Recovery Tools for Peers in
Medication Management
Programs
Presented to:
USPRA
June 13, 2011
© 2010 Community Care Behavioral Health

Presenters
• James Schuster: Supporting Recovery in Clinical Services In
Pennsylvania
• Pat Deegan: CommonGround: Electronic systems and portable toolkits that promote shared decisions involving recovery in medication clinics
• Leanna Plonka: Implementing Recovery focused toolkits with peers in medication clinics
• Andrew Henderson and Nick DeSantis: Using an electronic decision support system in a Peer Center
© 2010 Community Care

Definition of Recovery
• Recovery is a self-determined and holistic journey that people undertake and through which they can grow.
• Recovery is facilitated by relationships and environments that provide hope, empowerment, choices and opportunities that promote people reaching their full potential as individuals and community members.
• from “A Call for Change: Toward a Recovery-Oriented
Mental Health Service System for Adults”
© 2010 Community Care

The Role of Shared Decision Making
• Focus on
– Person Centered Care
– Respect for Autonomy
– Choice and Collaboration
• Uses te chnologies
– Decision Aids
– Electronic Decision Support Programs
• Goal is to put person centered and recovery values into practice
Drake, R, Deegan P, Rapp C: The Promise of Shared Decision Making in Mental
Health. Psychiatric Rehabilitation Journal 2010 34: 7-13
© 2010 Community Care

Relevance of SDM
• Aids in complex decisions, e.g. psychopharmacology
• Support for re-engineering psychiatric services, especially outpatient psychiatrist clinics
• Reinforces the patient centered focus that is key to success
• Identified as key by National Institute of Health
Improving the Quality of Health Care for Mental and Substance Use
Disorders, Institute of Medicine, National Academies Press, 2006
© 2010 Community Care

Impact of SDM
• Improves consumer satisfaction
• Lack of informed involvement may decrease patient adherence
• Not necessarily correlated with the “right” decision, but with individual’s consumer values
• No satisfactory research on relationship to long term outcomes
Curtis L, Wells S, et al: Pushing the Envelope. Psychiatric Rehabilitation Journal
2010 34:14-22.
© 2010 Community Care

Pennslyvania HealthChoices
• Medical Assistance (Medicaid) Managed Care
Program
• Department of Public Welfare; Office of Mental
Health and Substance Abuse Services Oversight
• Statewide Behavioral Health Carve-Out
– 1915b Federal waiver
– County government is the recipient of funds
– County government contracting models vary
© 2010 Community Care

About Community Care
• Behavioral Health Managed Care Company
• Founded in 1996
• Federally tax exempt non-profit 501(c)3
• Sole member corporation (UPMC) – provider owned
• Licensed as a Risk-Assuming PPO
• Major focus: publicly funded behavioral health care system
© 2010 Community Care

About Community Care
• Medicaid/HealthChoices membership: 700,000
• Commercial/Medicare membership: 430,000
• Statewide HealthChoices presence
– 36 of 67 Pennsylvania counties
• 8 offices across the Commonwealth
• More than 500 employees
• Approximately 110,000 people served
• Statewide network of more than 2,500 providers
© 2010 Community Care

• Department of Public Welfare
• Counties
• Advocacy Groups
• Other Stakeholders
– Law Enforcement
– Forensic Systems
– Education
© 2010 Community Care

Erie
Crawford
Venango
Lycoming
Mercer
Jefferson
Jefferson
Clinton
Lawrence
Butler
Beaver
Washington
Greene
Centre
Centre
Montou r
Armstrong
Indiana
Westmoreland
Fayette Somerset
Cambria Blair
Bedford
Fulton
Franklin
Perry
Cumberland
Dauphin
Lebanon
Lancaster
Northampton
Lehigh
Bucks
Montgomery
Delaware
Philadelphia
Community Care Office
Community Care Contract
© 2010 Community Care

• Transforming the attitudes of those who are directly or indirectly involved with the behavioral health system
• recovery is possible for all
• empowerment and integration for all behavioral health consumers is essential
• shared decision-making at all levels is key.
© 2010 Community Care

• Multiple annual, regional, and statewide conferences focused on recovery concepts and tools
• Hearing Voices trainings across the state with thousands of participants
• Recovery-focused webinars with thousands of participants
• Web-based information and tools
• Learning Collaborative Development
• Targeted Engagement with Psychiatrists
© 2010 Community Care

Community Care’s Recovery Institute
• Assistance through a multi-year contract with Pat
Deegan, PH.D. & Associates, LLC
– To provide consultation and training on systemwide efforts to implement recovery-oriented services at all levels of behavioral health service systems.
– Model is one of engagement and support with providers, not confrontation.
– Recognizes that safety issues can be addressed in a recovery model.
© 2010 Community Care

