Patient and Family Engagement and Retention. Care Manager Role. Who is on the recruitment/engagement team? General Recruitment Challenges

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1 Patient and Family Engagement and Retention Announcement from Archstone Foundation Rita Haverkamp, MSN, PMHCNS BC, CNS Expert Care Manager and AIMS Center Trainer Collaborative Care Team Approach Care Manager Role PCP Patient Care Manager(s) Psychiatric Consultant Identify & Engage Establish a Diagnosis Initiate Follow up Care & Treat to Target Complete & Relapse Prevention System Level Supports CBO Family General Recruitment Challenges Need to engage and treat 100 older adults with depression over 2 year grant Putting things into perspective In order to engage 25 patients in care by June 30, 2016, you will need to enroll ~ one patient per week It s easier to recruit from the pool of patients at the primary care clinic rather than the CBO Difficulty of individuals at CBO having a relationship with a PCP at another clinic Don t rely on one person or one plan to find patients Your workflows will change as you find new ways to identify and engage potential patients Document your changes to workflow in your Implementation and Innovation Guides Who is on the recruitment/engagement team? All team members support the system Provider sets the stage for getting the patient to accept the care and continues to support involvement Care manager explains the care model and uses the engagement process that will be described today. Encourages follow up in both systems Therapist encourages use of the rest of the team members in patient care CBO encourages follow up in both systems. Uses engagement

2 Borrow the trust the patient has with others in the system Stress the team work aspects of care Support the care in your partnering agency Be sure the patient is aware of the team work and is part of the team Reciprocal causality (everything affects everything) Alliance Tips on words Checkpoint Avoid program, study or any way you word it that makes it unusual Make it special or normal Avoid stressing therapy Some people will get better without therapy. This is an important part of the model. Some people don t want therapy or may have negative thoughts about it Why is engagement so important? Foundation to Process 3 Critical elements of Alliance: Engagement Assessment Crisis management Goals? Tasks? Bond? Depression Anxiety Behavioral Interventions Working Alliance All 3 must be agreed upon by patient & provider

3 Key #1 Quality of Alliance determines outcomes (coaching, counseling, medicine, teaching, job training) Strong alliance Weak alliance Good outcome Poor outcome Engagement Steps Elicit the story = understanding, summary of pros/cons to treatment Elicit treatment hopes and dreams Feedback = psycho education Barriers: practical, psychological, cultural Elicit commitment Practical tips to grow the bond Be warm up front, to patient and the family Have 3 or more contacts within first 2 months Get 5 10 phone numbers of those who are hard to reach or have unstable phone situations Have patients call back even if they are or are not doing well Educate & Inform Clinic provides whole patient care Focus on symptoms problematic for patient Don t argue about diagnosis, focus on symptoms options Patient preference Prior experience Family experience Set Expectations We have effective treatments Most patients need at least 1 treatment change Sometimes multiple changes We won t give up! You play an important role Selecting/changing treatment Goals Self management Family engagement Barriers Practical hard to get to appt can use phone Psychological not ready, fear, past failed treatment, I m not crazy open conversation, listen to fears, start slow Cultural we don t air our dirty laundry, we don t take meds acceptance, go at their pace

4 What happens when you have a patient difficult to engage? What does the patient do? What do you do in response? Some Provider Potholes Question and answer trap (closed questions) Correcting wrong thoughts with rational explanations (telling them what to do) Avoiding the patient (hiding, acquiescing with Rx) What are some you notice? Key #2 Not ready to change/engage? Not Ready On the Fence Ready Assessing for readiness What brings you to see me? What are you expecting in this visit today? What are you hoping to get from your care? After behavioral health assessment Set mutual goals Agree on the initial task to return for treatment Good reflections prove you understand Shows nonjudgmental understanding of the patient s point of view Most powerful technique for preventing and dealing with tough interactions Communicates respect and understanding of the patient s experience Does NOT mean you agree with their explanatory model nor endorse maladaptive behavior choices! Why Engage Caregivers / Family? Family sees mood and behavior changes over time Family can support treatment plan Especially self management plans Patient chooses level of family involvement

