Training of Trainers and Supervisors (ToTS) EPILEPSY

Training of Trainers and Supervisors (ToTS) EPILEPSY
For comments and suggestion on this guide, please to Draft ToTS, Version 4 March 2014

WELCOME Icebreaker: Small Groups of 2 Agenda
Find out the following and introduce your partner to the whole group Name Profession Current posting Interest in and experience of epilepsy Agenda Background and ToTS Objectives Pre-test Provide each participant with a nametag Have each person introduce themselves with the four items in the slide to the person seated next to them. Each person should then introduce their partner to the group Explain that you will discuss the agenda, background and administer the pretest

Agenda: Day 1 Name of the facilitator/s 8.00 – 8.30am Registration
Welcome Session Icebreaker Background & Learning objectives Pre-test (demonstration) 9.15 – 10.00am Introduction to ToTS on Epilepsy Mental Health Gap Action Programme (mhGAP) Principles of ToTS Course Materials 10.00 – 10.30am BREAK 10.30 – 11.30am Introduction to Teaching Methodology Use of mhGAP training material 11:30 – 12:30pm Introduction to Support and Supervision 12:30 – 1:30pm LUNCH 1.30 – 3.30pm Demonstration of Session “Epilepsy” 3.30 – 4.00pm Preparation for Facilitator Exercise for Day 2 4.00 – 4.30pm Recap and Closing Adapt the schedule on slide numbers 3 and 4 as appropriate. Add the names of the facilitators for the different sessions.

Agenda: Day 2 Name of the facilitator/s 8.00 – 10.00am
Facilitation of Epilepsy Sessions Feedback by Observers 10.00 – 10.30am BREAK 10.30 – 12:30 12.30 – 1.30pm LUNCH 1.30 – 3.00pm Practicing Supervision and Support 3.00 – 3.30pm BREAK (optional) 3.30 – 4.00pm Discussions 4.00 – 4.30pm Post-test 4.30 – 5.00pm Conclusion, evaluation, closing remarks

Background of the Training
WHO Programme on Reducing the Epilepsy Treatment Gap Four year multi-country project ToTS as first step towards capacity-building

Overall Objective for the Fight Against Epilepsy Programme
To improve access and care to services for people with epilepsy

Specific Objectives for the Programme
To develop and engage in the strategy for delivering epilepsy care To promote training of all professional health care providers, making them competent in diagnosing and treating epilepsy To improve awareness of community groups to decrease stigma and increase demand for epilepsy care To integrate provision of care and services for epilepsy within the primary health care system To monitor and evaluate the project and disseminate new ideas and knowledge

Epilepsy Training of Trainers and Supervisors (ToTS)
Master Facilitator Future Facilitators Health Care Providers Epilepsy Training ToTS Describe here the structure of the capacity-building program and where the ToTS fits in (red box). Master Facilitators will train Future Facilitators in the ToTS who will in turn train Health Care Providers in mhGAP-based Epilepsy Care.

What is a ToTS? A workshop to share knowledge on course content, to teach the training and supervisory skills necessary to share that knowledge to others, and to understand how to conduct monitoring of the project’s progress. What is my role as Master Facilitator? To teach mhGAP epilepsy care, teaching methodology, and supervision skills to Future Facilitators (YOU!) To train you to train and supervise others in epilepsy care and project monitoring

What is your role? Future Facilitators (You!) will learn about mhGAP and epilepsy care, and practice facilitator, supervision and monitoring skills. REMEMBER: You are learning how to conduct a training on Epilepsy Keep this in mind as we move through the course!

What are the skills for a good trainer? Brainstorm and Group Discussion: 5 mins EXERCISE: Ask participants of the ToTS: What are the skills for a good trainer? Write answers on a Flip Chart. There is no correct answer, but emphasize the one you think is important (interactive, stimulating, etc).

Objectives of Training of Trainers and Supervisors (ToTS) Workshop
Become familiar with mhGAP Epilepsy Module (EPI) and course materials Develop and practice facilitator and teaching skills for the EPI module and monitoring forms Learn how to interact with health care providers and conduct a participatory training workshop Develop and practice relevant supervision and monitoring skills

PRETEST This is a test of your knowledge and skills and also a demonstration of how to administer a pre-test Has 2 parts Test which health care providers takes at the actual training Question for future facilitators (you) Duration: 15 minutes

Introduction to mhGAP, Epilepsy ToTS and Course Materials
In this session, following topics will be covered. What is mhGAP and mhGAP Intervention Guide (mhGAP-IG)? Introduction to general principles of care Discussion of experiences & understandings of epilepsy and the implications of misunderstandings/stigma Facts & myths about seizures & epilepsy Defining & differentiating seizures (as a symptom) and epilepsy Day 1

Mental Health Gap Action Programme (mhGAP)
mhGAP is a WHO programme to scale up care for mental, neurological and substance use disorders Launched in 2008 The focus is on increasing non-specialist care, including primary healthcare, to address the unmet needs of people with mental health disorders mhGAP Intervention Guide (mhGAP-IG) is a clinical tool developed by WHO which explains management of priority conditions using protocols for clinical decision-making Explain that the WHO launched the Mental Health Gap Action Programme (mhGAP) for low and middle-income countries. Explain that the epilepsy project is under the umbrella of mhGAP. mhGAP and it’s tools would be used for capacity building. The objective is to scale up care for mental, neurological and substance use disorders. Stress that mhGAP-IG is evidence-based. It has been developed to facilitate delivery of interventions in non-specialized health-care settings Play the following 7 minute video: . Overview of the video: "When I first got the illness, everyone thought I was a wicked person or possessed by evil spirits. I could not get work because people didn’t know what to do if I had a seizure. In 2001 I started to take this medicine and started feeling better. I started my own business and now sell these woolen carpets. Life is now good." A person with epilepsy reflects on changes brought about by an epilepsy treatment program in China. In low and middle-income countries 75% of people do not get the mental health services they need. The mhGAP programme was developed to address this. This video shows that with costs as low as US$ 2 per person per year, and with proper care, assistance and medication, millions can be treated. As well as the epilepsy programme in China, it features a project for children with intellectual disabilities in South Africa, a project on services for persons with psychoses, and a suicide prevention project in India. Preparation note In case there is no high-speed internet connection in the workshop room, the video need to be downloaded before the training. Play the video

mhGAP-IG is entirely evidence-based
mhGAP-IG is entirely evidence-based. It has been developed to facilitate delivery of evidence-based interventions in non-specialized health-care settings Tell Future Facilitators about mhGAP-IG: -A technical tool -Contains diagnostic and treatment algorithm for 11 priority conditions -A model guide developed for use by non-specialist health-care providers -Used after adaptation for national and local needs. An evidence-based, clinical guide for the assessment and management of mental neurological and substance use disorders in non-specialized health settings

mhGAP-IG modules Depression Psychosis Bipolar disorder Epilepsy
Developmental disorders Behavioral disorders Dementia Alcohol use and alcohol use disorders Drug use and drug use disorders Self-harm/suicide Other significant emotional or medically unexplained complaints The priority conditions covered in mhGAP-IG were included because they represent Large burden High economic costs An association with human rights violations

