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Patient- and Family-Centered Mind-Body Empowerment Programs in the Military: Guideline Development and Evaluation

Katherine Smith, MPH Roxana Delgado, PhD

Samueli Institute

August 6, 2014

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Investigators and Research Staff

Brenda S. Hanson, PhD Military Principal Investigator

Roxana E. Delgado, PhD Samueli Institute Principal Investigator

Katherine Smith, MPH Samueli Institute Associate Investigator

Vickie Thomas, PhD Military Associate Investigator

Claudia Martin, LISW Military Associate Investigator

Sandra Gordon, BS Samueli Institute Associate Investigator

Michal Boyars Research Coordinator

Ames Davis Research Coordinator

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Disclaimer

“The views expressed in this document are those of the author(s) and do not reflect the official policy of

William Beaumont Army Medical Center, the Department of the Army, or the United States

Government.”

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Samueli Institute Uncovers the Science of Healing

THROUGH FOR TO• Improve

Performance

• Reduce Chronic Symptoms

• Enhance Wellness

RESEARCH

INNOVATION

EDUCATION

INDIVIDUALS

WARFIGHTERS

SYSTEMS

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Purpose of this Session

• Describe the Military Family Empowerment project.

• Provide an overview and results of Patient- and Family-Centered Mind-Body Program Guidelines.

• Describe and share results of a program evaluation of a military mind-body program.

• Discuss experiences involving patients and families in program development and evaluation.

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Project Background and Rationale

• Increased need for ongoing, long-term heath care treatment

• Increased stress and trauma

• Improve resilience

• Empower patients and families

• Provide the DoD with an approach to care that empowers patients and families to increase their own ability to cope with health related stress and trauma

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What are Mind-Body Family Empowerment Programs?

Two important elements:1) Family- and patient-centered principles of care delivery2) Use of self-administered evidence-based mind-body

practices

Programs that empower individuals and families by equipping participants with evidence-based self-regulation tools and showing them how to integrate the skills into their lives independently of an outside provider.

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What is the Evidence Based?

Strong evidence based for:1) Family- and patient-centered care2) Use of mind-body practices

• Effective in clinical and non-clinical populations• Benefits for patients, families, providers, hospitals, and payers

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Evolution of Guidelines

• 3 expert panels and papers at IPFCC 5th International Conference

• SME Working Group created draft

• Sent to DoD & 20 additional SME’s, patients, & program leaders for review

• Performed mixed-methods program evaluation of a military mind-body program & draft guidelines

• Revise and disseminate the guidelines

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What do Guidelines recommend?

• Program design and development

• Program implementation

• Program evaluation

• Privacy and confidentiality considerations

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Responses to Guidelines

“These [guidelines] are invaluable to anyone attempting to start a program like this. I wish I had a guide such as this when I started my program.”

LCDR MilleganHead, Mind Body Medicine

“I find [the Guidelines] to be practical and feasible. Having a good set of guidelines (and widely disseminated) will help lend legitimacy to mind-body work and provide a standards-based assessment and acceptance of design, implementation, evaluation, and sustainment.”

COL BrumageDeputy Commander for Clinical Services

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“This is a first rate, comprehensive manual for establishing multi-modal mind-body program in a military setting. It provides a safe, reproducible road map for navigating through the complicated terrain of program development with tremendous attention to the details of its creation. It is very well written, well researched.”

Audrey Schoomaker, RN, BSN, E-RYT Mind-Body Practitioner

Former Army Nurse

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Military Mind-Body Program Evaluation

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Evaluating a Patient- and Family-Centered Mind-Body Military Program

Collaboration

Information Sharing

Respect and Dignity

Participation

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Patient- and Family-Centered Mind-Body Military Program

• 4-weeks outpatient interdisciplinary program to treat posttraumatic stress disorder (PTSD) and depression

• Sample: active duty Service Members and their Family• Mixed-Methods Approach

• Retrospective outcome measures (N= 228)• Analysis: SPSS

• Experiential evidence- 30 interviews• Analysis: RAPID Assessment

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Using a Mixed-Methods Approach

