By: Howard Rosen, LifeWIRE CEO
and William D. Harms, LifeWIRE Director of Research
Post Traumatic Stress Disorder (PTSD) is quite unique. It is unique because it isn’t a single defined malady such as a ruptured organ, but instead a combination of symptoms (affectations) uniquely intertwined in each of its victims. The exact combination for each individual comes from a much larger list of possible symptoms, and each may be manifest in different combinations and intensities in different people. This results in a diagnosis (disease), that is unique to each individual, and one that requires unique, personalized, high-intensity interaction with professionals to help the patient identify and then take down each of their unique contributing factors.
The ‘state’ and intensity of the disease is most commonly identified and then monitored, through a series of abnormal actions. Lack of Sleep, Dreams, Anxiety, Fear, and Isolationism are several ‘common trigger’ behaviors that result from the ‘witches brew’ of affectations plaguing each patient. Treatment for Post Traumatic Stress Disorder (PTSD) begins with making an invisible injury visible according to neuroscientist Professor Ruth Lanius. In order to effectively work through the process of healing, each invisible injury must be constantly and diligently monitored. The most efficacious way to do this is through monitoring the ‘common’ triggers intermixed with individual attention to those factors that make this injury unique to each patient.
The problem facing treatment professionals is manpower. Each patient needs, and deserves, almost full-time monitoring and care. Exacerbating this problem is that episodic decompensation generally occurs when the patient is alone, when the home is quiet, and there are few distractions to pull their attention from the triggers. Most clinics are staffed during normal working hours, and therefore professional individual attention is often unavailable when the patient is most in-need. Many of the traditional obstacles to efficacious treatment for PTSD have been shown to be addressed through Telehealth. Telehealth is the use of digital information and communication technologies - computers and mobile devices, for instance - to access health care services remotely and manage your own healthcare. Evidence-Based Treatments such as telehealth can be uniquely customized to each patient, delivering just-in-time treatment at the time the patient is in crisis. Evidence also points to better outcomes when telehealth utilizes the patient’s existing devices and programs, thus reducing training and configuration in times of high stress or mental fragility. Automation has been shown to address up to 92% of required treatment-team/patient interactions automatically. The 8% of incidents requiring personal contact can be instantly routed to a professional specifically trained to address the issue. This is most effective when an integrated, unified platform is implemented that allows for a variety of means of communication and data collection for maximum effectiveness.
Treating PTSD is complex, however, and must be done right. Professor Neil Greenberg, an authority on psychological injury in the U.K. Armed Forces says doing it wrong can harm people, and also dissuade people from going to get other treatments. This is why proven Evidence-Based Treatments such as telehealth becomes paramount. The U.S. Veterans Affairs’ National Center for PTSD points out the importance of developing interventions that specifically increase engagement in evidence-based treatments, in order to have the greatest impact on patients’ health. Telehealth engages the patient at the time of their need using the devices they are familiar with through the media the patient regularly utilizes. It provides persistent and consistent communication between the patient and their treatment team. Debilitating as PTSD is and as difficult as individualized treatment may be, allowing the patients choose elements and timing of their treatment improves their quality of life and has been shown to reduce the symptoms of the disorder. Patient engagement is a key element in successful PTSD treatment. Engaging the patient directly, consistently, and in a timely manner is one of the reasons developments in telehealth is efficacious in the treatment of PTSD. According to VA’s research, “...intervention which included offering evidence-based treatments for PTSD via telemedicine was one of the most successful in improving engagement.”
Below are five (of many) value-added features of a patient engagement platform that can act as a conduit to patient care in PTSD treatment.
When a patient is at the heart of health care every facet of the treatment revolves around them. Telehealth empowers the patient to be involved in a program customized for their unique diagnosis, acuity, and lifestyle. The patient’s needs to drive the treatment rather than an available protocol.
A telehealth platform that can be easily customized for each patient’s diagnosis, acuity, and lifestyle helps to ensure all bases are covered according to the treatment plan designed by the treatment team.
Several telehealth platforms provide biometric feedback in addition to therapy, reminders, patient input, and motivations. Biometric feedback can be collected periodically, and in real-time providing the treatment team valuable feedback. These data may trigger treatment events, in some cases before the patient is aware that they are in need.
Telehealth provides auditable treatment records throughout the treatment process. Integrating telehealth into a treatment provider’s Electronic Health Record (EHR) provides the complete patient record in one place and accessible to the whole health care team. And, unique to telehealth, the patient can be informed to make real-time changes in their healing process based on treatment, biometric, and anecdotal feedback.
The communication tool - what, when, where and how it is to be used – should be for the patient to determine.
In PTSD care, it is important that patients feel heard, in control, and help enhance the needed trust with the therapist.
Behavioral Analysis and Predictive Modeling
With patient data comes power - the power to help co-produce better health outcomes and avoid adverse health events. Telehealth has been certified by the FDA to collect screening data, even using validated instruments and evaluation tools, as efficaciously as data collected in-person. Data from apps, wearables, and medical devices - both qualitative and quantitative - can be paired with mood data through patient-reported responses.
When compared and analyzed to determine patterns, changes in patterns, and dissonance between the wearable and interactions; then, predictive modeling can be used. In addition to traditional anecdotal patient interactions, current telehealth technology provides avenues to monitor the patient’s biometric levels. Even a patient’s lack of response or engagement with their health monitoring device or program could be a sign of risk. As a result, providers can be alerted, and interventions can be initiated.
Telehealth allows the treatment team to automate escalation criteria by applying standardized business rules to patient responses. These rules can address, escalate, redirect treatment, or refer the patient to the salient specialist based on the response. Predictive statistical modeling can be used to augment the business rules where best-practices have been established to standards of care. These instant treatment decisions have been shown to save lives.