Care for People With Epilepsy
75-90% of people with epilepsy are untreated in these settings Care is affordable, feasible and can be provided by non-specialists Up to 75% of people with epilepsy could lead normal lives if treated with oral antiepileptic drugs Cost as little as 5 dollars per year

General Principles of Care
Communication Assessment Treatment and monitoring Provision of social support Attention to overall well-being Protection of human rights -Explain that health-care providers should follow good clinical practices in their interactions with all people seeking care. They should respect the privacy of people, foster good relationships with them and their carers, and respond to those seeking care in a nonjudgmental, non-stigmatizing and supportive manner. These key actions should be considered when managing any person with MNS disorder including epilepsy. The first 5 actions will be covered in later sessions. Here we first explain “Protection of human rights”.

General Principles of Care: Communication
Ensure that communication is clear, empathic, and sensitive to age, gender, culture and language differences Be friendly, respectful and non-judgmental at all times Use simple and clear language Respond to the disclosure of private and distressing information (e.g. regarding sexual assault or self-harm) with sensitivity Provide information to the person on their health status in terms they can understand Ask the person for their own understanding of the condition

Who is the target audience for mhGAP-IG?
Staff not specialized in mental health or neurology General physicians, health technicians, nurses First point of contact and outpatient care First level referral centers, such as health posts or health centres Referral to a specialist at a rural or provincial hospital can also be the appropriate management Explain that this program is aimed at primary and general health care. However, psychiatrists also play a role in the program as supervisors. Referral to a psychiatrist can also be the appropriate management. REMEMBER: You are going to teach basic care providers how to use the epilepsy module of mhGAP!

Assess, Decide and Manage
The assess column guides clinical assessment of the person The decide column specifies different clinical scenarios The manage column describes how to manage the problem Explain to that there are three stages to the mhGAP-IG. Go through each briefly.

mhGAP-IG (p.34) Ask the participants to open the mhGAP-IG p34-35 and read the columns as you go through them Explain that this is the assessment column where you match up the signs and symptoms to the IG Show this and the next slides VERY BRIEFLY, with the purpose of only showing how the mhGAP-IG is organized to aid in assessment and management.

mhGAP-IG (p.35)

mhGAP EPI: Familiarization Activity
CASE STUDY: Patient comes into a health centre and you are the health care provider. He states that he had a ‘fall’ last week that he does not remember. His 7 year old son witnessed that he was shaking on the floor afterwards and did not talk for more than 5 minutes. There was urine on the floor when the patient woke up and blood in his mouth. This is the second time this has happened in the past two years. The patient has not had a fever, does not use substances and there are no metabolic abnormalities. In pairs, answer the following questions using mhGAP-IG Epilepsy Module: What is the diagnosis according to mhGAP? What is the treatment according to mhGAP? MF should read the case study above to the class. Instructions: Divide FFs into groups of 2 and have people work together for 5 minutes to answer both questions using mhGAP-IG EPI. Plenary: Get feedback from FFs about using mhGAP-IG EPI.

Course Materials Facilitators Guide Participants Guide
Presentation Slides Hand-outs Supervision and support Supervision and Monitoring Forms Checklist of training skills Teaching methodology Explain each and have the Future Facilitators flip through each one. Facilitator Guide: This guide is for future facilitators to utilize for planning and conducting mhGAP-Epilepsy training workshops for Health Care Providers. Participant Guide: Health Care Providers in your training will receive the participant guide for their review Presentation Slides: Lectures are provided in the form of slides and corresponding instructions in the mhGAP Facilitator Guide Hand-outs are provided for their use/practice during the ToTS . FFs will use all course materials for the Facilitator Exercise on Day 2

Introduction to Training Methodology
Day 1

EXERCISE [Write answers on a flip chart.]
What are the teaching methods that you are familiar with? [Write answers on a flip chart.] What tools, aids and/or equipment can you use? Which methods have been used in this ToTS so far? DISCUSS WHAT METHODS WE HAVE USED SO FAR: Icebreaker Brainstorm Lecture Discussion

Teaching Methodologies of mhGAP Courses
Presentations Demonstrations Small and Large Group Discussion Brainstorming (used in introduction) Case Study Role Playing Ask participants which of the methodologies have been used so far in this ToTS?

DISTRIBUTE HANDOUTS Teaching Tools PowerPoint Flipcharts Video
Video equipment Projectors What else? Distribute Handout on Teaching Methodology here. DISTRIBUTE HANDOUTS

Presentations Lecture-style format Can be in printed or oral form.
Lecture is telling someone about something Demonstrate a lecture Discuss: How effective is a lecture alone? MF’s should describe what a lecture is a do a brief demonstration using this slide. Ask participants how effective they think a lecture is to increase learning without any other methods? Discuss for a few minutes. More information: A Lecture is one of the oldest methods of training. This method is used to create understanding of a topic or to influence behavior, attitudes through lecture. A lecture can be in printed or oral form. Lecture is telling someone about something. Lecture is given to enhance the knowledge of listener or to give him the theoretical aspect of a topic. Training is basically incomplete without lecture. Main Features of Lecture Method Inability to identify and correct misunderstandings Less expensive Can be reached large number of people at once Knowledge building exercise Less effective because lectures require long periods of trainee inactivity. A lecture can be made attractive if: It is interactive and full of discussion with arguments and criticism. Delivered in Simple language. Combine it with visual aids and other techniques.

