Diane Grieder, M.EdAliPar, Inc.NYAPRS ConferenceSeptember 2011

USING PERSON-CENTERED PLANNING AS A ROADMAP FOR CARE COORDINATION AND BETTER OUTCOMES IN AN INTEGRATED TREATMENT SETTING

Learning Objectives

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

So, what are we really talking about today?

•Health Care Reform

•Accountability (Accountable Care Organizations)

•NYS Health Homes (for people with chronic conditions)

•Patient/Person Centered Medical Home

•Coordinated Care

•Integrated Care

•Better Outcomes for people

•Better collaboration between providers

Traveling the Transformation Highway

Integration and Care Coordination

SAMHSA Rationale for Integrated Care:

•Behavioral Health is part of Health

•Prevention Works

•Treatment is Effective

•People Recover

• Pam Hyde, Director of SAMHSA

© 2009 Coordinated Care Services, Inc.

What does a recovery oriented system of care look like?

From:

Illness Focused

“Compliance” valued

Deficit Focused

Being known by what’s wrong

Professional “in charge”

Learned Helplessness

“Silo of care” focused

Institutional resources

Planning is done for the person

To:Recovery Focused

“Choice” valued

Strength Focused

Being known as an individual

Shared decision making

Active Participation

Broad bio-psychosocial focused

Community resources/integration

Planning is collaborative, recurring, and involves an ongoing commitment to the person

CMHS/SAMHSA 10 x 10 Plan: Pledge for Wellness (2007)

We envision in which people with mental illnesses pursue optimal health, happiness, recovery and a full and satisfying life in the community via access to a range of effective services, supports and resources.

We pledge to promote wellness for people with mental illnesses by taking action to prevent and reduce early mortality by 10 years over the next 10 year time period.

Druss, 2007

Major Health Risks for MH Population

Cardiovascular disease is primary culprit• Risk factors include:

• Smoking• Physical inactivity• Medication side effects• Toxic effects of abused substances• Diet• Poor access to care: underuse of evidence-based medical services

• Higher exposure to medical errors

Causes of Health Disparities

•Medications, especially the atypical antipsychotic drugs, effect on:•Weight gain•Dyslipidemia (unhealthy cholesterol profiles)•Glucose (sugar) metabolism

•High rates of smoking

•Lack of weight management/poor nutrition

•Physical inactivity

Causes of Health Disparities

•Lack of access to & utilization of preventive community healthcare, including health promotion services/resources

•Poverty

•Social isolation

•Separation of health & mental health systems at the federal, state, local level•Lack of coordinated infrastructure, policy, planning, quality improvement strategies, regulation or reimbursement

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

Empowered,HopefulConsumer

ProductiveInteractions

Receptive,CapableTeam

Recovery / Wellness Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Mental Health System

Resources and Policies

Community

Health Care Organization

Mental Health Care Model

SocialInclusion and Opportunity

The Chronic Care Model

•Model depends on individual having continuous, planned care

•Part of the model includes care management: •To educate and support the individual in becoming a partner in healthcare decision making

•To adopt self-management strategies for health promotion & living well with chronic disease

•To access community resources

AHRQ Definition of Patient Centered Medical Homes (PCMH)

5 functions and components:

•Patient-Centered•Comprehensive Care•Coordinated Care•Superb Access to Care•A systems based approach to quality and safety

Integrated MH/SA Services

Goal: To improve the proficiency of both systems of care to identify and engage persons with co-occurring disorders•Screening/Assessment•Professional Development/Training•Program Models/Guidelines•System Coordination

Care Coordination •O

ne of the core functions of the PCMH – defined as:“The deliberate organization of patient care activities between 2 or more particiapnts involved in a patient’s care to facilitate the appropriate delivery of health care services”

•Reducing Care Fragmentation…A Toolkit for Coordinating Care. California Healthcare Foundation

Care Coordination vs. Case Management?

•Care coordination is the facilitation of access to and coordination of medical and behavioral/social support services for persons across different providers and 0rganizations.

•Case Management typically focuses on a medical model with an emphasis on the person’s mental health needs only.

Key Recommendations for Integrated Healthcare: Consumer Recommendations

•Assure there is no wrong door for receiving care

•Establish Team Based Coordinated Care

•Honor Consumer Choices

•Incorporate services to facilitate receipt of physical healthcare

•Educate providers and consumers

•Create environment of respect and acceptance

• Multnomah County MHASD Healthcare Integration Report 6/22/10

Bridging the two worlds

Cole & Davis (2004)

Care Manager Functions

•Develop and maintain rapport with individual and provider

•Educate the individual and family

•Monitor symptoms & communicate findings to provider

•Develop and maintain a self-care action plan

•Maximize adherence (interest) to the care plan (can be communiyt wide)through negotiation of solutions to treatment-emergent problems

A Solution…

Hypothesis

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

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Defining Person-Centered Practice

• Person-Centered Practice is defined as working with consumers in an individualized and empowering way to assist them in their personal recovery journey.

