ARCAdvancing Recovery Collaborative

Advancing Recovery CollaborativeLearning Session #3

Day 2 – June 25th, 2014

Learning Session #3 Agenda:Day 2

2

7:30 – 8:30 Breakfast

8:30 – 8:45 Questions and Feedback from Day 1

8:45 – 9:45 Model for Improvement: Implementation and Preparation for Spread

9:45 – 10:00 BREAK

10:00 – 12:00 Change Ideas: Overcoming Obstacles – The SUD Example

12:00 – 12:45 LUNCH

12:45 – 1:45 Data for Improvement: Using the ARC Measures

1:45 – 2:00 BREAK

2:00 – 3:00 Organizational Team Meeting #2

3:00 – 3:45 Team Report Out

3:45 – 4:00 Wrap-Up & Adjourn

3

Storyboard Learning &

Day 1 Highlights

4

Model for Improvement: Implementation and Preparation for Spread

Jerry LangleyGloria Frederico

BREAK

Overcoming Obstacles The SUD Example

Dianne AsherRick Goscha

6

BUILD HOPE AND BELIEF IN RECOVERY

Help clients and staff understand that recovery is a possibility for all people diagnosed with serious mental health issuesAssist each person to discover and express their evolving definition of recoveryDemonstrate organizational belief in recovery

IDENTIFY MEANINGFUL GOALS AND STRENGTHS TO ACHIEVE THEM

Identify clients’ usable strengths Set and achieve meaningful and important goals using highly individualized and specific strengthsAlign with client to build a collaborative working relationship

PLAN TO ACHIEVE GOALS

Plan to achieve goals by breaking them into smaller, measurable steps (short-term goals) Use stages of treatment scale to guide intervention and evaluate progressPrescribe medications using shared decision making techniques

ACHIEVE GOALS AND INDEPENDENCEEvaluate progress and update the plan at each visitAssist client with obstacle removal and create opportunities for goal achievement at every visit Make use of naturally occurring resources to help clients connect to their community Support clients to prepare to and then exit the systemUse self-management strategies to help people progress in their recovery

Movement to higher levels of recovery,

and greater purpose and connection

in their community of choice

DESIGN SYSTEM INFRASTRUCTURE TO SUPPORT INDIVIDUALIZED PATHWAYS TO RECOVERY

ADVANCING RECOVERY COLLABORATIVE

Provide leadership for recovery Provide supervisory supports and skill development that support clients’ recovery progressCreate and supervise effective use of peer supports (employed and volunteer) for clients at different stages of recovery Involve people with the lived experience of recovery in system design and improvementMake access and transitions easier and responsive to clients’ goals

2014 California Institute for Mental Health, Care Coordination Collaborative(Unpublished Work©2014, CiMH, copying and distribution permitted with citation to CiMH)

Change Ideas to be Presented

BUILD HOPE AND BELIEF IN RECOVERY • Demonstrate organizational belief in recovery

– Serve clients who are not taking medications, not clean and sober, and who don’t acknowledge that they have a mental illness”

IDENTIFY MEANINGFUL GOALS AND STRENGTHS TO ACHIEVE THEM • Set and achieve meaningful and important goals using highly

individualized and specific strengths– Use objective tools from mental health, substance use and other fields (e.g. WRAP,

Strength-Based Assessments, Importance/Confidence Ruler, What Color is My Parachute) to assist clients to frame their goals in ways that are concrete and specific and in a variety of life domains

– Use an agenda map to list goals and identify order of goals to be addressed for clients who have multiple goals and might be stuck.

