Achieving a 90 percent reduction in emergency department visits and an 88 percent reduction in hospitalizations among high-need, high-cost patients with inflammatory bowel disease (IBD) might seem impossible. But Mount Sinai researchers are proving that it can be done when patients have true “GRitT”—The Gaining Resilience through Transitions (GRitT) Method-IBD.
Developed by Laurie Keefer, PhD, Professor of Medicine (Gastroenterology), and Psychiatry, at the Icahn School of Medicine at Mount Sinai, The GRitT Method™ is a strengths-based, positive psychology-focused approach to strengthening resilience among patients with IBD. Through evidence-based, coordinated, multidisciplinary interventions, patients develop skills to manage the significant mental, emotional, and physical challenges of living with a chronic disease.
“We know that up to 40 percent of patients with IBD also experience depression and anxiety that are believed to be directly related to living with a chronic disease,” says Marla Dubinsky, MD, Professor of Pediatrics (Gastroenterology), and Medicine (Gastroenterology), at the Icahn School of Medicine. “We also know that clinical symptoms associated with anxiety and stress overlap with those that are associated with IBD, which means we often focus on getting patients better without stepping back to assess whether comorbid mental health conditions are driving the symptoms we see. Through GRitT, we are optimizing our patients’ access to medical care and teaching them resilience skills as early as we can in their disease course to prevent them from developing anxiety and depression, as well as symptoms unrelated to their underlying disease.”
After being referred to the program by their care providers, patients complete a questionnaire with the GRitT care coordinator, undergo an initial assessment, and receive a GRitT resilience score between 0 and 100, generated by a proprietary algorithm validated at Mount Sinai. A high score is predictive of better outcomes, less complexity, and stronger resilience. Based on that score, a customized playbook of interventions and treatment goals is developed and implemented by a multidisciplinary team that includes dietitians, pharmacists, nurse practitioners, and social workers. The playbooks target up to six behavioral categories that have been identified as predictors of patient outcomes—optimism, acceptance, social support, self-confidence, self-regulation, and resilience. As patients make progress toward their goals, the playbook is adjusted accordingly.
“Most of the resilience building occurs in the first two months through interventions such as pain management, cognitive behavioral therapy, peer mentorship, or addressing nutritional deficiencies,” Dr. Keefer explains. “We monitor them for six months and then evaluate their progress to see if we can step them down to regular care without any negative impact. Approximately 60 to 70 percent of participants meet that criteria at six months, but we continue to follow them annually and can step up their care if they need new skills to navigate a major life transition, such as a pregnancy or retirement.” Dr. Keefer adds that fewer than 5 percent of patients who have stepped down have returned to full GRitT team care to date.
An initial study of patient outcomes suggests that The GRitT Method is having a notable impact on both quality of life and health care utilization. Conducted from August 2016, when the program launched, to August 2019, the study enrolled 336 Mount Sinai patients with IBD (62 percent of whom had Crohn’s disease) between ages 18 and 70 who screened positive for low resilience. Of those patients, 126 were engaged in and graduated from the program and the other 210, who were eligible but did not engage, served as controls. Health utilization data from 12 months prior to referral to the program were compared with 12 months after referral to the program for both groups.
Graduates experienced a 90 percent reduction in emergency department visits and an 88 percent reduction in hospitalization at one-year follow-up. Among controls, they observed a 4 percent reduction in emergency department visits but a 65 percent increase in hospitalizations. Graduates also achieved an increase in GRitT score of 33 points, which demonstrates improved resilience. Reasons for nonengagement among controls were geographic distance (38 percent), lack of or limited (e.g., high deductible) insurance coverage (30 percent), declined (24 percent), and lost to follow-up (8 percent). The findings were presented at the American College of Gastroenterology Scientific Meeting in October 2020.
The program is continuing, with approximately 100 patients active at any given time. “Based on these results, we are confident that resilience building is really a very important strategy when it comes to reducing health care utilization,” Dr. Keefer says. “It demonstrates the efficacy of engaging patients before depression sets in and they stop engaging or are hospitalized for unnecessary surgeries. That said, there are challenges in engaging patients, particularly those who are not local, which we believe could be addressed by scaling up the program through technology.”
Having demonstrated the program’s efficacy in addressing the behavioral comorbidities associated with IBD and the considerable social and economic burdens they create for patients and the health care system, Drs. Keefer and Dubinsky are looking at refinements. Plans include patient stratification to facilitate development of playbooks and engaging clinicians to improve phenotyping of candidates. They have also founded Trellus Health in White Plains, New York, to commercialize GRitT Method-IBD and are looking at adapting The GRitT Method to support all patients living with chronic diseases.
“It was purposely developed to be as disease-agnostic as possible,” Dr. Dubinsky says. “Based on our findings, we believe it has the potential to be an invaluable preventive strategy for millions of patients, helping them make behavioral changes that impact the course of their disease so they are not just surviving with it; they’re thriving.”
Dr. Dubinsky and Dr. Keefer are co-founders and equity owners in Trellus Health, a for-profit company. The company’s aim is to develop digital health solutions to manage chronic conditions such as IBD. Dr. Dubinsky also serves on the Board of Directors of the company. In addition to Dr. Dubinsky and Keefer’s involvement in the company, the Icahn School of Medicine at Mount Sinai has equity ownership in Trellus Health.
Marla Dubinsky, MD
Professor of Pediatrics (Pediatric Gastroenterology)
Laurie Keefer, PhD
Professor of Medicine (Gastroenterology), and Psychiatry