Providing technical assistance and resources for new program implementation
• Use of Learning Collaborative or similar model
• A regional network of providers with initial external technical expertise
• Tap the collective strengths of members
• Goal is for the collaborative to be self sustaining
• Measureable progress
• Longer term goal is changing the agencies’ culture
© 2010 Community Care

Clinical Interventions supported by state policy and county direction
• Adaptation of Clinical Services
– Partial Hospital to Psych Rehab
– Peer Services
– Stress on Motivational and Engagement Strategies
– Close collaboration/integration with other psychosocial services (Housing, Employment, etc)
© 2010 Community Care

New Clinical Services
• CommonGround Decision Support Center
– Peer support
– Installation in medical clinic or peer center
– Reviews the consumer’s progress towards their recovery goals
– Reviews the consumer’s progress in treatment
– Prints out a summary report for the member and clinician
© 2010 Community Care

Development of CommonGround Toolkits
• Focus on Personal Medicine, Power Statements, shared decision making
• Can be paper and pencil or electronic
• Can be used in or out of clinical settings
© 2010 Community Care

Recovery Learning Collaborative
Erie
Crawford
Venango
Warren
Forest
McKean
Elk Cameron
Potter
Tioga
Lycoming
Bradford
Sullivan
Susquehanna
Wyoming
Lackawanna
Wayne
Pike
Mercer
Lawrence
Beaver
Allegheny
Washington
Greene
Butler
Clarion
Armstrong
Westmoreland
Fayette
Jefferson
Indiana
Somerset
Clearfield
Cambria Blair
Bedford
Clinton
Centre
Union
Snyder
Mifflin
Juniata
Perry
Columbia
Montour
Luzerne
Northumberland
Schuylkill
Dauphin
Lebanon
Berks
Monroe
Carbon
Northampton
Lehigh
Bucks
Huntingdon
Cumberland
Montgomery
Lancaster
Chester
Fulton
Franklin
Adams
York
Delaware
Philadelphia
Allegheny County
Chartiers Community
MR/MR, Inc.
Family Services of Western PA
MBH
Milestone
Northwestern Human Services
Residential Care Services, Inc.
Transitional Services, Inc.
Turtle Creek Valley MH/MR, Inc.
Staunton Clinic
WPIC
© 2010 Community Care
Lehigh-Capital Region
Bell Socialization
Familicare Counseling Center
SAM, Inc.
Berks Counseling Center
Threshold
Project Transition
Adams Hanover Counseling
Services, Inc.
York/Adams MH/MR Program
Chester County
Cherry Hill Lane LTSR
Fellowship
Holcomb
Elwyn
Human Services, Inc.
Kelsh Associates, Inc.
Penn Psychiatric Center
Salisbury BH, Inc.
Northeast Region
BH Services of Wyoming Valley
NHS Human Services of NE PA
NHS Carbondale
Northeast Counseling
Services
Scranton Counseling
Center
North Central Region
Beacon Light Behavioral
Health Systems
Clearfield-Jefferson
Community MH Center
Community Service Group
Dickinson MH Center
SAM, Inc.
-----------------------------------
Centre County MH/MR
Strawberry Fields, Inc.
The Meadows
Universal Community BH
Carbon, Monroe, Pike
Resources of Human
Development – Crossroads
Community Services
REDCo
NHS Mt. Pocono

Learning Collaborative
• The “learning collaborative” approach, in which clinical staff work together to redesign their systems to become more patient-focused and efficient.
*Chin, Mathew: Improving Health Care Delivery: “Learning Collaborative” Approach; The Commonwealth
Fund: June 2005.

Learning Collaborative
• According to the Institute of Medicine the Learning
Collaborative focuses on:
– Group management and processes through collaborative problem-solving, exchange of best practices and strategies for project implementation
– The sharing of information
– Working to design, develop, test, and evaluate innovative approaches to healthcare delivery and payment including, assessment of value
*President’s Report Supplement, 2009 Edition; Institute of Medicine; 15-18

Cost Efficiency
• Our experience:
– Use of the in-office tools (SDM/Common Ground) is supported by a Peer Specialist prior to the MD visit.
– The cost has not demonstrated any substantive increase in the overall cost per member.
– Literature clearly demonstrates that heightened recovery is associated with improved clinical outcomes
© 2010 Community Care

CommonGround:
Prepare, Participate & Self-Manage
Psychiatric Disorders and Recovery http://www.patdeegan.com

In today’s healthcare environment, there is no time for waiting in waiting rooms
• Prepare
• Participate
• Self-manage

Shared Decision Making

• 6,000 users
• 75% shared decisions entered for over 15,000
CommonGround
Health Reports
• 8/2006 – 3/2011 Shared decision making can happen within the constraints of the 15-min appointment

Analysis of 2,500 Personal Medicines
CATEGORIES
• Family/friends
• Music, TV, movies
• Physical activity/exercise
• Religion & faith
• Personal philosophy
• Hobbies & games
• Reading
• Relaxation, meditation, rest
EXAMPLES
• Cooking for my mom
• Reading my Bible
• Fishing on Sunday
• Providing for my family
• Playing hoop w/ my friends
• Petting my cat

A Power Statement helps your doctor know how YOU want medicine to help.

