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Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings. Barbara Walker, Ph.D. Clinical Professor, Department of Psychology Professor, Department of Family Medicine University of Colorado, Denver Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHS

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Evidence based practice transforming concepts into reality in collaborative care settings

Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings

Barbara Walker, Ph.D.

Clinical Professor, Department of Psychology

Professor, Department of Family Medicine

University of Colorado, Denver

Jeffrey L. Goodie, Ph.D., ABPP/ LCDR, USPHS

Assistant Professor of Family Medicine

Uniformed Services University of the Health Sciences

Bethesda, MD

Helen L. Coons, Ph.D., ABPP

President and Clinical Director, Women’s Mental Health Associates

Philadelphia, PA

Collaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.


Faculty disclosure
Faculty Disclosure in Collaborative Care Settings

Drs. Walker, Coons and Goodie have not had any relevant financial relationships during the past 12 months.


Need practice gap supporting resources
Need/Practice Gap & Supporting Resources in Collaborative Care Settings

What is the scientific basis for this talk?

In this symposium, we will define evidence-based practice (EBP), introduce participants to the associated skill-set, tools and new resources for doing EBP, and illustrate how it can be translated it into both primary and specialty collaborative care settings.


Objectives
Objectives in Collaborative Care Settings

  • Describe how evidence-based practice is used for clinical decision-making and the 5 steps associated with this process.

  •  Describe why it is necessary to adapt evidence-based methods for use in primary care.

  • List examples of evidenced based assessment and intervention strategies to improve physical and psychosocial outcomes among women seen in collaborative ob/gyn and oncology practices.

  • Describe how several interventions have been adapted to be effective in a primary care environment.


Expected outcome
Expected Outcome in Collaborative Care Settings

What do you plan for this talk to change in the participant’s practice?

  • Be familiar with and be better able to use evidence-based practice skills for clinical decision-making in collaborative care settings.

  • Increased ability to apply gender-specific research to improve outcomes in collaborative ob/gyn and oncology settings.

  • Increased use of evidence-based practice strategies that have been adapted for use in primary care, specifically with regard to insomnia, weight management, and PTSD.


Learning assessment
Learning Assessment in Collaborative Care Settings

A learning assessment is required for CE credit.

  • List the 5 specific steps associated with clinical decision-making in evidence-based practice.

  • Name and explain how to access and search at least 2 databases that contain synthesized evidence-based research.

  • Give at least one example of how evidence based care can improve health and psychosocial outcomes.

  • Describe how evidence-based treatment has been adapted and found to be effective in primary care for treating insomnia, weight, and/or PTSD.


Evidence based practice transforming concepts into reality in collaborative care settings1

Session # in Collaborative Care Settings

October __, 20110:00 AM

Evidence-Based Practice: Transforming Concepts into Reality in Collaborative Care Settings

Fundamentals of Evidence-Based Practice: It’s more than applying evidence-based treatments (Barbara Walker)

Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD (Jeffrey Goodie)

Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes (Helen Coons)

Collaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.


Evidence based practice transforming concepts into reality in collaborative care settings

EVIDENCE BASED MEDICINE in Collaborative Care Settings

Sackett et. al 1997

Straus et. al, 2011 (4th ed.)

What should I do for this particular patient in front of me?


Evidence based practice transforming concepts into reality in collaborative care settings

Best available research evidence in Collaborative Care Settings

Patient’s values

Clinical Expertise

CD


Psychology introduces ebpp in 2005
Psychology introduces EBPP in 2005 in Collaborative Care Settings

Best research available

Clinical Expertise

CD

Patient characteristics, culture and preferences

“The integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (became policy of the American Psychological Association in August, 2005)


The framework
The framework in Collaborative Care Settings

OPERATIONALIZATION :

5 STEPS

Best research available

CD

Patient characteristics, culture, preferences

Clinical Expertise

CLINICIAN

PATIENT

RESEARCH

1. ASK

1st

2. ACQUIRE

3. APPRAISE

4. APPLY

5. ASSESS

CD


Evidence based practice transforming concepts into reality in collaborative care settings

  • TOP DOWN:

  • What is the most effective intervention for this particular disorder?