Demonstration Demonstrate a demonstration:
Co-facilitators role play a doctor and patient interacting in a correct way and an incorrect way with respect to listening and communication skills Participant Discussion (10 minutes) Co-facilitators should prepare this in advance and demonstrate an incorrect way of interacting, e.g. poor communication skills and poor listening skills. Co-facilitators can then demonstrate good practice afterwards.

Small and Large Group Discussions
Some discussions during the mhGAP Course will be conducted in small groups under the supervision of facilitators Some discussions will be conducted with the entire group under the supervision of facilitators You can use information here to expand on these topics: LARGE GROUP DISCUSSION: Requires good facilitation and control over the group. Allow all participants to be present but not all participants usually provide input. SMALL GROUP DISCUSSION: This method allows participants to discuss in small groups on a given topic, giving them the opportunity to talk freely about their opinions and express theirs insights. This method enables participants that are shy and more reserved to express themselves. Moreover, small groups discussion have the indirect benefit to allow participants to know each other better and to familiarize with the subject in a more friendly way, without the fear of being heard by the trainer. Main features of Small Group Discussion It enhances confidence of the participants. No equipment and material is required. It lessens shyness among the participants. They take more time than lecturers People may lack in knowledge so they will not participate in the discussion Role of Trainers while conducting small group discussion Have skills of encouragement. Ability to seek and maintain attention. Skills of snubbing dominating and talkative participants and encouraging reserved and shy ones. Competent to keep the discussion on track. Keeping the discussion simple.

Small and Large Groups Discussions: Examples
5 minute large group discussion on the following question: How is epilepsy perceived and understood in the communities in which you work? Plenary and discussion for 5 minutes 2 minute small group discussion in pairs Discuss cases of epilepsy where stigma was an issue Facilitate a large group for 5 minutes asking the following question: How is epilepsy perceived and understood in the communities in which you work? During the small group, MFs should walk around and provide input where needed. Make sure that FFs understand the exercise. This is also a demonstration to FFs about what to do when they conduct the exercises themselves. Then ask the group to divide in pairs and discuss cases of epilepsy where stigma was an issue. After each exercise, ask for feedback from the FFs as to what they thought of the methods. Discuss benefits of each method with the group. Explain how to facilitate each exercise.

Brainstorming Generate an extensive list of ideas, thoughts or alternative solutions on a specific topic or problem Stimulates thought and creativity and is often used to start group discussion Remember, there are no wrong answers with brainstorming! Hint: Use a flip chart Explain that Brainstorming was used in the introduction as a demonstration but has not been integrated into the EPILEPSY training for health care providers. However, it is an effective method at increasing audience participation. Explicitly inform the FFs that this was the technique used in the opening of this session!!! The main purpose of brainstorming is to generate an extensive list of ideas, thoughts or alternative solutions on a specific topic or problem. This technique allows the wealth of life and work experience to be shared with the group. It is a highly effective way for adults to learn by allowing many ideas to be shared in a short period of time. It stimulates thought and creativity and is often used to start group discussions. Emphasize that any answer is a good answer (e.g. no answer is wrong!). Main features of Brainstorming. It encourages participants to express themselves and follow their thoughts No equipment and material is required. Shy participants may not be fully involved They take more time than lecturers

Case Study Choose a patient case as a teaching tool
Ask questions about the case to the audience Ideal for practicing assessment and management of mhGAP priority conditions, especially uncommon presentations or complex cases Emphasize that case studies are clinical case presentations read by the facilitator and discussed with the group in order to practice assessment and management of mhGAP epilepsy care. Good for complex cases and uncommon presentations.

Case Study: Example You are a primary care provider. A patient who has had two convulsive seizures on two different days in the last month has come to visit you. After your assessment and completion of a new patient form, there is no clear cause of the seizures and the person is otherwise well Q1) According to mhGAP EPI module, what is the diagnosis and treatment plan? Q2) What medication would you use and how would you explain the risks and benefits? Demonstrate how to use a case study. In this example, present the case to the FFs and ask them to individually use mhGAP EPI module and answer the questions. Allow them 5 minutes. Afterwards, ask for their answers and discuss. Introduce the idea of a new patient form, which will be discussed in detail later on. Get feedback from FFs on effectiveness of this exercise.

Role-Plays Effective for practicing assessment, management, and communication skills Small groups of 3 people in which 2 participants play active roles and one participant observes and provides feedback Large role-plays facilitated as a demonstration for the entire group by the facilitator and a volunteer Emphasis of role-plays should not be placed on acting skills, but rather on the content and the lessons of the activity. Emphasize that Role-play is an exercise in which the facilitators and the learners act the parts of different people and so begin to experience some of the feelings of these people. Role-play must have a clear learning objective and should be carefully planned. Always check the accuracy of the information given and the communication skills used by the role-players. • Role-play must have a clear learning objective and should be carefully planned. • Role-play means acting the part of another person in a specific situation. • Role-playing exercises are used to show a situation, enabling everyone to understand the attitudes and reactions involved in that particular situation. • Role-players should be given a basic description of who they are supposed to be and what the situation is and should be given time to prepare. • It may be difficult for the role-players to follow instructions if they are given too many details. • Describe to the class each player’s role and the situation to be enacted. • Role-play may come to a natural end or you may decide that it has lasted long enough for educational purposes and stop it. • When role-play is over, guide the discussion to emphasize the main points learned and summarize the session by asking questions rather than giving answers. • Check the accuracy of the information given and the communication skills used by the role-players.

Role-Play Exercise Need 2 volunteers, a primary care provider and a patient with epilepsy Primary Care Provider is seeing this patient for the first time and should interview the patient using mhGAP-IG module in order to come to a diagnosis. Take notes to fill out a new patient form. The patient has had 2 convulsive seizures in the past 2 months with no clear etiology Ask for 2 volunteers from the group to demonstrate a large group role-play exercise and have them play a patient with epilepsy and a HCP. Role-play should last no longer than 5 minutes. MF should mediate as needed and then lead a discussion thereafter with the group. The person playing the HCP should be given a new patient form, to get used to taking notes on. It’s ok if they are unsure how to complete it yet, but get them used to having it ready for all new patients and taking notes. Clearly indicate that role-plays can occur both in front of a large group and in small break-out groups.

