PRACTICE MANAGEMENT: THE ROAD AHEAD
The Role of Psychosocial Care in Adapting to Health Care Reform
Marci Reiss* and William J. Sandborn‡
*IBD Support Foundation, Los Angeles, California; and ‡Division of Gastroenterology, Department of Medicine, University of
California San Diego, San Diego, California
Care for patients with inflammatory bowel disease (IBD) is
more than just colonoscopy and biologic therapies. This is a
disease that profoundly affects the lives, social connections,
employment, and emotions of our patients. Recognizing the
complexity of IBD care, several innovative medical centers
and practices across the country have developed a care
model that includes psychosocial evaluation and manage-
ment, multi-disciplinary care, and patient hovering tools.
In this month’s Road Ahead column, Marci Reiss, a licensed
social worker, and William J. Sandborn, MD (University of
California San Diego) describe how to build and manage
an IBD care model that your practice could build. In fact, it
might be a model for care of many patients with chronic
medical conditions. As we move towards value-based care
and accountability for “whole” patients, these concepts will
provide us valuable insights.
John I. Allen, MD, MBA, AGAF
Special Section Editor
n an era of rapidly changing health care policy,
I community gastroenterology practices and inflam-
matory bowel disease (IBD) centers are looking for
methods to provide quality care within the context of
increasing time constraints and decreased reimburse-
ment. The Patient Protection and Affordable Care Act
(ACA), signed into law in 2010, brought revolutionary
changes without guidance on how to achieve the triple
aim of improving patient experience, improving the
health of populations, and decreasing the cost per capita
of health care.1 However, in light of real-time legislative
changes, providers and medical institutions are faced
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with the need to quickly adapt, often without evidence-
based practices driving these changes.
Perhaps the most daunting challenge of the ACA is
adapting to the dramatic transformation of reimburse-
ment to providers, which includes documentation of a list
of quality indicators of medical care, in addition to
requiring accountability for patient satisfaction and
health outcomes including psychosocial issues.2 The first
set of quality metrics for IBD has been published by the
American Gastroenterological Association3 and currently
is incorporated into the Centers for Medicare and
Medicaid Physician Quality Reporting System. However,
there already is disagreement about whether those met-
rics, if achieved by practitioners, lead to improved quality
of care for patients or reduced cost. Therefore, this set of
quality indicators is being reanalyzed and revised.
Patient satisfaction and psychosocial care are being
considered for inclusion in value-based reimbursement
models in part because of studies relating psychosocial
patient barriers with excess resource use and increased
rates of hospital readmissions for patients with chronic
medical conditions.4–8 Some studies have shown that
drivers of service utilization and readmissions include
psychosocial issues, such as anxiety, lack of emotional
and psychological support from family, friends and
caregivers, and a lack of communication and coordina-
tion of care for patients.8 Perhaps because there are no
published guidelines for incorporating psychosocial care
into usual clinical practice, it still is largely absent from
routine patient care in a structured and reproducible
manner. Although there is no uniform definition of psy-
chosocial care in medicine, the IBD Support Foundation
(IBDSF) defines psychosocial care in the health care
setting as the provision of psychological and emotional
support and practical advocacy as it relates to patients
adapting to their medical condition, accessing and
adhering to medical treatment, and developing coping
Abbreviations used in this paper: ACA, Patient Protection and Affordable
Care Act; IBD, inflammatory bowel disease; IBDSF, Inflammatory Bowel
Disease Support Foundation; UCSD, University of California San Diego.
Most current article
© 2015 by the AGA Institute
1542-3565/$36.00
http://dx.doi.org/10.1016/j.cgh.2015.09.010
Clinical Gastroenterology and Hepatology 2015;13:2219–2224
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued
skills to incorporate their illness successfully into their
lives.
