Health Behavior Counseling Research Articles

Clinical Outcomes and Qualitative Perceptions of In-person, Hybrid, and Virtual Cardiac Rehabilitation.

Cardiac rehabilitation (CR) is evolving to include both in-person and virtual delivery. Our objective was to compare, in CR patients, the association of in-person, hybrid, and virtual CR with change in performance on the 6-min walk test (6MWT) between enrollment and completion. Patients enrolled in CR between October 22, 2019, and May 10, 2021, were categorized into in-person, hybrid, or virtual groups by number of in-person and virtual visits. All patients received individualized exercise training and health behavior counseling. Cardiac rehabilitation was delivered to patients in the hybrid and virtual cohorts using synchronous video exercise and/or asynchronous telephone visits. Measurements at CR enrollment and completion included the 6MWT, blood pressure (BP), depression, anxiety, waist-to-hip ratio, and cardiac self-efficacy. Of 187 CR patients, 37/97 (38.1%) were in-person patients and 58/90 (64.4%) were hybrid/virtual patients ( P = .001). Compared to in-person (51.5 ± 59.4 m) improvement in the 6MWT was similar in hybrid (63.4 ± 55.6; P = .46) and virtual (63.2 ± 59.6; P = .55) compared with in-person (51.5 ± 59.4). Hybrid and virtual patients experienced similar improvements in BP control and anxiety. Virtual patients experienced less improvement in depression symptoms. There were no statistically significant changes in waist-to-hip ratio or cardiac self-efficacy. Qualitative themes included the adaptability of virtual CR, importance of relationships between patients and CR staff, and need for training and organizational adjustments to adopt virtual CR. Hybrid and virtual CR were associated with similar improvements in functional capacity to in-person. Virtual and hybrid CR have the potential to expand availability without compromising outcomes.

Trends in US Ambulatory Care Patterns During the COVID-19 Pandemic, 2019-2021

Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. In this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age- and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type. Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively. Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening. More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types). Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increase in use of these ambulatory care services was significantly lower for participants with Medicaid or Medicare-Medicaid dual eligibility than for those insured by commercial, Medicare Advantage, or Medicare fee-for-service.

Hallways to Health: School Health Beyond School-Based Health Center Walls

Objective: In this paper, we describe the implementation and outcomes of an initiative that engaged school-based health centers (SBHCs) in a learning community to create programmatic and policy school health changes beyond the health center walls. Methods: Sixty respondents completed impact surveys and 13 coalitions completed progress reports to document schoolwide wellness efforts and outcomes in stakeholder engagement, student healthy eating and active living, student social and emotional wellness, and school staff wellness. Results: Respondents reported pre- to post-intervention improvements in stakeholder engagement, including school administration promotion of school health policies (from 64% to 95%), and teacher participation in SBHC sponsored activities (from 63% to 98%). They reported schoolwide policy and programmatic achievements including increased opportunities for physical activity for students during school hours (from 55% to 85%), access to behavioral health counseling and support services to all students, either on-site or through referrals (from 62% to 89%), and offering healthy food or nutrition education to staff (from 10% to 73%). Conclusions: SBHC staff, school employees, and community members can work collaboratively to assess student physical and mental health needs, and develop and implement school policies and programs beyond the clinic walls.

Burnout and Perceptions of Stigma and Help-Seeking Behavior Among Pediatric Fellows.

Although burnout has been studied extensively among students and residents, in few studies have researchers examined burnout among fellowship trainees. We measured burnout among fellows in our freestanding children's hospital and evaluated fellows' perceptions of stigma around (and willingness to seek treatment for) psychological distress. The objectives are as follows: to (1) measure burnout among pediatric fellows, (2) assess fellows' perceptions of stigma around help seeking for mental illness, and (3) examine the relationship between burnout and willingness to seek behavioral health counseling. We distributed a 48-item inventory to all 288 fellows in our pediatric center. Items included the Maslach Burnout Inventory and Likert-type matrices to assess attitudes toward behavioral health treatment and associated stigma. We used 2-sampled t-tests to associate burnout with willingness to seek mental health treatment. A total of 152 fellows (52%) responded, of whom 53% met the threshold for burnout. Most reported believing that their program directors (78%), attending physicians (72%), and patients (82%) hold negative attitudes about mental illness and its treatment; 68% believed that employers would reject their application if they knew they sought counseling. Fellows with burnout were more likely to believe that others in the clinical learning environment hold negative views of help seeking for behavioral health (odds ratio 1.2-1.9). Just over one-half of the pediatric fellows in our center meet the threshold for burnout. They also experience significant workplace-based stigma around help seeking for psychological distress. Fellows with burnout are more likely than their peers to perceive significant stigma around help seeking for their distress, making them a particularly at-risk learner population.

