Inflammatory Bowel Disease Patient Experiences with Psychotherapy in the Community

Barriers to Engagement with Gastrointestinal Health Management

BACKGROUND

Although behavioral interventions have been effective in gastrointestinal (GI) conditions, barriers exist in implementing these interventions into clinical practice. The majority of previously published studies have focused on workforce limitations and have not considered individual and social determinants of health (SDoH) factors that can impact engagement in GI behavioral healthcare.

AIMS

To characterize barriers to engagement in appointment attendance and health management, explore individual and SDoH factors impacting GI behavioral healthcare engagement, and identify barriers that occur more often for patients with SDoH-related vulnerability (low health literacy and/or financial insecurity).

METHODS

A survey was distributed to adult patients who had been seen in Gastroenterology at the Dartmouth-Hitchcock Medical Center from June 2022 to December 2022.

RESULTS

One hundred participants [mean age = 58 years, 57.1% women] completed the survey. SDoH vulnerability was present in 32.3% of the population. For the entire sample, 73% reported at least one barrier to accessing care and 75% reported at least one factor which impacted health management. Those with SDoH vulnerability reported significantly more barriers to attending appointments and to managing health. In addition, they were significantly more likely to endorse physical health problems, difficulty affording medical bills, pain, mobility issues, trauma experiences, significant stress, and difficulty with concentration.

CONCLUSIONS

Patients in a GI clinic reported multiple barriers to accessing care and participating in health management. Innovative, multi-level strategies are needed to address barriers to ensure that all patients are able to obtain quality GI behavioral health services.

Role of stress and early-life stress in the pathogeny of inflammatory bowel disease

Numerous preclinical and clinical studies have shown that stress is one of the main environmental factor playing a significant role in the pathogeny and life-course of bowel diseases. However, stressful events that occur early in life, even during the fetal life, leave different traces within the central nervous system, in area involved in stress response and autonomic network but also in emotion, cognition and memory regulation. Early-life stress can disrupt the prefrontal-amygdala circuit thus favoring an imbalance of the autonomic nervous system and the hypothalamic-pituitary adrenal axis, resulting in anxiety-like behaviors. The down regulation of vagus nerve and cholinergic anti-inflammatory pathway favors pro-inflammatory conditions. Recent data suggest that emotional abuse at early life are aggravating risk factors in inflammatory bowel disease. This review aims to unravel the mechanisms that explain the consequences of early life events and stress in the pathophysiology of inflammatory bowel disease and their mental co-morbidities. A review of therapeutic potential will also be covered.

The IBD Clinic of Tomorrow: Holistic, Patient-Centric, and Value-based Care

There is increasing recognition of the associated bi-directional impact of inflammatory bowel disease (IBD) on patient well-being and the potential benefit of multidisciplinary teams to address these unique needs. At certain IBD centers, there has been an evolution towards patient-centric, holistic care to enhance well-being and improve health-related outcomes. Multiple models, incorporating various disciplines, care modalities, digital tools and care delivery, and resource support have arisen in IBD. Although most IBD centers of excellence are now incorporating such multidisciplinary care models, many practices still practice IBD-limited specialty care, limiting evaluations and interventions to the IBD itself and its direct consequences (eg, extraintestinal manifestations). In this piece, we seek to review the evolution of IBD care towards a patient-centric, holistic model (termed 360 IBD Care) including the role and impact of digital health tools, monitoring, and delivery in IBD, and a shift towards value-based care models with discussion of payor priorities in IBD. We also suggest potential opportunities for IBD practitioners to incorporate elements of holistic care on a local scale. Together, we hope such care models will enhance not only IBD-specific health outcomes, but also improve the general well-being of our patients with IBD today and tomorrow.

Perceived Need for Mental Health Care in a Cohort of Persons With Inflammatory Bowel Disease

BACKGROUND

Psychiatric comorbidity is common in inflammatory bowel disease (IBD) and can negatively affect disease outcomes. We explored the perceived need for mental health care among persons with IBD.

STUDY

Persons with IBD completed self-report questionnaires, including the Hospital Anxiety and Depression Scale (HADS), and reported whether they wanted help with their mood. Each was also assessed using the Structured Clinical Interview for DSM-IV-TR Axis-I Disorders (SCIDs). We used logistic regression analyses to determine factors associated with the perceived need for mental health care.