Ideally, one would propose clinical trials to determine
the impact of various psychosocial care services to help
identify most effective practices. However, the rapid
evolution from fee-for-service reimbursement to alter-
native payment models (where clinicians take financial
risk for health outcomes) may require infrastructure
change faster than data can be obtained. Clinical care may
be forced to change based on logic and clinical experi-
ence, while at the same time commencing relevant
research that allows evidence-based refinements in the
future models. At the University of California San Diego
(UCSD) IBD center, efforts are underway to adapt a
psychosocial care model to management of their popu-
lation of IBD patients in anticipation of value-based
reimbursement, and to improve patient experience. Spe-
cifically, we use medical social workers to help clinicians
identify barriers to treatment and wellness through
standardized psychosocial assessment and intervention.
The IBDSF is a not-for-profit 501(c)3 organization
that has partnered with the UCSD IBD center to provide
psychosocial care to patients with IBD.9 The first author
of this paper is the Founder and current President of
IBDSF. For nearly a decade, this organization has pro-
moted and designed clinical social work practices
focused on patients with IBD. Services have been pro-
vided in the tertiary care and foundation (faculty medical
practice) setting. Irrespective of the venue, the goals of
psychosocial care remain the same: to enable optimal
adjustment to illness by identifying psychosocial barriers
to care, and providing interventions to reduce or elimi-
nate them. Psychosocial assessment and intervention are
core activities of clinical social work practice. They
involve a systematic gathering of information to under-
stand an individual’s circumstances, difficulties, and as-
sets and to determine a subsequent course of action or
intervention plan10 to adapt to situations or achieve
goals. At UCSD, a study design has been developed to
conduct a randomized controlled trial to evaluate the
impact of structured psychosocial care in the tertiary
care setting, using the IBDSF’s Psychosocial Archaeology
(discussed next). This structure provides a conceptual
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paradigm that may improve patient care and optimize
outcomes in less time and with lower costs, through
provision of comprehensive psychosocial care by a
medical social worker, with specialized training in IBD.
Psychosocial Archaeology is based on the following
Best Outcomes Formula (Figure 1). To achieve best pa-
tient outcomes, one recognizes that patients are complex
individuals and to meet the needs of an individual facing
an illness, one must look at the entire complexity of that
human life. Achieving best outcomes requires an inclu-
sive viewpoint, such as the one illustrated by the Psy-
chosocial Archaeology approach. This is a formal process
of efficiently conducting a comprehensive analysis of a
patient’s psychosocial world and it is based on a clinical
social work practice that has been adapted to address
unique complexities of a chronic gastrointestinal disor-
der. The approach appreciates that all people must be
treated in the context of their personal lives, beliefs, and
backgrounds. It is this unique context that patients bring
to their disease and its management. Health care pro-
viders must understand that identifying the condition or
illness and recommending a treatment is only part of
effective care. If illness is addressed without addressing
its complex human host, barriers to treatment will pre-
vent best outcomes, even if best medical therapies are
offered. The human host with all the complexities of a
human life largely dictates acceptance, access, and
adherence to therapies.
Sandborn11 established the poor correlation between
objective evidence of inflammation and clinical symp-
toms. Effective psychological care can reduce clinical
symptoms resulting from irritable bowel12 and reduce
service utilization including telephone calls and emer-
gency department visits, when the driver of the services
is not inflammation but rather anxiety.13
Psychosocial Archaeology
The Psychosocial Archaeology involves a compre-
hensive analysis of the psychosocial world of a human
patient. Digging through their complex personal psy-
chosocial history enables the practitioner to see through
Figure 1. Best outcomes
formula. *Best outcomes
are defined as patients
who are functioning well
from both a physical and
emotional perspective.