Randomized Community Trial Comparing Telephone versus Clinic-Based Behavioral Health Counseling for People Living with HIV in a Rural Setting.

To test the efficacy of a theory-based behavioral intervention delivered via telephone versus clinic-based counseling to improve HIV outcomes and reduce alcohol consumption for people at-risk for treatment failure in a rural setting. Patients receiving HIV care (N = 240) were randomized using a computer-generated scheme to one of three conditions: (a) telephone behavioral health counseling, (b) clinic-based behavioral health counseling, or (c) attention control nutrition education. Behavioral counseling was delivered by either a community nurse or a paraprofessional patient navigator, with differences examined. Participants were followed for 12 months to assess medication adherence using unannounced pill counts and alcohol use measured by electronic daily text message assessments, and 18 months for HIV viral load and retention in care extracted from medical records. There was evidence for telephone and office-based counseling demonstrating greater medication adherence than the control condition but only in the short term. Clinic-based behavioral counseling significantly reduced alcohol use to a greater degree than telephone counseling and the control condition. There were no other differences between conditions. There were also no discernable differences between counseling delivered by the community nurse and the patient navigator. Telephone and clinic-based counseling demonstrated improved medication adherence in the short term, while clinic-based counseling demonstrated reductions in alcohol use. The modest outcomes suggest that intensive intervention strategies are needed for patients that clinicians identify as at-risk for treatment discontinuation and treatment failure.

Use of Medications for Treatment of Opioid Use Disorder Among US Medicaid Enrollees in 11 States, 2014-2018

There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees. To examine the use of medications for OUD and potential indicators of quality of care in multiple states. Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses. Calendar year, demographic characteristics, eligibility groups, and comorbidities. Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines). In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (-0.01 prevalence difference, 95% CI, -0.03 to 0.02) with state variability in trend (90% prediction interval, -0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups. Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.

Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care

Introduction Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Tier-based treatment for opioid use disorder in the primary care setting.

Background: Two primary care clinics implemented an opioid use disorder (OUD) treatment program that integrates behavioral health counseling with buprenorphine treatment and uses tiers. This project aimed to understand how patients moved through tiers in this program. Method: We purposively sampled 20 patients with at least 10 OUD-related treatment visits; we documented tier changes at all visits between September 1, 2016 and December 31, 2018 using a standard data collection instrument. These data were used to construct run-charts. Results: About 45% of sampled patients had at least one relapse noted and 60% of patients dropped in tier during the study. Reductions in tier often happened when the patient was navigating difficult psychosocial situations in their life, whereas increases in tier often accompanied positive life events. We also found variation in use of the tiers. Discussion: OUD treatment from two clinics by tier illustrates that recovery is an individualized process based on patient need that can fluctuate due to psychosocial triggers and significant life events. Having tiers can guide treatment and provide both clinicians and patients with information about what to expect during treatment while still allowing the flexibility to meet patients where they are. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Associations in preventive sexual health service utilization and pre-exposure prophylaxis (PrEP) interest among young Black women in the United States, 2018

