The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 2

Last week, in part 1 of the WPIC solution, I began defining a new type of wellness program based on a whole-person integrated-care (WPIC) model, which takes a whole-person (mind, body, spirit, and environment) view of health, and which coordinates sick-care with well-care across the entire healthcare continuum. I included an introductory discussion of the value proposition of such a wellness program and its goals and methods. I also mentioned that (at least) four types of people with different character traits require different approaches to wellness due to their other thoughts, emotions, behaviors, knowledge & understanding, and coping strategies. In this post and future ones, I examine these differences.

Definitions

Since I'm presenting additional terms, let me take a moment to define them:

• Thoughts refer to a person's attitudes, beliefs, perceptions, assumptions, reasoning, expectations, memories, "self-talk," and other mental processes (i.e., one's cognitions).
• Emotions refer to a person's feelings and moods (i.e., one's affect).
• Behaviors are what a person does (i.e., one's actions).
• Knowledge & understanding are related terms, which I discuss in some detail at this link. Briefly, knowledge refers to information someone knows about essential things, such as relevant people, things, places, times, reasons, rules, and methods. Understanding, on the other hand, is being able to apply that knowledge when doing such things as:
  
  • Explaining, interpreting, discovering, and gaining insights into the nature of things
  • Noticing contradictions/inconsistencies
  • Using logic and evidence to support decisions, make accurate predictions, and judge/evaluate things rationally and sensibly
  • Creating and imagining
  • Focusing attention on what's important (i.e., having good situational awareness), being prepared to act, and justifying one's beliefs/hypotheses.
• Coping strategies are adaptive or maladaptive ways of thinking, feeling, and acting when dealing with problematic situations. Following are ten common coping strategies people tend to use. The first five are positive strategies because they help a person solve a problem or learn to accept it with minimal distress. The latter five are negative strategies because they fail to resolve one's issues or enable healthy acceptance.
1. Logical Analysis is a positive approach strategy in which a person tries to understand what caused the problem and think of different ways to handle it.
2. Social Support is another positive approach strategy in which a person explains the problem to someone or asks others for advice or help. This can help determine what, if anything, can be done to solve it.
3. Problem-Solving is another positive approach strategy in which, after logical analysis, a person determines that a problem can be solved and what has to be done to solve it. Then, a specific action plan is created and implemented, and the person learns from the results and modifies the plan accordingly.
4. Positive Reappraisal is another positive approach strategy in which a person views a problem as helping him/her change or grow in a good way, find new faith, or learn valuable lessons. This strategy can be used whether or not a problem can be solved.
5. Rational Acceptance is a positive non-action strategy in which a person accepts—without undue emotional distress and self-defeating behaviors—that nothing can be done to solve a problem, so s/he does nothing except adopt a rational way of thinking about it, which fosters psychologically healthy acceptance.
6. Behavioral Distraction is a negative avoidance strategy in which a person tries to feel better emotionally by doing enjoyable or interesting things rather than trying to solve the problem or cope with it through positive reappraisal and rational acceptance. While it may help reduce one's upset temporarily, this strategy is maladaptive because it will never solve the problem and does nothing to help one cope with it long-term. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem rather than letting things get worse.
7. Cognitive Avoidance is another negative avoidance strategy in which a person simply acts as if there is no problem or tries not to think about the issue. As with behavioral distraction, the strategy may help reduce one's upset temporarily. Still, it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
8. Emotional Discharge is another negative avoidance strategy in which a person expresses negative emotions by yelling or crying, taking it out on others, or avoiding certain people or situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people, push them away, and waste precise time.
9. Wishful Thinking is another negative avoidance strategy in which a person simply hopes a miracle will make things better or that his/her wishes or prayers will be answered. As with the other avoidance strategies, this one may help reduce one's upset temporarily, but it will never solve the problem and does nothing to help one cope with it long-term, as well as wasting precise time.
10. Resignation is a negative non-action strategy in which a person determines that nothing can be done, so s/he does nothing while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helplessness), and/or anger.

Describing the Characteristics of Four Types of Individuals

As I discussed in my previous post, wellness programs should address the particular needs of (at least) four types of people: Activists, Wannabes, Inactives, and Ignorers/Deniers. In this post, I present the Activists. They are most motivated to deal actively and eagerly with health & wellbeing issues and are most likely to take advantage of wellness programs.

