The Maintaining Adherence
Programme
Practical use of psycho-education for
schizophrenia and bipolar disorder
Dr Llew Lewis
Consultant Psychiatrist
Medical Lead Maintaining Adherence Programme (MAP) UK
Deputy Medical Director
South Essex Partnership Foundation University Trust
(SEPT)
June 2013
Overview
1. Our organisations-partnership between
SEPT and Janssen
2. The Munich Compliance Programme
3. Developing our model: The Maintaining
Adherence Programme (MAP)
4. Practical tips for psycho-education based
on our experience in the MAP
5. Interim results
South Essex Partnership University
Foundation Trust
• Integrated care including mental health, learning
disability, social care, forensic and community
health services
• 200 locations across Bedfordshire, Essex, Luton
and Suffolk
• Employ approximately 7,000 people
• Serve a population of 2.5 million
• Annual turnover of approximately £350m
The “Munich Compliance Program”
• Dr Werner Kissling and colleagues,
Munich:
• Recognised significant relapse rates
in the year post discharge from
hospital
• Non-adherence to treatment a factor
• Developed a model to address nonadherence:
Munich Compliance Program developed to address
low adherence and high readmission rates
The impact of schizophrenia on healthcare budgets is substantial,
typically between 1.5 and 3% of total national healthcare expenditures.
THE SOLUTION
THE PROBLEMS
One year readmission
rates = 45%
>50% of patients
are non-compliant
Clinical studies have demonstrated that psycho-education
and wellness programmes significantly increase patient
compliance and outcomes*
Benefits of Psycho-education
Compliance programmes
are lacking
Annual costs of 5 billion
Euros in Germany
Frustrated patients,
payers, carers and
healthcare providers
Therapeutic alliance
Patient
knowledge
of disease
Self-management
of symptoms
Symptom severity
Adherence to
medication
Risk of relapse/
hospitalization
Functional outcomes
*Rummel-Kluge & Kissling. Curr Opin Psychiatry 2008; 21: 168–172
*Mueser et al. Psychiatr Serv 2002;53:1272–1284; Mueser & McGurk. Lancet 2004; 363: 2063–2072
Munich Compliance Program
1. “Differential diagnosis” of non-adherencea standardised approach to assessment
of risk factors (at baseline and 3 monthly):
• Insight
• Drugs/alcohol
• Side effects
• Beliefs and attitudes to treatment
• Cognitive factors, carer support…
Cont.
2. Psycho-education for all patients and
relatives:
• group setting, two facilitators
• 11-12 modules, manualised approach
• 1-2 hours per week
• Topics: symptoms, diagnosis, treatments,
early warning signs of relapse, crisis
planning, drugs/alcohol, relationships,
recovery
Cont..
3. Peer-to-peer psycho-education
4. Family-to-family psycho-education
5. Shared Decision Making:
• High quality information
• Collaborative partnership approach
Cont..
7. Incentives for patients:
• Financial
• Pleasant lounge atmosphere for groups
• Good coffee
8. Reminder systems
9. Home treatment
10.Wellness Elements:
• “Nordic Walking”, ”Coffee and Culture”
11.Depot clinic
12.Evaluation
13.Publication
The Joint Working Agreement &
funding arrangements
The “Maintaining Adherence Programme”
Objectives of the Project
• To partner with Janssen under a Joint Working
agreement*:
• To translate and modify an Adherence model
originally developed in Munich to a UK contextworking with Dr. Werner Kissling
• To test the model within SEPT, an innovative
mental health Trust in the south east of England.
• To produce an evaluation of the clinical and
economic benefits and outcomes
*Department of Health Joint working guidelines :
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082370
Why is this approach being considered?
• Despite advances in psychopharmacology and
service innovations(UK National Service
Framework 1999), patients still relapse,
• Therefore, the aim is to:
• Improve the quality of care and outcomes for
people with diagnoses of schizophrenia,
schizoaffective and bi-polar disorders through
a focus on relapse prevention
• Improve productivity: reduce overall resource
usage in a climate of radical financial
pressures
Who is the MAP team?
• Consultant Psychiatrist (0,4 WTE)
• 3 WTE nursing staff (inc. 1 WTE team leader)
• 2 0,5 WTE occupational therapists
Supported by:
• Project management: SEPT/Janssen)
• IT support (ipad data collection/synching with
Trust data systems)
What interventions does the UK model
provide?
• “Differential Diagnosis of non-adherence”
o initial and 3 monthly formal review of risks associated
with poor adherence
• Psycho-education for service users:
o Schizophrenia & Schizoaffective Disorder + Bi Polar
Disorder
• Psycho-education for families & care givers
o Peer to peer Psycho-education
• Reminder Service (telephone/text)
• Shared Decision making approach
• Wellness Activities
A.Establishing the team
1. Identify the team
• Experience in working with schizophrenia and bipolar
disorder
• Not necessarily group facilitation nor education skills
2. Familiarise with content of modules
3. Challenge clinician beliefs and assumptions
• “Patients wont understand the content”
• “I don’t understand the scientific/psychological
models”
• “I have never facilitated a group”
cont…
4. Role play:
–
–
–
–
–
Being the facilitator
Learning how to facilitate in pairs
Being a member of a group
Enacting different scenarios or answering questions
Getting used to using flip chart, writing on white
board, operating the iPad
5. Operational structure
• Guidelines, paperwork, ipad data syching
B. Identifying the patients
5. Raising awareness:
• Designing flyers
• Road-shows on wards, at CMHTs
• Developing referral criteria: an admission to a
ward, episode under CRHTT in the past 3 years
6. Recruiting and consenting patients
7. Designing and equipping a “Recovery Lounge”
C. Creating a process
8. Creating a process:
a) Streaming
b) Setting up
c) Settling in
d) Structuring
e) Summation
f) Skills
a) Streaming
• Be aware of differing chronicity of illness and
functional/ cognitive abilities
• The presence of positive or negative symptoms
• Whether symptoms are controlled or not
• Differing social skills
• Use wellbeing activities or baseline assessments
to form an opinion (MOCA)
Negative symptoms/ lower Global
Assessment Functioning (GAF)
•
•
•
•
•
•
Smaller groups (up to 5)
Slower pace, more didactic, more repetition
Adapt video clips..often shorter
More active facilitation,
Encouragement and positive feedback
Take time to tease out symptoms and help
participant relate content to experience
Cont...