Being a good dad and keeping up with my 1-year old daughter is the most important thing in my life. I want you to work with me to find a medication that will help me pay attention to my daughter and not my voices. We have to find a medicine that also has no sexual side effects.

Three minute videos that offer stories of recovery and hope!

The medication is helping but I still feel anxious.
I will attend the relaxation group and art group because they help manage my anxiety.
I’m working with the peer specialist to find the
Personal Medicine Cards that will work for me.

• The things that give my life meaning and purpose and that put a smile on my face
• The things I do that that help make me well
• The things I do that help me avoid jail, hospital, homelessness, losing my job, losing custody of my kids, etc.

 What we DO to be well
– Not what we take
 Is what we do NOW
– Not a future goal
 Is not a feeling or state of mind
– It’s what we DO to feel better

Quiz

Quiz

Quiz

Lift weights
Care for my cat
Don’t know
Smoke
Call my brother
Staying sober
Makes me less angry
Helps me stay out of the hospital
Calms me down
He makes me laugh
Staying sober gives me a future
√
√
√

Mon Yough Community Services
• Community Mental Health Center since 1969
• Serves the Mon Valley “Rust Belt”
• 2000 adults in Mental Health Outpatient
• Recovery Services include:
– Psychiatric Rehabilitation/ Social Rehabilitation
– Supported Housing, Supported Employment
– Peer Support, CommonGround Toolkits

Learning Collaborative
Personal Medicine Toolkit
• Proposal Submitted May 2009 / Objectives:
– Continue to build principles and practices of mental health recovery
– Within the first year, train Adult Outpatient staff in Hearing Voices simulation and watch the Personal Medicine and Power Statement screen casts.
– Within the first year have between 5-10% of active adult clients in the
Outpatient clinic with Personal Medicine and Power Statement
– Within the second year have between 15-20% of active adult clients in the Outpatient clinic with Personal Medicine and Power Statements,
85% of first year clients update their Personal Medicine and Power
Statements at 6 month Intervals.
• First Team meeting October 2009
• Team – Administrator, Quality Assurance, Clinical, Peer
• First Implementation of Personal Medicine February 2010
– Medication Clinic, CRR, ACT team (lite)
• Second Implementation of Personal Medicine June 2011
– Recovery Services, Outreach team, IOP Program
• First Implementation of Power Statements July 2011

1
5
6
2
3
4
7
8
9
10
11
12
13
14
15
17
MYCS PM Implementation Milestones
Timeline Personal Medicine Implementation
Milestones
Identify the members of and form the leadership team (see page two)
Review Toolkit Components
Sign the "Leadership Team Pledge"
Plan for/carry out agency-wide announcement of initiative
Schedule monthly meetings of the Team to track progress
Identify the program that will begin the implementation
Develop training plan:
QIT
OPA, Med Clinic, White Oak CRR, ESCS, Front Desk
Varies
Committee member PM
QIT
Adult SC, Intake/Crisis, Rehab, SE, Outreach
Varies
All Staff have completed their own PM Worksheet
Identify # of clients who will need to complete PM & partner with appropriate Staff Member MED CLINIC 150, ESCS
30, WHITE OAK 8
Prepare PM Cards for distribution
Begin Initiative is use of PM worksheet and PM cards
Develop plan for replenishing PM Cards
Develop plan for updating PM worksheets
Develop plan for collecting Performance Indicators (see page two)
Develop plan for using PM agency wide
QIT
QIT
QIT
Programs
QIT
QIT
QIT
Develop plan for integrating PM into new client orientation
QIT
QIT
QIT
Chair
Chair
Chair
QIT
QIT
Chair
05/01/2009
07/01/2009
09/01/2009
10/12/2009
05/01/2009 below
11/09/2009
09/01/2009
11/09/2009
09/01/2009
09/01/2009
11/04/2009
09/01/2009
12/07/2009
12/07/2009
11/01/2009
04/01/2010
04/01/2011
12/09/2009
Notes
08/26/2009
Sr Mgmt wants Res and SCU plan added
10/05/2009
11/01/2009
11/05/2009
BOD present, All Staff, Operations, powerpoint on sharepoint
08/26/2009
Added White Oak CRR and ESCS team below
02/01/2010
Committee agrees all staff in these departments will receive the 1.5 hr training by 12/15/09,
11/17/2009
02/01/2010 closer to beginning initiative. Intake/Crisis schedule 12/31 and 1/7, 1/5 ontrack
01/31/2009 all staff means anyone above or below
12/07/2009
02/01/2010
1/4/10 have prices for all supplies committee approval, debs restock card template idea, 1/4 on target
02/01/2010
02/01/2010
02/01/2010
02/01/2010
04/01/2011
Start up in phases with a plan to have PM agency wide by 4/1/12
04/01/2011
Target July 2011