  • (ESTs, EB guidelines)

  • BOTTOM UP:

  • What should I do for this particular patient in front of me?

  • (Clinical Decision Making)

EBIDM: Eddy, D. Health Affairs, 24, no.1 (2005):9-17

Evidence-Based Medicine: A Unified Approach


Ask questions are formulated in a specific way
ASK: in Collaborative Care SettingsQuestions are formulated in a specific way

Therapy

Diagnosis

Background

Foreground

By Content

By Format

  • Harm

  • Etiology

  • Prognosis

  • Cost-effectiveness

THIS SLIDE COURTESY OF SUE LONDON RUTH LILLY LIBRARY


Why bother
Why bother? in Collaborative Care Settings


Evidence based practice transforming concepts into reality in collaborative care settings

THIS SERIES COURTESY OF SUE LONDON IUPUI LIBRARY in Collaborative Care Settings


Evidence based practice transforming concepts into reality in collaborative care settings

High Sensitivity in Collaborative Care Settings


Evidence based practice transforming concepts into reality in collaborative care settings

High Specificity in Collaborative Care Settings

WHAT:

Scientifically synthesized literature

WHERE:

Specialized databases

HOW:

Specialized search strategies/filters


Step 2 acquire
Step 2. in Collaborative Care SettingsAcquire

Evidence that has already been (scientifically) synthesized for us:

Syntheses

Summaries

Systems


Evidence based practice transforming concepts into reality in collaborative care settings

HOW? in Collaborative Care Settings

Start at the top


What is ebp and why is it so important in collaborative care
What is EBP and why is it so important in collaborative care?

  • EBP has two sides: Top-down and Bottom up (a set of clinical decision-making resources and tools)

  • Common language

  • Setting / Context matters

  • Need for primary and secondary literature studies in collaborative care

  • Ultimate goal is to improve outcomes


To learn more
To learn more… care?

Norcross, Hagan & Koocher, 2008

  • www.ebbp.org has training modules


Adapting and delivering evidence based interventions weight insomnia and ptsd

Jeffrey L. Goodie, Ph.D., ABPP care?

LCDR, USPHS

Assistant Professor, Dept of Family Medicine

Uniformed Services University

Adapting and Delivering Evidence-Based Interventions: Weight, Insomnia, and PTSD


Outline
Outline care?

  • Three examples

    • Weight

    • Insomnia

    • PTSD

  • Medical or Behavioral health providers

  • Outcomes

  • Challenges


Weight
Weight care?

Goodie, J. L., Hunter, C., Hunter, C., McKnight, T., LeRoy, K., & Peterson, A. (2005, March). Comparison of weight loss interventions in a primary care setting: A pilot investigation. Paper presented at the 26th Annual Meeting of the Society of Behavioral Medicine, Boston, MA.


Specialty care evidence
Specialty Care Evidence care?

  • Identification

  • Setting realistic goals

  • Self-monitoring

  • Stimulus control

  • Exercise to maintain weight loss

"Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.“ (1998). National Heart, Lung, and Blood Institute, NIH.


Evidence based practice transforming concepts into reality in collaborative care settings
Does primary care provider delivered evidence-based behavioral interventions for weight result in more weight loss?


Procedures enhanced care group
Procedures behavioral interventions for weight result in more weight loss? Enhanced Care Group

  • Appointment 1

    • Set 10% weight loss goal for first 6 months

    • Maintenance goal for second 6 months

    • Discuss motivators and barriers

    • Provided w/ calorie book

    • Food diary for 12 days

  • Appointment 2 (2 – 4 weeks later)

    • Review food diary and C.A.M.E.S.