RESULTS

Of 245 participants, 28% met the criteria for a past diagnosis of depression or anxiety disorder by SCID, and nearly 23% met the criteria for a current diagnosis of depression or anxiety disorder. One-third (n = 74) reported a perceived need for mental health care. Among those meeting criteria for a current SCID diagnosis of depression or anxiety, only 58% reported needing mental health care. Need for mental health care was reported by 79% of persons currently treated for either depression or 71% treated for anxiety. Persons with a perceived need for mental health care had higher mean HADS for depression and HADS for anxiety scores and also higher IBD symptom activity scores. Of those reporting no perceived need for mental health care, 13% had a current diagnosis of depression or anxiety disorder by SCID; even fewer had symptoms of depression or anxiety.

CONCLUSIONS

Symptoms of depression or anxiety are more important than a formal diagnosis of depression or anxiety in predicting which persons with IBD will perceive a need for mental health care.

The Impact of Psychotrauma and Emotional Stress Vulnerability on Physical and Mental Functioning of Patients with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is a chronic health condition thought to be influenced by personal life experiences and emotional stress sensitivity (neuroticism). In the present study, we examined the impact of cumulative trauma experiences and trait neuroticism (as a measure for emotional stress vulnerability) on physical and mental functioning of n = 211 patients diagnosed with IBD (112 Crohn's disease, 99 ulcerative colitis). All patients were assessed for self-reported trauma histories, emotional stress vulnerability, clinical disease activity, functional gastrointestinal (GI) symptoms, and quality of life. Results showed that patients with severe IBD activity have endured significantly more interpersonal trauma and victimization than those with quiescent IBD. Moreover, cumulative trauma was found to exert an indirect (neuroticism-mediated) effect on patients' symptom complexity, with trauma and neuroticism conjointly explaining 16-21% of the variance in gastrointestinal and 35% of the variance in mental symptoms. Upon correction for condition (using a small group of available controls, n = 51), the predictive capacity of trauma and neuroticism increased further, with both predictors now explaining 31% of the somatic-and almost 50% of the mental symptom heterogeneity. In terms of trauma type, victimization (domestic violence and intimate abuse) proved the best predictor of cross-sample symptom variability and the only trauma profile with a consistent direct and indirect (neuroticism-mediated) effect on patients' mental (QoL) and physical fitness. Results are consistent with the growing body of evidence linking experiential vulnerability factors (trauma and neuroticism) and associated feelings of personal ineffectiveness, helplessness, and uncontrollability to interindividual differences in (GI) disease activity and quality of life.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Access to and Models of Care

Rising compounding prevalence of inflammatory bowel disease (IBD) (Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021;18:56-66.) and pandemic-exacerbated health system resource limitations have resulted in significant variability in access to high-quality, evidence-based, person-centered specialty care for Canadians living with IBD. Individuals with IBD have identified long wait times, gaps in biopsychosocial care, treatment and travel expenses, and geographic and provider variation in IBD specialty care and knowledge as some of the key barriers to access. Care delivered within integrated models of care (IMC) has shown promise related to impact on disease-related outcomes and quality of life. However, access to these models is limited within the Canadian healthcare systems and much remains to be learned about the most appropriate IMC team composition and roles. Although eHealth technologies have been leveraged to overcome some access challenges since COVID-19, more research is needed to understand how best to integrate eHealth modalities (i.e., video or telephone visits) into routine IBD care. Many individuals with IBD are satisfied with these eHealth modalities. However, not all disease assessment and monitoring can be achieved through virtual modalities. The need for access to person-centered, objective disease monitoring strategies, inclusive of point of care intestinal ultrasound, is more pressing than ever given pandemic-exacerbated restrictions in access to endoscopy and cross-sectional imaging. Supporting learning healthcare systems for IBD and research relating to the strategic use of innovative and integrative implementation strategies for evidence-based IBD care interventions are greatly needed. Data derived from this research will be essential to appropriately allocating scarce resources aimed at improving person-centred access to cost-effective IBD care.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Indirect (Individual and Societal) and Direct Out-of-Pocket Costs

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one's ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn's and Colitis Canada's 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.

National Prevalence of Psychological Distress and Use of Mental Health Care in Inflammatory Bowel Disease

BACKGROUND

Individuals with inflammatory bowel disease (IBD) have elevated symptoms of anxiety and depression. The burden of such symptoms, accompanied by functional impairment in IBD, is not well documented, nor is utilization of mental health care in this population.

METHODS

Adults ≥18 years were identified in the cross-sectional 2015-2016 National Health Interview Survey. Responses from the Kessler Index were used to estimate the national prevalence of psychological distress with impairment and mental health-care use in IBD. Factors associated with psychological distress with impairment in IBD were analyzed using logistic regression.