Patient engagement platforms can help track symptom change over time by comparing a patient’s response to earlier response patterns. Changes can include individual improvement or decline, but can also compare the patient to their treatment cohort providing the treatment team with valuable input as to applicability and intensity of therapies.
Real-time monitoring can observe trigger behaviors to help determine and alert the care team of risk factors leading up to thoughts of suicide/ hurting oneself or others, losing control, or relapsing on alcohol or drugs, are evident.
Medication and Therapy Management
In the care of PTSD patients, relationship with, and confidence between the patient and their treatment team is a factor. Patient engagement through effective telehealth builds rapport between the patient and their team through timely and consistent communication. Treatment progress and information are shared in real-time throughout the team and with the patient in the context of engagement, interaction, treatment goals and results. Including the patient in the matrix, both engage the patient and holds the patient to a level of accountability for their commitment in their recovery.
When medications are involved in the treatment plan, or when medications relating to diagnoses other than the PTSD diagnosis, the platform can coordinate compliance and titration with members of the whole care team. Telehealth effectively monitors fulfillment, compliance, detect non-compliance, and even flag possible abuse and diversion. More critically, integrating medication management throughout the treatment regimen using telehealth lowers the opportunity for contraindicated medications potentially offsetting the desired benefits.
Medication management is important in the treatment plan of PTSD, with studies showing that PTSD patients are 2-4 times more likely to have substance-use issues than people without the condition. A popular sociological precept – people tend to do what you inspect rather than what you expect – is reinforced through effective telehealth monitoring and patient notifications.
PTSD is a complex interaction of multiple symptomologies resulting from multiple contributing triggers and factors. Recovery is often systematic, where one or more factor is resolved reducing the overall acuity of the PTSD manifestation. Treatment is a continuum from incident through resolution and return to normalcy. Telehealth patient engagement can effectively span the multiple elements, timings and be adjusted to address the lessening acuity of the various components to the diagnosis. It can also augment the patient’s commitment to their recovery.
Treatment Engagement and Retention
PTSD is a unique combination of events and traumas for each patient. Recovery is generally defined as the patient returning to a state where none of these events significantly affects the patient’s quality of life. Focusing treatment solely on a specific event may not be the most effective approach to overall recovery. Telehealth can distribute treatment and foci across multiple events and affectations. Effectively designed and managed telehealth is personalized patient-centered care that provides unique treatment-specific support to a patient from a multi-disciplinary and multi-specialty treatment team.
Engaging the patients regularly through a combination of automated dialogue and interactive communication with various members of their treatment team helps to keep the patient on board and in engaged throughout the treatment process. Continuous dialogue between clinicians and patients makes a crucial difference in PTSD care.
Patient progress can be reviewed by the treatment time at any time from the multi-input, multi-disciplinary, multi-modal communications input. These types of patient-clinician interactions provide a more holistic perspective to the treatment team. These inputs can trigger additional assessment, biometric, and patient feedback means of data collection. Treatment can be modified based on how the patient feels after a therapy session. For example:
“Feeling as though they could manage their symptoms on their own (e.g., self-sufficiency) was the most frequent reason for treatment dropout given by soldiers with PTSD,” according to this research by the U.S. Veterans Affairs National Center for PTSD.
Treatment adherence can be greatly enhanced by engaging patients about their treatment-interfering behaviors. Increased risk or symptoms can be communicated across the whole care team of health providers in one channel.
Effective communication may be the simplest feature of a patient engagement platform but it is the crux of patient engagement. Humans do not communicate well interpersonally. Persons with a diagnosis such as PTSD are often less likely to communicate due to the misperception of their personal status or self-worthiness. Communications are not only limited between the patient and clinician. Effective communications must extend to the entire team of care providers, including the family, in one loop.
Communications is enhanced by more than just the technology. Telehealth address how communications are used. Communications can be customized to each patient through how the interactions are written reflecting the individual’s needs, or even when they are delivered. Automated telehealth platforms allow these flexibilities to be easily implemented providing the treatment team with structured data so they have the best, most efficient and timely information.
Communication support to a PTSD patient means more than just talking. Communication support is part of the treatment, and the platform for which that is carried out must be flexible and responsive. Communications must be timed to be delivered when the patient is in need. Communications must be delivered on the devices and tools the patient already has. And communications devices must not be an additional stressor, such as downloading and configuring an app but be available through whatever tools and utilities the patient normally engages in throughout their day.
Studies have also shown that highly engaged patients are those who have access to medical record progress notes and patient portals. Effective telehealth platforms facilitate this and offer a venue for providers to be more responsive and enable access to further information if and when required.
The patient telehealth platform that effectively provides support to the PTSD treatment team goes beyond appointment and medication reminders. It needs to support both the patient and care provider. It needs to be interactive where the patient’s response becomes a potential decision point in the treatment plan. For example: prompting the patient to provide ascent with an “are you okay with this?” question can motivate the patient to complete the treatment. The system should, give breaks if needed, encourage patients to take their time, and never be judgmental.
The aforementioned VA research on “Patient Engagement in PTSD Treatment” underscores that in psychotherapies, patient experience from this kind of relationship results in more empathy and collaboration, with shared goals and priorities associated with better retention, participation, and adherence to a program.
“Patient-provider communication places an emphasis on a collaborative relationship in which patients are encouraged to express questions or concerns, and engage in ongoing shared decision-making about treatment risks/side-effects, benefits, and the fit with the patient’s goals and resources,” the VA noted in its PTSD Research Quarterly publication.
Patient engagement in PTSD is more than just patient-provider communication. For the treatment, it is a LifeWIRE.