ABSTRACT Despite declines in HIV prevalence among all U.S. women, HIV remains a serious concern for Black women. PrEP is an effective biomedical intervention and has high acceptability among Black women. Therefore, offering PrEP, in addition to screening and testing for STI/HIV consistently, can reduce HIV risk among this population. We examine the associations of preventive sexual health service utilization (PSHSU) and PrEP interest among young Black women (YBW) (N = 209) in the United States in 2018. YBW, ages 18–25, completed a self-administered questionnaire, assessing sexual risk and prevention behaviors, HIV/STI testing, and PrEP interest. More than half of YBW were aware of PrEP and its benefits. YBW, who received an HIV test within the past three to six months, had higher odds of PrEP interest. The proportion of YBW who reported being interested in PrEP did not differ by PSHSU. Active contraceptive use was associated with PrEP interest. The results suggest YBW engage in preventive sexual health services, including HIV/STI testing, reproductive health, and sexual health behavioral counseling. Additional efforts should be made to normalize PrEP education for heterosexual, cisgender women at student health centers on college and university campuses, and other venues outside of traditional HIV/STI testing facilities.

The principles and practices of psychoeducation with alcohol or other drug use disorders: A review and brief guide

OverviewIn the current work, we build upon a small body of literature that delineates cross-cutting factors, or processes, of evidence-based alcohol or other drug (AOD) therapies. Here, we discuss Psychoeducation. We define psychoeducation as a brief process of therapy focused on the communication of varied aspects of disease- and/or treatment-related information. MethodThe authors conducted a literature review and qualitative content analysis to derive a set of principles and practices of psychoeducation. The review used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO. ResultsThe review identified nine principles and 21 practices. Together, the principles suggest that psychoeducation in evidence-based addictions therapies can be characterized as a collaborative approach to teaching, education, or other provision of information. The term collaborative denotes a shift in emphasis from compliance to a more egalitarian partnership focused on meeting individual health needs. Specific practices included ways to transition to psychoeducation (e.g., provide rationale and promote expectancy), teaching methods in psychoeducation (e.g., use plain language), tailoring content in psychoeducation (e.g., to learning style, to cultural worldview), and methods for facilitating a dialogue about the information (i.e., five question types), for facilitating understanding and retention of the information (e.g., tailor to individual needs, use of varied teaching modalities), and how to end psychoeducation and engage in related goal-setting, where applicable. ConclusionsWe frame psychoeducation as a collaborative approach to teaching where client engagement, understanding, and utilization of the information provided is the central goal. We offer a novel resource with pragmatic value to trainees, providers, and clinical supervisors who do not consider themselves aligned with a single evidence-based modality but who may benefit from training and proficiency assessment in core, behavioral health counseling competencies.

Perceptions of collaborative care team members on facilitators and barriers to care and glycosylated hemoglobin level as a diabetes quality metric at a federally qualified health center in Texas

ObjectivesFacilitators and barriers to collaborative patient care have been explored in previous studies. Few studies provide information about collaborative care team (CCT) members’ roles in treating patients with diabetes and how CCT members should be evaluated for their contributions to diabetes care. To describe the roles and responsibilities of CCT members at CommUnityCare (CUC), a federally qualified health center in Central Texas; identify the facilitators and barriers affecting referrals to other CCT members within CUC; explore the facilitators and barriers to collaborative patient care at CUC; and assess CCT members’ perceptions of quality metrics for diabetes care. MethodsA cross-sectional design was used. Data was collected by a survey and semistructured interviews of CCT members. The survey (32 questions) assessed roles and responsibilities, including the percentage of time spent on clinic activities, referral criteria, perceptions of quality diabetes care, and facilitators and barriers to care. The interview (32 questions) gathered a description of the CCT member’s role, referral process, and ideas for diabetes quality metrics. Descriptive statistics and content analysis were used for data analysis. ResultsTwenty-two CCT members (4 diagnosticians, 4 clinical pharmacists, 4 behavioral health professionals, 4 registered dietitians, 2 community health workers, and 4 care managers) participated in this study. Co-location (54%) and professional relationships with coworkers (32%) facilitated referrals to other CCT members. Appointment availability (32%) and lack of referral criteria knowledge (27%) were barriers to other CCT member referrals. Seventy-five percent of the dietitians and care managers thought that the glycosylated hemoglobin (A1C) level was a good quality metric for diabetes care, followed by 50% of the clinical pharmacists, 25% of the behavioral health counselors, and 0% of the community health workers and diagnosticians. ConclusionCo-location and professional relationships facilitated referrals to CCT members, whereas lack of CCT member availability and lack of referral criteria knowledge were barriers to CCT referrals. Metrics other than the lowering of the A1C level should be further explored to assess the quality of diabetes care.