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Being Person-Centered in Practice

• The consumer as a whole person• Sharing power and responsibility• Having a therapeutic alliance• The clinician as person

What is PCP? Taking a Closer Look

• Person-centered planning is a collaborative process resulting in a recovery oriented treatment plan is directed by consumers and produced in partnership with care providers and natural supporters for treatment and recovery supports consumer preferences and a recovery orientation

• Adams/Grieder

The Recovery Plan

•It is the “work/social contract”, created by the person and provider.

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Service Plan Functions

•Identifies responsibilities of team members--including person served and family• Increases coordination and collaboration• Decreases fragmentation and duplication• Coordinates multidisciplinary/multi-agency interventions

• Prompts analysis of available time and resources

•Provides assurance / documentation of medical necessity

• Anticipates frequency, intensity, duration of services

•Promotes culturally competent services

CARF Behavioral Health Standards 2011 on Integrated Care

•An individualized integrated plan regarding medical and behavioral health needs is developed with collaboration of:•The person served•All staff necessary to carry out the plan

Guidance to meet this standard includes:

The individualized plan is developed with the active involvement of the person served as well as the various disciplines needed to successfully implement the plan. The plan addresses and integrates, in a holistic manner, the medical and behavioral health needs of the person served

Why Shared Decision Making in Health Care?

The Problem

•High rates of failure to engage, disengagement, and non-adherence

•Less than 5% of people with severe mental illnesses receive most evidence-based services

•Important reasons include lack of information, inattention to the person’s goals, failure to empower the person, and failure to provide effective services

Finding Common Ground…

•Research indicates that physicians still fail to find common ground with patients• Without agreement about what is wrong, it is difficult for a patient and doctor to agree on a treatment plan that is acceptable to both

• Not essential that patient/doctor share the same perspective• doctor's explanation and recommended treatment must at least be consistent with the patient’s point of view and make sense in the patient’s world

Shared Decision Making is at the Core of Ethical, Patient Centered Care

Patient Centered Medical Home

Accountable Care Organizations

Meaningful Use of Health Information Technology

(HIT)

Patient Centered Medical Home

Accountable Care Organizations

Meaningful Use of Health Information Technology

(HIT)

Supporting PrinciplesA

utonomy

“The general trend has been to expand autonomy in health care decision making. [It] assumes the better informed an individual is, the better equipped he or she is to make health care decisions.”

•Surgeon General’s Report on Mental Illness

•1999 – Chapter 7

Supporting Principles

Transparency – Choice based on value“consumers deserve to know the quality and cost of their health care. Health care transparency provides consumers with the information necessary, and the incentive, to choose health care providers based on value. Providing reliable cost and quality information empowers consumer choice.”

US Dept of Health & Human Services

www.hhs.gov/transparency/

Supporting Principles

Person-Centered Planning•Treatment planning (and documentation) beyond reimbursement and administrative goals

•A roadmap for reaching individual goals

Pushing the Agenda

Shared Decision Making•As consensus building (not coercion)

•As a motivator for both experts to change

•As a systems change protocol

Decision Support Systems Address these Problems through

•A structured approach to :•defining one’s goals, •obtaining information on effective service options,

•choosing services, •participating in developing treatment plans, •on-going assessment of one’s progress, and • reviewing treatment decisions

Shared Decision Making

(Charles C, Soc Sci Med 1997; 44:681)

Clinician and patient work together

They share information

About options and outcomes

About preferences

They work toward a consensus about the preferred test or treatment

They reach an agreement on the test or treatment to implement

Decision-Making•P

rocess of making a choice (decision) from among two or more discrete options (Wills & Holmes-Rovner, 2006)

•Provider role as a consultant to support SDM (Adams & Drake, 2006)

•Majority of mental health treatment decisions are preference-driven (personal values do/should significantly guide the decision-making)

We Believe Patients Should Be

Benefits of SDM•R

educed decisional conflict•G

reater knowledge•I

mproved satisfaction with the decision-making process•I

mproved ability to make choices (fewer people left undecided)•I

mproved concordance of decisions with personal values•M

ore active involvement of consumers in decision-making•I

mproved communication between consumers and providers•L

imited study of how preferences and decision-making processes impact choices made by consumers, including service engagement and intervention outcomes

Outcomes of Shared Decision Making for Persons with Severe Mental Illnesses

•Have been demonstrated in randomized trials to: • Increase knowledge and participation in planning• Enhance patient satisfaction with care• Reduce unmet needs• Improve adherence and quality of life• Decrease symptoms of depression and alcohol abuse

•Practitioners • Increased insight into patient preferences• Improved efficiency of care• Some age and discipline related reluctance to participate

Discussion

•How do these functions relate to what you consider your role responsibilities (either as a provider or as a recipient of services) at this point in time?

•W

hat implications does this information have for clinicians/case managers/care coordinators/consumers in the future?

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