Exercise (Optional) OPTIONAL EXERCISE:
This can be used at the beginning or end of this session by the MF.

Checklist of Training Skills
A list of skills and actions that an effective facilitator should strive to utilize during training The list is aspirational – you are not expected to have immediate proficiency with all of these skills! Instead, use the checklist as a guide. Practice these skills throughout the ToTS training, and refer to the checklist when giving feedback to yourself and to other participants Ask participants to read the checklist of training skills in preparation for this exercise. DISTRIBUTE HANDOUTS

Checklist of Training Skills: Categories
Preparation Presentation Interaction Time Management Feedback These are the main categories on the checklist of training skills.

Take-Home Points 1) Instruction should be performance based
ToTS training teaches tasks that you will be expected to do on the job as a future facilitator of health workers 2) Active participation increases learning ToTS training involves all participants in active discussion, exercises such as role play, and practical work related to supervision and project monitoring. 3) Immediate feedback increases learning All participants will be given immediate feedback from master facilitator and other participants for each exercise Emphasize that didactic lecture alone is insufficient to promote good learning.

Introduction to Support and Supervision
Day 1

Overview: Support and Supervision
Introduction Why part of ToTS? Two types of supervision: Clinical Programmatic Supervision Methods Supervision Skills How to organize supervision and monitoring visits How to use the supervision forms How to supervise the use of monitoring forms

Introduction to Support and Supervision: Brainstorm
Questions for Participants: What do you think support and supervision refers to? (5 minute brainstorm) What kind of support do you feel would be appropriate for integrating epilepsy care into primary care? (5 minute large group discussion) Explain to future facilitators that support and supervision begins after they conduct the training for health care providers and that they are responsible for this. It refers to clinical support and supervision both for direct patient care as well as components of epilepsy service delivery including but not limited to medications, supplies, health information, clinic space etc.

Introduction to Support and Supervision
What is Support and Supervision? A source of guidance for discussing challenging cases and for clinical, administrative and programmatic issues What are the objectives of Support and Supervision? To improve knowledge and skills so that mhGAP trainees can independently assess and manage people with epilepsy Encourage and support mhGAP trainees in their daily clinical work Not to evaluate their performance! When do you begin? Following your mhGAP Epilepsy training Clarify roles and definitions here. Emphasize that supervision is an integral part of becoming a FF for mhGAP-EPILEPSY care and that it begins immediately following the training that FFs conduct to Health Care Providers.

Introduction to Monitoring
What is Monitoring? A source of information on whether the project is making a difference and for whom; it can identify programme areas that are on target or aspects of a programme that need to be adjusted Done continuously; collects programme inputs and outputs; is used to make immediate programme decisions What are the objectives of Monitoring? To provide vital information for improving planning and allocating resources, improving service delivery, and demonstrating results as part of accountability to key stakeholders When do you begin? Following your mhGAP Epilepsy training, as a component of supervision Clarify roles and definitions here. Emphasize that supervision is an integral part of becoming a FF for mhGAP-EPILEPSY care and that it begins immediately following the training that FFs conduct to Health Care Providers.

Why are Support and Supervision a part of ToTS? (1)
Support the process of translating mhGAP epilepsy knowledge into clinical practice Ensure adequate delivery of mhGAP-IG epilepsy interventions by addressing challenges Identify and help to address problems faced by mhGAP trainees in managing complicated cases Improve the motivation of non-specialized healthcare providers to treat persons with epilepsy Ensure that medicines, logistics and other support systems for mhGAP epilepsy implementation are operational

Why is Monitoring a part of Supervision and ToTS?
Ensure that monitoring forms are understood and usable Provide knowledge to train non-specialists in monitoring and the use of monitoring forms Emphasize the importance of monitoring for improvement of care delivery and health system strengthening Ensure adequate quality of epilepsy care by enabling monitoring of patients, health facilities and districts, and adjustments when problems are identified Ensure that allocation of resources and future planning is fully informed by data from consistent monitoring Ensure progress is adequately measured for accountability to key stakeholders

Types of Supervision Clinical Supervision:
To support mhGAP-trained Health Care Providers in delivering clinical epilepsy care Administrative and Programmatic Supervision: To provide support in the work environment as epilepsy care is integrated into the health care system. This includes supervision to ensure trainees are conducting regular monitoring.

Supervision Methods Supervision can be done in several ways:
On-site supervision Remote supervision Individual supervision Group supervision Master Facilitators can distribute the Hand-out here on Supervision Types and can discuss the pros and cons of each type. This can also be an opportunity for a Small or Large Group Discussion.

Supervision Methods: Stages Begins After Health Care Providers trained in EPI
Tell FFs that supervision begins after they conduct their initial EPI training to health care providers. In the first stage, the main type of supervision will be Clinical Supervision. As time progresses, Administrative and Programmatic Supervision will be more relevant. Supervision can be adapted a weaned based on HCP needs over time.

Supervision Methods: Required Structure
You will be a supervisor for each of your epilepsy trainees You will conduct at minimum: Monthly Supervision Visits at each facility starting 4-6 weeks after the initial training ½ day for each visit Supervision must include a confirmation that trainees can and are using the monitoring forms provided mhGAP district focal person will monitor the supervision activity and collect facility-level monitoring data Letter of introduction sent to each facility Emphasize that each FF after they conduct their initial mhGAP EPI training will become a supervisor. The supervision consists on on-site visits monthly and should be started 4-6 weeks after the initial training.

Additional Supervision Methods (optional)
Ongoing group supervision in the form of bi-weekly grand rounds/clinical case review in a group setting of non-specialist providers. Held at Provincial or District Hospitals Alternatively, can be in form of remote supervision Exact structure depends on available resources and the local context. Brief refreshers for how to use monitoring forms and reminders to complete them as indicated (e.g. monthly, 3-monthly, with each new patient…) This is an optional structure and can be used depending on available capacity and local resources.

Exercise: Small Group Discussion
In pairs, discuss: What types of supervision would be feasible for the settings in which you work? Duration: 3 minute discussion Ask participants to share their ideas with the group after 3 minutes of discussion.

