mine had required hospital admission since our last appointment due to missed dialysis, when asked about why he missed it was because his transportation company closed and he had no way of getting there for 2 weeks while new arrangements were made. These stories are common and should be kept in mind when we think about patient adherence to plans of care.

Behavioral/Substance use disorders are common and often difficult to both identify and treat. We often hold the picture of the junky in our heads when we think about substance use disorders but epidemics such as the current opioid issues that we have been seeing must be kept in mind. We are seeing well educated and apparently put together people succumbing to these disorders and we must be able to probe deeper/have a greater amount of suspicion at times in order to identify these patients. It is difficult to do so without it impacting patient/physician trust relationship, but is a fine line that must be worked in order to provide the best care for these patients.

Psychiatric:I had a patient with multiple notes indicating they had history of mental health disorder but little further explanation. I asked the patient to elaborate on this during an appointment this week to find out that they had history of suicide attempt when they were a teenager over 30 years ago, but had been doing well since that time and had not followed with a mental health provider in years, yet they continued to have this line of “mental health disorder” at the beginning of all of their notes. Patient with psychiatric disorders often carry significant stigma along with that title, both consciously and unconsciously with each health care interaction that they have and possibly could have impacted the care that they have received over the years because of this. I did not include it in my opening line for the encounter and hope that this breaks the cycle of it being included moving forward.

Biomedical can involve all of the above 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.

[Shanker das Kundumadam]

Five domains are support ,resources, psychiatric, behavioral and biomedical

Support – had a patient who mentioned history of suicidal Ideations.I asked the patient if he has any social support at home. He mentioned his mom lives with him and he has enough support. But when I asked him if he talk to his mom At the time when he gets this urge to Hurt himself, he mentioned he doesn’t. I told him to make sure that he talks with this mom about the stress he’s going through and also whenever he gets these thoughts

Resources : From my experience money, Insurance Status, transportation, Are the major resources which come into play in determining health. I had a patient with heart failure was coming with recurrent admission to the hospital. When I finally asked him the reason why this was happening even though initially he didn’t disclose, he mentioned that whatever income he was getting was being channeled to his kids education And groceries. So he hardly had any money left to buy medicines. So it’s important to ask this question in order to do a root cause analysis in some instances.

Beahavioral and substance abuse
Psychiatric
I strongly feel these two domains cannot be differentiated in terms of patient interview. So I could ask questions which would target both these two domains at once Rather than seeing them at separate. I asked patients if they had any mental health issues in the past, Any recent Lifestress and sometimes when the patients don’t want to commit that they had a mental health issue, it might be better to just ask them if they have ever been on psychiatric medications. Most of the patients who reported that they don’t have any mental health issues in the past eventually revealed that they have been on psychiatric medications and I’m digging deeper at that point define details of their Pyachiatric history.

Biomedical – Despite the terminology the module six for this very main focused really on the functional status of the patient. I would usually ask how physically active are you, how do you take care of yourself at home, is there anybody at home who helps you with your ADLs,. I noticed that even with these basic questions patients usually give us a pretty good picture about this domain pertaining to them. My patient with chronic foot pain told me how he needs help with pretty much every household activities like cleaning cooking grocery shopping. Despite this gentleman having a significant other because she got into an accident recently, and was incapacitated to help him out The need of help from a third-party.

[Marvin Kajy]

Module 6: PSYCHOSOCIAL AND BEHAVIORAL DETERMINANTS OF HEALTH AND HEALTHCARE

This week’s module dealt with the psychosocial aspect of a patient’s care which is based on several pillars that are social support, community and environmental resources, behavioral and psychiatric disorders.

Social support: Over the past week, I had diagnosed people with Major Depressive Disorder. One of the major questions that I ask an individuals who present with such a diagnosis is if they have social support system in place. Numerous studies have shown that social support is very important for maintaining good physical and mental health.It can enhance an individual’s response to stress, help protect against developing trauma-related psychopathology, decrease the functional consequences of trauma-induced disorders, such as posttraumatic stress disorder (PTSD), and reduce medical morbidity and mortality.

Community and environmental resources: It is very well known that the Detroit area is underserved. Low income, combined with low health literacy provide an excellent combination for poor health care access. Yesterday, I had a patient with diagnosed with COPD and he was running low on his albuterol inhaler. He asked if the clinic could give him a sample of albuterol inhaler. Unfortunately we did not have any. However, I know that Cass Clinic offers many drug samples and I was able to refer him there. I think that one of the best things that the WSU school of medicine offers is the free clinics that the medical students volunteer at. They literally serve as our extension and provide additional resources to our patients.

