1. Wellness Is Where It’s At Douglas Ziedonis, M.D., M.P.H. Professor and Chairman Department of Psychiatry UMass Memorial Medical Center/ University of Massachusetts Medical School

2. Wellness & Health Promotion for Everyone Why now? –National, State, Local Awareness and Commitment We each must do our part as individuals and as teams UMass Department of Psychiatry –Wellness Interest Group –Wellness Initiative Need Personal & Organizational Change Plan

3. Massachusetts DMH Data: Clinical Research in Our Clinical Programs 26 years shorter life Leading causes of death: –Cardiovascular –Cancer Many other health risks Need to link with wellness and recovery Address obesity, nutrition, exercise, stress management, mood management, vocational rehabilitation, relationship building, and significant other risk factor reduction

4. Why address tobacco addiction in Mental Health Settings? 44% of all cigarettes consumed in the US are by smokers with a psychiatric disorder Most individuals with mental illness are tobacco dependent & 50% are heavy smokers (>25 cigs/day) Increased health consequences, death, medication & discretionary costs, housing issues, and other addictions Treatment can work – more intensive motivation based treatments & organizational change –Watch psychiatric medication side effects with abstinence

5. Helping Staff who smoke: Adverse Employment Outcomes Associated with Smoking Involuntary turnover AccidentsInjuries Discipline problems Mean Absence Rates 17 workdays dedicated to smoke-breaks per year

6. Economic Benefits to Employers Reduced Absenteeism On-the-Job Productivity Reduced Life Insurance Reduced Medical Expenditures –workers, retirees, medicare, other Benefit to Cost Ratio –1:1 3rd year & 5:1 10th year

7. Stigma Misinformation / lack of information about General Health Implications for this population –Little data on why this group dies –Myths: “health risks exaggerated, just manipulating statistics, people are living longer, I don’t know anyone who died of smoking caused diseases” Stigma, rationalization, and minimization: –“other than increase morbidity and mortality why should we address tobacco?” –OR “You are taking away their only pleasure in life - What else are they going to do?”

9. Behavioral Risk Factors –Heart disease & Stroke & Diabetes Alcohol, tobacco smoking, other substance abuse, exercise, obesity, and diet –Cancer Tobacco smoking, alcohol dependence, obesity, diet –Respiratory diseases Tobacco smoking and other substance abuse –Traumatic injuries from Accidents Alcohol and other substance abuse Centers for Disease Control (www.cdc.gov/nccdphp/burdenbook2002/01_tables.htm)

10. WELLNESS ACADEMIC INTEREST GROUP UMASS DEPARTMENT OF PSYCHIATRY CONTACTS Betsy Austin –austine@ummhc.org, –austine@ummhc.org–austine@ummhc.org Paula Nims –paula.nims@umassmed.edu –paula.nims@umassmed.edu Marie Hobart- mhobart@communityhealthlink.org mhobart@communityhealthlink.org

11. Complete Wellness: Mental and Physical Health Complete Wellness Healthy Food Choices Daily Physical Activity Balancing Relaxation & Stress Addressing Addictive Behaviors Regular Checkups Mental Health & Recovery Plan

12. Wellness Initiative Targets for Intervention Diet - Nutrition Exercise Stress Management Smoking cessation Improving integration with primary care and specialty providers – –Minimizing drug interactions and side effects & medications – –Statins and other tools

13. Current Projects Interests of AIG Participants Caregiver and student health and wellness Tom Hopkins and Valerie Wedge- EAP, Brian Szetela, Mathieu Bermingham- Physician Wellness, Mai- Lan Rogoff- Medical Student Wellness

14. Decreasing Morbidity and Mortality for Individuals with Serious Mental Illness Sally Reyering- DMH Healthy Changes Initiative, investigating “Fit Together” model health club in Hadley. Rob Karr - DMH/ Community Partnerships in areas of diet, physical activity, and smoking cessation Colleen McKay / Doug Ziedonis / Greg Seward - Smoking cessation groups at Genesis Club- using the “Learning about Healthy Living”. Legacy Foundation funding to study and disseminate information.

