Presentation on theme: "Diane Grieder, M.Ed AliPar, Inc. NYAPRS Conference September 2011"— Presentation transcript:
1 Diane Grieder, M.Ed AliPar, Inc. NYAPRS Conference September 2011 Using Person-Centered Planning as a Roadmap for Care Coordination and Better Outcomes in an Integrated treatment SettingDiane Grieder, M.EdAliPar, Inc.NYAPRS ConferenceSeptember 2011
2 Learning ObjectivesUnderstanding how Person-Centered planning can be a bridge to providing coordinated/integrated careUnderstanding what is meant by shared-decision making and how it can improve outcomes for peopleLearn about the Mental Health Care Model (Wagner’s Chronic Care Model revisited)
3 So, what are we really talking about today? Health Care ReformAccountability (Accountable Care Organizations)NYS Health Homes (for people with chronic conditions)Patient/Person Centered Medical HomeCoordinated CareIntegrated CareBetter Outcomes for peopleBetter collaboration between providers
4 Traveling the Transformation Highway Integration and Care Coordination
5 SAMHSA Rationale for Integrated Care: Behavioral Health is part of HealthPrevention WorksTreatment is EffectivePeople RecoverPam Hyde, Director of SAMHSA
6 What does a recovery oriented system of care look like? From:Illness Focused“Compliance” valuedDeficit FocusedBeing known by what’s wrongProfessional “in charge”Learned Helplessness“Silo of care” focusedInstitutional resourcesPlanning is done for the personTo:Recovery Focused“Choice” valuedStrength FocusedBeing known as an individualShared decision makingActive ParticipationBroad bio-psychosocial focusedCommunity resources/integrationPlanning is collaborative, recurring, and involves an ongoing commitment to the person21st century- focus is on recoveryHighlight different emphasis between systems of care…System Goal: to provide recovery oriented care thru person centered planning and an integrated service delivery system (in all systems of care)
7 CMHS/SAMHSA 10 x 10 Plan: Pledge for Wellness (2007) We envision in which people with mental illnesses pursue optimal health, happiness, recovery and a full and satisfying life in the community via access to a range of effective services, supports and resources.We pledge to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10 year time period.In 2007, SAMHSA held a Wellness Summit in which there was a call to action for wellness for people with serious mental illness-Recent data from several states have found that people with serious mental illness served by our public mental health systems die, on average, at least 25 years earlier that the general populationRead vision and pledgeOver 50 organizations have signed on the pledgeThis is a major focus of our work with WNYCCP and Beacon Health Strategies
8 Major Health Risks for MH Population Cardiovascular disease is primary culpritRisk factors include:SmokingPhysical inactivityMedication side effectsToxic effects of abused substancesDietPoor access to care: underuse of evidence-based medical servicesHigher exposure to medical errorsDruss, 2007
9 Causes of Health Disparities Medications, especially the atypical antipsychotic drugs, effect on:Weight gainDyslipidemia (unhealthy cholesterol profiles)Glucose (sugar) metabolismHigh rates of smokingLack of weight management/poor nutritionPhysical inactivity
10 Causes of Health Disparities Lack of access to & utilization of preventive community healthcare, including health promotion services/resourcesPovertySocial isolationSeparation of health & mental health systems at the federal, state, local levelLack of coordinated infrastructure, policy, planning, quality improvement strategies, regulation or reimbursement
11 Clinical Information Systems Self- Management Support Chronic Care ModelCommunityHealth SystemResources and PoliciesHealth Care OrganizationClinical Information SystemsSelf- Management SupportDelivery SystemDesignDecisionSupportPrepared,ProactivePractice TeamInformed,ActivatedPatientProductiveInteractionsOur premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care.Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.OutcomesImproved Outcomes
12 Mental Health Care Model CommunityMental Health SystemSocialInclusion and OpportunityHealth Care OrganizationResources and PoliciesClinical Information SystemsDelivery SystemDesignSelf- Management SupportDecisionSupportOur premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.Receptive,CapableTeamEmpowered,HopefulConsumerProductiveInteractionsRecovery / Wellness Outcomes
13 The Chronic Care ModelModel depends on individual having continuous, planned carePart of the model includes care management:To educate and support the individual in becoming a partner in healthcare decision makingTo adopt self-management strategies for health promotion & living well with chronic diseaseTo access community resourcesCare coordinators are the health care team members best positioned to provide care management in the service of coordinated, planned care for our consumersCare coordinators: best positioned to help consumer have continuous planned care