5 How to Engage Families/Caregivers Checkpoint Shared view of depression Myths Stigma Cultural beliefs about causes of depression, treatments Provide resources to learn about depression Existing resources in your clinic? Share treatment plans Give family role in supporting treatment Engage family in relapse prevention planning Care Manager Role Diagnosis is it Distress? Identify & Engage Establish a Diagnosis Initiate System Level Supports Follow up Care & Treat to Target Complete & Relapse Prevention Distress differs from Depression / Anxiety External cause(s) May be fueled by lack of coping skills May look like depression, anxiety Intervention not the same! Important to differentiate Might be Distress AND Depression / Anxiety Needs to be depression or both to be in this model Is it Depression? How long has patient been feeling this way? Less than 2 months? Did something specific happen? Grief, bereavement? Adjustment reaction? Stress? Normal reaction to bad situation? Feeling upset, unhappy, distressed can be normal Making a Diagnosis Symptoms Functional Impairment Disorder

6 Collaborative Care Workflow Introducing Behavioral Activation Discuss how this helps and set a plan today with patient for what they can do before next contact Identify & Engage Establish a Diagnosis Initiate Follow-up Care & Treat to Target Complete & Relapse Prevention Medications Discuss how they work and results that can be expected, answer questions System Level Supports Psychotherapy (PST) Begin introductory session by briefly describing reasons for doing PST, the structure and how this will help Discussing Options The treatment that WORKS is the best one Person centered care means selecting treatments based on client preference, not clinician preference Try to be unbiased when offering treatment options Be eclectic: One size fits few Medication therapy is not right for everyone Psychotherapy is not right for everyone; Different therapies Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Ask questions and collect information Support patient being informed and active about all aspects of treatment plan Discussing Options Review all treatment options available Psychotherapeutic interventions Behavioral Activation, Problem Solving, Cognitive Behavioral, etc. Medications Discuss pros and cons of each option Collaborative Care Workflow Why Do We Focus on Follow up and Adjusting? Identify & Engage Establish a Diagnosis Initiate System Level Supports Follow-up Care & Treat to Target Complete & Relapse Prevention Keeps the alliance intact Critical to help make sure patients get better Patients who aren t getting better often give up drop out If it isn t working fix it whether it is therapy or medications

7 How to Be Sure You Make Each Appointment a Decision Point Three step process: 1. Frequent contacts and gather information use a PHQ 9 each time 2. Track and consider what is happening. Have patient s input. 3. Do I need to consult and/or change what I am doing? Using the Telephone A Way to Increase Contact and Engagement Under utilized tool Client centered approach convenient pro active improved bonding with patient The Many Circumstances in Which to Use the Telephone Patient who missed an appointment call NS s within 15 minutes and use this time for a telephone contact Patient who has transportation difficulties Patient doesn t want to or can t come in Patient who is caring for grandchildren at home Check in on patient between other in person visits i.e. patient who just started a new medication and is worried about side effects Helpful Hints for Scheduled Telephone Contacts This Is an Appointment Have a block of time in your schedule for this 1 2 hours so you can make numerous calls Set them about minutes apart Give patients a time for the call. Ask them if that time would be convenient free of distractions Mail them or send them a PHQ 9 so it is more easily done you can ask them to do it before the call so it is ready for discussion Structure for Telephone Contacts Ask them if this is still a good time set another time if not Have no distractions yourself and ask them not to have them either Set agenda for the call check on PHQ 9, medications and behavioral activation or have a PST session Do PHQ 9 early in call this helps to plan for the rest of the call End with plan for next appointment or call Behavioral Health Measures as Vital Signs Behavioral health measures are like monitoring blood pressure! explaining to patient increases compliance and their interest in this identify that there is a problem need further assessment to understand the cause of the abnormality help with ongoing monitoring to measure response to treatment

8 Reasons to Do It Each Time Sets evaluation of progress as the first step at each appointment with the patient Begins that discussion with patient Gives you a measurement to base consultation discussions on Patients can feel better but often do not have an idea how much better or really what better would look like Helps engagement with patient shared goals Tendency to Want to Decrease Use of PHQ 9 What are your concerns about doing it each time? Retention of patients Engagement is critical factor Continue to reassess the shared goals, tasks All members of the team supporting the care and having a shared care plan Follow up and treat to target Reasons patients drop out of treatment Not addressing patients goals Not clear in communicating this Not changing treatment plans Misunderstanding treatment Feeling better Not doing a timely relapse prevention plan Questions or challenges with patient and family engagement and retention once patients are identified? Case Call Next Month Dec. 16, 2015 Care managers come prepared to discuss a specific case involving patient and/or family engagement