Brian E. Sandoval, Psy.D. Juliette Cutts, Psy.D . Yakima Valley Farm Workers Clinic

1. Session # C3a October 17, 2014 Actualizing Our Vision: An Innovative Approach to Engaging Care Team Members in PCMH Self-Management Support Brian E. Sandoval, Psy.D. Juliette Cutts, Psy.D. Yakima Valley Farm Workers Clinic Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • Brian Sandoval currently has or has had the following relevant financial relationships during the last 12 months: • Consultant, primarycareshrink.com • Juliette Cutts has not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe how connecting training with organizational mission can differentiate “checking boxes” and true transformation • Discuss how a multi-modal approach can empower patients and their providers to participate in patient-centered care. • Identify strategies for leveraging Behavioral Health Consultants as well as data to drive transformative change • Describe benefits and challenges of integrating elements of motivational interviewing into chronic disease management

4. Bibliography / Reference Miller, W.R., Rollnick, S. (2012), Motivational Interviewing: Helping people change.Guilford Press: New York Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. Guilford Press: New York. National Standards for Diabetes Self-Management Education, 2011, Retrieved 8/22/14 from http://care.diabetesjournals.org/content/34/Supplement_1/S89.full – Need to incorporate Self-Efficacy, Problem Solving, and Social-Environmental Support Are Associated With Diabetes Self-Management Behaviors, 2010. Retrieved 8/22/14 from http://care.diabetesjournals.org/content/33/4/751.full.pdf+html – Need to Incorporate Stanford Patient Education Research Center, (Unpublished), Diabetes Self-Efficacy Scale. Retrieved 8/25/2014 from http://patienteducation.stanford.edu/research/sediabetes.html

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Establishing a Clear Intention and Plan for Self-Management: From Accreditation to Transformation • Leadership engagement • Starts with a concept! • Collaboration with marketing • Final product: “YVFWC Self-Management” • Operationalized our organization’s mission, vision, and values into evidence-based communication skills (motivational interviewing or MI)

8. From Vision to Frontline • Ultimate goal: Culture change at YVFWC • Create comprehensive, linked training programs for front desk/non-clinical and clinical staff • Combine core MI content with mission-driven reflection and activities • Initiate ongoing activities for staff engagement in enhancing self-management support

9. A Layered Approach: Fighting Scope Creep while Keeping It Integrated • YVFWC Vision, Mission, Values • Person Centered Communication skills • Self-Management skills • Motivational Interviewing skills

10. Person Centered Communication • Setting a Solid Foundation for All Staff • Connect General Communication Skills to our Vision, Mission, and Values

11. Self-Management Framework ASK PROVIDE ASK Putting Providers In the Patient’s Seat Made a Difference! * Based on Miller & Rollnick, 2012,

12. Putting Training Into Practice: Accepting Reality while Steering to Transformation • Shadow/observation of providers to understand workflows and demands • Train relevant, “real life” MI skills amenable for PCP/nursing visits • Train basic-level skills while recognizing those with more advanced skills • Shorter, multimodal approach favored over day-long trainings

13. Putting Training Into Practice: Accepting Reality while Steering to Transformation • Self Management Trainings to Drive NCQA Factor (2011) Achievement And Operational Design Processes • Documentation templates created to match clinical training/NCQA factors • Workflows Were Redesigned To Support Clinical Care Model And Self Management Philosophy • Risk-stratification protocols • Pre-visit prep • Huddles • Group visit model

14. Putting Training Into Practice: Working Towards Guidelines • The Diabetes Self-Management Education Task Force Recommends “Creative, patient-centered experience-based delivery methods…for supporting informed decision-making and behavior change…” (p. S91) • Research by King et al (2010) confirm the need to provide interventions that enhance problem-solving skills, increase self-efficacy, and increase patient engagement with community resources.

15. Training a Change Weary Team: Getting Real On the Road • Be Careful What you Ask For • Listening to Feedback • Creating Tools On The Road…Literally • Picture Based Action Plan

16. Self-Management Template Flow: The Plan DM Pt’s flagged by MA during Pre-Visit Prep Start by picking 1 pt/day to practice SM Plan in the last year? Yes PCP to refer to BHC/RD as usual Document SM Plan as part of visit No Refer to RN/RD/BHC if available No Major Concerns? Yes Schedule F/U with PCP/RN/ RD/BHC Specifically for SM Plan Hx of non-adherence, multi ED visits? Yes Refer to RN Diet or Activity Concerns Yes Refer to RD Hx of MH issues? Yes Refer to BHC

17. Self-Management Template Flow – Goal Target Population Pt’s flagged by MA during Pre-Visit Prep SM Plan in the last year? Yes PCP to refer to BHC/RD as usual Document SM Plan as part of visit No Major Concerns? (BP/A1C) No MA gives Self-Efficacy Eval Refer to RN/RD/BHC if available Schedule F/U with PCP/RN/RD /BHC Specifically for SM Plan Yes < 5 on 5, 6, or 7 or hx of non-adherence, multi ED visits Yes Refer to RN No < 5 on 2, 4, or 8 or MH issues? Tracking/Reporting Yes Refer to BHC Current Process Basic Process No At Risk Process Return Self-Efficacy Eval to BHC Refer to RD

18. Did it work? Using Data to Measure Engagement • Training session Feedback • Huddle tracking for Self-Management • Reporting structure for NCQA factor achievement • PCHH workgroup feedback and ongoing PDSA cycles

19. Bumps in The Road and Other Tales of Implementation • Successes • Connecting SM to organizational mission inspires culture change! • Training feedback overwhelmingly positive • Lessons Learned • SM care models difficult to roll out when clinics have drastically differing resources. • Timing, messaging, and constant PDSA important • Live training is impactful but takes considerable time and consumes significant resources

20. Self-Management Template Flow: Reality Target Population Pt’s flagged by MA during Pre-Visit Prep Clinic Visit Refer to RN Refer to RD Refer to BHC

21. What’s Next • Increasing SM adoption for 3 NCQA conditions • Enhancing SM to include all chronic conditions • Development of ongoing training for existing staff / training protocol for new staff • Performance monitoring - Maintaining and gaining ground

22. The Road Ahead Keeping the Message Relevant and Present

23. Questions?

24. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!