Acknowledgements

2. Acknowledgements • The Client Stories have been adapted and modified by the EnHANCE Ontario Project. They were originally published through the Canadian Collaborative Mental Health Initiative: Curran, V., Ungar, T., Pauzé, E. (2006). Strengthening Collaboration through Interprofessional Education:  A Resource for Collaborative Mental Health Care Educators. Mississauga, ON: Canadian Collaborative Mental Health Initiative. Available at: www.ccmhi.ca • The EnHANCE Ontario Education Programs have been published in Word and PowerPoint formats to permit for the adaptation of these materials for different educational timeframes, processes, contexts and learners. In the interest of sharing resources and preventing the duplication of work, the project provides permission to individuals to modify the materials, to change the formatting, to use only certain sections, and to add or delete content to suit their needs. Individuals may photocopy, modify and distribute these materials for their use provided that proper attribution is given to the source.

3. Welcome The Client Stories Facilitator Guide should be used in conjunction with: • the Provider’s Practice Toolkit, which provides essential background information for both facilitators and participants, and • the Provider’s Facilitator Guide, which provides education program facilitators with the necessary information to plan, implement and evaluate an interprofessional learning program for healthcare students.

4. Meet Scott • Scott is a 14 year old Caucasian male who lives with his parents. Scott has known his family doctor since he was 4 years old. He is in grade 8 and seems like “a good kid” from a supportive family. • Recently in school he had what was assumed to have had an allergic reaction in the cafeteria at lunchtime. Scott has told his family doctor that he is less interested in school and has become reluctant to go to school lately, even skipping classes at times.

5. 1. Communication • Discuss which team members can provide information or assist in this situation. • What is the role of the family physician and family health team members in responding to the school? • What are the possible diagnostic considerations in this case? • How can more information be gathered, and whose responsibility is it to gather this? • What consultations, if any, can be initiated? • What form of note should the family physician and/or family health team provide the school at this point?

6. 2. Roles and Responsibilities • What are the roles and responsibilities of a primary care provider physician, the social worker and other FHT members? • What is a reasonable limitation to the primary care provider and FHT involvement and expertise, and when should they initiate specialty consultations and referrals? • What is the role and responsibility of the family in advocating for resources, services, and investigations? • What types of conflicts might arise between the family physician and FHT and family with respect to their frustration about lengthy waiting lists for an assessment?

7. 2. Roles and Responsibilities (cont’d) • What can the FHT provide to the client and family, and who can let the school know what adequate clearance is, from a medical standpoint, prior to returning to school? • What is the school’s responsibility in this situation, particularly in what to require, when getting medical clearance to allow Scott and other students like him to come back to school?

8. 3. Confidentiality • How can team members work with an adolescent client and the school and address specific needs around confidentiality? • How is the viewpoint of an adolescent client taken into account? • What is the role of parent and/or guardian in the care of this person? What can or should the family do if feeling caught between two providers: the school health office and the FHT?

9. 4. Communication– Family and Caregivers • What is the role and responsibility of the parents in the care of this person? • How can the FHT help the family negotiate this situation? • How can the communication between parents be facilitated to prevent further conflict within the family? • How can the team help the family advocate for care and services for their son? • Are there any service agreements between local health provider organizations that could be explored? Who should lead this arrangement? Which organizations can be included?

10. 5. Treatment Options, Ethics and Client Advocacy • Whose responsibility is it to inform families of the risks versus benefits of various treatment options? Who can help explain to the school and teachers the nature of Scott’s condition and his needs? • What happens when organizations and team members differ in their perceptions of their role and administrative requirements, and treatment plan? • What is the area of expertise of various organizations and team members in this situation? • How can the family physician (or another primary care provider) and specialty health services provider work better together for this client’s well-being?

11. 5. Treatment Options, Ethics and Client Advocacy (cont’d) • What are team members’ ethics and values around access to resources such as waiting lists? What methods can teams put in place to ensure equitable access to resources? • What is reasonable advocacy by families and persons with mental illness for access to resources and ongoing care? • Can these community service providers, the school, FHT and hospital mental health clinic find a way to work together better going forward? Who can lead this?

12. 6. Communication and Stigma • How can the team and various organizations use this information on Scott’s behalf? • Whose role and responsibility is it to implement the interventions as suggested by the school psychologist? • How will team members and organizations communicate information so that Scott’s needsare met? • How might stigma about mental health/learning problems affect or limit Scott’s interactions in the school and social environment?

