Conceptualizing the Biopsychosocial-Spiritual Health Influences of Adverse Childhood Experiences and the Application of Primary Care Behavioral Health for Their Treatment.

Adverse Childhood Experiences (ACEs) are common and affect the overall functioning of adults, but there is a need to understand how to better address the health impact of ACEs on adults in primary healthcare settings. A narrative review was utilized to extract data from seminal articles to (1) operationalize the influence of ACEs on health outcomes, (2) assess the primary care behavioral health (PCBH) model as a mechanism to address the influence of ACEs, and (3) identify mechanisms to expand the PCBH model to explicitly address spiritual determinants of health. The extracted data revealed that ACEs influence the biological, psychological, social, and spiritual health of patients providing a rationale for integrating psychosocial and spiritual treatment within primary healthcare settings. Simultaneously, the PCBH model integrates psychosocial interventions into existing primary care services but does not explicitly address spiritual determinants. Recommendations for expansion include (1) training for clinicians on evidence-based interventions to address spirituality, (2) spiritual screening tools in PCBH settings, and (3) consultation with chaplains as needed.

Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs.

INTRODUCTION: People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs. METHODS: A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group. RESULTS: Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined. DISCUSSION: Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants. CONCLUSION: By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization.

Background: While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020. Objective: This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program. Methods: Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming. Discussion/Results: Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement. Conclusion: TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

Guiding Principles for the Practice of Integrative Physical Therapy.

Integrative health is an emerging specialty inside multiple disciplines within the medical community, yet the practice of integrative physical therapy remains undefined. This perspective paper suggests a set of guiding principles to support the role of physical therapy in integrative health. These guiding principles, including therapeutic partnership, whole person health, living systems, movement as an integrative experience, and salutogenesis, are described and explored in-depth as they relate to all aspects of patient care and clinician experience. These guiding principles are articulated within the context of social determinants of health and the interrelated roles that environment, trauma, stress, and lifestyle all play within an integrative physical therapy plan of care. Examples of current integrative physical therapy practices that embody these principles are described. The 5 guiding principles are designed to elicit interprofessional inquiry into how integrative health models can be applied to the art and science of physical therapy practice. The expansion of integrative health into the field of physical therapy has the potential to improve individual and population health, as integrative physical therapy can be used to address prevention, health promotion, primary care, and wellness while acknowledging the complex, dynamic, and interconnected nature of the human condition. IMPACT: This perspective article presents 5 guiding principles to establish a framework to define and shape the growing application of an integrative health model to physical therapy practice. These integrative physical therapy guiding principles aim to improve the quality of whole-person, patient-centered care.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Integrative Nursing: A Framework for Whole-Person Mental Health Care.

The incidence of mental illness continues to increase since the start of the COVID-19 pandemic (Mental Health America, 2022). Demand for mental health services has grown, and providers report being "unable to meet the demand" or having an increase in wait times for access to care (American Psychological Association, 2022, para. 1). Due to this increase in demand, more patients are seeking mental health care from their primary care providers. Over the past decade, integrative models of care have been expanding into mental health care (Lake, 2017). Integrative Nursing is a strategy for improving the quality of care provided to patients seeking care for mental health diagnoses, as well as those with a goal of increasing mental health and wellbeing. This article proposes that Integrative Nursing can serve as a framework for providing whole-person mental health care.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies.

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The impact of screening for social risks on OBGYN patients and providers: A systematic review of current evidence and key gaps.

BACKGROUND: Increasingly, policymakers and professional organizations support screening for social assets and risks during clinical care. Scant evidence exists on how screening impacts patients, providers, or health systems. OBJECTIVE: To systematically review published literature for evidence of the clinical utility of screening for social determinants of health in clinical obstetric and gynecologic (OBGYN) care. SEARCH STRATEGY: We systematically searched Pubmed (March 2022, 5,302 identified) and identified additional articles using hand sorting (searching articles citing key articles (273 identified) and through bibliography review (20 identified)). SELECTION CRITERIA: We included all articles that measured a quantitative outcome of systematic social determinants of health (SDOH) screening in an OBGYN clinical setting. Each identified citation was reviewed by two independent reviewers at both the title/abstract and full text stages. DATA COLLECTION AND ANALYSIS: We identified 19 articles for inclusion and present the results using narrative synthesis. MAIN RESULTS: The majority of articles reported on SDOH screening during prenatal care (16/19) and the most common SDOH was intimate partner violence (13/19 studies). Overall, patients had favorable attitudes towards SDOH screening (in 8/9 articles measuring attitudes), and referrals were common following positive screening (range 5.3%-63.6%). Only two articles presented data on the effects of SDOH screening on clinicians and none on health systems. Three articles present data on resolution of social needs, with inconsistent results. CONCLUSIONS: Limited evidence exists on the benefits of SDOH screening in OBGYN clinical settings. Innovative studies leveraging existing data collection are needed to expand and improve SDOH screening.

