Mental Health – Making It Real
Practice Support Program
Collaborative
Phase
Assessment of
Team/Practice
Readiness
Pre-work
Learning
Session (LS)
1
Revised: 23.May.09
Objectives
Mental Health Collaborative Plan
Activities
1) Assess the readiness of each team for
improvement work.
2) Select teams most ready to implement
change package ( limited number of teams
May to June 2009 – no more than 15 docs
per team) have GPs and psych from makeup
sessions joint to observe/participate
3) Coach works with other non-selected
teams in readiness preparation.
1) Orient teams to the collaborative aim,
measures, and an overview of the change
package.
2) Assist each individual team in
determining team membership, aim
statement, population of focus, and prework priorities.
3) Describe collaborative measures, data
collection and management tools (i.e.
registry).
1) Define the gap in care and the overall
aim of the collaborative.
2) Describe evidence-based guidelines that
support best care practices.
3) Describe the specific change package and
related measures.
4) Demonstrate the use of the model for
improvement in testing priority changes
(change package).
Tools
Timeframe
Recruitment conference call
to discuss
Collaborative Charter.
Collaborative Charter
Readiness
Assessment Tool (in
development)
Summer ’09
module: 2 weeks
prior to LS 1
(May to June
2009)
Usual Assessment
is 1 – 3 months
prior to LS.
Conference call to orient
teams to the collaborative.
Pre-work Packet
(limited in size)
Individual conference call
with each team.
Data collection and
management package
(i.e. registry)
Summer ’09
module: 2 weeks
prior to LS 1
(May to June
2009)
Usual 1 month
prior to LS 1
(May to June
2009)
Plenary and break-out
presentations.
Video role-playing
demonstrations scenarios.
Participant role-playing
activities.
Discussion
Team planning.
LS 1 Agenda
0.5 day LS 1
Course CD
MH Learning Manual
Handouts
Case Studies
CBIS Video
BounceBack Video
ASW video
Algorithms
1
Mental Health – Making It Real
Practice Support Program
5) Facilitate participant role-playing
activities.
6) Incorporate team planning and discussion
time to promote the development of PDSA
plan (project planning form) by each team.
7) Describe team participant deliverables
including testing, data and narrative reports,
conference calls attendance, and listserv
interaction.
8) Describe action period activities.
Web-based
Resources
PDSA Examples
Project Planning
Form
Action Period
1
1) Identify patients with moderate to severe
mental health problems (PHQ9).
2) Determine an accurate diagnosis for
patients with Axis 1 problems.
3) Develop an action plan for patients with
Axis 1 problems (Problem List and Plan).
4) Offer patients with mild to moderate
depression BounceBack telephone support,
ASW, etc.)
1) Conference call topics:
a) “Identification of
patients with Axis 1 MH
problems and accurate
determination of Dx”.
b) “Planning care for
patients with select MH Dx”.
2) Two monthly data and
narrative reports per team
with appropriate feedback
from coaches.
3) List serv messages
first test
Conference call
objectives, selection
of GPs to share
experiences, and use
of monthly
data/narrative to
guide discussion. Use
of conference call
and helpful question
sheet.
Learning
Session 2
1) Highlight provider experiences that
effectively demonstrate Dx and plan care
for Axis 1 patients (skills, content, and
office efficiency).
2) Use of additional screening tools to
identify complex MH needs.
Plenary and break-out
presentations.
Video role-playing
demonstrations scenarios.
Participant role-playing
activities.
LS 2 Agenda
0.5 day LS 2
Presentation template (September 2009)
Course CD
MH Learning Manual
Handouts
Activity Forms
Revised: 23.May.09
2 months
(July and August,
2009)
2
Mental Health – Making It Real
Practice Support Program
Action Period
2
Learning
Session 3
Revised: 23.May.09
3) Expand the intervention of MH patients
to Supported Self-Management and other
support methodology.
4) Review medication guidelines with
providers.
5) Describe “Stepped Care” and the use of
the interactive algorithms.
6) Describe action period activities.
Discussion
Team planning
1) Continue to identify patients with
moderate to severe mental health problems
(PHQ9).
2) Utilize advanced screening tools to
identify complex mental health issues.
3) Continue to build skills and efficiency in
using the Diagnosis Assessment Interview
for patients with Axis 1 problems.
3) Integrate Supported Self- management
Methodologies (ASW, BounceBack, etc.)
into the plan of care for patients with Axis 1
problems (Problem List and Plan).
4) Continue referring patients with mild to
moderate depression to BounceBack
telephone support, ASW, etc.)
5) Integrate the use CBT skills during clinic
visits with patients that have Axis 1
problems.
1) Highlight provider/patient experiences
using case studies that effectively
demonstrate Diagnostic Assessment
Interview, Problem list and action plan, use
1) Conference call topics:
a) “Use of advanced
screening tools – your
experience and how it went.”
b) “Using CBT skills in
supporting patients with MH
problems”.
2) Two monthly data and
narrative reports per team
with appropriate feedback
from coaches.
3) List serv messages
first test
Medication Algorithm
Treatment Algorithm
1) Case studies presented by
GPs.
2) Patient experience
3) Presentations by GPs
CBIS video
BounceBack Video
ASW video
Algorithms
Web-based
Resources
PDSA Examples
Project Planning
Form
Conference call
objectives, selection
of GPs to share
experiences, and use
of monthly
data/narrative to
guide discussion. Use
of conference call
and helpful question
sheet.
Learning Session 3
agenda
Discussion guidelines
Case study template
2 months
(October and
November, 2009)
Early December
2009
3
Mental Health – Making It Real
Practice Support Program
of CBT skills, utilization of Supported SelfManagement programs (ASW) and
BounceBack to support patients with Axis 1
problems.
2) Use case studies to demonstrate the use
of additional screening tools to identify
complex MH needs.
3) Highlight a patient experience (patient
sharing if possible)
4) Shared experiences by GPs, Psychiatrists,
and Mental Health Clinicians that
a) Demonstrate the navigation of patients
to access points within the continuum of
mental health resources/services.
b) Confidence in determining who to
refer and to which service, what to expect
and how to streamline that process in the
community.
5) Describe strategies for sustaining and
spreading the mental health change package
to other practices/providers
Revised: 23.May.09
related to use of advanced
screening tools and related
impact on care.
4) Presentation by GP and
Psychiatrists and Mental
Health Clinicians that
demonstrate identification of
referral persons, services and
the navigation of patients
through mental health access
points in the community.
5) Sustainability and spread
presentation and discussion.
4