14 AHRQ Definition of Patient Centered Medical Homes (PCMH) 5 functions and components:Patient-CenteredComprehensive CareCoordinated CareSuperb Access to CareA systems based approach to quality and safety
15 Integrated MH/SA Services Goal: To improve the proficiency of both systems of care to identify and engage persons with co-occurring disordersScreening/AssessmentProfessional Development/TrainingProgram Models/GuidelinesSystem CoordinationSimilar to our focus to integrate behavioral and physical health, we’ve been long part of another integration process- MH/CD. Each of the above have been the underpinnings/activities to support the transformation efforts. These are similar components necessary for physical and behavioral health integration.Screening:Modified MINI, DALITraining:TIP 42Program Models/Guidelines:Sequential, Parallel, vs. Integrated Models (ASAM’s: DDC/DDE model, CCISC, IDDT)System Coordination:Dual Recovery CoordinatorsQuadrant IV Task Group, Regional ForumsNY ModelNYS COCE (NY Health Foundation Grant)
16 Care Coordination One of the core functions of the PCMH – defined as: “The deliberate organization of patient care activities between 2 or more particiapnts involved in a patient’s care to facilitate the appropriate delivery of health care services”Reducing Care Fragmentation…A Toolkit for Coordinating Care. California Healthcare Foundation
17 Care Coordination vs. Case Management? Care coordination is the facilitation of access to and coordination of medical and behavioral/social support services for persons across different providers and 0rganizations.Case Management typically focuses on a medical model with an emphasis on the person’s mental health needs only.
18 Key Recommendations for Integrated Healthcare: Consumer Recommendations Assure there is no wrong door for receiving careEstablish Team Based Coordinated CareHonor Consumer ChoicesIncorporate services to facilitate receipt of physical healthcareEducate providers and consumersCreate environment of respect and acceptanceMultnomah County MHASD Healthcare Integration Report 6/22/10
20 Care Manager Functions Develop and maintain rapport with individual and providerEducate the individual and familyMonitor symptoms & communicate findings to providerDevelop and maintain a self-care action planMaximize adherence (interest) to the care plan (can be communiyt wide)through negotiation of solutions to treatment-emergent problemsCole & Davis (2004)
22 HypothesisPerson-centered treatment plans are a key lever of personal and systems transformative change in creating health homes/providing care coordinationNeal
23 Defining Person-Centered Practice Person-Centered Practice is defined as working with consumers in an individualized and empowering way to assist them in their personal recovery journey.First, we begin with a definition of Person-Centered Practice. We need to have a broad understanding of who the “person” is. In some cultures, the focus is on the individual or the nuclear family. In other cultures the individual is part of the extended family or community and is not seen as separate. The practitioner needs to talk to the individual about who to include in the planning process.
24 Being Person-Centered in Practice The consumer as a whole personSharing power and responsibilityHaving a therapeutic allianceThe clinician as personIn essence, being “Person-Centered” means that we view the person receiving services in a holistic way (not just by their diagnosis), that responsibility and power is shared (the clinician is not the sole authority – the individual is an authority on their own life), that a relationship is developed with the individual that is transparent, and that the provider can feel comfortable in terms of sharing information with the person receiving services.This is all consistent with what Carl Rogers wrote about 50 years ago when he talked about the importance of being genuine, honest, empathic, and respectful in providing mental health services.“Person-first” language is important to use. A person should not be known simply by their diagnostic label, e.g., “she’s a bipolar”, “he’s a schizophrenic”, etc. Instead, we refer to the person as an individual with schizophrenia.We do not refer to ourselves as providers who are “front-line staff” – “in the trenches.” This is the language of war. Instead, we are direct care staff providing compassionate care.
25 What is PCP? Taking a Closer Look Person-centered planning is a collaborative process resulting in a recovery oriented treatment plan is directed by consumers and produced in partnership with care providers and natural supporters for treatment and recovery supports consumer preferences and a recovery orientationAdams/Grieder2525
26 The Recovery PlanIt is the “work/social contract”, created by the person and provider.Sometimes referred to as our ‘social contract” with the recovery defining who is going to do what to help the recovery achieve his or her goal(s). It is a living, breathing, viable, clinically useful document! This is a far cry from how most providers typically think of the plan: as a bureaucratic, regulatory obligation!