RESULTS

The prevalence of psychological distress with impairment was significantly higher in IBD than non-IBD adults (7.69% vs. 3.50%, respectively; P < .01). Among those with IBD and psychological distress with impairment, only a third (36.29%) had seen or talked to a mental health provider in the preceding 12 months. About half of these found the cost of mental health care unaffordable. On multivariable analysis, factors associated with psychological distress in IBD included increasing emergency room visits and trouble finding a health provider.

CONCLUSIONS

A significant number of adults with IBD in the United States have psychological distress accompanied by functional impairment. However, mental health care is underutilized in this population. Many of these individuals find the cost of mental health care unaffordable, struggle to find a health provider, and experience repeated emergency room visits. Ongoing efforts to improve mental health care in IBD should address issues of access and cost. Additionally, these efforts should seek to understand other barriers to mental health-care use.

People Living with Inflammatory Bowel Disease Want Multidisciplinary Healthcare: A Qualitative Content Analysis

This study reports on the preferences of people with inflammatory bowel disease (IBD) for their healthcare. Overall, 477 people with IBD responded to an open-ended survey question within a larger study. We qualitatively content-analysed these responses with open coding using NVivo. Respondents expressed a desire for (1) better communication, (2) multidisciplinary care, (3) better treatment, services and specialist care, (4) whole person care, (5) health promotion, (6) proactive healthcare, (7) fewer administrative issues and (8) improved hospital experience. Patients with IBD want patient-centred, multidisciplinary care. Healthcare professionals should facilitate patients' access to proactive care.

The Pediatric Inflammatory Bowel Disease Medical Home: A Proposed Model

Care for patients with inflammatory bowel disease (IBD) can be complex and costly. Care delivery models to address these challenges and improve care quality are essential. The patient-centered medical home (PCMH), which was developed in the primary care setting, has recently been applied successfully to the adult IBD population. Following the tenets of the PCMH, this specialty medical home (SMH) emphasizes team-based care that is accessible, comprehensive, patient/family-centered, coordinated, compassionate, and continuous and has demonstrated improved patient outcomes. Children and young adults with IBD have equally complex care needs, with additional challenges not faced by the adult population such as growth, physical and psychosocial development, and transition of care from pediatric to adult providers. Thus, we advocate that the components of the PCMH are equally-if not more-important in caring for the pediatric patient population. In this article, we review what is known about the application of the PCMH model in adult IBD care, describe care delivery within the Center for Pediatric and Adolescent IBD at Nationwide Children's Hospital as an example of a pediatric IBD medical home, and propose a research agenda to further the development and dissemination of comprehensive care delivery for children and adolescents with IBD.

Resilience-based Integrated IBD Care Is Associated With Reductions in Health Care Use and Opioids

BACKGROUND & AIMS

Integrated inflammatory bowel disease (IBD) care is effective but not routinely implemented. Validated methods that simultaneously address mind and body targets such as resilience may improve access and outcomes. We describe the development and implementation of the GRITT method and its impact on resilience, health care utilization (HCU), and opioid use in IBD.

METHODS

Consecutive patients from an academic IBD center were evaluated for low resilience on the basis of provider referral. Low resilience patients were invited to participate in the GRITT program. Primary outcome was % reduction in HCU. Secondary outcomes were change in resilience and corticosteroid and opioid use. Patients were allocated into 2 groups for analysis: GRITT participants (GP) and non-participants (NP). Clinical data and HCU in the year before enrollment were collected at baseline and 12 months. One-way repeated measures multivariate analysis of covariance evaluated group × time interactions for the primary outcome. Effect size was calculated for changes in resilience over time.

RESULTS

Of 456 screened IBD patients 394 were eligible, 184 GP and 210 NP. GP had greater reduction in HCU than NP: 71% reduction in emergency department visits, 94% reduction in unplanned hospitalizations. There was 49% reduction in opioid use and 73% reduction in corticosteroid use in GP. Resilience increased by 27.3 points (59%), yielding a large effect size (d = 2.4).

CONCLUSIONS

Mind-body care that focuses on building resilience in the context of IBD care may be a novel approach to reduce unplanned HCU and opioid use, but large, multicenter, randomized controlled trials are needed.

Can an online expressive writing program support people with inflammatory bowel disease? A feasibility randomised controlled trial

BACKGROUND

We explored feasibility, acceptability and preliminary efficacy of an online writing intervention (WriteforIBD) against an active control condition for distress in people with inflammatory bowel disease (IBD) at the time of the COVID-19 pandemic.

METHODS

A feasibility RCT was conducted in 19 adults (89.5% female, aged 20-69 years) with IBD and mild-moderate distress. Participants allocated to the WriteForIBD group completed a 4-day 30-min writing program adapted for IBD. The active control group wrote about trivial topics provided by researchers. Feasibility was established based on the recruitment and retention while acceptability based on completion rates and a numeric rating scale. All participants completed measures of mental health and disease activity before and after the intervention (one week) and at follow-up three months after the study commencement.

