person-centered mental health care moving beyond the rhetoric and values of recovery in everyday...
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Person-Centered Mental Health Care
Moving Beyond the Rhetoric and Values of Recovery
in Everyday Practice
Neal Adams MD MPHNeal Adams MD MPHDeputy DirectorDeputy Director
California Institute of Mental HealthCalifornia Institute of Mental Health
PleonasmPleonasm
NOUN:
1a. The use of more words than are required to express an idea; redundancy. b. An instance of pleonasm.
2. A superfluous word or phrase. ETYMOLOGY:
Late Latin pleonasmus, from Greek pleonasmos, from pleonazein, to be excessive, from ple
Neal Adams MD Copyright 2008
Kuhn/Paradigm ShiftKuhn/Paradigm Shift
true paradigm shift new model for understanding
and experiencing relationship between consumer and provider
challenges earlier precepts can only supplant old model
Mental health recovery is a journey of healing Mental health recovery is a journey of healing and transformation enabling a person with a and transformation enabling a person with a
mental health problem to live a meaningful life mental health problem to live a meaningful life in a community of his or her choice while in a community of his or her choice while
striving to achieve his or her full potential. striving to achieve his or her full potential.
Traditional vs. RecoveryTraditional vs. Recovery
Recovery-Oriented person-directed strengths-based skill acquisition collaboration quality of life community-based empowerment/
choices least restrictive preventative/wellness
Traditional practitioner-based problem- based professional
dominance acute treatment cure/amelioration facility-based dependence episodic reactive
Managing the Illness…Managing the Illness…Focusing on DeficitsFocusing on Deficits
Promoting Recovery… Promoting Recovery… Building StrengthsBuilding Strengths
Decreased symptoms/Clinical stabilityDecreased symptoms/Clinical stability
Better judgmentBetter judgment
Increased Insight…accepts illnessIncreased Insight…accepts illness
Follows teamFollows team’’s recommendationss recommendations
Compliance with treatmentCompliance with treatment
Decreased hospitalizationDecreased hospitalization
AbstinentAbstinent
MotivatedMotivated
Increased functioningIncreased functioning
Psychiatric StabilityPsychiatric Stability
Healthy relationships/socializationHealthy relationships/socialization
Use services regularly/engagementUse services regularly/engagement
Cognitive functioningCognitive functioning
Realistic expectationsRealistic expectations
Attends the job program/clubhouse, etc.Attends the job program/clubhouse, etc.
Life worth livingLife worth living
A spiritual connection to God/others/selfA spiritual connection to God/others/self
A real job, financial independenceA real job, financial independence
Being a good mom…dad…daughterBeing a good mom…dad…daughter
FriendsFriends
FunFun
NatureNature
MusicMusic
PetsPets
A home to call my ownA home to call my own
Love…intimacy…sexLove…intimacy…sex
Having hope for the futureHaving hope for the future
JoyJoy
Giving back…being neededGiving back…being needed
LearningLearning
Treating Acute IllnessesTreating Acute Illnesses
Professionals as experts diagnosing illnesses and ordering treatment
Patient provides history and complies with treatment
Life is put on hold while in treatment Short term professional-patient
relationships
MEDICAL MODELMEDICAL MODEL
return to life return to life
symptomssymptoms
illnessillness
decrease symptomsdecrease symptoms
We Treat Almost Only We Treat Almost Only Chronic Mental IllnessesChronic Mental Illnesses
Mission of public mental health to focus on chronic illnesses
Because of stigma people don’t come into treatment until waiting has been ineffective
Mental illnesses are particularly disabling, difficult to rehabilitate and adapt to
Mental illnesses are often associated with hopelessness
Mental illnesses impact self image rapidly and powerfully
REHABILITATION MODELREHABILITATION MODEL
return to life return to life
illnessillness
functional impairmentfunctional impairment
improved functionimproved function
HardingHarding’’s s Schizophrenia StudySchizophrenia Study
Bottom 1/3 considered hopelessBottom 1/3 considered hopeless Degenerating course for restDegenerating course for rest of life Nevertheless 62% recovered or Nevertheless 62% recovered or
significantly improvedsignificantly improved Definition of recoveredDefinition of recovered