Physical Activity, Medical Home, and Health Behavior Counseling Among Adolescents with Special Health Care Needs: NSCH 2016-2017.

Aim 1 was to establish updated prevalence estimates for meeting national physical activity (PA) guidelines among adolescents with and without special healthcare needs (SHCN), 12-17years old. To identify at-risk subgroups, our sub-aim was to compare the distribution of prevalence estimates across PA levels by SHCN subtypes, and in reference to peers without SHCN. Aim 2 was to examine the association between meeting PA guidelines, having a medical home, and receiving positive health behavior counseling in this population. Weighted prevalence estimates for meeting the 2018 National PA Guidelines (inactive, insufficiently active, sufficiently active: guidelines met) were calculated from a secondary analysis of the National Survey of Children's Health 2016-2017 ( n = 16,171, 27% SHCN). Adjusted odds ratios and 95% CIs were estimated from logistic regression models to measure the association between PA, medical home, and postive health behaviorcounseling. Of adolescents with SHCN, 15% were reported to be meeting PA guidelines compared to 19% of peers without SHCN peers. Among adolescents with a medical home, regardless of SHCN status, those receiving positive health behavior counseling had 1.70 times the adjusted odds of meeting PA guidelines compared to peers without counseling. Adolescents with and without SHCN were more likely to meet PA guidelines if they had a medical home and received positive health behavior counseling, highlighting the value of comprehensive healthcare practices for PA promotion.

Reaching the Hard-to-Reach: Outcomes of the Severe Hypertension Outreach Intervention

Severe hypertension (≥180 mmHg systolic or ≥110 mmHg diastolic) is associated with a twofold increase in the relative risk of death. At the authors' Federally Qualified Health Center in the Southeast, 39% of adults (n=8,695) had hypertension, and 3% (n=235) were severe. The purpose of this project was to lower blood pressure and improve the proportion of patients achieving the Agency for Healthcare Research and Quality goal for blood pressure. This quality improvement project was performed in 2017 in three 3-month Plan, Do, Study, Act cycles using a multidisciplinary outreach model in a community-based primary care setting. A clinical team including physicians, nurses, patient navigators, behavioral health counselors, and pharmacists contacted adult patients with severe hypertension (≥180/110 mmHg), scheduled visits, and established blood pressure and medication management goals. The data review and analysis concluded in 2019. Among patients with blood pressure ≥180/110 mmHg (n=235), the average age was 57 years (SD=12 years), 37% (n=87) were male, 82% (n=193) were Black, and 46% (n=108) were uninsured. The majority of those contacted attended a follow-up appointment within the 9-month project (77%, n=181) and achieved an improved systolic blood pressure (87%, n=167) and diastolic blood pressure (76%, n=146). Target blood pressure of <140/90 mmHg was achieved in 29% of patients (n=53). Medication possession ratio improved from 23% to 40% among patients reached by pharmacists (n=30). Fewer deaths occurred in those reached by the intervention than in those not reached (n=1 vs n=3). Multidisciplinary outreach and use of evidence-based guidelines (Eighth Joint National Committee) were associated with lower blood pressure in patients with severe hypertension.

Chronic Disease Counseling and Screening by Dental Professionals: Results From NHANES, 2011-2016.

