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Sleep and BehavioralRx ®
Mobile Medicine for the Mind and Body
Table of Contents
Overview .................................................................................................................. 3
Sleep: Essential to Healthy Living ............................................................................. 4
A Day In The Life ...................................................................................................... 6
An Inside Glimpse into BehavioralRx ® , The Science of Precision Health ............... 11
References ............................................................................................................. 14
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Sleep is essential to human health and happiness. Depriving our bodies of sleep wreaks havoc on our rhythm and ability to manage our daily lives and responsibilities. The GoMo Health concierge-style system of care helps people with complex clinical conditions (diabetes, cardiac, cancer) cope with their daily stresses and provides activities that create a mental and physical state more conducive to achieving healthy sleep.
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Sleep: Essential to Healthy Living
How impactful is a regular sleep pattern on achieving healthier habits, critical milestones, improved outlook and quality of life?
Diabetes
Every human body has an internal clock, known as the circadian rhythm. This rhythm allows the body to know when to go to sleep and when to be alert. Sleep allows the body to regulate hormones, like insulin. However, when the circadian rhythm is interrupted, efficiency of insulin can be affected and impact a person’s ability to maintain a proper balance of insulin and blood sugar. Additionally, as an individual stays awake, the brain produces a hormone called cortisol. Cortisol is a stress hormone that causes the body to remain awake and alert once it is created. The more cortisol that is released, the harder it is for insulin to balance blood sugar. According to the American Heart Association, lack of sleep can drastically affect an individual’s cardiovascular system including such negative effects as high blood pressure and coronary artery disease. When a person is sleep deprived, stress hormones are produced and cause inflammation. These factors increase the risk of cardiovascular problems and research shows that the mortality rate for people who dealt with stroke, ischemic heart disease, etc. was lower for people who slept 7-8 hours a night. Research shows that a good night’s sleep is highly beneficial to reduce risk of cancer and help battle cancer for people who have been diagnosed. Scientists believe sleep is a therapeutic tool while treating cancer because it gives the body the opportunity to heal. During deep sleep, the body repairs damaged DNA and cells, allowing for healthy cells to develop instead. When healthy cells grow and damaged cells are repaired, the body’s immune system strengthens. Sleep deprivation exacerbates several risks, including cell replication error and damage to DNA, and evidence presents that cancer forms when there is an abundance of damaged cells.
Cardiovascular
Cancer / Immune System
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How Sleep Works
The sleep-wake cycle is regulated by two separate biological mechanisms in the body that interact and balance one other. This model, introduced by the Swiss sleep researcher Alexander Borbély in the early 1980s, is often referred to as the two-process model of sleep-wake regulation. The purpose of these two processes is to regulate the quantity and quality of sleep. There is a synergy that exists between these two processes as they work in conjunction with one another in order to effectively regulate one’s sleep cycle. These two processes are:
++ Circadian Rhythm, or Process C: The regulation of the body’s internal processes and alertness levels (including the circadian drive for arousal and circadian alerting system), which is governed by the internal biological or circadian clock. ++ Sleep-Wake Homeostasis, or Process S: The accumulation of hypnogenic (sleep-inducing) substances in the brain, is an internal biochemical system that operates as a timer or counter, generating a sleep drive or pressure to sleep and regulating sleep intensity.
Sleep-Wake Homeostasis
Sleep-Wake Cycle
Circadian Rhythm
BehavioralRx: Nurturing Daily Sleep Hygiene
BehavioralRx is an evidence-based science that engages millions of patients every month to improve health outcomes. It is the science of human motivation, activation, and resiliency for personalized therapies. Using proven psychological techniques and leveraging emotional attributes and cognitive brain functions to motivate in-the-moment actions at home, work, and play, BehavioralRx enables a person to manage their therapy by incorporating it into their environment of need, considering physical, behavioral and social factors. External factors, such as ambient temperature, meal times, stress, exercise, and drugs influence sleep times and durations, as do daily schedules (e.g. work, school, alarm clocks). The practice of consciously following daily guidelines in order to regulate these external factors and ensure a more restful and effective sleep is known as “sleep hygiene”, and can have a moderating or reinforcing effect on our underlying sleep patterns. BehavioralRx helps a person diagnosed with diabetes, heart disease, cancer or other physical and emotional health challenges improve sleep hygiene by motivating mental and physical activities that create a more balanced daily environment. This nurturing technology gives nature a higher probability of success by providing “in-the-moment of need” expert guidance delivered by a “virtual concierge” that supports and reinforces a daily schedule that optimizes the intended sleep outcomes of the two-process model of sleep-wake regulation.