    • Review barriers and motivators


Procedures enhanced care group cont d
Procedures behavioral interventions for weight result in more weight loss?Enhanced Care Group, Cont’d

  • Appointment 3 (2 – 4 weeks later)

    • Discuss physical activity

    • Provided w/ pedometer

      • Set baseline and increase by 10%

  • Appointment 4 – 5

    • Review progress. Again, discuss barriers and motivators

  • Appointment 6

    • Set maintenance goals

  • 1 year follow-up


Procedures minimal contact group
Procedures behavioral interventions for weight result in more weight loss?Minimal Contact Group

  • Appointment 1

    • Discuss cutting calories and increased exercise

      • No specific tools or training provided for PCP

      • PCP could recommend any weight loss strategy

  • Appointment 2 -5

    • Discuss any problems

  • Appointment 6

    • Plan for 6 month maintenance

  • 1 Year follow-up


Results
Results behavioral interventions for weight result in more weight loss?


Insomnia
Insomnia behavioral interventions for weight result in more weight loss?

Goodie, J. L., Isler, W., Hunter, C. L., & Peterson, A. L. (2009).Using behavioral health consultants to treat insomnia in primary care: a clinical case series. Journal of Clinical Psychology, 65, 294-304.


Specialty care evidence1
Specialty Care Evidence behavioral interventions for weight result in more weight loss?

  • Stimulus control

  • Sleep restriction

  • Sleep hygiene

  • Relaxation

Schutte-Rodin et al. (2008). J Clin Sleep Med.  Morin et al., (1989). Sleep Research; Morin et al., (1994), American Journal of Psychiatry.


Evidence based practice transforming concepts into reality in collaborative care settings
Do CBT evidence-based treatments for insomnia decrease insomnia symptoms when delivered by a BHC in primary care?


Methods
Methods insomnia symptoms when delivered by a BHC in primary care?

  • Case Control Series (Goodie et al. 2009)

    • 29 physician referred Primary Insomnia patients

      • Limited exclusion criteria

    • Intervention delivered by BHC

    • Attend four appointments

      • Assessment (30 mins)

      • 1-2 intervention appointments (15-30 mins)

        • Sleep hygiene, stimulus control, sleep restriction

        • Relaxation

        • Supplemental book

      • Follow-up


Outcomes
Outcomes insomnia symptoms when delivered by a BHC in primary care?

*Significant compared to α=.008;Goodie et al. (2009)


Evidence based practice transforming concepts into reality in collaborative care settings
PTSD insomnia symptoms when delivered by a BHC in primary care?

Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., Goodie, J. L., Hryshko-Mullen, A. Peterson, A. L., and the STRONG STAR Consortium. (2011). Treatment of active-duty military with PTSD in primary care: Early findings. Psychological Services 8(2), 104-113.


Specialty care evidence2
Specialty Care Evidence insomnia symptoms when delivered by a BHC in primary care?

  • PTSD Treatment

    • Prolonged exposure

    • Cognitive processing therapy

Powers et al. (2010). Clinical Psychology Review 30(6): 635-641.; Cloitre, M. (2009). CNS Spectr 14(1 Suppl 1): 32-43.


Evidence based practice transforming concepts into reality in collaborative care settings
Do CBT evidence-based treatments for PTSD decrease PTSD symptoms when delivered by a BHC in primary care?


Intervention
Intervention symptoms when delivered by a BHC in primary care?

  • Adapted forms of prolonged exposure and cognitive processing therapy

  • Assessed and treated by BHC

  • After initial assessment,

    • 1 to 4 (up to 6) < 30 min appointments

    • Weekly

    • Homework between meetings


Procedures
Procedures symptoms when delivered by a BHC in primary care?

Pt referred to BHC

Appointment 0

Testing

Appointment 1

Appointments 2-4

6 & 12 month Testing


Appointment 0
Appointment 0 symptoms when delivered by a BHC in primary care?

  • Duration: thirty-minute appts

  • Brief Assessment (PCL-M)

  • Education

    • Normal recovery curve; “getting stuck”

    • Role of avoidance in maintaining symptoms

    • Evidence for exposure-based treatments

  • Presentation of treatment options

    • Primary care vs Specialty care vs Self-care


Appointment 1
Appointment 1 symptoms when delivered by a BHC in primary care?

