This article is part of a series sponsored by HLTH highlighting topics that will be discussed at the HLTH conference November 13-16 in Las Vegas.
Clinicians used to wonder if there was a role for mindfulness meditation in healthcare. But after the Covid-19 pandemic laid bare the overwhelming need for practical solutions in behavioral health, the question has shifted to what role it can play.
The answer is getting longer all the time. A quick search on ClinicalTrials.gov reveals 700 active clinical trials studying applications for mindfulness across women’s health, insomnia, opioid use disorders, cancer treatment, recovery after surgery, primary care, physical therapy and more.
In addition to undertaking research, digital health companies and healthcare providers are collaborating on ways to get the apps into the hands of more people.
Digital health companies such as Calm, Headspace, and OmPractice are working with providers and payers to make their apps more accessible to patients. Clinicians are referring patients to these apps, and some health systems and payers have cultivated digital formularies to enable patients to download these and related apps themselves.
So what is mindfulness meditation, which is also referred to as mindfulness-based stress reduction? An article from American Physical Therapy Association, citing the American Mindfulness Research Association, describes mindfulness as the practice of remembering to observe moment-to-moment experiences with openness and without automatic patterns of previously conditioned thoughts, emotions or behaviors.
The article cites three components:
- Body scan — gradually sweeping attention across the body from head to feet, focusing non-critically on sensations or feelings and using periodic suggestions of breath awareness and relaxation.
- Mindful attention on breathing or rising and falling abdomen and nonjudgmental awareness of thoughts and distractions.
- Breathing exercises, simple stretches and posture to strengthen and relax the musculoskeletal system.
Pioneers of the field include Jon Kabat-Zinn, who established the Center for Mindfulness in Medicine Healthcare and Society at the University of Massachusetts Memorial Medical Center. Carolyn McManus, a physical therapist, established a mindfulness program at Swedish Health in Seattle and also offers a course on the topic. A concise summary of mindfulness on Swedish Health’s website written by McManus, in the context of pain management, states:
“Mindfulness means present-moment awareness and offers you a constructive, practical and effective way to observe your physical, cognitive and emotional reactions and make skillful choices that can decrease your pain and distress. Remember you may not have control over the sensation of pain, but you do have control over your reactions to the sensation of pain. Your choices directly impact your nervous system activity.”
Kaiser Permanente’s digital ecosystem for mindfulness and behavioral health
Prior to the pandemic, Kaiser Permanente developed the building blocks for the formulary focused on mindfulness. The need was clear. A survey of the health system’s members found that about 20% to 25% who did not meet the diagnostic threshold for clinical depression and related mental health issues were nonetheless reaching out for help. The health system sought to offer self-help tools that could be downloaded easily but that also embraced human-centered design principles.
In the preliminary stages of creating a digital health and wellness ecosystem in 2017, Kaiser Permanente conducted a survey of 38 patients with mild to moderate symptoms of depression and anxiety as well as 61 frontline clinicians and staff. Based on the insights gathered from that survey, in 2018 it created a multipronged health and wellness ecosystem. It included a curated portfolio of recommended apps with evidence of clinical efficacy and user satisfaction. The health system then enabled clinicians to refer patients to the apps and to document their referrals in the electronic health record and to easily send patients secure text messages containing links to download the apps. The health system also offered clinician training and support materials developed by its national team in collaboration with frontline clinicians. Kaiser Permanente also used the American Psychiatric Association’s app-evaluation model as a starting point to select existing apps for a pilot of the ecosystem. The ecosystem was constructed with a framework that also addresses privacy and security, patient engagement, and interoperability.
After pilots in 2018 and 2019, the digital ecosystem went live at the start of the pandemic in February 2020.
Kaiser Permanente’s digital formulary aggregates a group of six apps. They include mindfulness and meditation apps Calm and Rethink Care (previously known as Whil) and cognitive behavioral therapy apps myStrength, SilverCloud and Thrive.
By May 2020, Kaiser Permanente had trained 1,600 staff members to use the digital formulary and developed best practices for prescribing it to patients in myriad settings, especially in primary care. Last year, its work on the digital health and wellness ecosystem was published in NEJM Catalyst.
Of the 121,000 patients who have downloaded the apps to date after physician referrals, about 60% have engaged with mindfulness apps.
As the senior principal consultant for prevention, wellness and digital health with Kaiser Permanente, Trina Histon said in a phone interview that wellness apps focusing on mindfulness have an important role to play in healthcare.
“I think there are huge opportunities in connecting the head to the body,” she said. “We know from all the published papers on the pandemic – stress, anxiety, and insomnia make patients’ lives miserable … Certainly this area is ripe for innovation and a lot of folks are doing things in the digital health space, such as applications for mindfulness.”