15. More Projects Marie Hobart, Sarah Guzofski- Wellness Intervention in Assertive Community Treatment Alan Brown/ Rosalie Torres Stone CMHS - Addressing Health Care Disparities – proposed joint project with psychiatric providers and primary care in the Worcester area. Cross Cultural issues. To look for new source of funding Mike Archambault- CHL residential staff- Solutions for Wellness- training for 50 staff to implement program. Many already starting.

16. Improving health behaviors in those with chronic medical conditions Betsy Austin and Jennifer Lauretti Betsy Austin and Jennifer Lauretti Health Psychology Health Psychology Improving Health Status for those with Developmental Disabilities Carol Curtin and colleagues at the Shriver Center- Health U- a group model for teens with Down’s syndrome and family members. The focus is on healthy diet and physical activity. Carol Curtin and colleagues at the Shriver Center- Health U- a group model for teens with Down’s syndrome and family members. The focus is on healthy diet and physical activity.

17. Managing Chronic Illness and Addiction Monika Kolodziej- ADCARE- Group treatment for those in recovery from addiction with co-occurring Hepatitis C infection. Monika Kolodziej- ADCARE- Group treatment for those in recovery from addiction with co-occurring Hepatitis C infection. Obesity and ADHD Sherry Pagoto Sherry Pagoto

18. PCA tracking health measures, use of pedometers in outpatient mental health Mary Innis, Phyllis Wood- UMMHC OPD Mary Innis, Phyllis Wood- UMMHC OPD Smoking Cessation/ Prevention in Adolescents, Improving Health Behaviors in Teens Mathieu Bermingham- Child Psychiatry, Anne Lutz- CHL, Mathieu Bermingham- Child Psychiatry, Anne Lutz- CHL, Carolyn McGrath- Westboro State Hospital Carolyn McGrath- Westboro State Hospital

19. Promoting Healthy Lifestyles at Genesis Club Structured and independent exercise: Assumption College's Plourde Recreation Center Daily walks and Team Genesis the club’s running team Tobacco Cessation (Organizational Change, Learning About Healthy Living and CHOICES) Nutrition meetings are held weekly to discuss meals and food choices, and research and write articles regarding nutrition. Dual Recovery Anonymous (D.R.A.) meetings: An independent, self-help organization that help men and women who have a dual diagnosis of mental illness and substance misuse achieve dual recovery

20. Wellness Initiative Targeted Outcomes Wellness goals will be a standard part of all treatment plans. Wellness resources will be readily available for all Routine measurement of weight, waist circumference, blood sugar, lipids, and other lab indices as appropriate to care will be obtained.

21. Personalized feedback: what mattered Carbon Monoxide Meter score and feedback (like an alcohol breathalyzer) –Big impact on patients –Short & long term benefits to quit Cost of Cigarettes for the year Medical conditions affected by tobacco Links with other substances, relapses, etc Carbon Monoxide Meter score and feedback (like an alcohol breathalyzer) –Big impact on patients –Short & long term benefits to quit Cost of Cigarettes for the year Medical conditions affected by tobacco Links with other substances, relapses, etc

22. Wellness Initiative Targeted Outcomes Culturally relevant resources regarding affordable healthy diet and accessible exercise options in the community will be available at each site. Intervention focusing on health, wellness, smoking cessation and exercise will be available at all sites. This may include patient and family education, group programs or access to specialty services.

23. Wellness Initiative Targeted Outcomes Clinical research studies will be ongoing addressing the effectiveness of interventions, education and practice standards.

