1 / 53

Making Recovery Real :

Making Recovery Real :. Person-Centered Planning as a Tool for Systems Transformation. Janis Tondora, Psy.D . New Jersey Psychiatric Rehabilitation Association Annual Conference, November 21, 2013 . Person First Makes a Difference. Video clip…The Gestalt Project.

makya
Download Presentation

Making Recovery Real :

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Making Recovery Real: Person-Centered Planning as a Tool for Systems Transformation Janis Tondora, Psy.D. New Jersey Psychiatric Rehabilitation Association Annual Conference, November 21, 2013

  2. Person First Makes a Difference • Video clip…The Gestalt Project http://www.youtube.com/watch?v=QficvVNIxTI&feature=youtu.be

  3. Questions for Consideration • What stood out for you in the clip and why? • How did you feel emotionally MID-WAY through the clip? How did you feel at the end? • What did you learn? And how might this relate to person-centered recovery planning? • What if YOU were defined largely by ONE part of yourself – a part you really struggle with…maybe an illness, maybe a difficult experience in your life. What if that was what others focused on most all the time? What would that be like? • Are these the types of “stories” of the whole person that you tend to know about people you serve? If not, how can we use PCP to know people in different kids of ways?

  4. What we hope for THEM… What we value for US… • Compliance with treatment • Decreased symptoms/Clinical stability • Better judgment • Increased Insight…Accepts illness • Follows team’s recommendations • Decreased hospitalization • Abstinent • Motivated • Increased functioning • Residential Stability • Healthy relationships/socialization • Use services regularly/engagement • Cognitive functioning • Realistic expectations • Attends the job program/clubhouse, etc. • Life worth living • A spiritual connection to God/others/self • A real job, financial independence • Being a good mom…dad…daughter • Friends • Fun • Nature • Music • Pets • A home to call my own • Love…intimacy…sex • Having hope for the future • Joy • Giving back…being needed • Learning 5

  5. Beyond US and THEM • People with mental health and addictions issues generally want the exact same things in life as ALL people. • People want to thrive, not just survive… • Recovery-oriented care challenges us to move past the maintenance of clinical stability to the true pursuit of RECOVERY! 6

  6. In other words… • “You keep talking about getting me in the ‘driver’s seat’ of my treatment and my life… when half the time I am not even in the damn car!” Person in Recovery as Quoted in CT DMHAS Recovery Practice Guidelines, 2005 7

  7. Recovery-Oriented Care…a fuzzy concept? • Consumers demand it, public service systems endorse it, medical and professional programs are encouraged to teach it, and researchers investigate it. Yet, people struggle to understand exactly what “It” is and what “It” might look in practice. • Tondora et al., 2005, Implementation of Person-Centered Care and Planning: How Philosophy Can Inform Practice

  8. PCRP Moves Recovery from Concept to Practice • A Consumer and Family Driven System… • Recommendation 2.1 • The plan of care will be at the core of the consumer-centered, recovery oriented system • Providers should develop customized plans in full partnership with consumers • The PLAN is a window of opportunity to promote CONCRETE recovery-practice change! 9

  9. A Passing fad…flavor of the month? 10

  10. The Person-Centered Train:Who’s on Board?

  11. National Perspective IOM CARF JCAHO AACP Bazelon ACA 12

  12. First-Person Perspective • It made such a huge difference to have my pastor there with me at my planning meeting. He knows me better than anyone else in the world and he had some great ideas for me. • I had been working on my recovery for years. Finally, it felt like I was also working on my LIFE! • When I have a voice in my own plan, I feel a responsibility to “work it” in my recovery.

  13. What exactly is PCRP? • is reflected in the co-created written Recovery Plan which outlines the person’s most valued recovery goals and how all will work together to achieve them • Person-centered planning • is a collaborative process resulting in a recovery oriented care plan • is directed by persons in recovery in partnership with care providers and natural supporters

  14. Is it REALLY any different? YES! • In the experience of the persons served • when we “take stock” of current planning practices • and in the written recovery plan itself… Person-Centered Care Questionnaire: Tondora & Miller 2009 http://www.ct.gov/dmhas/lib/dmhas/publications/PCCQprovider.pdf http://www.ct.gov/dmhas/lib/dmhas/publications/PCCQperson.pdf

  15. And how do all the pieces come together in the written recovery plan?

  16. …and in a way that balances the spirit of person-centered care with the rigor required in clinical documentation? Regulations Required Paperwork Medical Necessity Compliance Collaborative Person-Centered Strengths-based Transparent

  17. and in a way that doesn’t BURY us!! “Apparently, Smith’s desk just couldn’t withstand the weight of the paperwork we piled on his desk.”