Activists

Activists' attitudes about managing their physical and mental health can be summed up in thoughts such as: "I believe I can do whatever must be done, and I'm willing to do it!" Such views reflect a joy of living and a willingness to take constructive action to reduce fear, uncertainty, and doubt through problem-solving (if their health problems can be resolved) or rational acceptance (if the problems can't be fixed). Activists tend to be confident, motivated, aware, rational, and assertive regarding their character traits. From a whole-person integrated-care perspective, they seek knowledge about their physical and mental health status and risks to help them make wise decisions. And they try to understand how to avoid health problems, self-manage chronic conditions, treat existing problems most safely and cost-effectively, and use their knowledge to live healthy lifestyles. Activists, in other words, are rational people who deal with their physical and mental health problems (existing conditions and risks) by using positive, proactive coping strategies, such as:

• Trying to understand what caused the problems by thinking of different ways to handle it
• Talking to someone about what they are going through and asking certain people for advice or help.
• Determining what must be done to solve a problem and then using a specific action plan.
• Viewing a problem as something that helps them change or grow in a good way, find new faith, or learn valuable lessons
• Rationally accepting when a problem cannot be solved to minimize their emotional distress.

When dealing with an existing health problem, Activists actively seek knowledge and guidance to understand the pros & cons of different treatment options. And when dealing with their health risks, they seek to understand the pros & cons of varying prevention options. If Activists have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they strive to find a way to afford what they need, including political action. If they have family and other demands that consume their time and thus make lifestyle change difficult, they find ways to make time available. And if they have physical handicaps or cognitive impairments that interfere, they will explore alternative approaches to health improvement that accommodates these limitations. Finally, the more a person's character traits resemble an Activist, the more likely s/he is to gain from a wellness program and improve his/her health and wellbeing. In my next post, I examine the Wannabes and Inactives.

Patient-Centered Life-Cycle Value Chain: the Well Care link

In my previous post, I discussed the second link in the Patient-Centered Life-Cycle (PCLC) Value Chain, which is sick-care. In this post, I discuss the third link, which involves well-care, as well as the integration of emergency-care, sick-care and well-care.

Well-Care (Prevention & Self-Management)

The third link in the PCLC Value Chain involves well-care, which includes prevention & self-management. Three well-care delivery models are the:

• Preventative Maintenance model, which focuses on (a) delivery of primary prevention -- such as physical activity, nutrition, stress relief, vaccinations, etc. -- that help people avoid health problems, as well as promoting peek performance, and (b) secondary prevention for at-risk persons to prevent recurrences of health problems, such as avoiding recurrent coronary artery disease events in a person with a history the illness.
• Recovery/Rehabilitation model, which focuses on adherence (compliance) to doctors’ orders to foster recovery, rehabilitation, and complication avoidance for patients having chronic or catastrophic health problems.
• Compassionate Home Care model, which focuses on making people near end of life as comfortable as possible in a supportive environment where they have dignity and family support.

Well-care is delivered by wellness coaches/practitioners, such as specially trained physician assistants, nurse practitioners, home health aids, personal trainers, and others:

• Recovery/Rehabilitation and Preventative Maintenance well-care may be delivered face-to-face, over the internet, and via phone sessions. They include processes for: (a) ongoing risk and health status assessments; (b) ongoing generation of personal health plans identifying any risk factors people may have, as well as primary and secondary prevention plans of action (i.e., health directives); (c) health education presenting concrete, understandable action steps and psychological counseling for dealing with physical problems and psychological stressors; (d) compliance motivation involving motivating and reminding people to do the things that will help them improve their own health; (e) accessing health coaches for health information and advice; (f) outcome studies used in continuous quality improvement feedback loops; (g) care coordination for patients with catastrophic health problems, so multidisciplinary teams can work together effectively; (h) promotion of environmental and workplace safety; and (i) encouraging lifestyle and attitudinal changes for peek performance.
• Delivering Compassionate Home Care well-care includes processes for helping individual obtain home care nursing and homemaking assistance; arranging for transportation to and from doctor appointments; and addressing the psychological, social and spiritual well-being of patients and families.

Integrating Emergency-Care, Sick-Care & Well-Care in the PCLC Value Chain

Instead of viewing emergency-care, sick-care and well-care as separate and distinct, the PCLC Value Chain solution integrating all three. This process involves a new kind of coordination and collaboration between:

• First responders focused on safe passage to and from disaster sites, victim rescue and triage, and trauma center response
• Medical and related sick-care practitioners focused on the diagnosis and treatment of health problems
• Well-care practitioners focused on prevention, recovery, and self-maintenance.