– Identify a goal and then use the Importance Ruler to evaluate confidence and evocate statements to support clients confidence for clients with repeated failures

Change Ideas to be Presented (cont’d)

IDENTIFY MEANINGFUL GOALS AND STRENGTHS TO ACHIEVE THEM • Align With Client to Build a Collaborative Working Relationship

– Use engagement strategies to build the working relationship and create an environment where substance use can be discussed:

– Focus on engagement strategies without discussing substance use during initial sessions, unless clients wants to (elicit non-substance use related goals that are meaningful and important to the client, engage clients around goals that they chose, build a trusting relationship, listening to the person’s perspective regarding their life or current situation)

– Ask permission to discuss substance use– Discuss substance use in the context of something that is meaningful and important (e.g. a

person’s desire to work, raise their child, buy a car, etc.)– Use the Motivational Interviewing Importance/Confidence Ruler to determine if the worker

needs to develop discrepancy between a person’s goals and current behavior or support self-efficacy to build a person’s internal confidence to change by looking at past accomplishments and applying those to the current situation (e.g. looking at past success and asking the person how they did it)

– Use the Pay-Off Matrix to understand pros and cons of behavior change

Change Ideas to be Presented (cont’d)

PLAN TO ACHIEVE GOALS • Plan to achieve goals by breaking them into smaller, measurable steps

(short-term goals)– Use Payoff Matrix and other MI techniques to understand where a person is with making

changes to achieve their goals, increase internal motivations

• Use Stages of Treatment Scale to Guide Intervention and Evaluate Progress

– Use stages of treatment worksheet on a monthly basis to assess where a client is

Overcoming Obstacles:The SUD ExampleDianne AsherRick Goscha

11

Key Points from Day 1• The worker is the primary tool in the Strengths Model, as it is

with other effective interventions

• These tools and methods are most powerful when they begin to transform us.

• All people can benefit from a strengths-based approach.

• But since each person we work with is unique, we must expand our ability to individualize our approaches with people

12

Moving to Day 2• To be effective recovery-oriented practitioners, we must

continuously expand our “toolbox”

• While we won’t use every tool in every situation, we must become skilled with when to use the right tool, in the right way, with the right situation

13

Working with people with co-occurring substance use disorders• Recognition that people who use substances are at different

stages of change in relation to their desire to stop using

• Therefore, stage-wise treatment interventions are indicated to help us align ourselves and our approaches with where the person is at

• Complex skill sets are involved when working with people with substance use disorders, so we will focus on only one stage of treatment in this session – Persuasion

• Focus will be on two tools – The importance/confidence ruler and the payoff matrix

14

Objectives

At the conclusion, you will be able to:Understand how to use the Stages of Treatment to identify

client’s stage of treatment and match it to appropriate interventions

Be able to carry out a test to see if staff are able to identify Stage of Treatment for client’s to determine stage-appropriate interventions

15

Objectives

At the conclusion, you will be able to:Use the Motivational Interviewing Importance/Confidence

Rulers to determine if the counselor needs to develop discrepancy between a person’s goals and current behavior or support self-efficacy to build a person’s internal confidence to change

Be able to carry out a test using the Importance/Confidence Rulers to guide direction of motivational interventions

16

Objectives

At the conclusion, you will be able to:Use a Pay-off Matrix and/or working with decisional balance to

elicit reasons to change

Be able to carry out a test using the Pay-off Matrix determines what direction the work needs to go to create an environment for change to occur

17

18

Precontemplation

Contemplation

Maintenance

Preparation/Planning

Action

Transtheoretical Model of Change Prochaska and DiClemente, 1992

HOW PEOPLE CHANGE

Stages of Change vs. Stages of Treatment

• Stages of Change: Internal, very fluid Measured by how client is feeling/thinking about change

• Stages of Treatment: Behavioral, Observable, Measured by what client is doing in treatment

19

Stages of Treatment

Engagement-Precontemplation• Irregular or no contact with clinician• Does not consider substance use or mental

illness a problem

Persuasion-Contemplation• Regular contact with clinician• May of may not view substance use or mental

illness as problem, but will contemplate impact of substance use on life/goals/values

20

Stages of Treatment

Active Treatment-Preparation/Action• Regular contact with clinician• Recognition that substance use or mental illness

interferes with personal goals/values• Working on acquiring skills and supports to move

towards life goals

Relapse Prevention-Maintenance• No substance abuse for 6 months• Furthering recovery to other areas of life

21

Name the Stageand Describe Stage Appropriate Interventions

22

Jim is 42 year old man diagnosed as having bipolar disorder. He was referred to the services four months ago. Initially Jim said that he’d never had a problem with drinking. After meeting with his case manager regularly and developing a trusting working relationship, he now admits that he sometimes feels his drinking has interfered with his goal of being a good father. Jim normally drinks on weekends, and for the past three weekends he has participated in sober activities with his family. Jim has cut down his intake of alcohol, though he still tends to get drunk on Saturday nights.