• May need to revisit content in one to ones
• E.g. Early warning signs identification and crisis
planning...
• Be sensitive to educational attainment
• Participants may lack basic reading and writing
skills
• May be ashamed, may not admit to deficits in a
group...check this out beforehand
Higher functioning/social skills
•
•
•
•
Up to 8 manageable
Often more engaged
Ask challenging questions
More likely to read materials and do inter-group
tasks
• As group matures, the group facilitation
becomes delegated: empathic, supportive and
encouraging of one another
b) Setting up
•
•
•
•
•
•
•
Soft incentives add value
The "Recovery Lounge"
Comfortable chairs, couches, temperature
Refreshments, coffee, tea, water
Toilet access
iPad and TV connected
Name labels
Cont..
•
•
•
•
Participant and facilitator manuals
Pens and paper
Group "rules" and "expectations" displayed
Other resources: leaflets for support groups,
patient medication info leaflets,
Flip charts and whiteboards
•
•
•
•
Agenda and group structure
Open questions referencing manual content
Prompts for video and activities
Whiteboard for recording group answers and
using "own words"
• Ordering spontaneous responses into clear
domains e.g. side effect types or classes of
antipsychotics
Prepare for surprises
• Ideally two facilitators
• If required one may have to leave the group with
a participant if distressed to handover to another
team member to contain
• Aim not to stop the group
• Managing distress well sends message
facilitators can contain difficult scenarios- the
group is safe
c) Settling in
• Report to reception
• Customer care approach: our values
Positive hellos/goodbyes, common courtesies,
keeping promises, active listening
•
•
•
•
Offer refreshments
Make introductions
Remind each other of names
Facilitators support informal social interactions
d) Structuring/timing
1. "Welcome..how are you?"
a. Needs to be time limited( especially in Bipolar
groups)
2.
3.
4.
5.
Recap:"what did we learn last week?"
"Any questions"
Make time to review any homework
Introduce new topic: aim to use open questions
to gauge knowledge of the group
For example:
• What medications do you know?
– Use whiteboard to capture responses
• Facilitate as much from the group as possible.
• Arrange information into understandable groups
like:
– Antipsychotics, antidepressants, side effect
medication
• Group quite possibly has experience of many
different types
Continued...
•
•
•
•
Get the group to do the work
Fill in the gaps at the end
Encourage participation
Acknowledge the lived experience and
knowledge of the group
• Move away from didactic stance to collaborative
participation
Continued ...
6. Review, recap and summarize
a) Consolidate using participant language if possible
7. Questions and answers
8. Hand out materials…homework
9. Feedback:
"How do you think the group went?"
"Did we pitch it at the right level?"
"What could we do better?"
e)Summation
• Process notes
• Signposting as required:
–
–
–
–
To consultant clinic
To review or booster sessions
Shared decision making session
One to one work on relapse signatures/ crisis
planning
– "Choice and medication“ website
• www.choiceandmedication.org
f) Skills
•
•
•
•
•
Communication
Verbal and non verbal
Group facilitation techniques
Educative techniques
Clinical skills: listening, empathising, limited
disclosing
• Customer service : values into action
Beyond the group..
• Operational staff:
 Wellbeing activities
 Three monthly adherence review
• Medical:
 Shared decision making
 Urgent assessments and reviews
…principles…
• Reminding… linking back to group content to
answer questions about:






The need for medication
How medication works
Dopamine and psychosis
Types of medications/comparisons
Identifying early warning signs
Crisis plans
How will we evaluate the MAP
program?
Retrospective evaluation to include:
Resource use
Prospective evaluation to include:
Resource use
Clinical measures
Patient satisfaction
Staff satisfaction
Recruitment summary
Demographics
Total number of MAP attendances
(clients at 12 months post MAP entry)
Nature of MAP contacts
(clients at 12 months post MAP entry)
MARS score (medication adherence rating
scale) - baseline Vs most recent
Risk score (baseline Vs most
recent)
Resource use in 12 months pre and 12
months post MAP entry
Client and carer MAP experience
questionnaires
Which parts of the program did you find
most helpful?
How well has the psychoeducation
programme helped your understanding of
the following......?
Psychoeducation evaluation
forms
Staff feedback
• Staff interview participants were overwhelmingly positive
about the MAP Program, describing many benefits from
it for both patients and staff. Where potential
improvements were identified, these related mainly to
support for the service; for administrative tasks and for
appropriate referral of patients into and onward from the
Program, and not to changes needed in the Program
itself. However there was great willingness to learn from
continuing feedback from patients and carers, to improve
the Program if necessary.
Summary
• MAP interventions in addition to usual care
plan
• Psycho-education, reminder service,
wellbeing components, SDM, rapid access
to consultant if required
• 12 month Qualitative and economic
evaluation promising
• Awaiting final evaluation
Thank you