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