 PRACTICE MANAGEMENT: THE ROAD AHEAD, continued
the eyes of the patient, identify barriers to treatment,
and tailor discussions and treatment accordingly. This
may sound like a daunting task; however, it can be done
relatively quickly and efficiently by a medical social
worker or allied health care professional with the
proper training, in the tertiary care and community
practice setting. Medical social workers are specifically
trained to help patients adjust to illness, diagnose and
treat behavioral and emotional disorders including
anxiety and depression, work with patients on behavior
modifications to adapt to difficult situations, and
respond to crisis situations. Their labor costs are
approximately $10 less per hour than a nurse and $13
less per hour than a psychologist in the United States
(United States Department of Labor, http://www.bls.
gov). With specialized training in IBD, social workers
can provide excellent and affordable psychosocial care
within an IBD center.
Another tool used by UCSD is the Psychosocial Patient
Radial that incorporates patient’s individual personality,
their family and friends, their work and/or school envi-
ronments, their finances and insurance situation, their
religious and cultural background, their health status,
Figure 2. Psychosocial Patient Radial.
and their relationship with their doctor and health care
team. All of these elements impact patients’ ability to
adapt to their disease; accept, access, and be compliant visits, a Hospital Anxiety and Depression Scale instru-
with treatment; and impact their level of satisfaction ment (Appendix B) can be used to identify elevated
with their providers and ability to incorporate disease anxiety or depression. The Hospital Anxiety and
successfully into their lives. The tapestry of the psycho- Depression Scale instrument can be given to the patients
social world of each patient’s unique and is additionally while they are in the waiting room because it is short and
affected by age and life stage of the patient (Figure 2). easy to complete and evaluate. When anxiety or
The Psychosocial Archaeology approach to patient depression levels are elevated, another full assessment
care was built based on an understanding that many should be done.
factors impact patients’ functioning relative to their
disease. Patients need to be assessed fully for these
factors and relevant interventions need to be imple- Inflammatory Bowel Disease Support
mented. For each patient, the impact of disease is sig- Foundation’s Psychosocial Assessment
nificant. However, each patient faces their own unique
“barriers to treatment.” To reduce or eliminate these The IBDSF Psychosocial Assessment is a question-
barriers, an individualized approach must be taken. naire that a social worker or nurse can use to assess the
Psychosocial Archaeology follows IBDSF’s Baseline domains in the psychosocial world of a patient. In con-
Psychosocial Assessment & Intervention Algorithms ducting the assessment, one starts with the patient in the
(Appendix A). The initial baseline psychosocial assess- middle. When a patient enters the tertiary care IBD clinic
ment can be completed by a trained medical social setting or community practice setting, the patient is
worker or nurse in 10–15 minutes. This assessment coming with a whole package of emotions and life ex-
should be done at baseline with each new patient periences that influence their ability to adjust to illness,
because it identifies potential barriers to treatment, and accept and adhere to treatment recommendations.
stratifies patients into high and low risk, and identifies One needs to start with a high-risk and basic life needs
interventions needed to reduce or eliminate the barriers assessment. If there are personal barriers, such as lack of
to treatment and wellness. The time needed for the in- adequate food or housing, significant anxiety or depres-
terventions varies depending on the circumstances and sion, and drug or alcohol use, the best medical treatment
not all patients require interventions. At subsequent recommendations will not be optimized, even if they are

2221
PRACTICE MANAGEMENT: THE ROAD AHEAD, continued
offered. Therefore, these barriers need to be identified
and interventions implemented.
Patients with supportive networks of friends and
family are more likely to accept therapies and be
adherent to complex medical therapies, yet social isola-
tion is present in a significant number of patients with
IBD.14 This works against development of supportive
networks, a situation that needs to be identified and
ameliorated if possible.15 Many patients with IBD believe
that their disease has an adverse effect on relationships16
and patients with IBD are more likely to have marital and
family problems.17
Patients with IBD face threats to job security because
many need time off to manage their illness and this too
may result in significant barriers to treatment.4 Em-
ployers may not support the time off required for doctor
visits, procedures, and medication infusions, forcing pa-
tients to make difficult decisions between compliance
with necessary components of care and keeping their job.