Outcome Measures

(N=228)

• Treatment Motivation Questionnaire (TMQ)

• Post Traumatic Growth Inventory (PTGI)• Patient Health Questionnaire 15 (PHQ-

15)• General Anxiety Disorder (GAD-7)• Patient Health Questionnaire-9 (PHQ-9)• Pittsburgh Sleep Quality Index (PSQI)• PCL-M (PTSD Check List-Military

Version)• World Health Organization Quality of

Life (WHOQOL-BREF) • Satisfaction Questionnaire

31 Interviews

(Individual and Focus Groups)

• Service Members (n=12)

• Family Spouses (n=5)

• Staff (n=12)

• Leaders (n=2)

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Quantitative Results:Outcome Measures

• PHQ9 and GAD7, were significantly lower and clinically represented a decrease of category from red flag to yellow flag

Behavioral Health Measures

• Higher (p<.05) positive outcomes in the following domains:• Relating to Others• New Possibilities • Personal Strengths

Post Traumatic Growth Inventory

• After 4 weeks, quality of life was significantly (p<.05) better for all domains (except Environment).

Quality of Life:

World Health Organization Quality of Life

• High satisfaction with the program and the providers.• Information was presented clear, concise and in a good pace.• Participants anticipate using what they learned at the program.• The majority of participants reported significant improvement in

social (64%), emotional (61%) and psychological (76%) state.

Satisfaction

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PTSD and Depression Symptom Improvement (N=226)

0 10 20 30 40 50 60 70 80 90 1000

10

20

30

40

50

60

Perception of PTSD Symptoms Im-provement

Percent Improvement

Freq

uenc

y

0 10 20 30 40 50 60 70 80 90 10005

10152025303540

Symptom Improvement Attributed to Intervention Alone

Percent Improvement

Freq

uenc

y

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Knowledge of PTSD

Minimal 1 2 3 4 5 6 Extensive05

10152025303540

Understanding of PTSD before the Program (N=226)

Perc

ent

Minim

al 1 2 3 4 5 6

Extensiv

e0

10

20

30

40

Understanding of PTSD after the Program (N=226)

Perc

ent

Before the program, how would you rate your understanding of PTSD?

Having completed the program, how would you rate your understanding of PTSD?

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Treatment Motivation QuestionnaireInternalized Reasons

Not at all True

Somewhat True

Very True0

102030405060708090

100

9.9

35.5

54.7

Perc

ent

Not at all True Somewhat True

Very True0

102030405060708090

100

8.2

28.7

63.1

Pre-Intervention 4 Weeks Post-Intervention

I came for treatment at the clinic because:• I really want to make some changes in my life.• I won't feel good about myself if I don't get some help.• I feel so guilty about my problem that I have to do something about it.• It is important to me personally to solve my problems.

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Treatment Motivation QuestionnaireHelp Seeking

• I want to openly relate with others in the program.• I want to share some of my concerns and feelings with others.• It will be important for me to work closely with others in solving my problem.• I look forward to relating to others who have similar problems.• It will be a relief for me to share my concerns with other program participants.• I accept the fact that I need some help and support from others to beat my problem.

Not at all True

Somewhat True

Very True0

102030405060708090

100

7.9

60.6

31.5

Perc

ent

Not at all True

Somewhat True

Very True0

102030405060708090

100

2.1

51.8 46.2

Pre-Intervention 4 Weeks Post-Intervention

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Treatment Motivation QuestionnaireConfidence

• I am not sure this program will work for me.• I am confident this program will work for me.• I'm not convinced that this program will help me stop drinking.• I doubt that this program will solve my problems.• I am not very confident that I will get results from treatment this time.