This integrated care strategy promises to bring the greatest value to patient/consumers over their life times by helping assure adequate resources are available and the right care is delivered cost-effectively in all possible situations. It provides a sensible way to keep people healthier longer, recover from illness and dysfunction more quickly, avoid complications of chronic disease, and enable first responders to rescue victims effectively in emergencies. This shifts our current healthcare system from being overly focused on episodic acute care to embrace prevention and chronic condition management, as well responding in emerging environments.

In subsequent posts [starting here], I discuss what’s needed to implement this integrated care strategy successfully, including:

• Specific clinical and financial processes of our current healthcare system that must be transformed
• Specific infrastructural needs, in terms of health information technology use.

Knowledge, Standards and the Healthcare Crisis: Part 10

In my last post [click here for first in series], I discussed how Radical Transformers and Minimalists differ in their view of health knowledge needs, and how they differ in their motivation to change our healthcare system. Following is a brief summary.

On the one hand, Radical Transformers are motivated by a vision calling for fundamental changes in our current healthcare system. They have immense data needs since they focus on making knowledgeable diagnostic, preventive and treatment decisions that continually improve care outcomes and value. They use comprehensive, personalized information, which comes from extensive data about:

• The "whole-person" (mind-body-environment) over one's entire lifetime, including all key psychological, physiological, genetic, environmental and other factors that may affect diagnosis and treatment prescription
• Both sick-care (allopathic) and well-care (wellness & prevention) interventions[1]
• Both conventional and CAM (complementary & alternative medicine) approaches.[2]

Minimalists, on the other hand, are not motivated by a desire to change our healthcare system profoundly; instead, they are satisfied with slow incremental change that barely disturbs the status quo. They need much fewer data for making health and healthcare decisions because, unlike Radical Transformers, they focus on making diagnoses using information about relatively narrow set of signs & symptoms. They then prescribe a conventional, allopathic treatment regimen based on that diagnostic information, which does not require knowledge of the whole person, CAM, nor well-care options.

The issue of how much data, information and knowledge we need for making health-related decisions does not, however, end here. The amount of data diversity also affects the reliability (dependability) and validity (accuracy) of the information we use to make determinations about diagnoses, treatments, risk factors, and preventive care. Data that are more complete yield more valid and reliable information, resulting in better decisions and outcomes. I will discuss this and then begin answering the question: What has to happen for good data to become useful knowledge that leads to ever-better and more affordable care?

Reliability

Reliability is a statistical measure that indicates the degree to which information presents a trustworthy picture of a patient's condition and satisfaction (before, during, and after treatment). You need highly reliable data to have useful and dependable information with which to understand a person's problems and needs and make wise decisions.

A major reason for low reliability is the failure to use an adequate amount of data. In fact, the reliability of a health assessment "…increases when the number of [data] items …are increased and aggregated. It is a truism, but too often forgotten, that we cannot have either validity or utility without reliability [and] … the accuracy or reliability of measurement increases with the length of a test [italics added]. Since no single item is a perfect measure, adding items increases the chance that the test will elicit a more accurate sample and yield a better estimate of the person's [condition]."[3]

So, while you want to limit the amount of data collected in order to save time and effort, you have to be careful that the pool of data defining your data standard is not too limited! Consider this analogy: Pictures produced by most computer printers are comprised of patterns of tiny dots. Each dot is a piece of data that forms a part of the whole picture. In general, the greater the number of dots used to compose a picture, the more clarity and detail (resolution) it has, as shown below:
Figure A

Figure B

What makes B a clearer image than A is the number of dots. The more dots per square inch, the more dependable our interpretation of what we see because the image with greater detail provides more useful information. In the same way, the more data one can use to diagnose and treat a patient's condition, the better one's understanding of the person's problems and needs. Better decisions and outcomes are the likely result of using this comprehensive knowledge.

Validity
While reliability refers to the dependability of information, validity refers its accuracy. To yield valid information, an assessment must accurately measure all of the data required to support sound diagnostic and/or treatment-related decisions.

Note that there are many types of validity. One is diagnostic or discriminative validity , which measures the ability of an assessment instrument to diagnose a patient's disorder. A useful assessment instrument must classify patients into homogenous groupings using rigorous statistical analyses. That is, patients with similar characteristics in terms of their physical and psychological signs & symptoms, symptom etiologies (causes), functional impairment levels, life-stressors, demographics, etc. should be grouped into a single, precise, diagnostic category. Furthermore, patients within that diagnostic category should respond in a similar way to particular healthcare interventions.