having a social life holding a job being symptom free not taking medication
RECOVERY MODELRECOVERY MODEL
illnessillness
personperson
workerworker
fatherfather
husbandhusband
OriolesOrioles fanfan
churchchurch goergoer
illnessillness
1.1. HOPEHOPE2.2. EMPOWERMENTEMPOWERMENT3.3. SELF-RESPONSIBILITYSELF-RESPONSIBILITY4.4. MEANINGFUL ROLESMEANINGFUL ROLES
Treatment ImplicationsTreatment Implications
Emphasize patient education, collaboration, and self-help
Focus on hope Try to keep people in their lives Incorporate rehabilitation and adaptation Focus on impact on self image Promote long term, more personal doctor-
patient relationships
Mental illness creates special challenges in all these areas
Recovery ImplicationsRecovery Implications
For acute illnesses recovery results from symptom elimination and cure
For chronic illnesses recovery results from achieving self-management of the illness maintaining hope and self-image carrying on with life through rehabilitation and
adaptation replacing professional supports with natural
supports
For acute illnesses recovery is illness-based For chronic illnesses recovery is person-based
illnessillness
housing (treatment setting)housing (treatment setting)
friends (social support network)friends (social support network)
vocational class (therapeutic vocational class (therapeutic activity)activity)
familyfamily
ILLNESS CENTEREDILLNESS CENTERED
Person Centered RecoveryPerson Centered Recovery
Recovery with chronic illnesses must be person centered not illness centered.
Illnesses don’t recover, people do.
Recovery is from the crippling, not the injury.
Recovery is from the destruction, not the illness
personperson
housing (home)housing (home)
illnessillness(a part of me)(a part of me)
employmentemployment
friendsfriends
familyfamily
PERSON CENTEREDPERSON CENTERED
Person Centered TreatmentPerson Centered Treatment
The foundation of a good treatment is a good relationship, not a good diagnosis.
The purpose of mental health treatment, including medication, is not just to treat mental illnesses. It’s to help people with mental illnesses have better lives.
Medications should be quality of life goal directed instead of symptom relief directed
Neal Adams MD Copyright 2008
Person-CenteredPerson-Centered……a fuzzy concepta fuzzy concept
everyone recognizes overall meaning different connotation for
different people core elements of
concept is clear but unclear on the periphery
difficult to operationalize in measurable elements
Patient-Centeredness
The concept of a medical home The concept of a medical home (practice team that coordinates a (practice team that coordinates a personperson’’s care across episodes and s care across episodes and specialties) is now reaching center specialties) is now reaching center stage in proposal for redesign of stage in proposal for redesign of the US health care systemthe US health care system.
The question remains open, however, about the degree to which The question remains open, however, about the degree to which medical homes will shift power and control into the hands of medical homes will shift power and control into the hands of patients, families and communities. In this paper patients, families and communities. In this paper I argue for a I argue for a radical transfer of power and bolder meaning of radical transfer of power and bolder meaning of ‘‘patient-patient-centered carecentered care, whether in a medical home or in the current , whether in a medical home or in the current cathedral of care, the hospital.cathedral of care, the hospital.””
““What What ‘‘Patient-CenteredPatient-Centered’’ Should Mean: Confessions Of An Extremist Should Mean: Confessions Of An Extremist”” Don Don Berwick, MD, Health Affairs, May 2009Berwick, MD, Health Affairs, May 2009
BerwickBerwick’’s Three Maxims Three Maxim’’ss
The needs of the patient come firstNothing about me without meEvery patient is the only patient
The experience (to the extent the informed, The experience (to the extent the informed, individual patient desires it) of transparency, individual patient desires it) of transparency,
individualization, recognition, respect, dignity, individualization, recognition, respect, dignity, and choice in all matters, without exception, and choice in all matters, without exception, related to onerelated to one’’s person, circumstances, and s person, circumstances, and
relationships in health care.relationships in health care.
