1. 1 Operationalizing Peer Support through the Lens of Family Driven Care and Motivational Interviewing One hospital’s journey to implement Peer support on an inpatient behavioral health unit National Presentation for Families with Mental Illness, 2014 Kendra Crookston, LPCC-S, Coordinator of Parent Partners Regina Saunders, Parent Partner

2. 2 Agenda Peer support Hospital System Family Driven Care Motivational Interviewing Identifying stages of Change in Caregivers HCIA background Parent Partner Case Manager Outcomes Parent Partner Experience Questions

3. 3 Aids in reducing stigma and isolation Promotes confidence and hope while activating strengths Why Peer support?

4. 4 Primary Goal= Provide support to parents and families coping with children with behavioral problems. Secondary goals include empower parent s in decision making normalize parent experience educate on coping, self care, and crisis management assist parent in identifying their own needs and concerns Integration of Peer Support into a Hospital System

5. 5 Family Driven Care is… Treatment is individualized to the specific patient and family Culturally competent and engaging Builds knowledge and skills Solution focused Promotes advocacy from caregiver to provider

6. 6  Match to family ability and desired treatment  Increased likelihood that families will follow through with treatment recommendations  Improved outcomes and reduction in reuse of emergent services  Assures family voice is valued  Assures that family choice is identified  Provides individualized support to caregivers Why Employ Family Driven Care in a Pediatric Hospital Setting?

7. 7 Motivational interviewing (MI) is a person-centered, guiding method of communication and counseling to elicit and strengthen motivation for change Motivational Interviewing’ 2 nd Edition, Miller & Rollnick, 2002, Guilford Press INTRODUCTION TO MOTIVATIONAL INTERVIEWING

8. 8 What is Motivational Interviewing (MI)? MI is a particular kind of conversation about change (counseling, therapy, consultation, method of communication) MI is collaborative (person-- ‐ centered, partnership, honors autonomy, not expert-- ‐ recipient) MI is evocative (seeks to call forth the person’s own motivation and commitment) Motivational Interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change. Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334

9. 9 Motivational Interviewing Techniques Used in Peer Support Ask open ended questions Affirm person by shedding light on strengths they have identified Reflect person’s meaning and feeling Summarize what you have heard from a Caregiver Focus on collaboration, evocation, compassion and accepting of others. Focus on Caregiver ambivalence

10. 10 Using the Stages of Change Model to Assess for Parental Readiness Not every parent is experiencing the same level of readiness for treatment recommendations Importance of assessing Parents for their specific ability to process information given by clinicians Treatment recommendations are tailored to Parent’s abilities

11. 11 Precontemplation is the state in which people are not considering changing or initiating a behavior. They may be unaware that a problem exists. Contemplation is the stage characterized by ambivalence about changing or initiating a behavior Preparation is the stage characterized by reduced ambivalence and exploration of options for change. Action is the stage characterized by the taking of action in order to achieve change. Maintenance is the stage characterized by seeking to integrate and maintain a behavior that has been successfully changed or initiated. Relapse is the stage characterized by a recurrence of the undesired behavior or elimination of a desired behavior. (Prochaska and DiClemente, 1986, 1992) Stages of Change Model

12. 12 HOW THE PROJECT WAS DEVELOPED, I.E., INTRODUCING PEER SUPPORT IN A PEDIATRIC HOSPITAL SETTING

13. 13  Akron Children’s Hospital received a 3-year, $13.3M collaborative award with Nationwide Children’s Hospital  Reduce COST: prevent readmissions to the inpatient behavioral health unit  Improve CARE: provide family-driven care and parent support/increase adherence to follow up mental health care  Improve HEALTH: support parents as they identify a reduction in their child’s negative behaviors Healthcare Innovation Award (HCIA) Centers for Medicare and Medicaid Innovation June 2012- June 2015

14. 14 CURRENT USE OF PARENT PARTNERS AND CASE MANAGER

15. 15 Parent Partner A person with experience navigating the mental health system with his/her own child Applied Peer Support Provides a framework to parents for what to expect for a child’s admission to the inpatient Behavioral Health Unit 99% of families accept the support of a Parent Partner when offered. Bridges the gap between provider’s treatment recommendations and family’s willingness to follow through