  18. Meet Mr. Gonzalez Mr. Gonzalez, a 31-year-old married Puerto Rican man, is living with bipolar disorder and a co-occurring addiction to alcohol that he often uses to manage distressing symptoms. During a recent period of acute mania, Mr. Gonzalez was having increasingly volatile arguments with his wife in the presence of his two young sons. On one occasion, he pushed his wife across the room that prompted her to call the police. When the police arrived, Mr. Gonzalez was initially uncooperative and upset. After he calmed down, Mrs. Gonzalez agreed not to press charges, but insisted her husband leave the house and meet with his clinician the following morning.

  19. Meet Mr. Gonzalez (cont.) Mr. Gonzalez’s wife is actively involved in his recovery and treatment, and she is open to reconciliation. However, she made it clear that he would not be allowed to live at home, or visit with his sons, until he “gets control of himself.” Upon visiting the Community Mental Health Center the following morning, Mr. Gonzalez tells his clinician repeatedly that his love for his family and his faith in God are the only things that keep him going when things are rough and he does not know what he will do without them. More than anything, he wants to be able to reunite with his family and be a good role model for his sons. He feels that the only person who understands this is the Center Peer Specialist with whom he has a close relationship.

  20. Snapshot: A Traditional Treatment Plan • Goal(s): • Achieve and maintain clinical stability; reduce assaultive behavior; comply with medications; achieve abstinence • Objective(s): • Patient will attend all scheduled groups in program; patient will meet with psychiatrist and take all meds as prescribed; patient will complete anger management program; patient will demonstrate increased insight re: clinical symptoms; patient will recognize role of substances in exacerbating aggressive behavior • Services(s): • Psychiatrist will provide medication management; Social Worker will provide anger management groups; Nursing staff will monitor medication compliance; Psychologist will provide individual therapy

  21. Uh, excuse me… I’m here to return YOUR goals. You left them on MY recovery plan! • Comply with meds • Stop drinking • Reduce aggressive behavior • Increase insight

  22. Recovery Goal: I want to get my family back. I don’t want the kids to ever be afraid of me. Strengths to Draw Upon: Devoted father; motivated for change; supportive wife; Catholic faith and prayer are source of strength/comfort; positive connection to Center Peer Specialist; intelligent Barriers Which Interfere: Acute symptoms of mania led to violence in the home; lack of coping strategies to manage distress from symptoms; abuse of alcohol escalates behavioral problems 23 23

  23. Sample Short-Term Objective(s) Within 30 days, Mr. Gonzalez will apply learned coping strategies to have a minimum of two successful visits with wife and children as reported by Mrs. Gonzalez in family therapy sessions. • Services & Other Action Steps • Center doc to provide med management to reduce irritability & acute manic sx • Psychologist to provide family therapy sessions to discuss Mrs. Gonzalez’s expectations and feelings re: future reunification • Rehab Specialist to provide Communication and Coping Skills training to teach/coach skills that will foster successful visits with wife and children • Center chaplain to promote use of faith/daily prayer as a positive coping strategy to manage distress • Wellness Recovery Action Plan with Peer Specialist to promote daily wellness through the use of self-directed strategies 24 24

  24. A More Hopeful Proposition… • We can balance person-centered approaches with medical necessity/regulations in creative ways to move forward in partnership with persons in recovery. • We can create a plan that honors the person and satisfies the chart! • In other words: PCP is not soft!

  25. What does all this mean for service users and their loved ones? PCRP is about making sure the services you receive help you achieve goals that are important to YOU! • Change is coming and YOU can be a part of it! • Consider today an invitation to get involved

  26. Systems Transformation:Lessons learned from the field… 27

  27. LL # 1: Nothing about us, without us (REALLY!) • Primacy of meaningful participation in ALL aspects of system from design to delivery to evaluation • Research showing we typically UNDERESTIMATE consumers’ desire to be involved (Chinman et al, 1999) – NH example • And… that consumer involvement often has the single-most critical impact on recovery-oriented systems transformation 28

  28. http://www.yale.edu/PRCH/documents/toolkit.draft.3.5.11.pdf

  29. LL#2:Listen & Respond To Common Concerns If given choice, people will make BAD ones Payers won’t let us do this; regs prohibit this The forms don’t have the right fields Consumers aren’t interested/motivated It devalues clinical expertise; violates professional boundaries Its what the clubhouse does… Lack of time/caseloads too high “My clients are sicker” It doesn’t fit with focus on EBPs Don’t we already do ROC? Is this what’s on YOUR mind… in your way??

  30. A Word of Caution… “We want to include you in this decision without letting you affect it.”

  31. LL # 3: Be clear on what PCRP is NOT • PCRP is NOT an “add-on” or “special” new program • Avoid “initiative fatigue” • Avoid “compartmentalizing” task of transformation • Rehab and peers are often natural leaders but… • Change must be embedded across the organization as a whole!