Supervision Skills Clinical skills and experience in managing mental, neurological and substance use disorders Facilitation and problem-solving skills Thorough understanding of how to complete the provided monitoring forms, and where to send any completed forms Available time to conduct Support and Supervision, including regular supervisory visits

Supervision Skills: Exercise
In small groups of 3 people, discuss: What additional skills should a supervisor have in order to provide guidance for health care providers and epilepsy care? Duration: 5 minutes This is an exercise to get FFs thinking outside of clinical skills and making them aware that supervision requires a role change from clinician to teacher.

Additional Skills Required for Supervisors
Building Trust Communication Listening Observance and Guidance Constructive Feedback Encouragement

How to Organize Monthly Visits: Overview
Conducting the Visit: Introduce activity Review facility supports Observe clinical interview User/Family Visits (optional) Interview Facility Director Observe use of monitoring forms Group Supervision (optional) Staff Feedback and Problem Solving Summary & Reporting Preparation Give a brief overview here of the supervision steps and explain that each will be discussed in detail in the subsequent sessions. Preparation is required before each visit. 2 of the steps are optional. (Practice required: Day 2) This part may fit better on 2nd day

How to Organize Visits: Preparation
Read the Support and Supervision Guide in full Review the supervision and monitoring forms Create a supervision schedule for Year 1 Letter of Introduction to each Facility Schedule monthly visits with each facility Invite EPI trained HCPs to each visit Ask each HCP to schedule 2-3 follow up EPI patients on that day for supervision FFs must prepare in advance for each visit. These are the steps. Main things are to invite mhGAP EPI trained HCPs and to ask them to schedule follow-up cases so that you can clinically observe them during your visit. Provide the FFs here with the S&S Handouts. Go through the forms and what resources are available here for support and supervision.

How to Organize Visits: Forms
Send appropriate forms to facilities beforehand Ask each facility to complete the Programmatic Support Form (Annex 2) at least 1 week in advance of each visit Send the Programmatic Support Form to the Director of the Facility 1 week in advance of your visit.

How to Organize Visits: Conducting the Visit, 6 Required Steps
Introduce activity Review facility supports Observe clinical interview User/Family Visits (optional) Interview Facility Director Observe use of monitoring forms, provide refresher training if needed Group Supervision (optional) Staff Feedback and Problem Solving Summary & Reporting

How to Organize Visits: Practicing
This takes practice!!! On Day 2, we will teach more about how to conduct a visit and practice in small groups HOMEWORK: Review the support and supervision guide for exercises on Day 2.

How to Use the Supervision Forms
Standardized forms designed to help you Five forms available for use before, during and after supervision visits All forms should be submitted at least every 3 months to mhGAP EPI focal points Found in Supervision and Support Handout Each form is to be used at a certain point in the process The supervision forms will be explained in more detail over the next few slides. They are found in the Supervision Handout and can be distributed at any point in this session. All forms should be submitted to the focal point at least every 3 months.

How to Use Supervision Forms: Purpose of Each Form - TBD
1. Programmatic Support Form Collects statistics on prevalence, patient care, facility supports and staff issues 2. Record of Supervision of Trained Healthcare Provider Tracks supervision and support activities 3. Clinical Support and Supervision Form Tracks progress of the HCP EPI skills and knowledge 4. Difficult Case Report Form Documents difficult clinical cases encountered by HCPs 5. Supervisory Report and Feedback Form Summarizes progress and challenges of the given facility Have FFs take a look at each form and flip through with you. This slide shares the purpose of each form.

How to Use Supervision Forms: When to Use - TBD
1. Programmatic Support Form Preparing Phase (sent to facility) 2. Record of Supervision of Trained Healthcare Provider Before and After the Supervision Visit 3. Clinical Support and Supervision Form Observing Clinical Interview 4. Difficult Case Report Form Preparing and Observing Clinical Interview 5. Supervisory Report and Feedback Form Reporting Phase This slide shows when to use each form during the supervisory process.

How to Supervise the Use of Monitoring Forms
Who should use? When to use? 1. New Patient Form Primary health care provider Any time a new patient presents to the clinic with epilepsy for the first time 2. Patient Follow-Up Form Any time an epilepsy patient returns to the clinic for a follow-up appointment 3. Facility Monthly Report Form Facility Staff Member Once per month This slide shows which monitoring forms the supervisor should ensure are being used during each supervisory visit.

Instructions: How to complete patient and facility monitoring forms
New Patient Form Patient Follow-Up Form Facility Monthly Report Form Provide trainees with a copy of each monitoring form. Explain, step by step, how each form should be completed. Make sure these forms are being completed during correct times and submitted to District Coordinator

Summary: Supervision and Support
Supervision and Support are critical to the integration of epilepsy care One training workshop alone is not enough Future Facilitators (YOU!) are trainers and supervisors You will conduct monthly supervision visits on-site initially, then quarterly Prepare and become familiar with the steps and forms (both supervising and monitoring)

Demonstration of Session “Epilepsy”

Demonstration of Session “Epilepsy”
Master facilitator give demonstration on epilepsy training [Slide of the epilepsy training] Demonstration of Session “Epilepsy”

Preparation for Facilitator Exercise
Day 1

Facilitator Exercise: Overview
Purpose: To practice training methodologies and gain experience in preparing, presenting and facilitating an mhGAP lecture on epilepsy To learn how to give feedback to other future facilitators

Facilitator Exercise: Instructions
Step 1. Prepare presentation on Day 1 Divide into pairs Prepare assigned topic using the facilitator guide and mhGAP-IG Follow ‘Checklist of Training Skills’ as a guide Step 2. Conduct Session on Day 2 Step 3. Receive Feedback Feedback form – this is shown 4 slides later, is it also in a Word Doc? Explain the instructions to the FFs for the exercise: Divide the FFs into pairs. This can be pre-determined by the Master Facilitators. Assign the topics to each pair – see next slide. Show participants and handout the checklist of training skills. Ask them to prepare their session tonight and focus on the teaching methodologies within each section. If they need help in the evening, MFs can be available for them for one hour at a set time. Show next slide to explain the length of the presentation

Facilitator Exercise: Suggested Instructions
Prepare a lecture with the following: Brief Introduction and Welcome At least 1 teaching technique other than presentation Interaction and Participation Use of mhGAP EPI module in lecture Length of presentation: 25 minutes Feedback provided by others: 5 minutes

Suggested Assignments
GROUP SLIDES METHODOLOGY 1 1-19 Introduction Group Discussion (skip pretest) 2 51-59 Medication Role-play Quiz 3 60-73 Emergency management of seizures Group Discussion Case Study 4 74-86 Emergency management of seizures (cont') 5 87-97 Advice, education and follow-up 6 Advice, education and follow-up (cont') Role-Play This can be adapted by the Master Facilitator. Slide was already covered by the master facilitator.