IntroductionDental visits may provide an opportunity to counsel and screen for chronic disease prevention. However, few studies have used nationally representative data to assess the potential role of dental professionals in chronic disease prevention. We examined the percentage of US adults who reported chronic disease counseling and screening by dental professionals.MethodsWe analyzed data from the National Health and Nutrition Examination Survey 2011–2016 for 5,541 participants aged 30 or older who reported seeing a dental professional in the past year and estimated the percentage who reported receiving counseling about selected chronic disease prevention during the visit. We used logistic regressions to examine associations between risk factors and counseling.ResultsOverall, 4.0% (standard error [SE], 0.3) of adults were told by a dental professional about the benefits of checking blood glucose, 42.4% (SE, 2.9) giving up tobacco (among tobacco users), 26.6% (SE, 1.2) about checking for oral cancer, and 43.0% (SE, 1.8) had an oral cancer examination. Groups with risk factors were more likely to receive health behavior counseling than those without (eg, those previously told they had diabetes risk factors were more likely to receive blood glucose counseling than those without [8.1% vs 3.3%, P < .05]). The pattern for oral cancer counseling and receiving an oral cancer examination was different: adults without oral cancer risk factors (no tobacco use, normal/underweight, and/or excellent/very good health) were more likely to receive oral cancer counseling or screening. Adjusted analyses did not change these associations.ConclusionMost adults were not counseled about chronic disease prevention during a visit with a dental professional. Current tobacco users and those with overweight or obesity were more likely to report receiving counseling.

The Effect of Depression on Patient Reported Outcomes Measurement and Information System Computer Adaptive Test (PROMIS-CAT) scores and Return-to-Sport following ACL Reconstruction

Objectives:Depression has been shown to have a negative effect on many orthopaedic surgical outcomes. The purpose of this study was to determine whether preoperative clinical diagnosis of depression and/or PROMIS (Patient-Reported Outcomes Measurement Information System) Depression scores predicted worse postoperative therapy compliance, functional outcomes, and return-to-sport after anterior cruciate ligament (ACL) reconstruction.Methods:A multi-surgeon series of consecutive patients who had undergone ACL reconstruction at a single institution between 1/4/16 and 7/19/16 were evaluated for inclusion. Patients who had completed preoperative PROMIS Depression (D), Physical Function (PF), and Pain Interference (PI) questionnaires were prospectively enrolled to complete minimum 2-year follow-up PROMIS and Return-to-Sport (ACL-RSI short-form) questionnaires. Chart review was conducted to determine depression diagnosis status, demographic data, and rehabilitation physical therapy (PT) compliance. PROMIS D score cutoff for mild depression was >52.5, based on previously established correlation to the validated Patient Health Questionnaire-9.Results:Ninety-five of 115 consecutive patients (81%) met inclusion criteria. Average follow-up was 34+/-1.9 months. Fourteen patients (15%) carried a clinical diagnosis of depression. Thirty-two (34%) had a preoperative PROMIS D score above the mild depression threshold; of those, 2 (2%) scored in the moderate depression range, and 3 (3%) scored in the severe depression range. Overall, the cohort (including depressed patients) showed improvement in PROMIS PF and PI scores postoperatively (p<0.001) (Table 1). Diagnosed depressed patients had a higher rate of PT non-compliance (30.8%±17.3% vs. 21.9%±12.6%; p=0.04) and lower postoperative physical function (50.8±7.7vs. 57.5±10.5; p=0.03), but no differences in post-operative PROMIS PI (50.8±6.9vs. 46.7±6.8; p=0.32), compared to patients without depression diagnosis. The percentage of missed therapy appointments showed a correlation with lower postoperative PROMIS PF scores (r=0.33, p=0.008) in our cohort. PROMIS depressed (PROMIS D>52.5) and undiagnosed depression patients (subgroup of preoperative PROMIS depressed without depression diagnosis) showed no difference in PT compliance or postoperative PROMIS PF or PI, compared to non-depressed patients (Table 2). Undiagnosed preoperative depressed patients (n=21/95 (22%)) also showed improvement in their depression scores postoperatively (mean PROMIS D = 57.4±5.0 preop vs. 44.5±6.6 postop; p<0.0001) (Figure 1) and 19/21 (90.5%) patients in this group showed resolution in their personal PROMIS D score to non-depressed range (p=.001). PROMIS depressed patients were less likely to participate in a sport (16/32 (50.0%) vs. 50/63 (79.3%); p=0.003), but PROMIS depressed athletes had no differences in return to sport rates (10/16 (63%) vs. 25/50 (50%); p=0.38) or responses to the ACL-RSI Short Form questionnaire (p>0.05 for all).Conclusion:Clinically diagnosed depression is predictive of worse rehabilitation therapy compliance and worse functional outcomes after ACL reconstruction surgery, but even depressed patients can be expected to show improvement. PROMIS Depression scores, particularly in those without a clinical diagnosis of depression, can be expected to resolve to non-depressed range after ACL reconstruction. Patients with depressed mood preoperatively but no depression diagnosis could be considered to have “situational depression” and can be reassured that depression will likely resolve after ACL reconstruction. Patients with depression diagnosis, however, should be counseled regarding tempered expectations after ACL reconstruction. Resources should be allocated to incorporate behavioral health counseling pre- and post-surgery in an attempt to maximize outcomes.