  • “Confronting Uncomfortable Memories” workbook

    • Write narrative of traumatic experience

    • Answer cognitive/emotional processing questions

  • Prescribe as homework

    • Goal: 30 minutes write/review daily

    • Self-monitor SUD’s

  • Problem-solve homework implementation

    • When/where of homework

    • Barriers to completion


Appointments two to four optional 5 6
Appointments Two to Four symptoms when delivered by a BHC in primary care? (optional 5, 6)

  • Discuss homework completion

    • Review SUD’s

  • Read narrative out loud (at least once)

  • Read answers to processing questions out loud

  • Socratic dialogue on problematic beliefs

  • Re-assign writing assignment as homework

  • BHC has option of other CP questions

  • Encourage opportunities for in vivo exposure


Evidence based practice transforming concepts into reality in collaborative care settings

% with PTSD Diagnosis (PSS-I) symptoms when delivered by a BHC in primary care?

N=24

N=17

N=16

N=11

Overall Χ2=8.95, p=0.03; All time points different from baseline (p < .01)


Evidence based practice transforming concepts into reality in collaborative care settings

PCL-M symptoms when delivered by a BHC in primary care?

N=24

N=17

N=17

N=10

Overall F=6.51, p=0.002; All time points different from baseline (p < .003)


Overall considerations
Overall considerations symptoms when delivered by a BHC in primary care?

  • What determines evidence-based care?

  • What outcomes should we expect?

  • Who can provide the evidence-based care?

  • Challenges with research in primary care


Questions
Questions symptoms when delivered by a BHC in primary care?

  • Jeffrey L. Goodie, LCDR, USPHS

    Uniformed Services University

    (301) 295-9461

    jgoodie@usuhs.mil


Evidence based practice transforming concepts into reality in collaborative care settings

Providing Evidenced Based Care to Women in Collaborative Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

Session #

October __, 20110:00 AM

HELEN L. COONS, PH.D., ABPP

PRESIDENT AND CLINICAL DIRECTOR

WOMEN’S MENTAL HEALTH ASSOCIATES

PHILADELPHIA, PA 19103

Collaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.


Faculty disclosure1
Faculty Disclosure Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

I have not had any relevant financial relationships during the past 12 months.


Need practice gap supporting resources1
Need/Practice Gap & Supporting Resources Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

What is the scientific basis for this talk?

The presentation provides examples of evidenced based care in collaborative obstetrics and gynecology and oncology settings to improve physical and psychosocial outcomes. Research on depression in women; preparing them for diagnostic and treatment procedures; and the important benefits of exercise will be translated.


Objectives1
Objectives Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

  • List research based interventions to assess and treat depression in women in collaborative ob/gyn and oncology settings.

  • Summarize evidenced based rational for preparing women for diagnostic and treatment procedures in collaborative ob/gyn and oncology settings.

  • Translate research on aerobic exercise to improve outcomes in collaborative ob/gyn and oncology settings.


Expected outcome1
Expected Outcome Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

What do you plan for this talk to change in the participant’s practice?

  • Increased focus on applying evidenced based interventions in collaborative primary care (i.e., ob/gyn) and oncology settings.

  • Increased application of gender specific research to improve outcomes in collaborative ob/gyn and oncology settings.


Learning assessment1
Learning Assessment Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

A learning assessment is required for CE credit.

  • Providing evidenced based care can improve health and psychosocial outcomes?

  • Actively preparing women for medical procedures in collaborative ob/gyn and oncology settings can improve health and psychological outcomes?

  • List the improved physical, psychological and cognitive outcomes associated with aerobic exercise in ob/gyn and oncology settings?