Behavioral and psychiatric disorders: It is very well known that patients with substance use disorders or psychiatric illness have poor access to health care. Many healthcare providers want to help them, but this often difficult given their social situation. One time I encountered an article that said that about two-thirds of PCP’s reported in 2004–05 that they could not get outpatient mental health services for patients—a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. GMAP already employs a dietitian in the clinic. I believe that having an in house psychiatrist and social worker would really benefit the population that we are serving.

The face of depression is a spectrum and it can occur in people from all walks of live. The PHQ2 questionnaire is an evidence based tool that can help providers identify people who may have depression. Just this past week, I had 2 patient encounters for just a check. When I used the PHQ2 and probed a little deeper, it turned out both patients both patients were experiencing depression.

[Amina Pervaiz]

the 5 domains of the psychosocial model include variety of aspects that might alter the goal of care as physicians in our patients that we see on regular basis. and despite having those 5 separate domains we can’t usually talk about one without including the other as most of them will be connected in the patients that we see in our hospital or clinic

having people who provide the emotional and psychological support to the patient might dramatically improve the efficacy of the treatment regimens from my personal experience where I’ve noticed patient’s who are living with their families have better blood pressure control from other patients who are living on their own, a study which was done on heroin abuse relapse showed an increase of 12% in those who didn’t have any emotional support. the lack of emotional support might also lead several patients to start seeking some forbidden routes which might include the use of illicit drugs in some cases, which might lead by the end of the day for unemployment and poverty hence the loss of insurance coverage and the inability to be able to afford the medications for the treatment which alters the goals of care in those patients and might delay their presentation to the healthcare which complicate their health situation and lead to a more advanced and dramatic presentations of their chronic diseases where it might jeopardize their own lives then. all those factors will play a major role by the end of the day on how functional the person is in his normal day and how dependent is the patient about doing his own personal needs back at home, which might be the contributor of the most impact on our goals of care.

all these challenges make it difficult for us as physicians to accomplish our objective, and the biggest step comes in to identify these threats and deal with them each on it’s own. for me I always try to build a trust relationship between me and my patients I always start asking them about their social life, starting with how do they feel today and how was their morning, then I’ll dive deep into the social history in terms of who is living with them and if they are happy with their current living situation and if they are feeling depressed and if there is anything that might bring them joy (PHQ2), and as a part of my social history I always ask about any history of substance abuse with the set of mind that I won’t be judging the patient no matter what his answer is . then I’ll start asking whether if they usually can afford the medications that they are usually prescribed and if they have the means and the ability to afford transportation from and to the clinic, then I’ll start to explore their ADLs and IADLs by asking about their daily routine and daily activities and if they are having any difficulties dealing with them back at home.
and despite the process of thought might be simple, sometimes it might come with a lot of obstacles most primarily being that there is not enough time to explore all these elements on each and every single visit that the patient has.

I’m planning to start making 20% of the patient’s visit exploring these elements as they have the most contributory effect on the management overall.

[Jared Goldberg]

Among the 5 domains of the psychosocial model of care, “resources” is the domain that I most often let slip through the cracks. Too often, I do not assume that the patient that misses 3-4 appointments in a row or the two patients that I had this week that missed their original scheduled appointments only to reschedule 1-2 days later have any issues with transportation or ability to receive their prescriptions. Even on the inpatient side, when we don’t necessarily forget about it, we dismiss it and assume it will be the social workers’ job to somehow magically alleviate the problem. It doesn’t. Patient’s inability to get necessary treatment or even get to doctor’s appointments should always be considered.

[Muhammad Usama]

The 5 domains of the psychosocial model That I incorporated in my clinical encounter this week were support, resources, behavioral, psychiatric, biomedical. I always try to assess and support behavioral readiness of patients to make changes in their lifestyle which would result in the long run in better health outcomes. In a lot of patients I saw at DCC there was “learned helplessness” i.e. the patients had faced so many hardships that they had kind of given up, they thought that nothing was going to change and no one cares about them or wants to solve their problems as a person. As physicians, they see us as just some form of authoritarian/status-quo giving them orders or judging them from the choices(e.g. drug abuse) they have chosen. Which is not true. One of my patients I saw a couple of months ago had uncontrolled diabetes, screened her for depression and she was a textbook picture of MDD. That was the reason that she did not feel like taking her medications. I referred her to a psychiatrist (lucky for me DCC has whole psychiatry team upstairs and they accept walk-ins) and overcoming months saw that by seeing objective results like improvement in her HbA1c and her blood glucose, she unlearned her learned helplessness, seeing all that improvement in her this follow up visit was very fulfilling experience for me. One other patient I saw basically could not take her insulin despite her having access to insulin because she was homeless and did not have a refrigerator to store insulin. I realized that she needs resources and support regarding that, which the social worker helped me with and she would be probably housed in temporary shelter and they will work together in getting her some of a stable living place. So my goal now is to start my every clinic encounter by starting to get to know the patient and exploring these five pillars of the psychosocial model.