Neal Adams MD Copyright 2008
quality
right care
right way
right time
Nothing About Me…Nothing About Me…Without MeWithout Me
Neal Adams MD Copyright 2008
quality
right care
right way
right time
person-centered
care person needs
manner person desires
time person desires
Nothing About Me…Nothing About Me…Without MeWithout Me
Surgeon GeneralSurgeon General
Established the scientific case for effective mental health practice
Identifies gaps between current practice and potential
Highlights inequities based on race and culture Lays the groundwork for President’s
New Freedom Mental Health Commission
…America's mental health service delivery system is in shambles
…we have found that the system needs dramatic reform….
…a dysfunctional service system that cannot deliver the treatments that work so well.
Michael Hogan, PhDMichael Hogan, PhDChairChair
PresidentPresident’’s New Freedom s New Freedom CommissionCommission
Interim ReportInterim Report20022002
President's MH President's MH CommissionCommission
in a transformed system…
“Consumers of mental health services must stand at the center of the system of care.
Consumers needs must drive the care and services provided.”
President's MH President's MH CommissionCommission
Goal 2 Mental Health Care is Consumer and Family
Driven Recommendation 2.1
the plan of care will be at the core of the consumer-centered, recovery-oriented mental health system
providers should develop customized plans in full partnership with consumers
IOM quality chasm reportIOM quality chasm report
Health care system is failing needs more than incremental change
Problems are structural and systemic views healthcare as a complex adaptive
system Proposes new paradigm
6 aims that define quality 10 operational rules 4 domains of change 4 levels within a system
IOM six aimsIOM six aims
Healthcare should be safe effective timely efficient equitable person-centered
IOM quality chasm reportIOM quality chasm report
Health care system is failing needs more than incremental change
Problems are structural and systemic views healthcare as a complex adaptive
system Proposes new paradigm
6 aims that define quality 10 operational rules 4 domains of change 4 levels within a system
Improving the Quality of Improving the Quality of Health Care for M/SU Health Care for M/SU
Conditions Conditions Six Key problem areas
assuring that the system is patient-centered enhancing the measurement and quality
improvement infrastructures that support care improving linkages across all systems of health
care promoting active participation by
representatives of both the mental and substance use field in the national health information infrastructure
building workforce competency and capacity the need to adapt to the unique marketplace for
the care of M/SU conditions
International PathwaysInternational Pathways
making mental health a public priority, promoting mental well-being and diminishing the stigma and discrimination associated with mental illness
improving access and enhancing the range of available services
assuring an adequate, competent, and skilled mental health workforce
making consumer involvement, a response to individual needs, and recovery and wellness the focus of mental healthcare
integrating and linking mental healthcare with general healthcare and other sectors and services
promoting evidence-based, measurable, and accountable mental healthcare
People who rely on public mental health services should be directly involved in designing their own care plan. Even though state and local agencies often include consumers and other advocates in care planning, they often allow them to have only a marginal role and fail to provide important information that could enable them to participate fully and effectively.
Bazelon Center 2008
“You keep talking about getting me in the ‘driver’s seat’ of my treatment and my life… when half the time I am not even in the damn car!”
Person in Recovery as Quoted in CT DMHAS Recovery Practice Guidelines, 2005
In Other Words...
Neal Adams MD Copyright 2008
Neal Adams MD Copyright 2008
Carl RogersCarl Rogers
congruence genuineness, honesty with
the client empathy
the ability to feel what the client feels
respect acceptance, unconditional
positive regard
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
Outcomes
Mental Health Care ModelMental Health Care Model
The (written) treatment planmakes EXPLICIT the shared understanding and the course of action agreed upon by the patient and provider
The plan is social contract
Shared Decision Making is an Shared Decision Making is an opportunity to make recovery real. opportunity to make recovery real. By developing and promoting By developing and promoting shared decision-making in mental shared decision-making in mental healthcare, we can advance healthcare, we can advance consumer-centered care and consumer-centered care and recovery. recovery.