23

Irene is a grandmother with years of polysubstance abuse. Her psychiatric symptoms are controlled with medication. She sees her worker at least twice per month. A month ago, she went on a binge drinking and smoked crack. She was out of control and was brought to the ER. She scared her daughter and two grandchildren. Since that incident Irene successfully managed to avoid crack use and is trying to cut down on her drinking. She wants to be able to still drink in a controlled manner but if this does not work she states that she would have might stop.

24

Fred has been a client of the mental health center for many years. He has had numerous hospitalizations, been homeless and has been in jail twice for drug use. He smokes pot daily, but does not want to talk about this with his worker. He meets with his worker weekly. Fred’s goal is to keep his apartment so that he has a place for his kids come and visit. Fred is in danger of losing his apartment as he has numerous people coming in and out of the apartment at all hours of the day and night and is disturbing his neighbor. 25

Importance/Confidence Rulers

• As with all aspects of MI you are working to “elicit change talk”

• Using the Importance/Confidence will guide you in the direction you need to elicit change talk.• Low on Importance-develop discrepancy

between current behavior and meaningful goals

• Low on confidence-support self-efficacy26

Importance/Confidence Rulers

Importance Ruler

1. How important is it to you to make this change? Not Imporant Very Important

0 1 2 3 4 5 6 7 8 9 10 Follow-up Questions

2. Ask why they chose the given number and not a lower number. e.g., Why did you choose a 5 and not a 2?

0 1 3 4 6 7 8 9 10

3. Ask what might happen to increase the number by a point or two. e.g., What might happen to increase the importance even a little bit?

0 1 2 3 4 6 7 8 9 10

Importance/Confidence Rulers

Confidence Ruler

1. How confident are you that you could make this change if you decided to? No Confidence Very Confident

0 1 2 3 4 5 6 7 8 9 10 Follow-up Questions

2. Ask why they chose the given number and not a lower number. e.g., Why did you choose a 5 and not a 2?

0 1 3 4 6 7 8 9 10

3. Ask what might happen to increase the number by a point or two. e.g., What might happen to increase your confidence even a little bit?

0 1 2 3 4 6 7 8 9 10

Exercise StepsSTEP 1• Review preliminary PDSA Worksheet• Revise the questions as needed• Make predictions about answers to the questions

STEP 2• Pair up• Run the test

STEP 3• Compare predictions to actual test results• Document initial learning• Plan next PDSA

29

Exercise: PDSA Cycle #1

• Objective: Practice using Importance/Confidence Ruler before using it with a client (your next PDSA)

• Questions to Answer (you can add others):• Does using the Importance/Confidence Ruler elicit change talk from the

client? • Do they speak about the change with more hope?• What about the process helped to elicit the change talk?

• How does rating importance on the ruler help the person better verbalize the importance of making a behavior change at the current time?

• How does rating confidence on the ruler help the person verbalize what contributes to making a behavior change at the current time or what would help increase confidence to make the change?

• Does the worker begin to see more possibilities for successful change?• Others

30

Exercise: PDSA Cycle #1 • Plan:

1. Pair up with the person next to you (if you have an odd number at your table, let faculty know)

2. Think about something you would like to change (e.g. exercise more, reduce caffeine, lose weight, etc.)

3. Use all 6 questions in the Importance/Confidence Ruler to guide discussions with your partner

4. Reverse roles and do it again

• Data Collection: 1. What data are you going to collect

1. Worker2. Individual

2. Who is going to collect it

• Predictions: (make predictions about each question before you run the test;) 31

Report Back…

• DO: Share what happened versus what was expected

• STUDY: Share what you learned

• ACT: Share you will do next

32

Questions for Future PDSA Cycles

• How does rating importance on the ruler help the person better visualize the importance of making a behavior change at the current time?

