Sleep Problem Clinical Pathway Outline

  1. Identification of Patients for Sleep Problem Clinical Pathway

a.Criteria for inclusion into sleep problem clinical pathway: Patients meeting the following criteria should attend an IBHC appointment as part of their standard evidence-based team healthcare:

  1. Patients requesting sleep medications
  2. Patientshaving difficulty falling asleep (taking longer than 15 minutes)
  3. Patientshaving difficulty staying asleep (waking throughout the night)
  4. Patients having difficulty falling back asleep after waking (taking longer than 15 minutes)
  5. Patients who do not feel rested in the morning or who feel sleepy throughout the day

b.Process for identification: Multiple methods should be used to identify sleep problem patients for referral to the IBHC.

  1. Morning huddle review of PCM patient roster
  2. Identification of patient by nurse/tech during screening for PCM appointment
  3. Identification of patient by PCM during PCM appointment
  4. Patient self-referral
  5. Referral of patient by other
  6. Data pull from AHLTA or Care Point (sleep disorder diagnosis, individuals with 2 or more sleep medication prescription refills, etc.)
  1. Methods of Linking Identified Patients with the IBHC

a.During a PCM appointment with a patient who meets any of the inclusion criteria, the PCM, nurse, and/or other designated team memberensures the patient receives a same-day appointment with IBHC (warm handoff) or schedules a future IBHC appointment.

b.If patients are identified through data pull from AHLTA or Care Point:

  1. PCMH nurse or technician calls patient to schedule a future IBHC appointment. Caller uses standard pathway telephone script.
  2. PCMH nurse, technician, PCM, or IBHC may also send secure email to encourage an IBHC appointment.

c.If patient refuses the to see the IBHC,the PCM, nurse, or technicianmay ask the IBHC to review the available medical record and information from the PCM, and document recommendations for care based on available medical data.

  1. Initial IBHC Appointment

a.Biopsychosocial functional assessment questions specific to sleep problems:

  1. Nature of the sleep problem: Trouble with falling asleep, staying asleep, waking in the middle of the night, waking too early in the morning, nightmares
  2. Do you remain in bed when having difficulty sleeping? How long are you awake in bed?
  3. Do you worry in bed?
  4. Do you read, watch TV or do other activities in bed?
  5. Is your bedroom environment quiet and comfortable?
  6. Do you snore or wake with a headache?
  7. Has someone told you that you gasp for breath while asleep or that it looks like you’ve stopped breathing?
  8. Do you take naps? If so, when and for how long?
  9. Do you drink caffeinated drinks within 6 hours of going to bed?
  10. Do you use tobacco within 2 hours of going to bed?
  11. Do you do physical exercise with 2 hours of going to bed?
  12. Do you use alcohol or over the counter sleep medications to help you sleep?
  13. How long have you had this sleep problem?
  14. Was anything associated with the sleep problem starting?
  15. How many nights a week do you have difficulty sleeping?
  16. Are sleep problems worse on work versus non-work days?
  17. Has the sleep problem gotten better, worse or stayed the same over time?
  18. On average what is the total amount of time you are asleep each night?
  19. What time do you typically get into bed?
  20. When you get in bed are you sleepy?
  21. On average how long does it take you to fall asleep?
  22. On average how many times do you wake each night?
  23. On average how long does it take you to fall back asleep?
  24. What time do you typically awake in the morning?
  25. What time do you typically get out of bed in the morning?
  26. Do you wake and/or get out of bed at different times on non-work days?

b.Assessment Measures

  1. At each IBHC appointment the BHM-20, a broad spectrum measure of physical, emotional, and social health,will be given.
  2. At each IBHC appoint theInsomnia Severity Index (ISI) will be given
  3. Consider using a sleep diary as another measure of sleep change that can be reviewed with the patient (See sleep diary 1 and 2).

c.Intervention Options: There are numerous evidence-based interventions that can improve sleep problems. The IBHC and patient should collaboratively select the intervention(s) that are most appropriate given the nature of the patient’s difficulties as well as readiness for change. Possible interventions might include:

  1. Providing education on the biopsychosocial factors of sleep
  2. Providing education and setting a plan for sleep hygiene and stimulus control behaviors to improve sleep (See Handout 1)
  3. Providing education and setting a plan for sleep restriction to improve sleep (See Handout 2)(Caution: Sleep restriction might be contraindicated in some patients due to potential safety risks. For example, drowsy driving in people who have excessive daytime sleepiness, triggering seizures in people with seizure disorders, possible negative effects on mood in people with bipolar disorder, etc.).
  4. Teach patient relaxation techniques (e.g., relaxed breathing)
  1. Follow-Up IBHC Appointments

a.Recommended follow-up interval:

  1. The time between appointments with the IBHC will vary depending on the IBHC’s assessment of the patient’s readiness to change, their ability to successfully make changes with self-management approach, and the nature of the intervention selected.
  2. For most patients having a follow-up in two weeks after the initial consultation appointment would be enough time for the patient to implement the plan and for sleep improvement to start occurring.

b.Recommended number of IBHC appointments:

  1. Two to four IBHC appointments is likely sufficient for most patients to show significant sleep and daily functional improvement.
  2. The rare complex patient (e.g., multiple comorbidities) may benefit from continuity consultation (more than 4 appointments) to show sleep and functional improvement. If this type of patient has not shown any significant improvement after 6 appointments, consider referral for specialty behavioral medicine treatment.

c.Assessment at follow-up appointments:

  1. BHM-20
  2. Insomnia Severity Index (ISI)
  3. Sleep diary as indicated