Kathryn PowersKathryn PowersJuly 10, 2007 July 10, 2007
Shared decision-making is an interactive and Shared decision-making is an interactive and collaborative process between individuals and their collaborative process between individuals and their health care practitioners about decisions pertinent to the health care practitioners about decisions pertinent to the individualindividual’’s treatment, services, and ultimately their s treatment, services, and ultimately their personal recovery. personal recovery.
An optimal decision is one that is informed, consistent An optimal decision is one that is informed, consistent with personal values, and acted upon. Participants are with personal values, and acted upon. Participants are satisfied with the process used to make the decision.satisfied with the process used to make the decision.
Shared decision-making is particularly relevant when there is uncertainty about a particular decision
Uncertainty may stem from multiple or competing options each with advantages and disadvantages, incomplete or inconclusive scientific outcome evidence or individual factors such as personal values and beliefs, a limited knowledge about the options, or lack of support to make a clear choice.
Effective shared decision-making requires both informed and involved consumers, and practitioners who are willing to enter into meaningful dialogue with the person about the decision to be made.
Advantages of SDMAdvantages of SDM
Clients can best make decisions because of the unique values they place on outcomes and the necessary trade-offs based on preferences and needs (Charles and Demaio, 1993).
Surveys demonstrate near universal client desire to receive health care information and to participate in treatment decision-making (Benbassat, Pilpel & Tidhar, 1998).
Shared decision-making leads to improvements in the provider-client relationship and health outcomes, such as treatment adherence, treatment satisfaction, and biomedical outcomes (Stewart, 1995).
SDM in Mental HealthSDM in Mental Health
The critical first step to productive interactions and shared decision-making in mental health is shared understanding of consumer’s personal hopes and dreams, as well as the barriers that may lie in the way of success.
Without this understanding, there is no real basis for shared decision
SDM in Mental HealthSDM in Mental Health
In most service delivery systems today, this essential step is all too often overlooked and neglected—or at minimum done poorly.
Even when such understanding is considered, disagreements that become barriers to true mutuality in decision–making are avoided and go unrecognized rather than acknowledged and resolved.
Common GroundCommon Ground
The critical first step to “productive interactions” and shared decision-making is shared understanding of the patients personal hopes and dreams and wellness vision the barriers that may lie in the way of success appreciation of the patient’s experience and life context
Common Ground / Shared Understanding / Formulation must be an explicit step in the process supports phenomenological / integrative rather than
nosological approach to diagnosis
Without this understanding, there is no real basis for shared decision making and person-centered care.
In most service delivery systems today, this essential step is all too often overlooked and neglected—or at minimum done poorly.
Even when such understanding is considered, disagreements that become barriers to true mutuality in decision–making are avoided and go unrecognized rather than acknowledged and resolved.
Common GroundCommon Ground
DecisionalDecisional ConflictConflict
The uncertainty about which course of action to take when choice among competing actions involves risk, loss, regret or challenge to personal life values
Every day, people are faced with options affecting their health Surgery or medical management Condoms or the Pill? More aggressive options when simpler strategies
are not controlling acne, depression, cholesterol, blood sugar, menopause symptoms, insomnia, or attention deficit disorder?
Care at home or in a nursing home?
Decisional ConflictDecisional Conflict
Decision making is the process of choosing between alternatives, which may include doing nothing. Competent decision makers need to
understand and consider• the courses of action open to them• the chances of positive and negative effects• the desirability or value of these effects.
People are more likely to choose an option they think is likely to achieve valued outcomes and to avoid undesirable outcomes.