16. 16 Parent Partner A person with experience navigating the mental health system with his/her own child Applied Peer Support Continued.. Acts as a liaison between the clinician and family to effectively tailor treatment planning Collaborates with clinical staff to identify caregiver’s experience of the crisis Reinforces family-driven care practices by viewing the family as capable/expert Allows families to identify their own needs and influence decisions regarding their child’s care

17. 17 Parent Partner family interaction

18. 18 Parent Partners support, empower and activate parents/caregivers at different touch points Parent Partner Activities

19. 19 Triage and assist families in need of services Assess for fit of current services Remains with family until patient/family engages in agreed upon services Introduction of a Case Manager into the Peer Support System

20. 20 The Case Manager Contacts each family:  following discharge prior to their first-follow up appointment  after their first mental health follow up visit Works intensively with Parent Partner-identified, high acuity families to reduce barriers to treatment ** Note: Limited to families receiving Medicaid based on grant parameters

21. 21 Case Manager (Continued)

22. 22 OUTCOMES

23. 23 Mission: To decrease the incidence of avoidable inpatient readmissions AIM Our goal is that 10% or less of our patients will be readmitted within 60 days of their initial AIM Our goal is that 10% or less of our patients will be readmitted within 60 days of their initial OUTCOME Our average re- admission rate over the last 12 months is 5.1%. This is a 50% reduction in readmissions to the inpatient behavioral health unit.* OUTCOME Our average re- admission rate over the last 12 months is 5.1%. This is a 50% reduction in readmissions to the inpatient behavioral health unit.* *Data reflects ACH data only

24. 24 Readmission Rates Start of PP Intervention *Data reflects ACH data only

25. 25 Decreased Emergency Services Used Has the Parent Partner Program contributed to a decrease of patients coming to PIRC after their behavioral health inpatient discharge? 20112014% Change IP Admissions (February-April)241263 Patients who came to PIRC after IP discharge2212-45.5% % of patients who came to PIRC after IP discharge9%5%-50.0% Data notes: 2014 data is available through Aug 16 th. Therefore, for 2011, a cutoff of August 16 th was also used for PIRC returns. Some patients may have returned to PIRC more than once, but only counted 1 visit (unique by patient) Includes all payors Source system: Strata (with previous ADS and PIRC tracking spreadsheet verification)

26. 26 Inclusion in huddle process in multidisciplinary team rounds Participation in unit transformation meetings to provide family perspective Inclusion of Parent Partner in transitioning patients from the Emergency Room to Inpatient Increased understanding of parent perspective and challenges among all staff Request from consult psychiatrist seeing patients on medical floors who will be admitted to the inpatient behavioral health unit Integration of PP into a Behavioral Health Inpatient Unit

27. 27 Program Successes Inpatient Behavioral Health unit staff comments: “Parent Partners change the whole dynamic of comfort and care. Not only does the patient feel satisfied but the families feel confident and taken care of.” (Survey Monkey of Inpatient staff feedback) “We can’t imagine life without Parent Partners.” (Inpatient leadership) Many parents gave unsolicited positive feedback about the care they received from the Parent Partners (Press Ganey survey administered at time of discharge from Inpatient Behavioral Health Unit)

28. 28 Comments made by clinicians..

29. 29 Program Volume Month Unique HCIA Program Participants Total Touches September 2013169272 October 2013186304 November 2013153264 December 2013181270 January 2014157249 February 2014134194 March 2014135223 April 2014102177 May 201477119 June 201486176 July 201488141 August 201497178 Total1,5652,567

30. 30 OUTCOMES: Vignette

31. 31 Parent Partners and the Case Manager are an integral part of the treatment team Parents easily build rapport with someone who has had a shared experience Lack of program orientation to non-grant staff Ever changing process requiring support and collaboration Transition for Parent Partner staff into hospital culture Parent Partners may need to take time off to support their own children’s ongoing mental health needs Lessons Learned