Women s health and mental health improving outcomes using ebp
Women’s Health and Mental Health Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial OutcomesImproving Outcomes Using EBP

Collaborative/Integrated Health Care Settings

  • Primary Care Settings (IOM)

    • Internal and Family Medicine

      • Geriatric Medicine

    • Pediatrics

      • Adolescent Medicine

    • Obstetrics and Gynecology

  • Specialty Care Settings

    • Oncology

    • Surgery

    • Cardiology

    • Neurology

    • Endocrinology

    • PMR

    • Other


  • Evidenced based care in ob gyn and oncology settings
    Evidenced Based Care Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial OutcomesIn Ob/Gyn and Oncology Settings

    Clinical Research

    • Depression in Women

    • Preparing for Dx and Tx Procedures

    • Exercise

    • Assessment Treatment Prevention


    Costs of depression
    Costs of Depression Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

    Patient and family

    Health Care System

    • Quality of life, loss of hope, resilience

    • Functioning (days of disability, quality of work)

    • Poor self-care

    • Adherence to treatment recommendations

    • Risk/Co-morbidity for other health conditions

      • Obesity

      • Cardiovascular disease

      • Pain

      • Medications

    • Impact on children and other relationships

    • Health care system

      • Increased Utilization

    • Only 50% of adults with depression are getting treatment from a health professional

    • Less than half (47%) of adults who get treatment receive minimally adequate care

      WHO Report (1996), JAMA (2003)


    Depression in ob gyn settings
    Depression in Ob/Gyn Settings Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

    General Factors

    Specific

    • Depression rates in women

    • Trauma

    • Caregiver issues

    • Chronic stress

    • Sleep deprivation

    • Inadequate support

    • SES

    • Pregnancy Related

      • Depression

      • Anxiety

      • Loss in any trimester

      • Infertility

      • Complications

    • Gyn chronic conditions

      • Pelvic

      • ICS

      • Vulvar diseases


    Women with depression in ob gyn settings
    Women with Depression in Ob/ Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial OutcomesGyn Settings

    Inadequate care

    • Not evidence based/informed

    • Partial symptom reduction without full resolution of depression

    • Failure to address underlying issues

      • Misdiagnosis of medical disorder

      • Medication complications

      • Gender issues in etiology, assessment, treatment or prevention strategies

      • Poor sleep quantity and quality

      • Cognitive style

      • Trauma history

    • Failure to minimize risk for relapse or prevention

      • patient

      • future generations


    Active application of cognitive treatment
    Active Application of Cognitive Treatment Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

    • Reduce and then resolve depressive symptomatology and anxiety

    • Markedly improve sleep

    • Calmer, more intentional response to host of issues with less catastrophizing, over-personalization, etc.

    • Earlier recognition when negative or ruminative cognitive style is present

    • More aware of how cognitive style impacts children

    • Specific strategies to reduce risk recurrent depression

    • Improve over-all well-being for the long haul


    Evidenced base care in oncology
    Evidenced Base Care in Oncology Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

    Breast Cancer

    • One in 8 life time risk

    • Second most common cause of cancer death after lung cancer

    • Over 192,370 new cases dx annually in the USA

    • 40,610 women die annually in USA

    • Long term survival rate for early breast cancer has improved with new therapies – especially in younger women

    • Prevalence rate is 2,533, 193 – survivors!

    • Chronic disease model focused in enhancing quality of well-being and reducing impact of late effects of cancer and its treatment

      ACS 2010 Facts and Figures


    Depression in women with breast cancer
    Depression in Women with Breast Cancer Ob/Gyn and Oncology Practices: Strategies to Improve Physical and Psychosocial Outcomes

    • Women highly resilient

    • Depression rates roughly 20% to 25%

    • CBT

    • Medications

      • Tamoxifen metabolism and antidepressants

        • Jin et al (2005) J Natl Cancer Inst.


    Preparing women for diagnostic and treatment procedures in collaborative medical settings
    Preparing Women for Diagnostic and Treatment Procedures in Collaborative Medical Settings

    • Preparing women for initial and late issues

      • Physical

      • Cognitive

      • Emotional

      • Sexual

      • Relationships

      • Employment and professional

      • Genetic risk across family

      • Health and life insurance

    • Preparing women for challenges across disease course

      • Different trimesters

      • Disease recurrence

      • Advanced and end-stage disease


    Potentially difficult exams procedures in ob gyn settings
    Potentially Difficult Exams/Procedures Collaborative Medical Settings in Ob/Gyn Settings