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A Day in the Life The following three scenarios of a person undergoing a cancer journey illustrate the application of BehavioralRx engagement methods and how they contribute to sleep hygiene:
++ Time of Day Management ++ Stress Management ++ Home Environment Management
Rachel Ducker
Patient:
42
Age:
Overcoming Breast Cancer
Scenario:
Rachel Ducker is a fifth-grade teacher for Gold Elementary School. After school, she coaches the local swim team. In her free time, she continues to enjoy swimming at the local Y and looks forward to her book club every other week. Rachel is a proud mom of two, Nicole, 8 and Brody, 4. For the last 5 months, Rachel has been on the journey towards overcoming breast cancer. Yesterday, Rachel had a mastectomy and reconstructive surgery. After surgery, she was moved to the recovery room where staff monitored her body temperature, heart rate, and blood pressure. From the recovery room she was admitted into a hospital room where she will stay for a few days. During this time, she will meet with a physical therapist who will show her exercises to prevent arm and shoulder stiffness on the side where the mastectomy was completed. This will also help prevent the formation of scar tissue.
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Last Day In Hospital
The discharge nurse took a moment to explain all the steps needed while recovering at home during her leave of absence from work.
In a fact-filled, accelerated ( the wheelchair was waiting! ) discharge planning session, they reviewed: pain management, wound care/caring for the bandage (dressing) over the incision, caring for a surgical drain, stitches and staples, recognizing signs of infection and lymphedema, hygiene, and the importance of resting. Rachel asked the nurse questions related to recovery but felt overwhelmed with all of the information that was provided to her. The nurse noticed her body language and reassured her. Furthermore, the nurse introduced her to the Concierge Care (BehavioralRx) program that will guide her to best manage toward full recovery upon discharge.
Rachel completed the initial Concierge Care assessment to be used to personalize the engagement experience that fits with her specific lifestyle, emotional and physical challenges and preferences. Some of her input included:
1. Physical Activities: “I always wanted to try yoga.” 2. What time of day is the most difficult for you? “Anxiety strongest in evening”; “ Trouble sleeping” 3. What time of day do you typically eat breakfast, lunch and dinner? “10 a.m., 2 p.m. and 5:30 p.m."
4. What time do you get ready for bed? “9 p.m.” 5. Do you take oral medication for treatment? “Yes” 6. What kind of oral medication do you take? “ IBRANCE” 7. When do you normally take your medication? “Dinner” 8. Do you ever forget to take your medication? “Yes”
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First Morning Home
9:30 A.M.
Rachel is lying in bed and feeling sad because her kids are staying at grandma’s for the next few weeks to ensure a peaceful and quiet recovery. Rachel remembers that the BehavioralRx program offers her an easy-to- access library of content to support her with helpful information. She texts in MYPAGE to 52046 and is directed to her very own personalized library of content that’s been “built” for her based on her assessment inputs. Rachel clicks on "Dealing with Children" and finds a section on ways to cope with family changes. Rachel is happy to read that many patients go through what she is experiencing and now feels empowered and motivated to join the many to fight through this feeling of sadness. Rachel gets out of bed and decides to go into the kitchen to eat breakfast.
52046 MYPAGE
10:00 A.M.
Rachel receives her morning message that guides her to eat slowly while sitting upright and to not drink too many liquids with her meal in order to avoid feelings of nausea.
1:00 P.M.
In the afternoon, Rachel receives a message about the stretches she should complete to prevent stiffness and the risk of blood clots forming. She is feeling fatigued but knows she should complete this recommended activity. For motivation, she texts the BehavioralRx program code BOOST to 52046 . Seconds later, she receives a motivating message that helps her push through her fatigue and complete her activity. To relax her body and mind and act as a cool down, she decides to meditate for 10 minutes.
52046 BOOST
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5:00 P.M.
Later, as Rachel is relaxing, she starts to experience tingling and shooting pains in her armpit. Rachel becomes worried and texts the word CARE to 52046 , indicating the symptoms she is experiencing via the interactive mobile feedback form. Her Personal Concierge responds immediately with a message explaining that nerve pain is very common after surgery and usually takes a couple of weeks for the nerves to fully heal. The message also includes a link that directs Rachel to a page within her personalized library where she reads up on ways she can best manage the pain.
52046 CARE
5:30 P.M.
Rachel receives a Care Message reminding her to take her IBRANCE with dinner in conjunction with the medication management recommendation that IBRANCE be taken with food and at the same time each day.
7:00 P.M.
Rachel receives her evening message that helps relieve her stress and promote relaxation. The activity is a 10-minute yoga video. The yoga helps put Rachael in a more para-sympathetic state which reduces the anxiety she has been experiencing as nighttime approaches.