Decisional ConflictDecisional Conflict
Unfortunately, many health care decisions have alternatives that have both desirable and undesirable
outcomes have desirable outcomes occurring partly
with one option and partly with anotherNo alternative will satisfy all our
personal objectives and no alternative is without its risk of undesirable outcomes
Preference-Sensitive Care Preference-Sensitive Care
comprises treatments that involve significant tradeoffs affecting the patient’s quality and/or length of life
decisions about these interventions – whether to have them or not, which ones to have – ought to reflect patients’ personal values and preferences
ought to be made only after patients have enough information to make an informed choice
Preference-Sensitive Care Preference-Sensitive Care
Treatments for conditions where legitimate treatment options exist options involving significant tradeoffs
among different possible outcomes of each treatment • some people will prefer to accept a small risk of
death to improve their function• others won’t
decisions about these interventions should• reflect patients’ personal values and preferences• should be made only after patients have enough
information to make an informed choice, in partnership with the physician
Variations in Rates of Variations in Rates of Preference-Sensitive CarePreference-Sensitive Care
Extreme variation arises because patients commonly delegate decision-making to physicians under the assumption that doctors can
accurately understand patients’ values and recommend the correct treatment for them
Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians
Research on Decision-Making Research on Decision-Making Capability Involving Individuals With Capability Involving Individuals With
Psychotic Symptoms Psychotic Symptoms
IOM findings Although as a group, persons with
psychotic symptoms exhibit impaired decision-making capability to a greater extent than non–mentally ill individuals, there is considerable heterogeneity within the group.
Psychotic symptoms have less influence on decision-making capability than do cognitive abilities (i.e., the ability to remember, learn, under- stand, and reason).
Research on Decision-Making Research on Decision-Making Capability Involving Individuals With Capability Involving Individuals With
Psychotic Symptoms Psychotic Symptoms
IOM findings Individuals with severe mental illnesses,
such as schizophrenia, that can affect cognition may have much in common with those having other chronic general medical conditions, that can impair brain functioning, memory, and cognition
There is substantial evidence that understanding of factual information--even among persons with psychotic symptoms-- can be improved through interventions
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HypothesisHypothesis
Person-centered treatment plans are a key lever of personal and systems transformative change at all levels: Individual and family Provider Administrator Policy and oversight
Neal Adams MD Copyright 2008
essential role essential role of treatment planningof treatment planning
key lever for systems changes at all levels making it real
opportunity to assure that individual recovery-- oriented life goals direct services
not about documentation all about the process
frequent point of failure
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A Plan Is A Road MapA Plan Is A Road Map
Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served
A E
B C D
“life is a journey…not a destination”
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What Do People Want? What Do People Want?
Commonly expressed goals of persons served
Manage their own lives Quality of life Social opportunity Education Activity / Accomplishment Work Transportation Housing Spiritual fulfillment Health / Well-being Satisfying relationships
... to be part of the life of the community
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Building a PlanBuilding a Plan
Request for services
Assessment
Services
Understanding
Goals
Objectives
Outcomes
Prioritization
Strengths/Barriers
The Problem is, However… Many/most clinician’s have little training in
writing plans The focus tends to be on filling out forms and
meeting paperwork requirement The plan is viewed as an administrative
requirement with little relevance to patient care Because clinician's don’t know how to plan well,
they don’t see it as useful for themselves or patients
Rather than using the plan as a point of engagement, it is a burden outside their “real work”
Neal Adams MD Copyright 2008
Neal Adams MD Copyright 2008
Creating The SolutionCreating The Solution
the treatment / recovery management plan can be the bridge between the system as it exists now and where we need to go in the future
Neal Adams MD Copyright 2008
Competencyknowledge, skills and abilities
Project Management
work / business flow
Change Management
behavior and attitude
Change ModelChange Model
In Conclusion…In Conclusion…
We must move beyond endorsing the values of person-centered medicine shared decision-making and make it the everyday norm—for patients and providers
Treatment planning based on common ground and shred decision-making can be an effective strategy for making practice more person-centered and recovery oriented
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