Implementing Office-Based Opioid Treatment Models in Primary Care.

Primary care practices are ideal sites for integrating medication-assisted treatment (MAT) for opioid use disorder, but little is known about how practices have achieved this. Our study aimed to describe the implementation experiences and treatment models of practices implementing MAT. We conducted a qualitative analysis of MAT integration at 26 practices across Virginia after the state implemented the Addiction and Recovery Treatment Services (ARTS) benefit in 2017. Data collection activities included interviews with clinic team members, including buprenorphine-waivered prescribers, behavioral health clinicians, care coordinators, and peer counselors. We used a template analysis approach to thematically analyze data. Our study identified various ways in which MAT can be implemented in primary care clinics and other ambulatory settings. Although state regulations and treatment guidelines suggest colocating behavioral health counseling and medication management, providing care coordination, and conducting regular urine drug screens, we found a wide spectrum of ways in which practices can adapt and innovate treatment models to fit local needs. As the fight against the opioid epidemic continues, we need to identify feasible and effective MAT treatment models and integration approaches for primary care.

The Association of Direct Observation of Medical Students With Patient-Centered Care for Obesity.

Teaching medical students patient-centered approaches to weight loss counseling occurs in myriad ways. We examined lectures and direct faculty observation to see which was associated with better patient-centered care in medical students, measured by both self-perception and independent observer evaluation. Third- and fourth-year students attending one medical school were surveyed regarding their education in (1) weight loss and health behavior counseling, (2) obesity stigma, and (3) whether they had experienced direct faculty observation of their weight loss counseling. Several weeks later, the students were observed during a standardized patient encounter for obesity and an obesity-relevant comorbidity. A postencounter survey assessed overall student satisfaction with the encounter and with the care they provided. Independent coders rated their patient-centered communication using a validated measure. There was no consistent association between any dependent variable and student ratings of adequacy of instruction, nor with instructional content. Direct faculty observation was not associated with overall encounter satisfaction or their overall patient-centeredness. However, experiences with direct faculty observation were significantly and positively associated with students' perceptions of patient engagement (b=0.1, P=.05), and with independent coders' ratings of student friendliness (b=0.13, P=.01), responsiveness (b=0.113, P=.03), and lower student anxiety (b=-0.1, P=.01). Independent observation and self-report of instruction adequacy and content had no consistent association with care quality. However, direct faculty observation predicted improvement in both student self-reports and independent observer ratings of students' interpersonal quality of care. Further work is needed to define optimal methods of imparting patient-centered care.

Lifestyle counselling as secondary prevention in patients with minor stroke and transient ischemic attack: study protocol for a randomized controlled pilot study