32. 32 HCIA grant dollars have provided the impetus for developing a new model of care (Parent Partners), in preparation for an Accountable Care model. ACH and Nationwide are the only two hospitals in U.S. to implement peer support in a behavioral health inpatient unit As risk is assumed, Parent Partners continue to be a preventative intervention Well-trained, highly competent staff have been hired/and trained, ready to provide family driven care (little start-up cost) The Future As An Accountable Care Organization

33. 33 Parent Partner/Case Manager Intervention has decreased the readmission rate on 8100 by 50% Parent Partner/Case Manager intervention in (PIRC) emergency service use has decreased by 50% since the intervention Caregivers of children who suffer from mental health issues are seen more regularly as expert and as capable Abstract accepted by the National Federation of Families for Children’s Mental Health 2014 conference, Washington, D.C., November, 2014, presentation “Operationalizing Peer Support through the Lens of Family Driven Care and Motivational Interviewing” Accomplishments

34. 34 The Parent Partner Perspective

35. 35 Being the Parent, the Professional and the lost. As if being a mother wasn’t enough I became the mother of a child with mental illness. I began my journey working on the flip side of the coin, not realizing how much I did not know. Now what were the things I needed to know? Parent Partner Experience

36. 36 Working As A Professional Having worked in Crisis Intervention, I was trained and ready to help any where and any time. I wanted to help and I am sure that given the opportunity I can fix this for you. I am a professional fixer.

37. 37 My Experience Parenting I realized that my child was struggling What I began to notice in my own home, in my own child. Am I truly being heard? But I am her mother, I am expert in my child.

38. 38 Watching My Child Be Admitted To An Inpatient Behavioral Health Unit I was not prepared to have a child admitted to a mental health unit. However, I believed the professionals such as myself would wave the “Magic Mental Health Wand” and heal my child! I soon learned that my journey was just in its infancy and I needed to become my child's biggest advocate.

39. 39 Things I did not know, that I did not know. How can I help the professionals to understand my child. I am her mother and I am a professional why am I not being understood? (what language was missing between myself and the professionals?)

40. 40 A Family Meeting On the Inpatient Behavioral Health Unit Now we are getting somewhere! “Today when I arrive, all of the Professionals are prepared to help me with the child I am expert on.”

41. 41 Learning the Nuances of Behavioral Health Jargon They said it was a Family Session, “Was this for my family or someone else's?”

42. 42 Unanswered Questions Following My Child’s Inpatient Admission I had several questions and few answers They were very kind but that did not help me to “fix” the way I was feeling. What did I miss?

43. 43 Okay, calling all of my IN NETWORK Professionals… I decided to talk with friends in the field. Was it helpful? I then thought I would call other persons in the field that may help my child on an outpatient basis. They will definitely understand me! Outcome

44. 44 Myself the Helper, Professional and Know it All! I worked as a Crisis Interventionist during this period of time. “I am certain I helped 90% of them, or did I ?”

45. 45 Fast-forwarding to Parent Partnership What is this “Parent Partner” I hear of? “Having been a “Helper” for many years I am certain I can do this job.” “All I have to do is give these Parents my expert advice, and my work is done, right?”

46. 46 Exploring the Parent Partner Job Opportunity I did not know what I thought I knew about the position of a Parent Partner. I learned much this day, and felt honored to even be considered for my slight understanding of what this program could be.

47. 47 Being Hired as a Parent Partner We definitely had our work cut out for us.

48. 48 A New Way of Thinking I began to hear many new words buzzing about our trainings, conferences and meetings. Many new Ideas and smart thoughts began to show themselves. We began to “fumigate” our minds, replacing “Professional think” with memories of being the parent of a mentally ill child only!

49. 49 Setting the Parent Partner Program in Motion I was mentally unprepared to handle what it would mean to bring a totally family driven approach to the Medical Model method. “Mama’ said there would be days like this!”

50. 50 Parent Partners, We came, We learned, We conquered! What it means to “me” to be a part of this movement. What I have learned by helping to pioneer Parent Partnership. How we have maneuvered collaboration with those holding fast to Medical Model Practice. And what value we possess as Parent Partners in collaboration with Parents.

51. 51 In Closing, Smart Thoughts and Question Session Any Questions or Comments Welcome at this Time. Lessons