One benefit of the apps is that they can help patients who may be uncomfortable with a referral to a therapist or need a way of addressing their anxiety and stress immediately. Histon added that despite all the terrible things that have come out of the pandemic, it has at least highlighted the need for easily accessible mental health resources and led to a more candid conversation about mental health in general.
“The silver lining in the pandemic is that people are more willing to talk about the struggles they’ve been having,” said Histon. She also observed that unlike other generations who fear being stigmatized for discussing their mental health needs, members of Generation Z are much less afraid.
Looking ahead, Histon said she is currently working with a team to develop an ecosystem focused on health and wellness for young people.
Digital health companies and mindfulness
Anxiety and insomnia have spurred use of Headspace’s app, said CEO Russ Glass..
“Anxiety is one of the most common issues that Headspace members come to the app to work on; 36% of new members (who’ve used Headspace for less than one month), state that their goal is to sleep better. ‘Reduce or manage stress’ is the second most chosen goal for new members,” Glass shared, citing a December 2021 census of Headspace members. “When asked which meditation topics were most relevant to them, 62% of Headspace users shared that happiness, kindness and patience meditations were most relevant; 55% of users shared that meditations for handling difficult emotions were relevant, and 59% of users cited anxiety-focused meditations as most relevant.”
Asked about the roles that apps like Headspace can play in healthcare, Glass pointed out that they provide affordable and easily accessible meditation and mindfulness exercises, offering a scalable approach to begin addressing the current mental health crisis.
Looking ahead, Glass said Headspace plans to continue to build its content library by including more voices and more representation of the cultures and experiences of its members. Given the ways Covid-19 has touched people’s lives, the company has added content specific to helping manage grief, fear and uncertainty. It also plans to work toward completing the integration of Ginger.
Although patients referred to wellness apps like Headspace and Ginger make up much of the users who download them, overworked healthcare staff and clinicians are another important group of users. OmPractice has worked with self-insured employers, as well as hospitals, to provide its mindfulness and yoga exercises to users.
“We tend to attract companies who must perform in a high-stress role (like the employees of Beth Israel Lahey Healthcare), or with partners/payers whose employees/members use their bodies in the course of their work being on their feet all day,” said OmPractice Co-founder Chris Lucas. “One of our earliest customers was the Massachusetts Interlocal Insurance Association (MIIA) which serves many of our state’s municipal employees (DPW, teachers, and so on). Since then, we’ve worked with numerous other large health insurers who want the known benefits of mindful movement and stillness for their members and employees.”
“Back care and yoga for neck pain” classes are always well-attended, according to Lucas. Among the feedback from users, 69% said their stress had decreased through use of the app and 63% said they felt happier in general.
OmPractice’s app is also provided to veterans through partnerships with Veterans Affairs Medical Centers and Veteran Integrated Service Networks. Although it began as a pilot in 2019, OmPractice’s work with veterans has taken off since then. Lucas said more than 2 million veterans have access to its app.
“Our goal is to start updating medical records documenting class attendance so that clinicians can see the full picture of a patient’s well-being,” said Lucas. “In the next year we aim to radically upgrade our data platform so we can show users the more granular progress that can often be hard to see or feel early on. This is the number one reason people don’t stick with these practices, and we will change that.”
Mindfulness in physical therapy and pain management
Mindfulness techniques are also a great fit for physical therapy and mitigating chronic pain for a few different reasons, according to McManus.
“I think it is so important to help patients feel at home in their body. So many people are judging and critical of their body to begin with and then they can be angry that they have been ‘let down’ by their body,” he said. “This conflicted relationship can further drive stress and distress that is an obstacle to well-being. Physical therapists are the ones who can help patients learn to pay attention to their body with mindful attitudes of acceptance, kindness and curiosity.”
McManus also noted that mindfulness fits well into physical therapists’ treatment approach because they appreciate “the complex nature of pain as a complex process of perception” that includes the interaction of sensory information, cognition and emotion.
“To be successful, we appreciate taking a biopsychosocial approach, especially to chronic pain treatment. Mindfulness fits well into our treatment approach as it enables us to address these multiple factors as we introduce patients to calmly observe the physical sensation of pain and their physical, cognitive and emotional reactions to pain. We can then coach them in the self-regulation of their reaction to pain.”
The collaborations between health systems, payers, and digital health companies to provide ways for patients and clinicians to manage stress, anxiety and chronic pain are encouraging. Mindfulness could become an important component of improving the patient experience in healthcare and addressing how we prevent clinician burnout. Although these examples offer valuable insight into how behavioral health needs can be addressed, it will be interesting to see whether mindfulness becomes an integral part of healthcare in the future.
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