Minnesota Health Care Roundtable #42, on the challenges of treating patients with chronic medical conditions: a review, and call to action for behavioral professionals!

On October 30, 2014, I attended the Minnesota healthcare Roundtable number 42, “Treating Chronic Illness: Is Health Care Reform Helping?” It was presented by Minnesota Physician Publishing, Incorporated, publishers of several magazines, including Minnesota Physician and Minnesota Health Care News.

The program objectives included, “we will examine new community-based partnerships that are forming to address prevention, compliance, and better identification of risk. We will look at specific diseases and how workplace solutions, insurance companies, clinics, hospitals, long-term care facilities, and home care providers are working together to lower costs and improve outcomes.”

I attended because I was curious about whether the local medical and regulatory authorities view non-psychiatric behavioral professionals as partners, or even part of the team, for patients with chronic illness.

The discussion was moderated by the publisher of these magazines, Michael Stearns. The panel was composted of:

  • Kari Benson, MPA, Minnesota Board on Aging
  • Durand Burns, MD, Minneapolis Heart Institute Foundation
  • Crystal Twynham, MD FACS, Bariatric Surgery
  • L. Read Sulik, MD, PrairieCare
  • Gretchen Taylor MN Department of Health

Mr. Stearns kept the discussion focused and moving as necessary in order to cover a detailed agenda during the 3 hours of the roundtable. He wove together several different themes as the discussion involved, and at times asked provocative questions. I found him to be informed about both treatment and policy/regulatory issues. The panelists were all equally knowledgeable. At times some of the panelists, as would be expected, disagreed with each other, but in a respectful and non-defensive manner. Overall, I found the discussion to be lively and informative.

The panelists started by debating the definition of “chronic illness,” and all readily agreed that the term “condition” is preferred to “illness.” They noted that it is both value neutral, compared to “illness” or “disease,” and it also expands the focus beyond the traditional medical model to include psychosocial and behavioral factors.

Two themes came up repeatedly during the discussion: 1. the challenges of managing psychosocial and behavioral factors when treating patients with chronic conditions, and 2. the need to integrate services among the various disciplines involved in the care of patients with chronic medical conditions. 

Dr. Sulik, a psychiatrist, noted that the cost of treating chronic health conditions increases many times, “sometimes exponentially,” when the patient has co-occurring mental health conditions. This obviously has significant implications for both the outcomes for individual patients and the costs to the health care system. He also expressed concern, as did all of the other panelists, about treatment compliance problems for patients with chronic conditions, but asserted that this is often due to barriers to obtaining treatment and not” a lack of desire or lack of will.” Dr. Sulik advocated, several times during the 3 hour session, for including behavioral services, but usually seemed to be referring most specifically to psychiatry.

The other panelists also expressed concern about treatments compliance challenges for this patient group. Dr. Burns, a cardiologist, stated that one of the most common challenges for treating patients with chronic cardiac failure is treatment compliance problems, such as patients tending to not attend appointments regularly, not following their prescribed diet and activity plan, not taking their medications consistently, and generally having the attitude, “I’ve seen my cardiologist, I’m feeling better, so I don’t need any more treatment.”

The panelists all agreed that patients with complex medical conditions often have some the following problems, all of which could be potentially the territory of behavioral specialists:

  • being in denial about the seriousness of their symptoms and health risks
  • rationalizing their decisions to avoid change or not follow through with treatment, even if it is life-saving care;
  • having difficulty engaging with their medical team;
  • having difficulty developing, and following through with, a specific behavioral action plan for managing their condition;
  • needing help managing co-occurring mental health and/or substance abuse conditions;
  • having communication problems, such as having difficulty explaining their concerns and asking questions;
  • requiring more time then is usually allowed for the average medical patient;
  • needing a higher level of reinforcement of change in the average medical patient;
  • caretakers needing a higher level of support and guidance than the average medical patient.

Unfortunately, as might be expected for a discussion presented by a medical organization, the panelists tended to recommend referral to psychiatry to address these problems. There was some mention of social workers, usually in reference to helping patients to obtain funding, access to services and other very valuable services. Psychologists and other mental health therapists were, however, mentioned only briefly and in passing.

Mr. Stearns allowed time for questions, and I took the opportunity to ask the following:

The panelists all seem to agree that patients with complex medical conditions often have problems that seem to be the territory of psychologists and other behavioral specialists, such as rationalization, denial, engagement, and so on. The panelists have, however, said very little about the possible roles of mental health therapists. Is this because mental health therapists need to reach out more to medical teams of patients with chronic medical conditions, or do the teams need to reach out more to the therapists?

The response was interesting. It appeared, at least to the only behavioral professional in the audience, that some of the panelists, perhaps Dr. Sulik in particular, developed a bit of the “deer in headlights” appearance as they scrambled to explain that indeed mental health therapists are valued members of the team. They did, however, choose to move on to a new question fairly quickly and I was left without a clear sense of how they specifically value mental health therapists and would include them actively in the treatment of patients with complex medical conditions. They clearly said little spontaneously about non-psychiatric referrals, other than referrals to social workers for help with working with the insurance and social support systems. The panelists all agreed on specific behavioral challenges that they often see in these patients, but their default referral appears to be to psychiatry. 

My take-away: it is evident that patients with complex medical conditions have complex and challenging treatment needs that are not adequately being met by the current medical system.  It is also evident that they often have co-occurring mental health and substance abuse conditions for which most medical providers do not have the training to manage, and also do not have the time to adequately manage in their busy medical practice. Finally, these patients have a high frequency of behavioral needs for which most medical providers are not trained or lack the time to address in their busy office practice.

There is considerable opportunity for mental health therapists to reach out to these physicians and care teams. If we can demonstrate that we can help them manage these complex and challenging patients, perhaps they will start spontaneously including us as part of the team.

In addition, it is important for behavioral professionals to be part of these types of discussion. I found this Roundtable format to be informative, and Mr. Stearns and his crew were friendly and were very well organized- it clearly helps to have done 41 previous events!

 

 

 

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