exercise and mental health counseling services exercise and mental health counseling services...

Exercise and Exercise and Mental Health Counseling ServicesMental Health Counseling ServicesResources and Expectations for

Affiliated Programs

October 2009

Joslin Care = Team Care

• Endocrinologist• Nurse educator, CDE• Dietitian educator, CDE• Exercise physiologist

(or related degree)

• Mental health provider– Social worker– Psychologist– Psychiatrist

Orientation policy:

•Policy AO-20

•Come to Boston for training

•Use Psychosocial Manual (Tab A)

October 2009

Our Findings….

• Affiliates are not all engaging and/or using the team to its full potential.– Results from conference call polls– Results from Survey Monkey assessment

• Joslin/Boston may not have provided enough support to mental health and exercise providers– Expanding services with Clinic departments

October 2009

Introducing…

• John Zrebiec • Jacqueline Shahar

October 2009

Minimum Standards

• All clinic staff will meet basic qualifications, receive appropriate orientation, and maintain CE as per the requirements of their positions and Joslin policies.

• Each outpatient receives team care, including a complete initial assessment and treatment plan by a diabetologist and a diabetes educator.

October 2009

Orientation – Policy AO-20

• All psychosocial and exercise counselors are to come to Boston for training– Exceptions made by Director AP– 1-2 day orientation in Boston– Review Exercise and Psychosocial manuals

October 2009

How is behavioral medicine integrated at Joslin?

• People– Large staff (social worker, psychologist, psychiatrist)

• Materials– Assessment tools– Handouts (stress management, emotions)

• Classes / Support groups– Usually begin with discussions related to feelings, common

misunderstandings – You Did It – a specific class on goal setting– Blood Glucose Awareness Training (BGAT)– Support groups

• Counseling Approaches– A focus on behavioral goal setting – Understanding barriers– Patient directed action steps

• Participate in team meetings – discuss cases

October 2009

Assessment Gather clinical and exercise history

Perform exercise capacity tests

Stress test, 6-Minute Walk Test, billing code: 94620

Pulmonary function test

Waist and hip measurements, body composition

Questionnaire – barriers to exercise

Provide an individualized exercise plan

Follow up appointment to evaluate results and progression

Do you have an exercise facility and/or exercise specialist your

work with?

October 2009

Expectations for Affiliates

• Identify, orient and use your Mental Health Provider and Exercise Physiologist/Physical Therapist

• Clarify roles and responsibilities:– Attend periodic staff meetings– Attend annual Affiliate Site Visit– Conduct classes for patients/training for Joslin staff– Participate in team clinical case conferences– Conduct support groups and/or other classes – See patients individually by appointment

• Identify someone on the Affiliate staff who will be the primary link to these providers (to forward Joslin related materials, updates, etc)

October 2009

Depression and Anxiety Disorders

• Depression is common– 2-3 times more common than in general population– 19% met criteria for major depressive disorder

• Twice as likely to miss medication doses– About 70% type 2 report some depression symptoms

• Linked with poorer adherence to diet, exercise, meds and higher A1C levels

October 2009

Eating and Related Disorders

• Eating disorders more common in type 1 women– 2.4 times higher risk for developing eating disorder than

age matched women without diabetes

• Insulin restriction common in type 1– 30% insulin restrictors at baseline– Higher rates morbidity and mortality– Screening question: I take less insulin than I should

(often – sometimes – never)

Goebel-Fabbri, D.Care March 31(3):415-9, 2008

October 2009

0

5

10

15

20

25

30

35

Exercise Helps Preserve Muscle Mass During Weight Loss

Diet Only

Loss

of M

uscl

e M

ass

(% T

otal

Wei

ght L

oss)

Diet PlusExercise

Men

Women

*P<0.05Ballor et al., 1994; Garrow et al., 1995;

October 2009

Flexibility Exercise Stretching:

Helps avoid stiff, sore, tired muscles Helps performing daily activities easier Helps avoid injuries

Options: static or dynamic stretching, yoga Perform stretching exercises when muscles are warm Hold a stretch for 30-60 seconds and repeat twice Stretch to a point of tightness, without inducing

discomfort

* ACSM’s Guidelines for Exercise testing and Prescription, 2006.

October 2009

Facts about Exercise BehaviorFacts about Exercise Behavior

Exercise is voluntary & time consuming Exercise compete with other valued interests &

responsibilities of daily life Dropout rate is high in the first 3 months, increasing to

50% within 1 year

October 2009

Lack of time

Social influence/support

Lack of energy

Lack of motivation

Barriers to Being or Staying Barriers to Being or Staying

ActiveActive Fear of injury

Lack of skill

Lack of resources

Weather

October 2009

Strategies to Overcome Exercise

Address and overcoming barriers Use the Barriers to Being Active Questionnaire

Time management Social support SMART goals Teach exercise skills

October 2009

170

180

190

200

210

220

230

Effect of Long vs Short Bouts of Exercise on Adherence and Weight Loss

Long bout = one 40-min session.Short bout = four 10-min sessions.

Act

ivity

(m

in/w

k)

LongBouts

ShortBouts

LongBouts

ShortBouts

10

8

6

4

2

0

Weight Loss (kg)

P=0.08 P=0.07

Jakicic et al., 1995

October 2009

Summary Assess patients and incorporate tests to identify

current exercise capacity and progression Address barriers and solution to being active Discuss blood glucose management, insulin and meds

adjustments on days of exercise Connect with exercise experts to provide individualized

exercise program