13. 7. Attitudes and Feelings • What are team members’ attitudes and feelings about using medications for mental health problems in children and adolescents? • How can team members ensure that treatment decisions are based on the best available evidence for outcomes and not only on attitudes? • How can the team continue to support and work with this client and family? • What role can the school and community play in the prevention of mental health problems? What role can a FHT and other health providers have in responding to the health needs of their local schools? • How does a team or organization cope with a dominant member who may try to take over?

14. Meet Gloria • Gloria is a 24 year old First Nations female, who has been an alcoholic for several years. She began drinking when she was 12. She also self-harms by cutting when she is frustrated. • Gloria used to live with her mother and 6 siblings, but recently left home due to conflicts with her mother. Her father, who was also an alcoholic, died when she was 8. • She is currently living in a women’s shelter.

15. 1. Care Planning – Roles and Responsibilities • What are the responsibilities of the various organizations in the provision of service to this person and community? How can you deal with a repeating conflict between service providers over administrative requirements? • What are the roles and what does each team member and organization have to potentially offer this client? • Consider what other team members/ individuals/ organizations you might involve to meet the care needs of this client.

16. 2. Forming a Team • What types of health team members may be of help to this person? What organizations may be able to get involved? • Who is responsible for initiating the inter-organizational referrals and what are the requirements and work in doing so?

17. 3. Conflict Resolution • What types of conflict and communication problems can arise between team members in the same or different organizations in this situation? How might you resolve these? • What common inter-organizational barriers exist to meeting a person’s care needs in your work setting?

18. 4. Communication– Structures, Resources and Culture • What are best or better practices for providers and provider organizations in meeting the needs of this client? • Discuss communication, record keeping and information sharing among team members and organizations. How do teams maintain confidentiality amongst each other? • Are there any organizational or government regulations that can expedite or discourage best or better practices regarding this client’s care needs? • How does the client’s culture affect the provider team and organizations work in helping her recovery?

19. 5. Conflict Resolution • Discuss team conflict over the treatment plan and differing mandates of organizations and how to respond to the client’s needs and alcohol use. • What framework and values do team members bring to the treatment of a client with substance abuse or the treatment of a client that does not follow a care provider’s or organization’s requirements? • Explain/demonstrate how to resolve the conflict situation when one team member or organization has spoken poorly about another or allegedly done so. Can you recall incidents where this has occurred between team members and how this was handled?

20. 6. Collaboration • Who in an organization has the responsibility and ability to affect improvements to inter-organizational process to meet a client’s needs? How can they go about this? What next steps can Jill and her manager take? • How might the organizations move forward towards inter-organizational collaboration agreements? What are the steps and timelines for this process? Who should they invite and who needs to be included?

21. 6. Collaboration (cont’d) • Are there any best practices or regulations that can expedite or discourage inter-organizational collaboration? How do you work with these? Share your experiences and lessons learned from these inter-organizational arrangements from your work. • Are there any opportunities for shared projects, policy, research, funding submissions between the organizations? Who would lead this and what steps could be pursued? Share any of your experience with joint organization projects and lessons learned about the process.

22. 7. Clients, Families & Caregivers– Roles and Perspectives • What is the client’s role in her recovery? • How can the team help with a support network and family relationships? • Can the team offer any support to family members? • How would a team or organization deal with one member or organization whose value system may preclude him/her/them from working with a client due to personal, racial or stereotypical prejudicial beliefs or different philosophical mandates?

23. Meet Hazel • Hazel is an 84 year old South Asian woman who came to Canada as a young woman, married with 2 small children. She is now widowed and has dementia which is worsening. She is becoming less able to live independently. • Her two daughters will not agree to institutionalize her, and would like more supports at home. The hospital has a policy that in order to qualify for behavioural rehabilitation you must be placed on a waiting list for a nursing home…

24. 1. Managing Multiple Perspectivesand Demands • Discuss resolution to this situation with differing opinions on placement requirements for this older person. • How can team members resolve conflict and improve communication with the family about their requests and demands? • How might the cultural background of the family affect the team’s approach? • How can the team’s care plan solve an administrative hurdle such as requirement of an application form being signed before the client can have access to the requested services? • What role can the various team members play in designing a treatment plan for this person?

25. 2. Communicating with Clients, Families and Caregivers; and Stigma • Discuss how a treatment plan, including medication risks and side effects, is communicated to clients and family members, especially when the care organization has members with differing opinions. • How can the team approach a client or family’s idealization and devaluation of the team members/care organization? • How can the team better work with this family member to reduce conflict? • How does stigma affect this family and client with respect to her now being prescribed a psychiatric medication?