Moving towards holistic rehabilitation - A qualitative study exploring how people diagnosed with cancer and cancer survivors experience a dance-like intervention.

BACKGROUND: Rehabilitation that supports the individual on the journey back to their usual selves after cancer treatment becomes increasingly important. Studies have shown that a focus on the connection between body and mind might be beneficial. Consequently, Whole Person Care and initiatives that fall in line with this holistic approach to health care, such as a dance-like intervention needs further examination. The aim of this study was to explore the qualitative aspects of 5Rhythms® as experienced by people diagnosed with cancer. METHOD: A total of 29 (17 in 2017) participants were recruited through purposeful sampling. Participants underwent one 5Rhythms® session per week for 2 months. This qualitative study with a phenomenological approach used diaries and individual interviews as its methods for data collection. Data were analysed using Giorgi's phenomenological framework and Maurice Merleau-Ponty's theoretical perspectives on phenomenological approaches to the body, perception and consciousness were applied. RESULTS: Three main themes ('(now) I sense my entire body', 'Something liberating is happening inside my body' and 'We travel together') and five connecting sub-themes were identified through the analysis process. CONCLUSION: Participating in 5Rhythms® contributed to reconnecting body and soul during or after battling cancer. It evoked thoughts and feelings of existential matter. Results suggest that participating in 5Rhythms® can assist in personal growth. The benefit of being among peers while on the path to recovery was also illuminated. In regard to rehabilitation, this study underlines the importance of being aware of the connection between body and mind.

Pilot Observational Study of Patient Reported Outcome Measures for Long COVID Patients in Virtual Integrative Medical Group Visits.

Background: Long COVID is a common, debilitating post-infectious illness for which effective management is unknown. Integrative Medical Group Visits (IMGV) are effective interventions for chronic conditions and could benefit Long COVID patients. More information is needed regarding existing patient reported outcome measures (PROMs) to evaluate efficacy of IMGV for Long COVID. Objective: This study assessed the feasibility of specific PROMS to evaluate IMGVs for Long COVID. Findings will inform future efficacy trials. Methods: The Perceived Stress Scale (PSS-10), General Anxiety Disorder two-question tool (GAD-2), Fibromyalgia Symptom Severity scale (SSS), and Measure Yourself Medical Outcome Profile (MYMOP®) were collected pre- and post-group by teleconferencing platform or telephone and compared using paired t-tests. Patients were recruited from a Long COVID specialty clinic where they participated in 2-hour - 8 weekly IMGV sessions online. Results: Twenty-seven participants enrolled and completed pre-group surveys. Fourteen participants were reachable by phone post-group and completed all pre and post PROMs (78.6% female, 71.4% non-Hispanic White, mean age 49). MYMOP® primary symptomatology was fatigue, shortness of breath and "brain fog". Symptoms decreased in interference when compared to pre-group levels (mean difference -1.3 [95% CI-2.2, -.5]). PSS scores decreased (-3.4 [95% CI -5.8, -1.1]), and GAD-2 mean difference was -1.43 (95% CI -3.12, .26). There were no changes in SSS scores of fatigue (-.21 [95% CI -.68,0.25]), waking unrefreshed (.00 [95%CI -.32, -.32]), or trouble thinking (-.21 [95% CI -.78,0.35]). Conclusion: All PROMs were feasible to administer via teleconferencing platform or telephone. The PSS, GAD-2 and MYMOP® are promising PROMs to track Long COVID symptomatology among IMGV participants. The SSS, while feasible to administer, did not change compared to baseline. Larger, controlled studies are needed to determine the efficacy of virtual IMGVs to address the needs of this large and growing population.

The Relationship Between Eating Disorders, Disordered Eating, and Injury in Athletes: A Critically Appraised Topic.

