The Patient in Context: Teaching Core Psychosocial Assessment Skills Through the Use of Ecomaps Amy J. Odom, DO Sparrow/Michigan State University FMRP Katy Kropf, DO Ohio University Heritage College of Osteopathic Medicine

Taking a closer look…

… changes perspective!

Today’s Objectives 1. Identify the patient-centered benefits gained by understanding the complex components of a patient’s life. 2. Learn the components of an Ecomap 3. Construct an Ecomap based on pertinent psychosocial information gathered from a patient 4. Consider applications of Ecomaps in practice to help both patients and providers to see potential strengths and intervention opportunities, and to enhance the doctor-patient relationship Identify the patient-centered benefits gained by understanding the complex components of a patient’s life. 2. Learn the components of an Ecomap 3. Construct an Ecomap based on pertinent psychosocial information gathered from a patient 4. Consider applications of Ecomaps in practice to help both patients and providers to see potential strengths and intervention opportunities, and to enhance the doctor-patient relationship

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. Life Course- complex interplay of biological, behavioral, psychological and social factors (risk and protective) to health outcomes. Life course perspective elaborates the importance of time, context, process, and meaning on human development and family life (Bengtson and Allen 1993). ACEs- Association between childhood exposure to abuse/neglect + significant household dysfunction and later-life health/well-being (depression, anxiety, sub. abuse, sexual risk behavior, chronic disease, etc.) 1998 Knowing what a patient’s life is like, helps us assess concerns accurately and form meaningful patient-centered treatment plans (e.g. identifying key support people, resource limitations). 5 5

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 Ann Hartman developed ecomap (aka sociogram) to illustrate individual and family relationships to larger system Hartman, A. (1978, reprinted 1995). “Diagrammatic assessment of family relationships.” Families in Society: the Journal of Contemporary Human Services, 76(2), 111-122. 6 6

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 7 7

Ecomap Domains Significant Relationships Neighborhood Social Groups Employment Education Community Services Other Call attention to Ecomap Worksheet for domain details. Inquiry into these domains result in greater understanding of the patient’s context and facilitate the construction of the ecomap… provides structure/framework to obtain and record information. Includes some social determinents of health $ Rx 8 8

Ecomap Construction Social Groups Other Community Services Education Patient Employment Neighborhood Practice asking questions… how do you take a social history beyond asking about marital status, alcohol and tobacco and seatbelt use. See domains/worksheet on back of ecomap. Read some sample questions… put key relationships in circles (get their own… not all in one domain) and connect based on strength quality and resource flow. These are the areas you may touch on… but each relationship gets it’s own circle… hopefully will have many circles. Significant Relationships ______ _______ - - - - - - - /\/\/\/\/\/\/\/\/\/\ _______ Connected Strong Weak Stressed/Conflict Arrows should aim in the direction of the flow of energy 9 9

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 What is an Ecomap? Hartman, A. (1978, reprinted 1995). Diagrammatic assessment of family relationships. Families in Society: the Journal of Contemporary Human Services, 76(2), 111-122 10 10

Ecomaps: A Resident’s Perspective Insert Greenblatt1

Case Example: Sam 48 yr. old, married male Uncontrolled diabetes “Guest patient” Use SpongeBob, Simpsons, Modern Family etc.

Sparrow/MSU FMRP Behavioral. Science Team 2014 Ecomap Demonstration 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

When to Use an Ecomap 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” AR how to teach… AO sim. Ecomap construction/questions 20 20

“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 22 ______ _______ - - - - - - - /\/\/\/\/\/\/\/\/\ _______ Connected Strong Weak Stressed/Conflict Arrows should aim in the direction of the flow of energy 22

“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? 23 23

“Isn’t it time consuming?” Insert Greenblatt3

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

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 Process enables provider to better understand what it is like to be the patient Partnership Leverage points