52046
9:00 P.M.
Rachel is getting ready for bed and begins experiencing feelings of anxiety in anticipation of the mind-racing she experiences when she lies down each night. Aware that this is a time of vulnerability for Rachel, the virtual concierge sends Rachel a Care Message timed to her bedtime suggesting that she create a relaxing environment by trying certain breathing techniques. She falls asleep mid-way through her breathing exercise.
52046 .....
The next day, Rachel receives a "how are you doing?" message asking her if her nerve pain has gotten worse. Rachel notices that is has not gone away and she actually is feeling more numbness in the area. She responds to the message with YES. Five minutes later, Rachel receives a call from her oncology nurse navigator who recommends that Rachel take over-the-counter pain medication and apply topical cream to help relieve the nerve pain. A couple days after following the nurse navigator’s recommendation, her nerve pain subsides and she responds as such to her next "how are you doing?" message.
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Following Weeks Post-Surgery
Over the next few weeks, Rachel receives morning, afternoon and evening messages related to nutrition, stress relief, motivation, medication management tips, reminders to refill her lBRANCE, support, different yoga videos/ healthy activities and tips towards a healthy sleep environment. She also receives weekly messages to rate her stress level on a scale of 1 to 10 (10 being most stressed). If Rachel replies with a 4 or higher, she is prompted to fill out a quick form, explaining the challenges she may be having so that the Concierge Care program can provide her with the support she needs. A few times a week, Rachel also texts in the word RELAX to 52046 to receive a relaxing activity like meditation and BOOST to 52046 to receive motivational messages. Rachel has a follow-up appointment with her surgeon to discuss her procedure results and progress with subsequent recuperation and self-care. The surgeon is pleased with her progress and her journey towards recovery. Upon returning home from her appointment, Rachel receives a message from the Concierge Care program asking if she would like to give a program review. She provides feedback explaining that she was grateful to have the program because she felt connected with her clinical care team, supported during her recovery and confident that she was taking the right steps towards healing. She also feels like the messages helped her and her husband create a more relaxing and emotionally healthy environment for themselves and their children during this difficult time.
Situational Summary
Overcoming breast cancer is a trying and draining experience that requires strength and courage to overcome. Rachel utilized every support system she had available to her: family, clinical care team, and BehavioralRx. She allowed Concierge Care and BehavioralRx, a personalized and customized support system, to ensure that her treatment and post-care was tailored to her lifestyle and provided her with the guidance to manage her recovery.
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An Inside Glimpse into BehavioralRx ® , The Science of Precision Health
A fundamental principle of BehavioralRx is anchoring technology, or the concept of coupling new activities with those that are already part of an existing routine. This ties directly to the psychological baseline that the highest probability of being successful with life change is to indoctrinate the modification into existing behaviors – not interrupt them. GoMo Health Concierge Care, the cloud-based software implementation of the BehavioralRx CARBs ( Cognitive Action Response Behaviors ) machine learning methods and algorithms, delivers resources to people and can engage in a two-way dialogue in the moment based on preferred time of day and day of the week. Support is personalized and within participants' lifestyles; consistent with their day-to-day behaviors and cognitive processes. The simplicity and convenience of this model, structured to deliver a tailored “menu” of resources based on participants' input ( Influence Technology ) is what makes this lifestyle modification program so successful.
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BehavioralRx machine intelligence has integrated evidence-based scientific principles from:
++ Behavioral Psychology Focused on human motivation and activation; highly correlated to emotional attributes such as trust, credibility, outlook, reciprocity.
++ Cognitive Neuroscience
Focused on cognitive human factors engineering; highly correlated to brain functions such as short and long-term memory encoding and movement, learning and memory storage and persistence, and in-the-moment memory retrieval and recall.
Concierge Care gives time back to patients and clinicians using proven BehavioralRx CARBS (Cognitive Action Response Behaviors; discussed in next section) within a behaviorally and cognitively sound engagement approach as follows:
1. Goes to the Person • Creates bonds •
3. Creates Intimacy •
Immediately responsive
•
Nurtures feelings of belonging
Provides reciprocity therefore stimulates same in return
•
Reduces emotional and social isolation
•
Patient can initiate “conversation” flows
2. "In the Moment" •
4. Simple and Highly Directed
Preferred time of day and day of week influences message timing Typically, one thought/question/action at a time
Stimulates AHA! moments and memory recall
•
5. In the Moment Patient Influence Responsive to “human need”: Patient can interrupt current regimen and have Concierge Care go into triage mode to handle their “event/issue”
•
Snackable bites of information
What were the behavioral and cognitive scientific principles, methods, and engagement algorithms that Rachel experienced in her cancer journey? For purposes of orienting the reader, we highlight six of the BehavioralRx CARB methods that produced the outcomes. To maximize memory encoding, long-term memory storage, persistence, and recall, BehavioralRx mixes and matches the various CARB engagement methods described below using proprietary algorithms. See table on page 13.