[Leslie Kao]

Of the five domains of the psychosocial model of care, the resources domain is the one that is the hardest to address and rectify with my patients. Without proper social support and easy access to resources like transportation, the patient’s health suffers as a consequence. I rarely ask how a patient arrived at the clinic, but realize that many of our patients are too sick to drive or do not have enough money for a car and are thus dependent upon public transportation, medical transportation companies or friends/family. All these methods are unreliable and often patient’s will arrive late to appointments, at times close to or even past the clinic closing time. Obviously in these circumstances, we do not have time to address all of the patient’s medical problems, only dealing with the most acute.

One of my patient’s came in today for a follow-up appointment for various chronic conditions an hour late due to the weather and slow public transportation. She had dropped off transportation paperwork 2 weeks ago and was told that the paperwork would be filled out and mailed to her. By today’s appointment, she still had not received anything. Nor was anything scanned into our system. At first I asked her to return and drop off new paperwork (neither of us knowing which form she had originally had), but was informed that it was too difficult for her to get to the clinic easily. Additionally, she did not have the educational means to fill out the patient required part of the form and needed her children’s help who would only be around this holiday weekend. Her situation reminded me of the importance of asking about barriers to treatment including ability to travel to and access it. Eventually, I was able to find the form that she needed and had to have her wait till after the end of clinic to fill out the form so that she could have it today. My goal is to now not to judge patients when they arrive late and instead ask them what prevented them from showing up on time. Additionally, to take extra time on the same day to ensure that they do not have to make another futile trip to the clinic.

[Sahrish Ilyas]

The 5 domains of the psychosocial model of care are support, resources, behavioral, psychiatric, biomedical.
The questions I asked my patients in reference to each category included:

1. Support: who do you live with? do you have any close friends or family members who you can rely on for social support?
2. Resources: are you able to pay for all your prescription medications?
3. Psychiatric: I have asked my patients if their prescription antidepressants and antipsychotics are really working for them?
4. Behavioral/substance abuse: generally ask every patient if they use any tobacco products (if so how much), consume etoh, use any illic substances.

The most provoking answer I received was from an individual who came to clinic reporting that he had been having multiple syncopal episodes over the past several weeks. He lives alone in his apartment, endorses both feelings of anxiety and depression, does not have any family members to check on him (he is elderly) or any close friends for that matter. He is taking multiple medications as prescribed by his psychiatrist for depression and anxiety. When I asked him to please go to the ED because I was very worried about him he stopped and looked at me for a few seconds and said doc “nobody has said that to me in a long time.” It was a revealing moment – realizing how truly alone he must feel and also scared the days he has episodes of losing consciousness. He walked into the clinic all smiles and I wouldn’t have thought from the first look that this is a deeply lonely or troubled gentleman. This is why screening for illnesses (whether organic or mental health diseases) is so crucial as primary care physicians.

[James]

– Social Support refers to the personal connections, relationships, and relatives a patient has. On many patients, we take this for granted, often assuming that patients have some sort of support at home. Asking questions of each patient about who they live with, if they feel safe, if they feel supported are easy to ask. However, more specific questions are easy to overlook. Do you have someone to talk about with your illness? Do you have someone who can go with you to appointments? How is your support system? While hard and awkward at times, it is vital to really assess who has what they need in terms of support in order to ensure the best chance of success.
– Resources refers to the actual building blocks of that person’s life and situation. Do they have transportation? Housing? Food? While money may be a simple way to look at this, one has to really pursue what options the person has. At the lower end of the socioeconomic spectrum, every resource has to be accounted for so that the highest return on health is obtained.
– Behavioral and substance use disorders are pervasive and often insidious, making good care difficult even when resources and social support are particularly strong. Asking about past history of substance use in a nonjudgmental way will often reveal a good history as long as good rapport is obtained. However, behavioral disorders can be subtle and usually will be revealed through the course of a thorough history.
– Psychiatric disorders can also make good treatment and follow through difficult. Asking questions of patient such as “do you have a history of mental illness” or “have you seen a psychiatrist in the past” can lead into a good discussion of psychiatric history.
– Biomedical conditions and medications finally rounds out the psychosocial model of care and should be reviewed for any barriers to treatment. Additionally, medication reconciliation can help identify conditions for which the patient is poorly educated about and can help identify conditions that the patient cannot.

The most revealing response I got to these questions was speaking to a wonderful woman who was the picture of a sweet grandmother. While asking about social support, it was revealed that her daughter and her sister both passed away recently, nearly wiping out her support network. While she had some friends, her foundations were shattered within a week. It is important to remember that while many of these areas of the psychosocial model can feel static, they are in flux, just like our patients. What may seem solid one moment can be whisked away in the next.

[wsumed]

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