  32. The Person-Centered Plan as an Integrating Framework for Quality in a Changing Healthcare Climate Maximizes Self-Determination & Choice Incorporates EBPS, including IMR Derived from a Comprehensive Assessment of Needs & Strengths Encourages Peer-Based Services Informed by Stages of Change & MI Methods Promotes Cultural Responsiveness Respects Both Professional & Personal Wellness Strategies Focuses on Natural Supporters/Community Settings Consistent w/ Standards of Fiscal & Regulatory Bodies, e.g., CMS, JCAHO, CARF Emphasis on the Attainment of Meaningful OUTCOMES 33

  33. LL # 3: Be clear on what PCRP is NOT • PCRP is NOT “anti-clinical/anti-tx” • PCRP respects the value of clinical expertise but also emphasizes the value of lived experience • There is a critical, but changed, role for practitioners • providers of hope • assessment / formulation • knowledge of the wide range of EBPs • …and emerging recovery/rehab practices • Skilled in practice of shared decision-making • knowledge of the illness and possible solutions • teachers/trainers/coaches 34

  34. If the person is in the driver’s seat of their care, where does that leave me? • PCRP is based on a model of PARTNERSHIP… • Respects the person’s right to be in the driver’s seat but also recognizes the value of professional co-pilot(s) and natural supporters

  35. LL # 3: Be clear on what PCRP is NOT • PCRP is NOT only for people who are “high-functioning” or well on their way to recovery • Move beyond belief that some are “too sick” to engage in recovery • Communicate a message of hope and a belief that life can be different • Understand sources of perceived “resistance” or lack of motivation • Flex as needed/ be creative in how we listen to/solicit preferences

  36. Davidson, L, Harding, C., & Spaniol, L. (Eds). (2006). Recovery from severe mental illnesses: Research evidence and implications for practice.

  37. LL # 4: “Training” is necessary, but not sufficient Competency knowledge, skills and abilities Transformation Change Model Culture Management behavior and attitude ProjectManagement work / business flow

  38. LL # 5: Attend to (real) external barriers Competency knowledge, skills and abilities • “When you pit a bad system against a good performer, the system always wins… (Rummler, 2004). Transformation Change Model Culture Management behavior and attitude ProjectManagement Work flow / business practice

  39. LL # 5: Attend to (real) external barriers • Many administrators DO feel stuck between a rock and a hard place… as they struggle to reconcile (seemingly) competing tensions • Clinical gate keeping vs. direct access • “Eligibility criteria” for voc services • Offering copies of plans • Compliance and billing issues 40

  40. LL # 6: But, be prepared for red herrings • While attention to organizational factors is important, sometimes this EXTERNAL focus can mask more complex change barriers… 41

  41. People may resist change in subtle, and “not-so-subtle” ways! 42

  42. LL # 6: Be prepared for red herrings • Based on misunderstanding, or biases/assumptions? • Can’t do PCP because we won’t get paid for it… • We aren’t allowed to give people a hard copy of their plan because our Medical Records department prohibits it… • Peer staff can’t have access to confidential material… • Make it possible, see what happens, then hold people accountable to deliver! 43

  43. LL # 7: Different arguments appeal to different audiences… • Personal stories • Outcomes data • Values imperative • Fiscal benefits of systems transformation

  44. What is the evidence behind PCRP? • Emerging research shows PCRP has a significant IMPACT on OUTCOMES • greater engagement in services as evidenced by reduced no-show rates & higher rates of medication adherence (Stanhope et al., 2013) • Significant improvements in wide range of recovery outcomes, e.g., Sense of Community, positive coping, therapeutic relationship with primary practitioner; QOL, self-esteem, psychotic symptoms (Tondora et al, in press) • New York Care Coordination Program*: • 43% decrease in emergency room visits per enrollee • 44% reduction in days spent in a hospital • 56% decrease in self harm among • 51% reduction in harm to others *http://www.carecoordination.org/results.aspx

  45. What is the evidence behind PCRP? • Emerging evaluation data shows PCRP is COST-EFFECTIVE • Comparison of Medicaid costs for Case Management and ACT populations in WYCCP counties to same populations in 6 comparison counties shows WNYCCP costs significantly LOWER in: • inpatient services; outpatient services; and community support programs • Enhanced employee satisfaction led to significant reductions in STAFF TURNOVER and re-training costs

  46. LL # 8: Provide clarity in expectations • Promote increasing accountability among providers and system as a whole • Provide a road-map for trainees/providers who WANT to make changes, but are unsure which direction to move • Help prioritize state training & consultation objectives • Implications for range of HR protocols, e.g., hiring decisions • Educate consumers and families re: what they can/should expect from the system

  47. http://www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdfhttp://www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf Manuscript available for download at: www.ct.gov/dmhas/lib/dmhas/publications/practiceguidelines.pdf

  48. LL # 9: SOME risk IS necessary at individual and systems level • Is the system organized to perpetuate the “status quo” • How tolerant of risk/change is the system as a whole? • How is the burden of risk shared across all stakeholders – including PIR? • Who is held accountable when things don’t work out as planned? • Just as in individual recovery, taking risks opens door to new opportunities! 49

  49. “We’ve considered every potential risk except the risks of avoiding all risks.”

More Related