For complex or multifaceted medical conditions, and for problems with a psychological component, a substantial amount of information is often necessary for making valid diagnoses. Consider, for example, evaluating depression. It is important to assess the nature, severity, and etiology (causes) of the depressive symptoms in light of a person's current life-events, past experiences, and personal demographics. This means using a vast data pool that measures:

• The intensity, frequency, duration, and cyclical time occurrences of the depression
• The etiology of the depression, including family history, current psychosocial and biomedical problems, medication side-effects, and psychoactive substance abuse
• The nature and degree of dysfunctional cognition associated with the depression such as thoughts of helplessness, hopelessness, suicidal ideation, self-deprecation, and existential/spiritual dilemmas, as well as cognitive slowing, rigidity, and focusing problems
• The nature and degree of concomitant (co-occuring) physiological symptoms such as lethargy versus agitation, changes in sleeping and eating patterns, and physical complaints
• The nature and degree of behavioral disruptions such as social alienation versus clinging dependence, and occupation or education dysfunction
• The nature and degree of coexisting emotional problems such as anger toward self, anxiety, guilt, and shame
• Demographics such as age, sex, ethnicity, and socioeconomic status.

After diagnosing a patient's problems, a particular treatment regimen is determined. Helping decide what treatments work best for a particular patient calls on another form of validity, i.e., predictive validity . This form of validity measures the ability to predict the specific treatments and levels of care that will produce the best outcomes for each type of patient. High predictive validity is difficult to achieve and, as is the case with diagnostic validity, it requires a pool of data comprehensive enough to relate to all patient populations and treatment modalities.

Another example of the need for comprehensive data comes from a recent article about the value of "meta-analysis," i.e., analyzing data combined from multiple clinical trials as a strategy for monitoring and assuring medication safety.[4] It reports how a researcher discovered a dangerous public health threat after stumbling upon data about Avandia, a medication for Type 2 diabetes, which may increase the risk of heart attacks. The report not only generated concerns about of Avandia's safety, but also resulted in considerable controversy about the validity of the conclusions from clinical trial about the risk-to-benefit tradeoffs.

By combining the data from multiple studies, meta-analysis is able to use more comprehensive information than typically available from a single study. This information comes from data about the types of patients enrolled in clinical trials, including demographic characteristics, disease severity, treatment regimens, and use of concomitant medications, among other factors.

The article concluded with a discussion of how the current day data standardization process, which aims to form consensus among multiple stakeholders, often sacrifices rich data "granularity" (i.e., diverse data containing fine details). This loss of detailed nuances can mean the loss of essential information required for making good decisions about the problems and needs of a particular patient in a particular situation.

A third example making the case for data comprehensiveness is that longitudinal data, which may span decades, reveals health problem trends (e.g., prostate cancer[5]) based on changes over time that cannot be determined accurately with an occasional data “snap-shot.”

And a final example, as presented in my previous post, is the need for adequate data variety to a valid evaluation of the mind-body connection. This includes factors such as medication side-effects that cause cognitive, emotional or behavioral problems; stress-related disorders that cause or magnify physical symptoms; and medical illnesses that present as a psychological condition.

Now that I've discussed how data comprehensiveness relates to the reliability and validity of information we use to make diagnostic and treatment decisions, let's return to the question: What has to happen for good data to become useful knowledge that leads to ever-better and more affordable care?

Good Data - Useful Knowledge

While a large, comprehensive pool of data is often essential for making good decisions about one's health and healthcare needs, it is important to make the data pool as concise and useful as possible by eliminating poor, unnecessary and redundant data using scientifically rigorous procedures such as reliability and validity analyses. Existing data pools ought to be continually updated and revised based on these analyses.

Accomplishing this requires, in part, flexible, dynamic information systems that evolve continually to (a) accommodate changes in a patient's condition over time, and (b) adjust to changing data standards by which health problems, treatments and outcomes are assessed.

I will continue this discussion in my next post.

References:

[1] Beller, S. and Sabatini, S. (2007). Integration of Sick-Care with Well-Care.
[2] National Institute of Health's National Center for Complementary and Alternative Medicine (NCCAM)
[3] Walter Mischel (1979). Distinguished Scientist Award Address. American Psychologist: 34(9); 742.
[4] Grasela, T.H. (2007). Data Standardization - Square Pegs in Round Holes?
[5] PSA Trends Predict Aggressive Prostate Cancer