CLINICAL SCENARIO: Eating disorders (EDs) and disordered eating (DE) result in numerous physical and psychological complications for female and male athletes. Besides bone-related injury, little research exists investigating what injuries EDs and/or DE contribute to. CLINICAL QUESTION: Are EDs and/or DE a risk factor for injury incidence in athletes? SUMMARY OF KEY FINDINGS: We searched for prospective studies assessing EDs or DE as a risk factor for injury in female or male athletes high school age and older. Our search returned 5 studies. One study found Eds, or DE were not a risk for any type of injury in female cross-country and track-and-field athletes. Two studies found a possible relationship between EDs or DE, as one contributing factor of others, in the incidence of bone stress injuries (BSIs) in female athletes who compete in various sports. One study found female, but not male, cross-country and track-and-field athletes with a history of EDs were more at risk for stress fractures than those without a history. One study found Eds, or DE were not a risk for BSI in female runners and triathletes. CLINICAL BOTTOM LINE: Large and important gaps in the literature exist investigating injuries related to EDs or DE outside of BSIs. There is low-moderate evidence that EDs and/or DE are either a sole, or contributing, risk factor for BSIs in female athletes. STRENGTH OF RECOMMENDATION: Grade B evidence exists to support the idea that EDs and/or DE are a risk factor for a specific type of injury (BSI) in female athletes only.

Human Services and Behavioral Health Integration: A Model for Whole-Person Medicaid Managed Care.

A comprehensive, whole-person approach to individuals' health care can be achieved by aligning, integrating, and coordinating health services with other human services. HealthChoices, Pennsylvania's managed Medicaid program, delegates responsibility for Medicaid-funded behavioral health service management to individual counties or multicounty collaboratives. County administrators' programmatic and fiscal oversight of Medicaid-funded services allows them to create synergies between behavioral health and other human service delivery systems and to set priorities on the basis of local needs. This model supports access to community-based care, integration of general medical and behavioral health services, and programs that address social determinants of health.

Spirituality in Surgery-A Double-Edged Scalpel.

Investigating, respecting, and working with surgical patients' spiritualities is as critical a skill as the proficient technical performance of operations. When spirituality is ignored, sacred patient values remain undiscovered, authentic trust is hindered, and healthy shared decision-making processes suffer. These are instances when the other edge of the spiritual scalpel comes back to cut us as surgeons, but more importantly, upon withdrawal of spiritual understanding, it deeply injures our patients and their families. Spiritual screening, spiritual history taking, engaged, active listening, and big-picture prognostic truth-telling while promoting hope are critical skills for efficacious whole-person surgical care and the healing of our surgical patients' suffering-in all aspects of their humanity. These skills require surgeon introspection and vulnerability, however, as well as regular practice, and can be quite difficult; frequently leading to understandable discomfort, particularly when the surgeon does not share the patient's spiritual orientation or religious commitments. This literature-based essay addresses all of these issues, providing surgeons with a variety of new spiritual tools for their holistic armamentarium to promote healing, rather than further injury.

Person-centred communication with cancer survivors: Exploring the meaning of follow-up coaching conversations.

AIM: The aim of this study was to explore the meaning of a coaching intervention for cancer survivors. BACKGROUND: Cancer survivors often experience existential concerns and worries after adjuvant treatment. A number of "care transition interventions" have been developed to improve person-centred care by empowering patients. Several of these interventions include a "care transition coach". A coaching approach to communication used in health care communication have among others shown to assists in establishing confidential relationships between health professionals, increase the patient's well-being and support the patient's experience of being met and viewed as a whole person. DESIGN: This is a qualitative study using semi-structured interviews to explore the meaning of a coaching intervention. In analyzing and interpreting the qualitative interviews Ricoeur's theory of interpretation was applied. METHOD: The intervention consisted of two parts: (1) a two-day training program in coaching for nurses and (2) a specially developed communication intervention for cancer survivors. RESULTS AND DISCUSSION: The analysis of the transcribed interview material led to the development of two themes: (1) Support in moving forward in life, and (2) An opportunity to talk about existential thoughts and worries. Our results show how the experience of cancer, even when cured, leaves the survivors with profound existential worries. The cancer survivors described how coaching conversations allowed them to express their current concerns and provided them with an opportunity to discuss wider issues than treatment, symptoms, and after-effects, which had been the main focus during treatment. CONCLUSION: The time immediately after the end of adjuvant treatment can be challenging, with many existential concerns and opposing emotions. We found that the follow-up coaching conversations performed helped the cancer survivors to process many of these difficult thoughts and feelings.