27 Service Plan Functions Identifies responsibilities of team members--including person served and familyIncreases coordination and collaborationDecreases fragmentation and duplicationCoordinates multidisciplinary/multi-agency interventionsPrompts analysis of available time and resourcesProvides assurance / documentation of medical necessityAnticipates frequency, intensity, duration of servicesPromotes culturally competent services27
28 CARF Behavioral Health Standards 2011 on Integrated Care An individualized integrated plan regarding medical and behavioral health needs is developed with collaboration of:The person servedAll staff necessary to carry out the planGuidance to meet this standard includes:The individualized plan is developed with the active involvement of the person served as well as the various disciplines needed to successfully implement the plan. The plan addresses and integrates, in a holistic manner, the medical and behavioral health needs of the person served
30 The ProblemHigh rates of failure to engage, disengagement, and non-adherenceLess than 5% of people with severe mental illnesses receive most evidence-based servicesImportant reasons include lack of information, inattention to the person’s goals, failure to empower the person, and failure to provide effective services
31 Finding Common Ground… Research indicates that physicians still fail to find common ground with patientsWithout agreement about what is wrong, it is difficult for a patient and doctor to agree on a treatment plan that is acceptable to bothNot essential that patient/doctor share the same perspectivedoctor's explanation and recommended treatment must at least be consistent with the patient’s point of view and make sense in the patient’s world
32 Shared Decision Making is at the Core of Ethical, Patient Centered Care Patient Centered Medical HomeAccountable Care OrganizationsMeaningful Use of Health Information Technology (HIT)
33 Supporting Principles Autonomy“The general trend has been to expand autonomy in health care decision making. [It] assumes the better informed an individual is, the better equipped he or she is to make health care decisions.”Surgeon General’s Report on Mental Illness1999 – Chapter 7
34 Supporting Principles Transparency – Choice based on value“consumers deserve to know the quality and cost of their health care. Health care transparency provides consumers with the information necessary, and the incentive, to choose health care providers based on value. Providing reliable cost and quality information empowers consumer choice.”US Dept of Health & Human Services
35 Supporting Principles Person-Centered PlanningTreatment planning (and documentation) beyond reimbursement and administrative goalsA roadmap for reaching individual goals
36 Pushing the Agenda Shared Decision Making As consensus building (not coercion)As a motivator for both experts to changeAs a systems change protocol
37 Decision Support Systems Address these Problems through A structured approach to :defining one’s goals,obtaining information on effective service options,choosing services,participating in developing treatment plans,on-going assessment of one’s progress, andreviewing treatment decisions
38 Shared Decision Making Clinician and patient work togetherThey share informationAbout options and outcomesAbout preferencesThey work toward a consensus about the preferred test or treatmentThey reach an agreement on the test or treatment to implement(Charles C, Soc Sci Med 1997; 44:681)
39 Decision-MakingProcess of making a choice (decision) from among two or more discrete options (Wills & Holmes- Rovner, 2006)Provider role as a consultant to support SDM (Adams & Drake, 2006)Majority of mental health treatment decisions are preference-driven (personal values do/should significantly guide the decision- making)
40 We Believe Patients Should Be Supported & encouraged to participate in their health care decisionsFully informed with accurate, unbiased & understandable informationRespected by having their goals & concerns honored
41 Benefits of SDM Reduced decisional conflict Greater knowledge Improved satisfaction with the decision-making processImproved ability to make choices (fewer people left undecided)Improved concordance of decisions with personal valuesMore active involvement of consumers in decision-makingImproved communication between consumers and providersLimited study of how preferences and decision-making processes impact choices made by consumers, including service engagement and intervention outcomes
42 Outcomes of Shared Decision Making for Persons with Severe Mental Illnesses Have been demonstrated in randomized trials to:Increase knowledge and participation in planningEnhance patient satisfaction with careReduce unmet needsImprove adherence and quality of lifeDecrease symptoms of depression and alcohol abusePractitionersIncreased insight into patient preferencesImproved efficiency of careSome age and discipline related reluctance to participate
44 DiscussionHow do these functions relate to what you consider your role responsibilities (either as a provider or as a recipient of services) at this point in time?What implications does this information have for clinicians/case managers/care coordinators/consumers in the future?