• How does rating importance on the ruler help the person better visualize what might elevate it to a level of more importance?

• Does the information collected help determine if ambivalence is related more to importance or confidence?

• What kinds of follow-up questions did the worker use to elicit additional change talk?

• In what kind of setting or circumstances is it most effective to introduce the Importance/Confidence Ruler?

33

Introduce Payoff Matrix

• The Pay-Off Matrix is a tool designedto help a person examine the pros/cons of continuing the behavior or making a change

• What happens when a person starts using/abusing substances

• Using a Pay-Off Matrix will help you determine what is missing in a person’s life that prevents behavior change (e.g. sober friends, meaningful activities) 34

Pay-Off MatrixPros Cons

Staying the Same

1. 2.

Making the Change

4. 3.

35

Pay-Off Matrix Demonstration

36

37

Pros Cons

Staying the Same

1. 2.

Making the Change

4. 3.

Decisional Balance

Staying the Same

Making the Change

38

Follow with Evocative Questions/Reflections

• What is the best thing that could happen if you make this change?

• What is the worst thing that could happen if you don’t make this change?

• If you woke up tomorrow and everything was just the way you wanted it to be, what would it look like?

• If I saw you 6-months from now and you made the change what would that look like?

39

DISCUSSION AND QUESTIONS:• What clients would benefit from using the Payoff Matrix?

• How could you fit this into your daily practice?

• What questions do you have about making this change work you (to be answered through testing)?

• What PDSA Cycles might you run first to figure out how to make this change work in your program?

40

How does these changes idea serve as solutions?

• Using the Importance/Confidence Ruler with a person elicits change talk

• Using the Importance/Confidence Ruler helps me better assess whether I need to work to develop discrepancy or support self-efficacy

• Using the Pay-off Matrix helps me understand specific reasons why a person is using

• Using a Pay-off Matrix helps give direction to treatment planning

• Using evocative questions/reflections in conjunction with these tools helps the person envision change 41

What tools & supports are needed to make the change work

• Practice using the tools with other team members as needed

• Person who is willing to talk about using substances or other behavior change

• Blank sheet of paper• Review/lessons learned from use of the

tools with team 42

Tips for Making the Change Work• Incorporation into everyday workflows

• Practice, practice, practice with individuals you work with

• Common pitfalls and/or challenges• Forget to ask permission to use a tool• Moving ahead of the person I am working with trying to

use the tools before they are ready• Asking the Importance/Confidence Rulers questions

incorrectly and getting sustain talk• Spending too much time on maintaining the status quo

• Follow-up/accountability• Report back to the team

43

That’s it from Kansas

LUNCH!

45

FUNNY/SPOOF VIDEO RE DATA

46

Data For Improvement:Using the ARC Measures

Jerry Langley

BREAK

Organizational Team Meeting 2

49

50

Organizational Team Meeting 2

• Add to and/or revise the list of changes you would like to test– Individuals share their notes from their “Finding Ideas” form– Team leaders facilitates creation of a consolidated list of change ideas to test

• Plan those tests– Solidify changes to test– Plan at least one test of change to be completed by next Tuesday– Plan to report results of at least two tests of change during the Action Period call

on Monday, July 14th (2:00-3:00)• Prepare to briefly report-out your team’s plan

• TOOLS:– “Finding Ideas” Form– ARC Planning Form– PDSA Worksheets

Team Report Out

51

52

Team Report Out

• Team representatives provide present ‘highlights’ of their plans to pursue changes

• Break in to three groups– Group 1: Main meeting room– Group 2: Breakout Room (xxx)– Group 3: Breakout Room (xxx)

53

Upcoming Action Period Calls

• All Participants (2nd & 4th Mondays, 2:00-3:00)– July 14th and 28th

– August 11th and 25th • Team & Data Leads (2nd Monday, 12:00-1:00)

– April 14th – August 11th

• Executive Leaders (4th Monday, 12:00-1:00)– July 28th – August 25th

Questions?

54

Closing

55