Learning Collab vs Training
• Advise
• Resource rich
• Everyone is an expert
• Openness about what is working/not working
• Many team members
• Learn how to participate in conf calls
• Teach
• Set curriculum
• Trainer is expert
• Are you doing it or not
• Individualized/Dept
• Webinar/ Face-to-Face

Lessons Learned
• Realistic objective targets – met 1st year objectives by the 2 nd year
• Value in Guiding tools / Guiding learning collaborative
• Value of the Learning Collaborative focus on success and problem solving barriers
• Strength in unique provider plans
• Strong internal Team
• Borrow excellence, fail fast
• Strength of the Organizations Integrated care vision

Lessons Learned
• Proposal anticipated challenges: Staff turnover, competing training demands, competing program development demands
• Challenge - staff buy-in
• Challenge - staff turnover
• Challenge – Org Development: Improved Access,
Integrated Care
• Challenge – lack the visibility of the Decision Support
Center in the Med Clinic

Lessons Learned
• Challenge – Med Clinic vs CRR / ECSC
• Challenge – Shifting culture and service recipients experience of typical med visit

Data
CRR – all 8 residents have completed PM worksheets, with updated every 6 months with trt plans and medical records referencing
PM.
ECSC – all 28 service recipients have completed
PM worksheets
Medication clinic – 27 service recipients have completed PM worksheets

COMMONGROUND in a Peer Center
The County Vision was to have this recovery tool in a Peer
Center, making Community Crossroads the first Peer Center to fully implement CommonGround
• Challenges
– Privacy parameters of system restrict psychiatrist from viewing online report
– Training of all county providers and psychiatrists
© 2010 Community Care

COMMONGROUND in a Peer Center
• Advantages
– Open to entire county
– Participants have unlimited access
– All staff are trained CommonGround
– Implies that the use of CommonGround is voluntary
– Builds relationships with all stakeholders
© 2010 Community Care

COMMONGROUND in a Peer Center
Concepts that mesh with peer support philosophy
• Engagement
• Self-esteem
• Personal Medicine
• Power Statement
© 2010 Community Care

COMMONGROUND in a Peer Center
CommonGround as a self-assessment
• Aided by resource library
• A way to ask tough questions/ non judgmental
• Share experience with doctors
• Ability to feel comfortable with each other which allow some difficult discussions
© 2010 Community Care

COMMONGROUND in a Peer Center
Preparing for a Brief Psychiatric Appointment
• Review report and help prioritize questions/concerns
• It can be hard to organize thoughts, answer the doctor's questions, ask questions, speak up about concerns and make decisions
• Aids in motivating someone to go to the appointment
• CommonGround Report creates partnerships in treatment decision-making and in peer support
© 2010 Community Care

COMMONGROUND in a Peer Center
Statistics (
As of April 30, 2011)
• 102 Active Users
• 170 Finished Reports (172 Started)
• 2,255 Clicks to links to other resources in CommonGround
April 2011
• 31 Used CommonGround
• 28 Reports started and finished
• 20 Users updated their Pill Medicine, Personal Medicine and/or Power Statement.
© 2010 Community Care

COMMONGROUND in a Peer Center
Anecdotal outcomes-Lessons Learned
• In Self, Service & Support Look for Similarities not Comparisons
• "From Resentment to Resolution“: The CommonGround Road to Recovery
• "While my Guitar Gently Weeps”: So I don't have to.
© 2010 Community Care

© 2010 Community Care
Questions or Comments?

List of Presenters
James Schuster, MD. MBA – Chief Medical Officer Community Care schusterjm@ccbh.com
Pat Deeganpat@patdeegan.com
Leanna M Plonka, MS, CRC, CRRPplonkalm@mycs.org
Andrew HendersonANDREW.HENDERSON@hhinc.org
Nick DesantisNICK.DESANTIS@hhinc.org
© 2010 Community Care