General Suggestions Use mhGAP-IG and the Facilitator Guide side by side to prepare your sessions Strengthen your knowledge by reading mhGAP-IG on epilepsy Be clear with role plays, instructions and discussions after Don’t read from PowerPoint slides Do interact and participate with the audience Read these to FFs.

Other General Suggestions
Repetition, repetition, repetition Observe one, do one and teach one Be simple and clear Less slides, more exercises More interaction

Feedback Form Observers complete this form after each pair of co-facilitators on Day 2 EVALUATION OF PARTICIPATORY PRESENTATION: Tick the appropriate box and make comments. Please give your classmate the benefit of honest feedback. Scale: 1-excellent /2-very good /3-satisfactory /4-fair /5-poor 1 2 3 4 5 Clarity of Introduction Clarity of Main Points Clarity of Main Goals Use of Summary Body Language Voice Tone/Speed/Clarity Level of Student Interest Level of Student Learning Level of Student Participation This is a feedback form that will be completed by observers of the Facilitation Exercise immediately following each exercise. MFs should collect this and score the results and present to the FFs who conducted the exercise. MFs should ensure that enough photocopies are made so that each FF can evaluate each pair of FFs.

Training Skills Tips While participants are working
Look available, interested, and willing to help Encourage questions Watch participants as they work; offer individual help to participants who appear confused This may be a good time to engage participants who have been shy or quiet during the group portions of the training Offer FFs tips of how to be a good trainer.

Demonstration Tips Demonstrations (videos)
If there is no video available for a module that should have one (such as not available for the training language or a power outage), act out the entire correct script (no short cuts) with a co-facilitator Follow the instructions in the Facilitator's Guide State clearly the objective of the demonstration Ask participant’s questions to check their understanding of the material Demonstrations videos are powerful tools. Give these instructions to FFs. Encourage FFs to use this if they can in their future sessions.

Role-Play Tips Role-Plays
Clearly introduce the role-play by explaining its purpose, the situation, and the roles to be enacted Keep the role-play brief and to the point After the role-play, guide a discussion. Ask questions of both the players and observers Summarize what happened and what lessons should be taken away from the exercise Role-plays must be well facilitated. Make sure that the roles are clear for each person. Watch the time and step in as needed. Afterwards, facilitate a discussion and ask the audience what went well and what did not go well. As MF, provide lessons learned.

Tips for Group Work Practical Sessions and Group Work
Before dividing into groups, explain clearly the purpose of the activity, what participants will do and the time limits of the exercise If needed, demonstrate a skill before asking participants to do it on their own Try to get participants to identify their own strengths and weaknesses. Ask questions like - What did you do well? What difficulties did you have? What would you do differently in the future? Group work also needs to be instructed well. Make sure that instructions are clearly explained and that there is a clear time limit. Any facilitator should walk around to each small group and provide input as the activity is going on. In the plenary, facilitators should manage the discussion and get feedback from the participants.

Facilitation Exercises by Participants

Structure 25 minute presentations by pairs 5 minute feedback orally and written with the Feedback Form Each pair of FFs will conduct their practice session. Following this, each participant of the ToTS will complete the Feedback Form. **MFs can complete the more comprehensive form found in Annex D (version 2) of the Guide ‘Preparing and Planning the Epilepsy ToTS’. For 5 minutes following each presentation, MF’s should provide 5 minutes where audience members have a chance to give feedback on all aspects of teaching skills.

Feedback Form Use this form after each pair of co-facilitators
EVALUATION OF PARTICIPATORY PRESENTATION: Tick the appropriate box and make comments. Please give your classmate the benefit of honest feedback. Scale: 1-excellent /2-very good /3-satisfactory /4-fair /5-poor 1 2 3 4 5 Clarity of Introduction Clarity of Main Points Clarity of Main Goals Use of Summary Body Language Voice Tone/Speed/Clarity Level of Student Interest Level of Student Learning Level of Student Participation These should be distributed so that each FF has at least 5 forms each. Each FF should score each pair of facilitators using this form after each session.

Practicing Support and Supervision
In this session, following topics will be covered. What is mhGAP and mhGAP Intervention Guide (mhGAP-IG)? Introduction to general principles of care Discussion of experiences & understandings of epilepsy and the implications of misunderstandings/stigma Facts & myths about seizures & epilepsy Defining & differentiating seizures (as a symptom) and epilepsy Use of Monitoring forms Day 2

Overview Detailed Steps on How to Conduct the Supervision Visit
Role-Play Demonstration Small Group Role-Plays

Remember that… You have already conducted the epilepsy training for health care providers You have scheduled your first visit at Facility A You have ensured that all EPI-trained HCPs will be present and have scheduled follow-up cases

Conducting the Visit Step 1. Introduce Supervisory Visit
Meet briefly with the facility director upon arriving to the facility Explain the purpose and the schedule of the visit, including the interview with the director Introduce yourself to the facility staff and explain the purpose of the visit Clearly mention that you have not come here for auditing or rating; instead you have come to make the situation better and to help all of them, by making constructive suggestions. As the supervisor, it is important to first meet briefly with the facility director upon arriving to the facility. Explain the purpose and the schedule of the visit, including the interview with the director. The visiting supervisor(s) should introduce themselves to the facility staff (those who have been trained in mhGAP and those who have not) to explain the purpose of the visit. Cleary mention that you have not come here for auditing or rating; instead you have come to make the situation better and to help all of them, by making constructive suggestions.