RESULTS

The retention rate in the study was high (100% WriteForIBD; 82% control). All participants attended every session. 84.2% of participants were satisfied with the intervention. All participants reported a significant improvement in IBD-Control immediately after the intervention; F (2, 33.7) = 7.641, p = .002. A significant interaction of group*time for resilience was noted, R² = 0.19, p < .001, with the active control group reporting a significant decline in resilience from the first follow-up to three months while no significant change in resilience for the WriteForIBD group was recorded.

CONCLUSIONS

Online expressive writing is potentially feasible and highly acceptable to people with IBD who report distress. Future large-scale trials should explore the intervention that is adapted from this feasibility study.

REGISTRATION

ID: ACTRN12620000448943p.

A Framework for Clinical Trials of Neurobiological Interventions That Target the Gut-Brain Axis in Inflammatory Bowel Disease

A growing body of evidence from preclinical, translational, and clinical studies supports a bidirectional relationship within the gut-brain axis that contributes to neurobiological symptoms including anxiety, depression, fatigue, stress, and sleep disturbance. These symptoms have a significant impact on health-related quality of life and functional ability in individuals with inflammatory bowel disease. Clinical studies that generate high-quality evidence on pharmacological and nonpharmacological (eg, psychosocial, behavioral) interventions are needed to ultimately improve access to safe and effective therapies that have a meaningful impact on patients and to guide medical and regulatory decisions. This review outlines a framework for designing and conducting randomized controlled trials for interventions that target neurobiological symptoms in patients with inflammatory bowel disease based on the most recent guidance published within the past 5 years from policy makers, clinicians specialized in inflammatory bowel disease, patient-reported outcomes methodologists, health economists, patient advocates, industry representatives, ethicists, and clinical trial experts.

How Should Pain, Fatigue, and Emotional Wellness Be Incorporated Into Treatment Goals for Optimal Management of Inflammatory Bowel Disease?

Early diagnosis and the optimal control of inflammation, with a continuous cycle of assessment, treatment, monitoring, and adjustment of therapy, is best practice for the management of inflammatory bowel disease. However, patients express frustration with ongoing challenging symptoms, often discordant with inflammation, including abdominal pain, fatigue, depression, anxiety, and emotional wellness; these are often not optimally addressed by inflammatory bowel disease clinicians due to lack of time or resources. This review will highlight the burden of these symptoms and issues, suggest ways of assessing these in clinical practice, highlight the importance of acknowledging and validating the symptoms and issues with patients, reassuring them that they are being heard, and discuss different possible models of service delivery for psychosocial support, from fully integrated gastropsychology models to referral pathways that optimize community support. We suggest the importance of the treat-to-target concept, where the target is not only control of inflammation but also emotional wellness.

Psychological aspect of patients with inflammatory bowel disease, which may be related to the quality of life, sleep and disease characteristics

OBJECTIVES

Inflammatory bowel disease (IBD) usually present with systemic and gastrointestinal problems. This may result in both physical and psychological burden. The aim of the study was to investigate the association between psychological burden and Health Related Quality of Life (HRQoL), sleep quality and disease characteristics.

METHODS

A total of 106 patients and 165 general populations were enrolled in this study. The demographic information, disease characteristics of participants were investigated. The SCL-90 was self-administered to evaluate psychometric properties. SF-36 and IBDQ were both used to the assessment of HRQoL, and PSQI to quality of sleep.

RESULTS

The SCL-90 score of IBD was significantly higher than that of the control (p = .0007), especially in somatization, anxiety, depression, hostility and psychosis dimensions. Similar to IBDQ (p < .0001), the results of SF-36 (p < .0001) showed that the HRQoL of both Ulcerative colitis (UC) and Crohn's disease (CD) were somehow inferior to control. However, undifferentiated results were noted in patients between UC and CD. Good linear relationship between disease activity and SCL-90 (R_UC = 0.53, p_UC = .001; R_CD = 0.36, p_CD = .002), SF-36 (R_UC = -0.42, p_UC = .01; R_CD = -0.49, p_CD < .0001), IBDQ (R_UC = -0.57, p_UC = .0005; R_CD = -0.52, p_CD < .0001), PSQI (R_UC = 0.50, p_UC = .003; R_CD = 0.27, p_CD = .02) were observed. With the score of SCL-90 of patients increased, the SF-36 (R = -0.78, p < .0001) and IBDQ decreased (R = -0.74, p < .0001), PSQI increased (R = -0.70, p < .0001). Multiple stepwise regression analysis revealed that disease activity, extraintestinal manifestations, weight loss may contribute to identify the psychological anomalies.