Patients may not feel comfortable asking for needed ac-
commodations or if they do, their requests may not be
met with ease. Although employees with disabilities are
protected against discrimination, a nonsupportive work
environment may still pose substantial barriers to
treatment. Without assessment and intervention, pa-
tients may not understand the full range of choices and
become noncompliant with treatment recommendations.
Patients in school may face similar challenges.2,18
Patients have different comfort levels regarding
disclosure and may have insufficient support from their
professors or academic institution. Laws to assist pa-
tients with disabilities are in place for academic- and
school-related programs. Section 504 Plans provide
benefits for disabled and chronically ill students in
grades kindergarten through 12 and there are many
sample 504 Plans obtainable on the Internet.19 At the
college level, the Americans with Disabilities Act requires
all educational institutions make any necessary course
modifications for students with disabilities to enable
higher education for these students.20 Using these laws,
however, takes time and effort and requires a learning
process and development of advocacy skills for patients.
The existence of the laws does not sufficiently enable
academic accommodations or do so with ease and speed.
As a result, patients may simply lessen their treatment
compliance if it infringes on their time at school. Inter-
vention is required to reframe the prioritization of
medical care as a means of enabling academic success, in
addition to teaching necessary advocacy skills and
helping patients access support.
One of the primary goals of ACA is to increase access
to care for individuals frequently left out of the
2222
employer-based insurance market through state and
federal insurance exchanges. However, access to health
insurance does not necessarily mean access to optimal
care for patients with IBD. Patients may be restricted by
insurance benefits that include a narrow network of
providers and often face severe financial constraints
because of limits on medications available within their
pharmacy benefits. Copayments and deductibles
required for medications, such as infusion or injection
biologics, may be so high that their use is precluded.
Patients face barriers because of requirements for
prior authorizations for procedures and medications and
this can be cumbersome for patients and providers. Cost
pressures caused by the increase in use of biologics have
forced payers to implement financial barriers and
sometimes patients simply cannot afford care.5,6,21 Even
if patients ultimately might be able to find their way
through the insurance maze, many do not have time to
spend during their workday to make or receive neces-
sary telephone calls. Additionally, we cannot neglect the
costs of over-the-counter medications, transportation,
parking, child-care, household help, and other indirect
costs. Thus, a full psychosocial assessment of barriers
to care must incorporate the full scope of these issues
so patients can access and adhere to treatment
recommendations.
Religious and cultural perspectives may pose barriers
to treatment, reduce patients’ adaptation to their disease,
and influence medical decisions.7,22 Cultures view illness
as more or less stigmatic. In cultures where illness is
stigmatized, patients can become ostracized and isolated,
potentially compromising their willingness to accept a
diagnosis or follow through with a treatment plan. Reli-
gious and cultural perspectives of the elderly life stage
may impact a patient’s feelings of self-worth. When the
elderly are viewed negatively, increased isolation and
depression may result. As we conduct a psychosocial
assessment, we realize that religious and cultural per-
spectives may be additional barriers to care and should
be given consideration.
The health domain has several components including
disease severity, doctor-patient relationship, and systems
of health care delivery. The influence of both disease
severity and symptoms on illness adjustment should not
be underestimated. Knowles et al15 demonstrated a rela-
tionship among disease activity, illness perceptions, coping
strategies, and depression and anxiety. When assessing
the psychosocial picture, one considers the impact of the
severity of a patient’s disease. For example, a patient with
mild disease may have different disclosure and adjustment
needs than a patient with a draining perianal fistula or a
diverting ileostomy. The severity of disease in itself may
 PRACTICE MANAGEMENT: THE ROAD AHEAD, continued
not be a barrier to treatment; however, the severity could
increase psychosocial fallout of disease to the patient and
result in further barriers to care.
At times the doctor-patient relationship can be a bar-
rier to treatment. This relationship is crucial in enabling
patients to trust their physician and overcome their own
concerns so that they can accept treatment.6 For many
patients, lack of sufficient time with the physician, insuf-
ficient access, and insufficient communication all have the
potential to damage the therapeutic relationship, less-
ening the patient’s willingness to trust their doctor’s
treatment recommendations. If the patient does not feel
comfortable with their nurse or even the scheduling staff,
there is more frustration and less faith in the overall team.