26. 3. Decision Making and Power • Discuss each team member’s organization’s attitudes and model for including clients and family in care and recovery decision making. • Discuss team/organizational differences in power for making various care/admission decisions. • Discuss team members’/organizational roles, attitudes and feelings about residential placement of clients with mental health problems versus community care and mandates in where they provide services. • Do team members or different organizations take into account the costs and resource requirements of client treatment plans and efficiencies and impact of collaboration decisions?

27. Meet Stan • Stan is a 43 year old Caucasian male with chronic schizophrenia. He has had multiple admissions for his illness and is well known to the hospital and community team. • His mother, who had been his primary care giver, moved into a retirement home 5 years ago and has become more removed from his care. • When well, Stan is pleasant with a good sense of humour. Everyone likes him. When ill, Stan can be threatening and people quickly become afraid.

28. 1. Theoretical and Problem-Solving Frameworks • What should the CHC team do? Are there other care team members or other providers from another organization to involve at this point, and if so, who and how do you involve them? • Discuss and make explicit each team member’s feelings and attitudes about the person’s threats and behaviours. How should the team manage these attitudes and feelings? Whose role and responsibility is it to deal with this situation?

29. 2. Roles and Responsibilities • Whose role is it to monitor the medication? • Who can the family call if they are concerned about Stan’s health declining? • How do team members and different providers from other organizations communicate with one another? • Who is responsible for monitoring missed appointments or prescriptions that have not been obtained? • What methods do team members/organizations use to communicate with one another? Telephone? Fax? E-mail?

30. 2. Roles and Responsibilities (cont’d) • Who can assess and intervene in the community to prevent the decline in mental health or an unsafe situation? • What feelings do team members/organizations have about each other’s responsibilities? Who did or did not do their job? How will this affect team/organizational relationships when working with each other?

31. 3. Roles, Responsibilities, Record Keeping and Stigma • How and when do team members and organizations contact family members? How is family input used? • What information is available to the team in crisis situations, including past history, medications and medical problems? Who is responsible for obtaining this information? What method of information and record keeping does the team/ organization use? • Discuss stigma that mental health clients face when seeking or obtaining medical examinations and related care services. • What role does each organization and provider have in crisis situations? What are your personal or your organization’s role and availability in crisis situations?

32. 4. Client Advocacy and Power Differentials • How does the team/organization ensure advocacy for clients when well or when involuntarily certified? • Who advocates for clients in the hospital and community? • What are the barriers to obtaining rights and advocacy when unwell or in the community? • Discuss power differentials between clients and team providers/organizations.

33. 5. Conflict Resolution and Team/Inter-Organization Communication • Discuss how team/organization conflict is identified, communicated and can be resolved in the care of this client. • Discuss differences in role and power relationships in terms of clinical decisions between providers and organizations. • What power do families have in team/organization relationships, and how can they communicate their positions during disagreements and conflicts or advocacy regarding the care of the person with mental illness?

34. 5. Conflict Resolution and Team/Inter-Organization Communication (cont’d) • How can the multiple providers and organizations better communicate to share information along the continuum of care for this person? How does your organization communicate or share information about clients as they move between care providers and care organizations? What are the barriers? How can these be improved?

35. 6. Stigma • Discuss stigma for family members, clients and clinical staff/providers and organizations in treating the person with mental health problems. What situations have you or your organization encountered? How did you address this? • Can providers or organizations jointly advocate to address systemic barriers and stigma for persons with mental health problems? How could you or your organization do this? • What can clinical providers/teams/organizations do to assist persons with transitions of care for between providers, hospital, community, etc.?

36. 7. Discharge Treatment Plan • Discuss a discharge treatment and continuing care plan for Stan. • What communication systems can be put into place should he require care again? • Who can Stan or the family contact? • Who can monitor Stan in the community? • What role does Stan play in the plan and in his recovery? • What best practices can be put in place?

37. 7. Discharge Treatment Plan (cont’d) • How can the team/various provider organizations help Stan reintegrate into his community peer support group, housing and social environment? • Discuss what an inter-organizational collaboration or service agreement might consist of for the care of clients with severe mental illness along the continuum of care? Do you have any of these in your workplace? Brainstorm ideas and organizations with whom it would be helpful for you to develop these inter-organizational agreements.