CONCLUSIONS

Altered psychological status can be found in IBD, reflecting the necessity of providing psychological care for them. The disease itself results in lower HRQoL. Better HRQoL and sleep quality are in concordance with better psychological health.

Self-help Cognitive Behavioral Therapy Improves Health-Related Quality of Life for Inflammatory Bowel Disease Patients: A Randomized Controlled Effectiveness Trial

Patients with inflammatory bowel disease (IBD) often have poor health-related quality of life (HRQL) and are at risk for anxiety and depression. Cognitive behavioral therapy (CBT) can help patients with IBD cope with their disease. Unfortunately, barriers to care include expense and availability of qualified therapists. Stand-alone, self-help CBT could improve access to care. This study examined the effectiveness of a self-help CBT workbook for patients with IBD. A randomized controlled trial compared the CBT workbook to an active psychoeducational control workbook. A total of 140 participants enrolled. In both groups, scores improved on a range of measures, including catastrophizing, visceral sensitivity, and HRQL, although pre-post effect sizes were generally larger in the CBT group. Only participants in the CBT group experienced significant improvements in anxiety and depression. Improvements were generally maintained or consolidated at 3-month follow-up. Self-help CBT can be an effective and inexpensive way to improve HRQL for patients with IBD.

Patients' Experiences and Challenges in Living with Inflammatory Bowel Disease: A Qualitative Approach

PURPOSE

Inflammatory bowel disease (IBD) significantly impacts patients' quality of life and imposes a considerable psychological, social, and financial burden. While the relationship between disease activity and quality of life is well established, the subjective challenges of living with IBD are more difficult to assess, and suggestions for improving patient experiences are lacking. The aim of this paper was to explore the various challenges patients encounter in living with IBD and to propose suggestions for overcoming them.

PATIENTS AND METHODS

This study utilized a qualitative descriptive design with thematic content analysis. Patients were recruited from the Gastroenterology Clinic at McMaster University Medical Centre from December 2014 to April 2015. Data were collected over the course of 5 focus group interviews using a semi-structured interview guide.

RESULTS

Seventeen patients aged 25 to 77 years old (mean age 43 years, SD 17 years) were interviewed. Fifteen patients were diagnosed with Crohn's disease and 2 patients were diagnosed with ulcerative colitis. Findings were categorized into 18 subthemes which were grouped into 4 broader themes: awareness factor, psychosocial impacts, financial burden, and quality of care.

CONCLUSION

IBD is associated with complex personal challenges across various demographics. Identifying and meeting the unique needs of individual patients may be achieved through improving communication between patients and their healthcare providers. Family-based education approaches, individualized psychotherapy with therapists familiar with IBD, awareness initiatives addressed to important stakeholders, and patient involvement in community support groups may improve overall IBD care.

Access to Psychological Support for Young People Following Stoma Surgery: Exploring Patients' and Clinicians' Perspectives

Psychological problems are common among people with inflammatory bowel disease (IBD) following stoma surgery. However, the ways in which stoma-related psychological needs are identified and addressed in health care settings remain unexplored. In this study, we investigated the perspectives of young people with a stoma and health care professionals about access to psychological support. Semi-structured interviews were conducted with young people with an IBD stoma (18-29 years, n = 13) and health care professionals (n = 15), including colorectal surgeons, gastroenterologists, specialist nurses in IBD and stoma care, and general practitioners in England. Data collection and analysis were informed by constructivist grounded theory. Three analytic categories were developed: "initiating support-seeking," "affirming psychological needs," and "mobilizing psychological support," which capture young peoples' trajectory to access psychological support. Based on the findings, we highlight the need for both patients and health care professionals to assign greater priority to the identification of psychological symptoms post-stoma surgery. More effective care pathways, which include responsive psychological services, would enhance access to psychological support for young people with a stoma.

Adapting 'Tame Your Gut' for patients with inflammatory bowel disease and co-morbid anxiety and/or depression

This qualitative study collected stakeholders' views on adapting an existing online psychotherapy programme, 'Tame Your Gut', to the needs of patients with inflammatory bowel disease (IBD) and comorbid anxiety and/or depression. Adult patients (n = 13) and health professionals (n = 12) participated in semi-structured focus groups or interviews, analysed with a thematic analysis. Patients had a generally positive attitude towards 'Tame Your Gut', while health professionals saw it as useful for selected patients only. Both groups indicated their preference for clinician-assisted online psychotherapy. 'Tame Your Gut' is acceptable to patients and health professionals but only when supported by clinicians.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.