BackgroundMost patients with minor stroke or transient ischemic attack (TIA) are discharged with little or no specialised follow-up. Nonetheless, these patients have a high prevalence of cognitive impairments and a considerable risk of recurrent stroke. Smoking cessation, physical activity, and adherence to antihypertensive and antithrombotic medication are highly recommended in patients with minor stroke and TIA. Evidence suggests that simple encouragement to change lifestyle is ineffective. Behavioural interventions might therefore be needed to support patients in managing their own health post-discharge.ObjectivesWe aim to test the (1) feasibility of randomisation acceptance and an early initiated, client-centred lifestyle and behavioural intervention in a clinical setting, and (2) potential effect of the intervention on arterial blood pressure in patients with minor stroke or TIA and (3) explore the participants experience of barriers and facilitators for health behaviour after a stroke, including perceived needs and social support.MethodsWe will conduct a randomized controlled pilot trial: Eligible patients with acute minor stroke or TIA (n = 40) will be randomly allocated to either early initiated counselling with four weekly post-discharge follow-up sessions for 12 weeks or usual care. The primary outcome will be program feasibility and to discuss the relevance of arterial blood pressure as primary outcome after 12 weeks intervention. Selected participants will be invited to participate in semi-structured interviews, based on purposeful sampling, to evaluate the intervention and explore their experience of life after a stroke. The interviews will be analysed using a five-step thematic analysis approach.DiscussionThe study will provide evidence of the feasibility and potential effect of early initiated counselling on cardiovascular risk factors in patients with minor stroke and TIA. Qualitative interviews will contribute with a more nuanced understanding of the barriers and facilitators of health enhancing behaviour. Optimizing health behaviour counselling and providing formal support to the patients’ post-discharge may ease the transition and help more patients adhere to lifestyle and medication recommendations.Trial registrationClinicalTrial.gov, NCT03648957

“How do I help this kid adjust to what real life is for them?”: Youth service providers experiences on supporting children with incarcerated parents

IntroductionOver five million youth, or one in every 14 children, in the United States have lived with a parent incarcerated at some time point in their childhood. Research has found strong associations between the exposure of parental incarceration (PI) and a host of negative social, economic, and health outcomes in youth. Multi-level community and family supports for those exposed to PI are encouraged, yet research is limited on the experiences of the youth service providers that would be tasked to help support these youths. ObjectiveThe goal of this study was to provide a detailed account and description of the experiences of youth service providers (including teachers, behavioral health specialists, counselors, and youth mentoring personnel) who have worked with children currently or previously exposed to PI. Qualitative data were gathered from 30 providers using semi-structured, in-depth phone interviews. Data were analyzed using qualitative content analysis. ResultsProvider experiences working with children exposed to PI were delineated by phase of incarceration of the parent: upon arrest, during incarceration, and upon re-entry into the community. Three primary themes were identified for the child for each phase of incarceration: justice contact needs 2) social and economic needs and 3) communication needs. ConclusionOur results underscore the imperative need for timely and sensitive screening for youth exposure to PI, resource guides on how to communicate and navigate the justice system, and a coordinated hub of social services to support economic and housing stability for the child and/or family. Trauma-informed and trust-building approaches were also important strategies providers used when supporting youths exposed to PI.

Overcoming Technological Challenges: Lessons Learned from a Telehealth Counseling Study.

Background: Telehealth methods, including video chat counseling, have been growing in popularity within the behavioral health counseling field for over a decade. While video-based counseling methods have been shown to be effective and convenient, they have unique challenges stemming from the technology they use. Technical challenges can negatively impact appointment flow, intervention effectiveness, and the satisfaction of both patients and clinicians. Methodology: The Y2TEC (Youth to Text or Telehealth for Engagement in HIV Care) study is a pilot randomized control trial examining the feasibility and acceptability of a video counseling series provided to young adults (ages 18-29) living with HIV. The study's clinicians provided about 500 video-based counseling sessions through the Zoom videoconferencing platform. The study team then developed recommendations for overcoming technical challenges through a review of the best practice literature, insights from the clinicians and study coordinator, engaging in consultations during supervision meetings, receiving verbal feedback from participants, and reviewing logs of technical challenges. Results: Through our experience, we have found that quality of video-based counseling services can be greatly improved with minor intentional technological modifications in preparation and provision of services. We provide an overview of common challenges and corresponding recommendations to address them. Conclusion: This article can help clinicians improve their quality of telehealth sessions by identifying several common technological challenges that can occur during video chat sessions, exploring the impact of these challenges on session dynamics and providing concise, best practice-based recommendations to mitigate these issues that clinicians face.