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BehavioralRx Applied CARB Machine Learning Component
Applied to Rachel’s Daily Life
Behavioral and Cognitive Effect
Influence Technology Activation through shared decision making
Rachel is self-identifying her own preferences and feelings and as a result, becomes more invested and activated in her care plan as she has a clear and simple way to adjust the therapy support to her lifestyle and needs.
Concierge Care adjusts the content, tone, frequency, and questions based on Rachel’s individualized input and actual mental and physical state throughout her journey; for example, Rachel indicated her “trouble sleeping”, preferred form of exercise, and times of day when she eats and takes her medication. At 10 A.M., Rachel receives her Care Messages about eating upright and not drinking too many liquids with her breakfast. These Care Messages are personalized and automated around Rachel’s lifestyle in support of her treatment plan. Rachel had indicated that she would usually take her IBRANCE around dinner time but would sometimes forget. BehavioralRx responds to this personal information in conjunction with the information that IBRANCE needs to be taken with food and at the same time every day. Rachel receives daily care messages that are designed to mentally create an association between IBRANCE and dinner. As Rachel experiences physical pain or mental fatigue during her recovery, she texts a simple keyword in order to relieve the symptoms she is experiencing in the moment. When feeling down she texts MOOD to receive an uplifting message to redirect her mindset, or SMILE for a happy thought to boost her spirits. As Rachel is doing her recommended stretches, she starts to feel fatigued. She is ready to give up but recognizes it is important for her to complete the exercises for her recovery. She texts BOOST and is immediately given motivational messages and activities to help her push through the fatigue and complete the stretches. BehavioralRx is designed to follow and adjust to the ups and downs of the patient journey; the Care Messages, activities, and questions are timed to the various stages of Rachel’s cancer therapy and care and include helping Rachel with emotional, social, physical, and practical problems along her journey to recovery.
Environment of Need Technology Intervening at the right moment
Rachel starts to get back to her daily life and feel less emotionally isolated and fatigued as the Concierge Care program, resources and support work symbiotically within her preferred day in the life. The therapy actually adjusts to her and not vice versa. Concierge Care is providing a disciplined and consistent method to train Rachel’s muscle memory to more seamlessly gather the neurons needed to connect the activity of dinner to that of her medication.
Wander and Wonder Technology Activation by increasing memory persistence and recall via mental and physical activities that stimulate contextually relevant neuroreceptors
Reduction Technology Activation through simplifying
The fact that Concierge Care is immediately responsive to Rachel once she takes a simple action (to indicate her issue) makes her feel more confident in her ability to self-manage and begins to build believability in her recovery process, thereby reducing daily anxiety and stress.
Tailoring Technology Activation through “in-the-moment” customization
Rachel is learning that by letting Concierge Care know her issues, it helps get through her daily challenges. This cognitive connection modifies her behaviors to be pro-active in her care.
Nurturing Technology Guided Motivation
By rewarding Rachel with “in-the-moment” resources, support, motivation and activities based on her challenges throughout her journey, she begins to develop a deeper self-awareness to head off potential adverse issues. Plus, because she can express herself and receive “non-judgmental” helpful information when she needs, Rachel is building resiliency to manage her recovery.
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REFERENCES
Joslin https://www.joslin.org/info/sleep_problems_and_diabetes.html
National Sleep Foundation https://www.sleepfoundation.org/articles/link-between-lack- sleep-and-type-2-diabetes The Sleep Doctor Michael J. Breus, PhD https://thesleepdoctor.com/2018/05/08/understanding-the- connection-between-sleep-and-diabetes/
How Sleep Works, Mark Thompson https://www.howsleepworks.com/how_twoprocess.html
Two-Process Model of Sleep Regulation https://www.countingsheep.net/author/countingsheep/
GoMo Health ® is a leader in population health management and digital therapeutic solutions that support the continuum of care, improved patient satisfaction and MACRA value-based reimbursements. GoMo Health Concierge Care ® personalizes patient interactions using our proprietary science, BehavioralRx ® , The Science of Precision Health, building trust and credibility to motivate higher levels of activation and resiliency. In partnership with health care organizations worldwide, GoMo Health delivers a highly scalable and cost-effective solution for the management of high-risk, chronic, and complex conditions, enabling better self-management, healthy decision making, and improved outcomes.
GET IN TOUCH
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info@gomohealth.com
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