The Ideal Clinician(s) – How Do We Find Him or Her? (Hint: Look at How They Were Trained)

1. The Ideal Clinician(s) – How Do We Find Him or Her? (Hint: Look at How They Were Trained) Leighton Y. Huey, MD Birnbaum/Blum Professor and Chair Department of Psychiatry University of Connecticut School of Medicine

2. The Continuum of Recovery No Recovery Partial Recovery Fully Recovered Resources and Support Required

3. Old Description “Well Trained” • What does this mean? • Well trained in what? • How is “well trained” assessed? • ….and by whom? “Bio-Psycho-Social” • What does this mean?

4. New Description “Well-Trained” =Comprehensive Assessment, Treatment, and Follow-up • Think in terms of multiple possibilities and narrow the choices as one gets to know the patient and the family • Differential Diagnoses based on strong training in diagnostics • Competent in Research Literacy • The approach to individuals with a First Episode vs. the approach to individuals who have experienced multiple episodes – is there a difference?

5. “Well-Trained” continued….. • Truly consider Biological, Psychological, Social Factors in the context of how the individual presents and what is ultimately desirable (con’t)

6. Comprehensive, Assessment, Treatment, and Follow-up (continued) • Biological Physical Health, Physical Symptoms Heredity Possible Contributing Factors to the Clinical Presentation Possible endogenous factors contributing to the clinical presentation (e.g. thyroid disorder, etc.) Possible exogenous factors contributing to the clinical presentation (e.g., drugs, etc.)

7. New Description • Psychological State of mind of the individual and their family Events impacting the presentation (e.g. trauma, incarceration, etc.) Style of the individual

8. New Description • Social Life circumstances (e.g. socioeconomic, living situation etc.) Level of Function Supports Legal Educational Spiritual Other Prior Assessment and Treatment Response to Prior Treatment

9. Old Description “Evidence Based” • What does this mean? • We want evidence, but what is the evidence? • How does a clinician take the evidence into account? • What compels a clinician to consider the evidence and utilize it? • How broad is the application of the evidence? • When do we run out of evidence and have to rely on common sense?

10. New Description(from Gray, 2004) • “Evidence-Based” • Formulate the Question • Search for Answers • Appraise the Evidence • Apply the Results to the Patient • Assess the Outcome

11. “Evidence-Based” – (continued) • Track Improvement and Outcomes • A Form of Services Research Built Into the Multidisciplinary Effort (i.e. what works and what does not work)

12. New Description Treatment Algorithims • Integration of Biological, Psychological and Social approaches using only what is most appropriate, what is needed, and what the evidence tells us to do • Tracking Outcomes, Quality of Life, Function

13. Old Description “Culturally Competent” – What does this mean? • Can only African Americans treat African Americans? • Can only Asian-Americans treat Asian-Americans? • Can only Hispanic-Americans treat Hispanic-Americans? • Can only Caucasian-Americans treat Caucasian Americans? • Can only First-Generation Americans treat First-Generation Americans? • Can only Middle-Class Americans treat Middle Class Americans?

14. Can only women treat women? • Can only children treat children? Etc. • How about, for starters, we insist on just being competent?

15. New Description • “Culturally Competent” • In providing care, clinicians must understand the beliefs that shape a person’s approach to health and illness • Knowledge of customs and healing traditions in the design of treatment and interventions

16. Old Description “Patient and Family Focused” • What does this mean? • Does it really happen? • What is meant by “Focused”? • Is taking a history, doing an assessment, coming up with a diagnosis, translate into “Patient and Family Focused”?

17. New Description • Shared Decision-Making • A basic principle of treatment, i.e., a collaboration Consumer/patient Treating System Family • Setting the tone early at the first visit

18. New Description • Multidisciplinary in scope • Conscious utilization in a cost-effective manner • Use whatever resources are directly necessary for the individual and their family Nursing Social Work Public health Psychiatry Primary care Psychology Consumer/patient family Legal Educational Occupational Supports

19. Old Description “Transformation” • What does this mean? • “Transform” – like casting a magic wand and suddenly things are better? • “Transform” – because this concept is used, it means we all agree on what the transformation should be?

20. New Description • Turn the System Upside Down • Consumer/Patient and Family are the Center of the attention • But a caveat, if at the center , does this establish a dependent position unintentionally vs. shared decision making where the consumer/patient and family are part of the health care system? Patient/Family vs Patient/Family

21. Old Description “Fee-for-Service” • Fee for what service? • Piece-work and therefore fragmented • By definition, not comprehensive and not integrated

22. Old Description “Capitation” • Still not integrated, not comprehensive – covers only the medical health side

23. Old Description “Carve-Out” • Specialty services but still piece-work, not comprehensive or integrated

24. New Description • Need for New Economic Models • Pay for Performance within a Quality Improvement, Cost-Effectiveness Paradigm • Multidisciplinary a Requisite • Outcomes and Follow-up Essential • Fund Innovation Models

25. Enter the Annapolis Coalition • Charged by SAMHSA to develop a National Strategic Plan on Workforce • A broad-based, consensus-building national effort focusing on pre-professional and the established workforce in the context of Consumers/Patients and Families, Children, Information Technology, Dual Diagnosis, Rural Behavioral Health, Integration with Physical Health, etc.

26. New Description • Multidisciplinary in scope utilizing a consciously cost-effective manner

27. The Annapolis Coalition on the Behavioral Health Workforce Board of Directors

28. The Annapolis Coalition on the Behavioral Health Workforce Steering Committee

29. The Annapolis Coalition on the Behavioral Health Workforce Steering Committee (continued)

30. The Annapolis Coalition on the Behavioral Health Workforce Consumer/Patient and Family Work Group Executive Committee

31. The Annapolis Coalition on the Behavioral Health Workforce Consumer/Patient and Family Work Group Executive Committee (continued)

32. New Description and Clinical Curriculum Reform • Each discipline starts training by itself • Build interdisciplinary seminars and clinical case conferences into the training experience focusing on the integration and coordination of care among disciplines • Place multidisciplinary teams into clinical sites and have them function in the way they were trained • Create Interdisciplinary Workgroups/Institutes to develop Innovation Models • Study the Models and their Outcomes compared with treatment as usual

33. New Description • Developing a Strategy for Curriculum and Training Reform (Get Political!! Time for Return on Investment • Identify Innovators • Mobilize the Strength of the Respected National Advocacy Organizations to Work Together • Press the Education and Training Establishments in each discipline to modify the way it educates and trains • Focus on both pre-professional training and on the established workforce • Develop funding systems that will drive and sustain innovation at the Federal and State Level