    • Breast exam

    • Gyn procedures

      • Pelvic exam

      • Pelvic ultrasound

      • Colposcopy

      • Endometrial biopsy

      • HSG

      • Hysteroscopy

      • IVF procedures

      • Dx. laps

    • Cystoscopy/Urodyamics

    • GI procedures

      • Abdominal exam

      • Rectal exam

      • Endoscopy

      • Colonoscopy

    • Venipunctures

    • Anesthesia

    • Oral or dental exam

    • Childbirth: Vaginal or C-section

    • Any type of biopsy and surgery

      • Hysterectomy

      • Sterotatic core biopsy/needle loc

      • Sentinel node biopsy

      • Lumpectomy

      • Mastectomy

      • Reconstructive surgery

      • Breast reduction

      • Cancer surgery – colon/pelvic ext.

    • Chemotherapy and Radiation

    • MRI, Cat Scan, etc.

    • Cardiac procedures


    Preparing women for breast cancer medical procedures
    Preparing Women for Breast Cancer Collaborative Medical Settings Medical Procedures

    • Diagnostic

      • Mammograms

      • MRI

      • Ultrasound guided core biopsies

      • Stereotactic core biopsies

      • Needle localizations

      • Dye Injection for Sentinel Node

      • Biopsy

  • Surgical

    • Lumpectomy

    • Mastectomy

    • Reconstruction – several types

    • Treatment

      • Chemotherapy

      • Radiation

      • Hormonal

  • Palliative

    • Chemotherapy

    • Shunt

    • Nerve blocks

  • Preventive

    • Mastectomies

    • TAB, LAVH with BSO


  • Actively use evidenced based practice to prepare women for procedures
    Actively Use Evidenced Based Practice Collaborative Medical Settings to Prepare Women for Procedures

    • Provide accurate information about cancer and its treatments

    • Assess patients/families fears and hopes

    • Facilitate decision making about procedures

    • Ask important questions, get second opinions

    • Make decisions they will trust and not regret

    • Mobilize informational, practical, social, and esteem support

    • Help to pace the patient

    • Decrease pain, bracing, and physiological reactivity

    • Reduce anxiety and fatigue

    • Increase feelings of self-efficacy, control and quality of life

    • Encourage patients to be active participants in their recovery and healing

    • Impact time to recurrence and survival?


    Benefits of regular exercise in ob gyn and oncology
    Benefits of Regular Exercise Collaborative Medical Settings in Ob/Gyn and Oncology

    General

    Ob/Gyn and Oncology

    • Improves self esteem with sense of accomplishment

    • Improve body image

    • Improved cardiovascular fitness

    • Reduce muscle discomfort

    • Increase strength, flexibility, coordination

    • Decreased risk for diabetes

    • Weight control

    • Weight bearing exercise to build bone and joint strength

    • Reduced risks for falls

    • Improve sleep

    • Reduce hot flashes

    • Reduce depression and anxiety

    • Helps with cognitive functioning

    • Improves sexual energy

    • Improves intimate relationships

    • Improved Quality of Life

    • Improve immune function

    • Improves post-surgical healing

    Ob/gyn

    • Sleep

    • Perinatal anxiety and depression

    • Improved pregnancy outcomes

    • Post partum anxiety, depression, energy, wt management, body image

      Oncology

    • Manage treatment side effects

    • Increase energy, stamina

    • Lymphedema symptoms

    • Reduced risk of recurrence in ER+ breast cancers or general mortality


    Ebc in women s primary care and oncology
    EBC in Women’s Primary Care and Oncology Collaborative Medical Settings

    • Improve health outcomes

    • Improve mental health outcomes

    • Women’s well being!


    Evidence based practice transforming concepts into reality in collaborative care settings
    Feel free to contact us Collaborative Medical Settings Barbara Walkerbarbara.walker@ucdenver.eduJeffrey L. Goodiejgoodie@usuhs.milHelen L. Coonshcoons@verizon.net


    Session evaluation
    Session Evaluation Collaborative Medical Settings

    Please complete and return theevaluation form to the classroom monitor before leaving this session.

    Thank you!