Patient-focused training programs for IBD staff are avail-
able and may even be offered by some pharmaceutical
companies whose medications fall within the IBD space.
The Chronic Care Model is a comprehensive model of
care that uses a systematic approach to restructuring
care around partnerships between a health system and a
patient population.23 This model has been shown to
impact financial and clinical outcomes and was adapted
into the Psychosocial Patient Radial. Although important
in addressing chronic illness, to be maximally successful,
patients must agree to changes in their care and inte-
grate them into their lives.24 In the Chronic Care Model,
this is called “self-management support.” The Chronic
Care Model does not address all of the psychosocial
complexities described previously, which are an inherent
challenge in that model.
Financing Psychosocial Care
The greatest current barrier to implementation of
psychosocial care, especially within the fee-for-service
reimbursement model of care, is cost. How can a social
worker or nurse devoted to psychosocial assessment and
intervention be funded in either a tertiary care center or
a private practice?
In a referral IBD center, the social worker is usually
funded by the hospital, health system, or by philan-
thropy. Services they provide could be billed under
complex chronic care coordination services codes,
although these codes usually are not familiar to gastro-
intestinal practices. These codes cover patient-centered
management and support services provided by physi-
cians or other qualified health care professionals and
have very specific infrastructure and time requirements.
Other than offsetting salary with revenue generation
from these codes, the return on investment for incor-
porating the psychosocial model of care might include
improvements in Consumer Assessment of Healthcare
Providers and Systems and Hospital Consumer Assess-
ment of Healthcare Providers and Systems scores, and
cost savings in terms of decreased hospital readmissions.
Both are indirect savings that frequently do not fall
within the gastroenterology cost center. As more value-
based reimbursement models are implemented, better
clinical outcomes caused by improved access and
adherence to treatment will likely lead to increased
savings.
In the community practice setting, social workers
might be used in a telemedicine model to provide sup-
port for multiple community practice sites. Depending on
patient volume, community gastroenterologists can
share the cost of a single social worker. Psychosocial
services can be provided using secure and inexpensive
telemedicine programs. Patients do not need to go to a
telemedicine center, but only require access to the
internet via a smart device. The anticipated benefit to
community practice gastroenterologists includes better
clinical outcomes, improved patient satisfaction, and
increased market share as word spreads on social media.
Conclusion
The simultaneous goals of health care are captured by
the triple aim: improved patient experience, better health
outcomes, and reduced per capita health care expendi-
tures. A coordinated health care program for patients
with IBD that includes psychosocial care can improve the
patient experience by providing individualized psycho-
social patient care, reducing barriers to treatment, and
optimizing adherence. Psychosocial care can be provided
by a medical social worker with experience and training
in IBD. Although clinical trials have not yet been
completed to determine the true effectiveness of this
approach, clinical experience and demands of legislation
make it a feasible starting place to adapt to health care
reform.
Supplementary Material
Note: To access the supplementary material accom-
panying this article, visit the online version of Clinical
Gastroenterology and Hepatology at www.cghjournal.org,
and at http://dx.doi.org/10.1016/j.cgh.2015.09.010.
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Reprint requests
Address requests for reprints to: Marci Reiss, LCSW, IBD Support Foundation,
8806 Horner Street, Los Angeles, California 90035. e-mail: marci@ibdsf.org.
Conflicts of interest
This author discloses the following: Marci Reiss is Founder and President of
IBD Support Foundation (IBDSF), a 501(c)3 nonprofit organization. IBDSF has
copyright and/or trademark protection for some material used in this article.
This material is sold and profits accrue to IBDSF to further its mission. Marci
Reiss draws a salary from IBDSF. The remaining author discloses no conflict.