24. Moving Toward Healthier Behaviors Model healthy behavior Health belief model: weigh benefits and risks 1 Most people move through predictable stages in their efforts to change 2 The stages-of-change model can be applied to most health related behaviors 2 Match clinician strategies to stage of change 3 1. Rosenstock I, Strecher V, and Becker, M. (1998). Health Education Quarterly, 11, 403-418. 2. Prochaska J, DiClemente C, Norcross, J (1992). Amer Psychologist, 47: 1102-1114 3. Miller W. & Rollnick S. (2002). Motivational Interviewing: Preparing People to Change Addictive Behaviors

25. Learning About Healthy Living TOBACCO AND YOU Jill Williams, MD Douglas Ziedonis, MD, MPH Nancy Speelman, CSW, CADC, CMS Betty Vreeland, MSN, APRN, NPC, BC Michelle R. Zechner, LSW Raquel Rahim, APRN Erin L. O’Hea, PhD

26. Mindfulness in Medicine, Health Care and Society Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and IllnessMBSR –Based on intensive training on meditation and yoga –Notion of a Way (of Being); a Way (of Seeing)

27. What is mindfulness? “Mindfulness means paying attention in a particular way: on purpose, in the present moment and not judgmentally”

28. Practicing Mindfulness The engagement in these stress reduction techniques provides and/or increase: clarity of mind, sense of purpose, greater self-esteem, and personal commitment, All important elements to make necessary changes in our lives

29. From Automatic-Pilot to Intentionality Dis-AttentionDis-ConnectionDis-RegulationDis-OrderDis-Ease

30. “Only that day dawn to which we are awake” H. Thoreau UMassMemorial Medical Center

31. ATTOC: Agency Goals and Accomplishments Tool Major goal for ATTOC –Staff Training & Improving Clinical Services –Program Development –Supporting Staff Recovery –Implement Policies for Smoke-free grounds For Staff For Patients Performance Measures Metric Threshold, Target, and Stretch Goals Importance of Communication (within organization and with outside network) Tracking and Sustaining Change

32. Organizational Change 1. Establish preliminary organizational goals for change. –consulting team and “champions” –articulate the organization’s vision of change, provisional goals –ensure leaders are supportive 2. Establish a leadership group and prepare for change. 3. Assess readiness for change –conduct strengths and needs assessment 4. Develop a draft Change Plan –Working document 5. Develop and document a communication plan –determine how to initiate and maintain two-way communication with stakeholders throughout the change process –including how to communicate new policies and procedures

33. Organizational Change 6. Work area: Patients / Clients / Consumers –The agency identifies opportunities to address wellness and health promotion, implements selected strategies, tracks and assesses progress. 7. Work area: Staff / Faculty / Peer Counselors –Based on an assessment of staff readiness to change, the agency implements selected strategies to help staff support clients in their recovery and to assist staff in their own recovery. Progress is tracked and assessed. 8. Work area: ENVIRONMENT –Based on its assessment of factors supporting and impeding environmental change –EX the agency implements selected strategies to discourage or end smoking through environmental changes and policies (e.g., discouraging or ending smoking on the grounds).

34. Organizational Change 9. Document changes in policies and procedures. –After assessing the success of the intervention, the agency formally documents changes in policies and procedures and ensures they are reflected in agency operations (e.g., training of new staff, performance review). 10. Support, encourage, and sustain environmental change. –The organization sustains change by publicizing successes, maintaining an ongoing feedback loop, and ensuring the existing of an infrastructure within the agency capable of sustaining change.

35. Psychosocial treatment research issues: Cognitive, affective, and motivational issues How modify and integrate tobacco dependence psychosocial treatments? What medication platform? What length of time for treatment intervention? –number of sessions, length of session, etc Adjunct Service versus Integrate Component analysis of current approaches Role for Contingency Management? What rewards? Involvement of significant others?

36. Champions What is a Champion? Assemble Leadership Team Facilitate leadership team activities Can oversee our consultant activities and motivates the cultural change process. Criteria: –Passion and commitment for the topic –Leader in system –Knowledge in topic area

37. Conclusion The Time is now to focus on Wellness and Health Promotions – for everyone Leadership & Organizational Change Motivation Based Intervention Strategies are needed Having the tools – education and training Program and system changes are critical to the broad-based success