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Diane Grieder, M.Ed AliPar, Inc. NYAPRS Conference September 2011

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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 Setting Diane Grieder, M.Ed AliPar, Inc. NYAPRS Conference September 2011

2 Learning Objectives Understanding how Person-Centered planning can be a bridge to providing coordinated/integrated care Understanding what is meant by shared-decision making and how it can improve outcomes for people Learn about the Mental Health Care Model (Wagner’s Chronic Care Model revisited)

3 So, what are we really talking about today?
Health Care Reform Accountability (Accountable Care Organizations) NYS Health Homes (for people with chronic conditions) Patient/Person Centered Medical Home Coordinated Care Integrated Care Better Outcomes for people Better collaboration between providers

4 Traveling the Transformation Highway
Integration and Care Coordination

5 SAMHSA Rationale for Integrated Care:
Behavioral Health is part of Health Prevention Works Treatment is Effective People Recover Pam Hyde, Director of SAMHSA

6 What does a recovery oriented system of care look like?
From: Illness Focused “Compliance” valued Deficit Focused Being known by what’s wrong Professional “in charge” Learned Helplessness “Silo of care” focused Institutional resources Planning is done for the person To: Recovery Focused “Choice” valued Strength Focused Being known as an individual Shared decision making Active Participation Broad bio-psychosocial focused Community resources/integration Planning is collaborative, recurring, and involves an ongoing commitment to the person 21st century- focus is on recovery Highlight 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 population Read vision and pledge Over 50 organizations have signed on the pledge This is a major focus of our work with WNYCCP and Beacon Health Strategies

8 Major Health Risks for MH Population
Cardiovascular disease is primary culprit Risk factors include: Smoking Physical inactivity Medication side effects Toxic effects of abused substances Diet Poor access to care: underuse of evidence-based medical services Higher exposure to medical errors Druss, 2007

9 Causes of Health Disparities
Medications, especially the atypical antipsychotic drugs, effect on: Weight gain Dyslipidemia (unhealthy cholesterol profiles) Glucose (sugar) metabolism High rates of smoking Lack of weight management/poor nutrition Physical inactivity

10 Causes of Health Disparities
Lack of access to & utilization of preventive community healthcare, including health promotion services/resources Poverty Social isolation Separation of health & mental health systems at the federal, state, local level Lack of coordinated infrastructure, policy, planning, quality improvement strategies, regulation or reimbursement

11 Clinical Information Systems Self- Management Support
Chronic Care Model Community Health System Resources and Policies Health Care Organization Clinical Information Systems Self- Management Support Delivery System Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Our 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. Outcomes Improved Outcomes

12 Mental Health Care Model
Community Mental Health System Social Inclusion and Opportunity Health Care Organization Resources and Policies Clinical Information Systems Delivery System Design Self- Management Support Decision Support Our 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, Capable Team Empowered, Hopeful Consumer Productive Interactions Recovery / Wellness Outcomes

13 The Chronic Care Model Model depends on individual having continuous, planned care Part of the model includes care management: To educate and support the individual in becoming a partner in healthcare decision making To adopt self-management strategies for health promotion & living well with chronic disease To access community resources Care coordinators are the health care team members best positioned to provide care management in the service of coordinated, planned care for our consumers Care coordinators: best positioned to help consumer have continuous planned care

14 AHRQ Definition of Patient Centered Medical Homes (PCMH)
5 functions and components: Patient-Centered Comprehensive Care Coordinated Care Superb Access to Care A 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 disorders Screening/Assessment Professional Development/Training Program Models/Guidelines System Coordination Similar 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, DALI Training: TIP 42 Program Models/Guidelines: Sequential, Parallel, vs. Integrated Models (ASAM’s: DDC/DDE model, CCISC, IDDT) System Coordination: Dual Recovery Coordinators Quadrant IV Task Group, Regional Forums NY Model NYS 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 care Establish Team Based Coordinated Care Honor Consumer Choices Incorporate services to facilitate receipt of physical healthcare Educate providers and consumers Create environment of respect and acceptance Multnomah County MHASD Healthcare Integration Report 6/22/10

19 Bridging the two worlds

20 Care Manager Functions
Develop and maintain rapport with individual and provider Educate the individual and family Monitor symptoms & communicate findings to provider Develop and maintain a self-care action plan Maximize adherence (interest) to the care plan (can be communiyt wide)through negotiation of solutions to treatment-emergent problems Cole & Davis (2004)

21 A Solution…

22 Hypothesis Person-centered treatment plans are a key lever of personal and systems transformative change in creating health homes/providing care coordination Neal

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 person Sharing power and responsibility Having a therapeutic alliance The clinician as person In 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 orientation Adams/Grieder 25 25

26 The Recovery Plan It 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 family Increases coordination and collaboration Decreases fragmentation and duplication Coordinates multidisciplinary/multi-agency interventions Prompts analysis of available time and resources Provides assurance / documentation of medical necessity Anticipates frequency, intensity, duration of services Promotes culturally competent services 27

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 served All staff necessary to carry out the plan Guidance 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

29 Why Shared Decision Making in Health Care?

30 The Problem High rates of failure to engage, disengagement, and non-adherence Less than 5% of people with severe mental illnesses receive most evidence-based services Important 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 patients Without agreement about what is wrong, it is difficult for a patient and doctor to agree on a treatment plan that is acceptable to both Not essential that patient/doctor share the same perspective doctor'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 Home Accountable Care Organizations Meaningful 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 Illness 1999 – 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 Planning Treatment planning (and documentation) beyond reimbursement and administrative goals A roadmap for reaching individual goals

36 Pushing the Agenda Shared Decision Making
As consensus building (not coercion) As a motivator for both experts to change As 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, and reviewing treatment decisions

38 Shared Decision Making
Clinician and patient work together They share information About options and outcomes About preferences They work toward a consensus about the preferred test or treatment They reach an agreement on the test or treatment to implement (Charles C, Soc Sci Med 1997; 44:681)

39 Decision-Making Process 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 decisions Fully informed with accurate, unbiased & understandable information Respected by having their goals & concerns honored

41 Benefits of SDM Reduced decisional conflict Greater knowledge
Improved satisfaction with the decision-making process Improved ability to make choices (fewer people left undecided) Improved concordance of decisions with personal values More active involvement of consumers in decision-making Improved communication between consumers and providers Limited 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 planning Enhance patient satisfaction with care Reduce unmet needs Improve adherence and quality of life Decrease symptoms of depression and alcohol abuse Practitioners Increased insight into patient preferences Improved efficiency of care Some age and discipline related reluctance to participate

43

44 Discussion How 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?

45 Diane Grieder, AliPar, Inc., www.alipar.org, 757-647-8716


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