The Patient in Context: Teaching Core Psychosocial Assessment Skills Through the Use of Ecomaps Amy M. Romain, LMSW, ACSW Amy J. Odom, DO Sparrow/Michigan State University FMRP 2015 STFM Annual Conference

Today’s Objectives Participants will be able to: Construct an Ecomap based on pertinent contextual information gathered from a patient Utilize the Ecomap in teaching psychosocial assessment and intervention skills to residents Apply the Ecomap to a variety of areas of residency curriculum

Why is context important? Life Course Theory Risk & protective factors contribute to health outcomes ACE’s Relationship between childhood maltreatment and later-life health & well-being Social Determinants of Health Enable patient-centered assessment & treatment planning through greater understanding of whole person Halfon, Neal, and Miles Hochstein. "Life course health development: an integrated framework for developing health, policy, and research." Milbank Quarterly 80.3 (2002): 433-479. Felitti, Vincent J., et al. "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study." American Journal of Preventive Medicine14.4 (1998): 245-258. 3 3

What is an Ecomap? Developed by Dr. Ann Hartman in 1970’s Ecosystem theory applied to human communities and relationships Illustration of psychosocial status based on key domains in patient’s life Strength and quality of relationships Flow of energy or resources Hartman, A. (1978, reprinted 1995). “Diagrammatic assessment of family relationships.” Families in Society: the Journal of Contemporary Human Services, 76(2), 111-122. 4 4

Why use an Ecomap to elicit context? Provides structure for discovering patient’s context Gives a window to person’s environment that goes beyond just family Includes social determinants of health Efficient Easy to read (retrievable) Strengthens provider-patient relationship 5 5

Ecomap Domains Significant Relationships Neighborhood Social Groups Employment Education Community Services Other $ Rx 6 6

Ecomap Construction Social Groups Other Community Services Education Patient Employment Neighborhood Significant Relationships ______ _______ - - - - - - - /\/\/\/\/\/\/\/\/\/\ _______ Connected Strong Weak Stressed/Conflict Arrows should aim in the direction of the flow of energy 7 7

Case Example: Sam 48 yr. old, married male Uncontrolled diabetes “Guest patient”

Sparrow/MSU FMRP Behavioral. Science Team 2014 Ecomap Demonstration video removed Sparrow/MSU FMRP Behavioral. Science Team 2014

Family Elise 35 Church Diabetes Ben son-7 Sam 48 Truck Driver cannot drive truck while on insulin Truck Driver Katie dtr.-9 need to add bedrooms for kids $ Trying to get Custody House

Context Informs Assessment & Intervention Understand stressors & potential barriers Identify supports Reinforce strengths Patient education (health literacy, family health beliefs) Readjust goals Opportunities

Practice Exercise Divide into pairs Interview your partner & construct their Ecomap Switch roles Discussion

Ecomap Teaching Tips PGY1 Introductory workshop pop-culture example practice on each other practice on a case in workshop Practice on patients Interview patient, construct Ecomap Present Ecomap - tell the story and discuss Ecomap patients during video review Use SpongeBob, Simpsons, Modern Family etc.

Ecomap Teaching Tips (cont.) PGY2 & 3 Mental Health Clinic (create while listening) Pre-req for in house mental health consult PGY1-3 Home visits Family conferences Case presentations BM didactics

Worksheets help early learners with “script”… how to ask questions and considering possible interventions

When to Use an Ecomap video removed Multiple problems, complicated, new chronic or life altering diagnosis, mental health, new patient, home visit etc.

Teaching Case: Depressed Mother “EMILY” 35 yr. old, married with two young children Hx. of depression Employed Here with her mother Episodes include “ignoring her children to get things done” 18 18

“Using the Ecomap Worksheet, What additional questions do you have about Emily?”

Emily church Mike Finances Sarah Charlie Dad Mom Julie Kate Grandma Health Insurance church Little Lambs Preschool Mike 38 Finances Sarah 4 Depression Emily 35 Charlie 2 Part-time biller Orthodontist office Dad Bipolar Suicide 1980 Mom Texas Julie Kate Grandma Dementia 20 ______ _______ - - - - - - - /\/\/\/\/\/\/\/\/\ _______ Connected Strong Weak Stressed/Conflict Arrows should aim in the direction of the flow of energy 20

“How does your understanding of Emily’s context impact your intervention?” Discussion: Family history of suicide! Insurance/financial issues with meds… no generic for lamictal. Corroborators for history? Who can help with kids while she is so ill? Does she need medical leave from work or can Mike get FMLA to be around more? Counseling referral? 21 21

Other Applications of Ecomaps Intern Wellness or “get to know you exercise” Systems-based Practice Health System Management

Ecomap Resources on FMDRL Introductory Powerpoint Blank Ecomaps Ecomap Worksheets Sample Case with Ecomap (Emily)

Summary Ecomap provides structure to explore the patient’s context At a glance, patient and provider can see strengths & intervention opportunities Enhances doctor-patient relationship Understanding patient’s context is central to providing appropriate, patient-centered care