USING PERSON-CENTERED
PLANNING AS A ROADMAP FOR
CARE COORDINATION AND
BETTER OUTCOMES IN AN
INTEGRATED TREATMENT
SETTING
Diane Grieder, M.Ed
AliPar, Inc.
NYAPRS Conference
September 2011
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
What does a recovery oriented system of
care look like?
From:
To:
Illness Focused
Recovery Focused
“Compliance” valued
“Choice” valued
Deficit Focused
Being known by what’s wrong
Strength Focused
Being known as an individual
Shared decision making
Professional “in charge”
Active Participation
Learned Helplessness
“Silo of care” focused
Institutional resources
Planning is done for the person
Broad bio-psychosocial focused
Community resources/integration
Planning is collaborative, recurring, and
involves an ongoing commitment to
the person
© 2009 Coordinated Care Services, Inc.
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.
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
Druss, 2007
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
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Outcomes
Improved Outcomes
Mental Health Care Model
Community
Resources
and Policies
Social
Inclusion
and
Opportunity
Empowered,
Hopeful
Consumer
Mental Health System
Health Care Organization
SelfManagement
Support
Productive
Interactions
Delivery
Decision
System
Support
Design
Receptive,
Capable
Team
Recovery / Wellness Outcomes
Clinical
Information
Systems
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
• One 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
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
Cole & Davis (2004)
A Solution…
Hypothesis
• Person-centered treatment plans are a key lever of
personal and systems transformative change in
creating health homes/providing care
coordination
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.
23
Being Person-Centered in Practice
•
•
•
•
The consumer as a whole person
Sharing power and responsibility
Having a therapeutic alliance
The clinician as person
24
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.
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
27
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)
Supporting Principles
Autonomy
“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
 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
(Charles C, Soc Sci Med 1997; 44:681)
Decision-Making
• Process 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 decisionmaking)
We Believe Patients Should Be
Supported & encouraged to participate
in their health care decisions
Fully informed with accurate, unbiased
& understandable information
Respected by having their goals &
concerns honored
Benefits of SDM
• Reduced decisional conflict
• Greater knowledge
• Improved satisfaction with the decision-making process
• Improved ability to make choices (fewer people left
undecided)
• Improved concordance of decisions with personal values
• More active involvement of consumers in decision-making
• Improved communication between consumers and
providers
• Limited 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?
• What 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