Not at all True

Somewhat True

Very True0

102030405060708090

100

2.5

63.5

34.0

Perc

ent

Not at all True Somewhat True

Very True0

102030405060708090

100

9.2

52.338.5

Pre-Intervention 4 Weeks Post-Intervention

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Qualitative Results: Findings from Experiential Evidence

Process Structure

OutcomesMaintain Gains in Health

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Qualitative Results: Findings from Experiential Evidence

Process Structure

OutcomesMaintain Gains in Health

THEMES:• Quality of Care

• Providers• Treatments• Environment

• Command Support• Stigma

• Treatment Modalities• Reiki• Art• Massage• Yoga/Movement• Individual• Groups• InVivo

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Qualitative Results: Findings from Experiential Evidence

Process Structure

OutcomesMaintain Gains in Health

THEMES:• Aftercare

• Critical• BH can’t help –

too busy• Longer is better

• Transitioning• Too abrupt• No chance to

practice• Pay It Forward

• Volunteering to help with WRC

• Want to help other Soldiers

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Qualitative Results: Findings from Experiential Evidence

Process Structure

OutcomesMaintain Gains in Health

THEMES:• Program Awareness

• Referrals (EBH)• Command Support

• General support of EBH

• Family Involvement• Weekly support

group• Treatments• Childcare• Awareness• Barriers

• Post-Program Support• Aftercare

• Appointments• groups• Treatments

• IM Experience• No previous• Some previous• Future plans

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Qualitative Results: Findings from Experiential Evidence

Process Structure

OutcomesMaintain Gains in Health

THEMES:• Overall Experience

• Last Resort• Group Impact• Quality of Life• Shared Experience

• Empowerment• Self-Awareness• Growth

• Social• Family• Work• Recreation

• Emotional• Recognize triggers• Anger • Calm/quiet

• Physical• Sleep• Pain• Energy

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Themes from Interviews

Structure

•Program Awareness•Referrals (EBH)•Command Support•General support of EBH

•Family Involvement•Weekly support group•Treatments•Childcare•Awareness•Barriers

•Post-Program Support•Aftercare•appointments•groups•treatments

•IM Experience•No previous•Some previous•Future plans

Process

•Quality of Care•Providers•Treatments•Environment

•Command Support•Stigma

•Treatment Modalities•Reiki•Art•Massage•Yoga/Movement•Individual•Groups•InVivo

Outcomes

•Overall Experience•Last Resort•Group Impact•Quality of Life•Shared Experience

•Empowerment•Self-Awareness•Growth

•Social•Family•Work•Recreation

•Physical•Sleep•Pain•Energy

•Emotional•Recognize triggers•Anger •Calm/quiet

Maintain Gains in Health

•Aftercare•Critical•BH can’t help – too busy•Longer is better

•Transitioning•Too abrupt•No chance to practice

•Pay It Forward•Volunteering to help with WRC

•Want to help other Soldiers

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LESSONS LEARNED

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Barriers and Facilitators in Implementation

Barriers• Lack of resources• Leadership buy-in & turnover• Finding a champion• Perceptions of CAM/IM• Modality choice• Time, $, planning for evaluation• Support during re-entry (military)• Follow-up care• Family engagement

Facilitators• Benefactor/resources• Local champion• Choice of evidence-based

modalities• Experiential sessions for providers• Family involvement in treatment

options/goals• Regular patient/family feedback• Ongoing aftercare• Participants as referrals

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Patient and Family Involvement

• Project focus on empowerment of patients and families

• Role in panel presentations at IPFCC 5th International Conference

• Involvement in writing Guidelines

• Participation in reviewing Guidelines

• Role on WRC program evaluation team

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Patient and Family Involvement

Conference (Fish Bowl Panelists)

Study Participation

Guidelines Development and Review

Military MB Program

Evaluation Design and Execution

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Questions?

www.SamueliInstitute.org/Guidelines

ACCESS GUIDELINES:

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www.SamueliInstitute.org/Guidelines

ACCESS GUIDELINES:

“They can manage their anger, their anger doesn’t manage them. They can manage their anxiety, their anxiety doesn’t manage them.”

Staff and Leaders

“When I'm about to lose it, I remember what I learned and calm myself...I think first and I can walk away [from anger].”

Participant

“This place has saved marriages and lives.”

Family Member

“Four weeks at WRC program helped more than a year of counseling could have.”

Participant