Conducting the Visit Step 1. (con’t) Introduce Supervisory Visit
Explain that you will: Observe clinical session of the health care provider who received mhGAP training in order to reinforce skills and knowledge learned during mhGAP training Review facility supports such as equipment, medicines and supplies in order to identify any problems that might interfere with implementation of mhGAP, Review the use and reporting of monitoring forms, and Meet with facility staff to discuss progress and how to solve problems Explain that you will: Observe clinical session of the health care provider who received mhGAP training in order to reinforce skills and knowledge learned during mhGAP training Review facility supports such as equipment, medicines and supplies in order to identify any problems that might interfere with implementation of mhGAP, Review use of facility-level monitoring forms, and Meet with facility staff to discuss progress and how to solve problems

Conducting the Visit Step 2. Review Facility Supports
Review the Programmatic Support Form from the facility Orient yourself to the facility and look at conditions that affect the implementation of mhGAP Are space, equipment, availability of medicines and other supplies, and clinic hours are optimal? How is the examination area and where the supplies and equipment are kept, as well as the storage and organization of patient records and drug supplies? Ensure that the examination rooms promote confidentiality for the patient. Review facility supports – expanded notes One of the most important challenges of implementing mhGAP is that the facility may not be fully organized to use and support the new approach and/or may not have the essential medicines and supplies required for addressing MNS disorders. The healthcare providers training may be insufficient if he or she does not also receive help solving administrative or logistical problems encountered. As part of supervisory visit, the supervisor must orient themselves to the facility and look at conditions that affect the implementation of mhGAP. The supervisor’s role is to ensure that facility supports such as space, equipment, availability of medicines and other supplies, and clinic hours are optimal for treating people with MNS disorders. The supervisor may ask to be shown the examination area and where the supplies and equipment are kept, as well as the storage and organization of patient records and drug supplies. Often, MNS cases are handled variably depending on the setting of the facility and its examination room. It is important to ensure that the examination room promotes confidentiality between the health care provider and the patient. The lack thereof may create an uncomfortable setting for implementation of an effective diagnosis and treatment of the individual with an MNS condition. The supervisor must emphasize the importance of confidentiality and suggest that no other people apart from the healthcare provider and the patient (and family members, if needed) no other people can hear what is discussed in the room there is a door to the examination room and that it shuts The supervisor should try to suggest possible solutions if the facility support is inadequate.

Conducting the Visit Step 3
Conducting the Visit Step 3. Observe Clinical Interview and Use of Monitoring Forms Select an epilepsy follow-up patient Observe the healthcare provider during case interview and assessment. Observe the use of monitoring forms (new patient form or follow-up patient form) Complete the Clinical Support and Supervision Form and make additional comments on performance Give feedback on health provider’s performance EXPANDED INFO BELOW: Recall that the task of the supervisor is to reinforce the skills acquired in the mhGAP training course, rather than teach new skills. They can use Clinical Support and Supervision Form (Annex 3) to guide their observation of the healthcare staff having session with person with MNS conditions. The following section provides a suggested format for observation. 1. Select a EPI follow-up patient visiting the clinic. If there are several patients waiting, select one who has multiple symptoms and signs of illness. If there are specific skills which the health provider needs to improve, select a individual with a corresponding condition that will allow practice and review of these skills. Obtain consent from the patient if they agree to be seen together with the supervisor. 2. Observe the healthcare provider during case interview and assessment. Use the Clinical Support and Supervision Form adapted to the context to guide your observation. Begin observation from the time when the health provider greets the individual with the MNS disorder and/or the carer. It is important that the health provider to address the person as it is in daily clinical practice. Avoid interfering with the management of the person so that you can observe what the mhGAP trainee is able to do alone, without assistance. Intervene with the trainee only if what the worker is doing leads to harming the person in a sensitive manner. If it is not urgent, wait until the patient leaves the room to correct the trainee. 3. Complete the part Clinical Support and Supervision Form and make additional comments on performance This form enables the supervisor to assess the individual health providers’ insight of the mhGAP training and how they are able to implement it during treatment of individuals with MNS disorders. This form is a tool used to determine the progress of a health provider in caring for people with MNS disorders 4. Give feedback on health provider’s performance In a setting where they are observed and evaluated, healthcare providers may become flustered or perform less than optimally. The supervisor must address all short-comings in a helpful and respectful manner. Feedback, positive or negative, should always be constructive and leave the healthcare provider feeling confident and empowered. Supplementing all negative feedback with suggestions for improvement will allow the healthcare provider to address their shortcomings.

Conducting the Visit Step 4. Interview Facility Director
Discuss and evaluate how epilepsy care is being integrated in terms of: Logistics, monitoring supplies, medicines and equipment, and facilitating the administrative and/or clinical aspect of patient care. Discuss the result of the Facility Form and the observation of the clinical setting Discuss the use of patient and facility-level monitoring forms, and their reporting to district level Discuss steps towards improvement of mhGAP implementation of epilepsy care Remember that the director of a given facility is the person in charge of the health facility and most probably direct superior of the health care providers at that site. They are responsible for managing the logistics, monitoring the use of supplies, medicines and equipment, and facilitating the administrative and/or clinical aspect of patient care. Interview with the facility director is a resourceful means of evaluating the function of the facility and improving the environment in the facility to implement mhGAP. Discuss the result of the Facility Form and the observation of the clinical setting, and discuss about steps towards improvement of mhGAP implementation.

Conducting the Visit Step 5. Give Feedback and Problem Solve with Staff
Facilitate a meeting with all health facility staff and the director (co-chair) Explain that purpose of meeting is to solve problems by discussion including challenges and conflicts with staff Provide positive feedback such as acknowledging progress in treating epilepsy Discuss points of improvement Tell FFs that at the end of the visit, the supervisor facilitates a meeting with all the health facility staff (those trained in mhGAP as well as those who are not). Invite also the facility director; the director may serve as a co-chair of the meeting. The supervisor can begin by giving the positive feedback such as acknowledging the progress the staff has made in treating people with MNS disorders and provide some points which needs improvement to better implement mhGAP in the facility. Explain them that the purpose of this meeting is to solve problems by discussion. In providing Support and Supervision, the supervisor is responsible for recognizing the challenges and conflicts within staff. Support and Supervision impact not only the clinical care aspect of the supervisors’ duties, but problems solving in the administrative aspects of many healthcare settings.