Challenges of Teaching Humanities in Health Professions Education: Classroom Implementation and Educational Effectiveness of 'Mindful Practice' / 医学教育

The goal of medical education is to nurture healthcare professionals who can provide “excellent care.” However, our current medical education has many challenges to overcome to achieve this goal. The reasons are that deep mutual understanding between patients and healthcare professionals, self-awareness, and understanding of humanity, are all necessary for practicing medicine. However they have not been sufficiently verbalized and utilized in education. For medical education to be useful to healthcare professionals, educators, students, and patients, it is necessary to properly articulate these elements and put them into practice as education. This article introduces the “Mindful Practice” approach implemented at the University of Rochester, and explains how it can be used as material for medical education.

Integrative Nursing and the ANA Scope and Standards of Practice: Expanding the Reach of Nursing for Families and Society.

The American Nurses Association's (ANA) recently published 4th edition of the Scope and Standards of Practice provides authoritative guidance on actions and behaviors that all registered nurses are expected to perform competently, regardless of role, population, specialty, or setting. The newly defined scope emphasizes the art and science of caring, compassionate presence, and the expectation that nurses be advocates for all, recognizing the connections of all humanity. It also makes frequent reference to whole-person care and highlights the importance of mindfulness by inviting nurses to reflect on how they can incorporate mindfulness and other integrative therapies into their self-care and professional practice. A new standard explicitly states that advanced practice registered nurses should have the competency to prescribe evidence-based traditional and integrative treatments, therapies, and procedures that are compatible with the consumer's cultural preferences, norms, and abilities. Integrative Nursing is aligned with the ANA Scope and Standards of Practice and provides a useful framework for practice that expands the reach of nursing across clinical and community settings and patient populations. In this article, exemplars highlight how Integrative Nursing is being implemented in clinical settings and nursing education programs.

The ICU Bridge Program: volunteers bridging medicine and people together.

BACKGROUND: The intensive care unit (ICU) is an emotionally taxing environment. Patients and family members are at an increased risk of long-term physical and psychological consequences of critical illness, known collectively as post-intensive care syndrome (PICS). These environmental strains can lead to a high incidence of staff turnover and burnout. AIM: The ICU Bridge Program (ICUBP) is a student-led organization that attempts to mitigate these stressors on patients, family, and staff, by assigning university volunteers to ICUs across Montreal. SETTING: ICU. PARTICIPANTS: ICU volunteers, staff, patients, and families. PROGRAM DESCRIPTION: The ICUBP volunteers support staff by orienting patients and families, while using effective communication strategies to provide comfort and promote a calm environment. The presence of volunteer visitors is helpful to patients who do not have the support of family members and/or friends. The program provides students with profound learning experiences by allowing them to shadow multidisciplinary teams, gaining a privileged and varied exposure to an acute medical environment, while developing their communications skills. PROGRAM EVALUATION: The program reassesses its methods and impact via internal student-designed surveys distributed on a yearly basis to staff and volunteers. DISCUSSION: Research is warranted to assess the impact of the program on ICU patients, visitors, staff, and volunteers.

There is More to 'Making Connections to Improve Health Outcomes'.

Langevin1 rightly points to the reductionist mindset being the stumbling block for providing person-centered care. While considering the interconnections between the various domains underpinning health is a necessary first step towards more person-centered care, it ultimately is not sufficient. Person-centered care arises from the appreciation of the interdependencies and interactions between the various domains across its large-scale supersystems as much as its small-scale subsystems. Viewed with a complex-adaptive systems mindset health and disease are the phenotypical outcome categorisations of a person's whole-of-systems dynamics across all scales of organisation.2,3.

Co-constructing conversations about suicide: the Meeting Space Framework.

This article draws on research conducted for the author's doctoral thesis. It presents the development of the Meeting Space Framework to address what is needed to engage in meaningful conversations about suicide, from the perspective of student nurses. An interpretive methodology of constructivist grounded theory was used, underpinned by the theoretical perspective of symbolic interactionism. The core category of Meeting Spaces resulted; engaging in meaningful conversations about suicide is co-created in illuminating space within the context of a human pivotal encounter (positive) as opposed to an unceremonious pivotal encounter (negative). A certain kind of space is required to support engagement in meaningful conversations about suicide. It requires humanness and an intention and ability to see the whole person beyond the limiting word of 'suicide'.