Conducting the Visit Step 6. Reporting
Write a brief summary of the visit Use the Supervisory Report and Feedback Form as a guide (Replace with “Use the Supportive Supervision Checklist as a guide”?) Include: Strengths and problems identified Actions taken to address challenges and conflicts Future actions needed during the next supervisory visit and at the district/national level Complete a Summary Report of the Visit Tell FFs that before leaving the facility or within few days after the visit, the supervisor must write a brief summary of the results of the visit. The completion of a summary report provides an opportunity to review the activities of the visit. The Supervisory Report and Feedback Form (Annex 5) provides a prompt for the type of information that needs to be recorded in a summary report. The purpose of the Supervisory Report and Feedback Form is to assess the visit and address what was seen, how mhGAP implementation is progressing, and what improvements should be made. It allows the supervisor to summarize the supervisory visit and provides a means of recording and feedback for future improvements. This information may also be useful for the Monitoring and Evaluation aspects of mhGAP. The supervisor can also utilize the final summary report to alert the necessary individuals at national or district level to correct problems within their areas of expertise. The summary report must describe: Strengths and problems identified during the visit, Actions taken during the visit to address challenges and conflicts, Future actions that are needed to resolve problems: During the next supervisory visit At the district/national level A copy of this form must be left at the facility and another sent to the National committee or the district office.

Conducting the Visit Step 6. Reporting & Using the Forms
The Supervision forms and reports must be submitted to the focal point at least every 3 months Forms have been adapted to the country context, and can be adapted to the local context Familiarize yourself with supervision and monitoring forms prior to your mhGAP Epilepsy training MF can go through the handout here and walk through each form to show FFs in detail what they look like.

Practicing Supervision and Support: Exercise for Step 1
Exercise for Step 1: Introducing the Visit Role-Play Demonstration (5-10 mins) 1 supervisor, 1 facility director and 1 facility staff Supervisor to speak with director and staff member using Step 1 instructions Plenary Discussion: 10 minutes This is a role-play demonstration in front of the whole group. Depending on the FF skill level, the MF can choose to role-play the exercise themselves with the MF as the supervisor and the FF class as the staff member. The co-facilitator can play the role of the Facility Director. If the skill level among the FF group is high, then 3 volunteers can be selected from the group with 1 as supervisor, 1 as facility director and 1 as a facility staff member. In this role-play demonstration, the supervisor should follow the following steps: Meet briefly with the facility director upon arriving to the facility Explain the purpose and the schedule of the visit, including the interview with the director Introduce yourself to the facility staff and explain the purpose of the visit Clearly mention that you have not come here for auditing or rating; instead you have come to make the situation better and to help all of them, by making constructive suggestions. Explain that you will: -Observe clinical session of the health care provider who received mhGAP training in order to reinforce skills and knowledge learned during mhGAP training -Review facility supports such as equipment, medicines and supplies in order to identify any problems that might interfere with implementation of mhGAP, -Review use of monitoring forms for patient and facility level, and -Meet with facility staff to discuss progress and how to solve problems Ask director and staff if they have any questions. Director and Staff can ask questions.

Exercise for Step 3: Observe Clinical Interview Small Group Role-Play (10 mins) 3 roles: 1 epilepsy-trained Health Care Provider, 1 Supervisor, 1 Follow-up Patient with Epilepsy Supervisor should be completing the Clinical Support and Supervision Form during the interview Health care provider should be completing the Patient Follow-Up form Plenary Discussion: 10 minutes Role-Play 1) Divide the FF group into groups of 3. 2) Assign roles: 1 epilepsy-trained Health Care Provider, 1 Supervisor, 1 Follow-up Patient with Epilepsy. 3) Introduce the exercise: --- Background for the Role-Play: A supervision visit is conducted by the supervisor at a health facility. The Health Care Provider trained in mhGAP Epilepsy Care has identified a patient and has scheduled that patient for a follow-up interview today. The supervisor will observe the clinical interview and use the Clinical Support and Supervision Form for guidance. The Patient Role: The patient is a case that will come from one of the Future Facilitators – see above. A suggestion is that during Day 1 of the ToTS, ask participants to provide cases for this role-play from real clinical examples of patients with follow-up visits and complaints/maintenance treatment. The Health Care Provider Role: The HCP obtains consent from the patient and interviews the patient according to mhGAP Epilepsy Module. Health care provider must ask about general signs and symptoms, diagnostic categories, and discuss a management plan, education and treatment. HCP fills out Patient Follow-Up Form. Supervisor: Observes clinical interview without making comments. After the interview is complete, ask the mhGAP trainee if they have any problems related to mhGAP implementation (e.g. referral process, availability of drugs, examination room, clinical notes, working hour, etc). Audience (e.g. Future Facilitators and other participants of the ToTS): All participants of the ToTS should complete the Clinical Support and Supervision Form during the role-play so that all FFs become familiar with the Form and what is expected in the supervisory process. Plenary: Group Discussion (10 minutes)

Exercise for Step 4: Interviewing the Facility Director Role-Play Demonstration (5-10 mins) Ask for 2 volunteers: 1 Facility Director and 1 Supervisor Supervisor should be reviewing the Facility Form while speaking with the Facility Director Plenary Discussion: 10 minutes Ask for 2 volunteers, a Supervisor and a Facility Director. MF: Give a completed Facility Form to the supervisor. Instruct all FFs in the audience to also follow along with a Facility Form in front of them. Ask the Supervisor to: Discuss with the facility director and evaluate how epilepsy care is being integrated in terms of: Logistics, monitoring supplies, medicines and equipment, and facilitating the administrative and/or clinical aspect of patient care. Discuss the result of the Facility Form and the observation of the clinical setting Discuss steps towards improvement of mhGAP implementation of epilepsy care

Additional Role-Plays and Exercises
(Optional) Role Plays in Groups of 3 20 minutes Plenary and Group Discussion See guide for examples of other role-plays and exercises that can be conducted here.

Discussions: Lessons learnt and next steps

POST-TEST Post-test End of Training Evaluation
Must complete to get your training certificate! Duration: 15 minutes

CONCLUSIONS, EVALUATION AND CLOSING REMARKS
Day 2

EVALUATION AND CLOSING REMARKS
THANK YOU FOR YOUR PARTICIPATION!

Training of Trainers and Supervisors (ToTS) EPILEPSY

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Training of Trainers and Supervisors (ToTS) EPILEPSY

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