clinical care collaborativeaims.uw.edu/care-partners/sites/default/files/follow-up and...

Follow up and Treatment to Target

Rita Haverkamp, MSN, PMHCNS BC, CNSExpert Care Manager and AIMS Trainer

Learning Objectives

By the end of this training, participants shouldbe able to:

– List strategies to optimize follow up care andmeasurement based treatment

– Recognize patients that need to have treatmentadjusted

– Prioritize patients to discuss during caseloadconsultation

Collaborative Care Workflow

Identify & Engage

Establish a Diagnosis

Initiate Treatment

Follow-up Care & Treat to Target

Complete Treatment & Relapse Prevention

System Level Supports

Clinical Roles: Patient Centered Team Care

New Roles

PCP

PsychiatricConsultant

Patient

Care Manager Role

CommunityPartner PCC


Identify & Engage


Initiate Treatment




Initial Assessment

• Systematic information gathering– Presenting complaints, symptoms and relevanthistory

• Essential part of building therapeuticalliance bond

• Have systems in place to discuss patientswith your partner in care

• Review of case early with team/consultant

Follow-up and Treatment to Target 1/15/16

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Identify & Engage


Initiate Treatment




Diagnosis

Why do we care about diagnosis?– Guides treatment and clinical decision making!

Provisional Diagnosis

Provisionaldiagnosis

andtreatment

plan

Screeners filledout by patient

Assessment byBHP and PCP and

CBO

PsychiatricConsultant casereview or direct

evaluation

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Identify & Engage


Initiate Treatment




Treatment Planning

• Patient, PCP & Care Manager all involved inmaking the treatment plan

• Treatment plans individualized because patientsdiffer in:– Medical comorbidity– Psychiatric comorbidity– Prior history of depression and treatment– Current treatments– Treatment preferences– Treatment response

3 Critical Elements of Alliance

WorkingAlliance

Goals?

Tasks?

Bond?

Discussing treatment options helps facilitate all of these elements.


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Discussing Treatment Options

• Review all treatment options available:– For follow up, this discussion is critical in case youneed to add a treatment later if patient isn’tprogressing

– Psychotherapeutic interventions• Behavioral Activation, Problem Solving Treatment,Cognitive Behavioral Treatment, etc.

• Evidence based!– Medications

• Discuss pros and cons of each option so patientcan make an informed choice

Discussing Treatment Options

• The treatment that WORKS is the best one– Person centered care means selecting treatmentsbased on client preference, not clinician preference

• Try to be unbiased when offering treatment options– Be eclectic: “One size fits few”

• Medication therapy is not right for everyone• Psychotherapy is not right for everyone; different therapies

• Supporting whole person treatment is important– This may include medication therapy

• You can support medication therapy within scope ofpractice


Identify & Engage


Initiate Treatment




WhyWe Focus on Follow up andMeasurement Based Treatment

• Overall model of care– If it isn’t working fix it, whether it is therapy ormedications

• Critical to help make sure patients get better

Follow Up Contacts

• Weekly or every other week during acute treatmentphase– In person or by telephone to evaluate symptom severity(PHQ 9, GAD 7) and treatment response

• Initial focus on:– Adherence to medications– Side effects– Follow up on activation and PST plans

• Later focus on:– Complete resolution of symptoms and restoration offunctioning

– Long term treatment adherence

Each Appointment is a Decision Point

• Three requirements:– Frequent contacts and information gatheringuse a PHQ 9 each time

– Track and consider what is happening– Do I need to consult and/or change what I amdoing? What does the patient want to do? Howsatisfied are they with progress? Are they willingto do something else?


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1. Frequent Contact

• Improves compliance• Enhances engagement bond• Sharing goals and tasks• Gather more information• Get a pattern to PHQ 9 scores

Intensity of Early Engagement DrivesImprovement• In studies, patients with early follow up wereless likely to drop out and more likely toimprove (Bauer, 2011)

• Patients who have a second contact in lessthan a week are more likely to take theirmedications

• Follow up contact within four weeks of theinitial assessment is key to earlyimprovement (Bao, 2015)

Frequent Contacts as It Relates toBehavioral Activation/PST• Report on progress increases patient’smotivation to act

• Reminder to patient if they haven’t done it• Time to make a new plan

Frequent Contacts as It Relates toMedications• Check on adherence• Time to talk about side effects/concerns regarding medications

• Maximize treatment effects if problemsare addressed early

• Consulting in a timely manner

Typical Frequency of Care ManagementContact• Active Treatment

– Until patient significantly improved/stable– Minimum 2 contacts per month

• Mix of phone and in person

• Monitoring– 1 contact per month

• After 50% decrease in PHQ 9• Monitor for ~3 months to ensure patient stable• Complete relapse prevention


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Typical response to treatmentchanges6 months is average treatment length

– Only 30 50% patients respond fully to 1sttreatment

– 50% 70% of patients need at least one change intreatment to improve.

– Each change of Tx moves an additional ~20% ofpatients into response or remission

Checkpoint Discussion

Who is using the phone now or has in the past?– How have you made it work?– What did patients like about it?– If you haven’t done it what do you think is avalue to it?

Using the Telephone – A Way toIncrease Contact and Engagement• Under utilized tool• Client centered approach

– Convenient– Pro active– Improved bonding with patient

The Many Circumstances in Which toUse the Telephone• Patient who missed an appointment

– Call NS’s within 15 minutes and use this time for atelephone contact

• Patient who has transportation difficulties• Patient doesn’t want to or can’t come in• Patient who has children at home• Check in on patient between other in personvisits– I.e., patient who just started a new medication and isworried about side effects

Helpful Hints for Scheduled TelephoneContacts – This Is an Appointment• Have a block of time in your schedule for this—1 2 hours so you can make numerous calls

• Set them about 15 20 minutes apart

• Give patients a time for the call. Ask them ifthat time would be convenient – free ofdistractions

• Mail them or send them a PHQ 9 so it is moreeasily done – you can ask them to do it beforethe call so it is ready for discussion

Structure for Telephone Contacts• Ask them if this is still a good time – set anothertime if not

• Have no distractions yourself and ask them notto have them either

• Set agenda for the call – check on PHQ 9,medications and behavioral activation or have aPST session

• Do PHQ 9 early in call – this helps to plan for therest of the call

• End with plan for next appointment or call


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2. Track and Consider

• Review the treatment history page and thegraph of PHQ 9

• Think about:– Improving or not could they improve more?– How long in this treatment?– Are they engaged? Involved in treatment outsideof sessions?

– Are there other challenges and how will weovercome them?


Tendency to Want to Decrease Use of PHQ 9– What are your concerns about doing it eachtime?

Behavioral Health Measuresas Vital SignsBehavioral health measures are like monitoringblood pressure!

– Identify that there is a problem– Need further assessment to understand thecause of the abnormality

– Help with ongoing monitoring to measureresponse to treatment

Advantages of Using BehavioralHealth Measures• Objective assessment• Creates common language• Focuses on function• Avoids potential stigma of diagnostic terms• Helps identify patterns of improvement orworsening

• Flexibility of administration

Reasons to start each session withPHQ 9• Sets evaluation of progress as the first step ateach appointment with the patient

• Begins that discussion with patient• Gives you a measurement on which to basedecisions and discussions

• Helps patients know what better looks orfeels like

• Helps engagement with patient – sharedgoals

Common Measures

Anxiety, Substance Use, PTSD, Bipolar, ADHD,etc.

Can be expanded when want to use


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Treatment Expectancies

• Outcome Expectancy– Is treatment working?

• Shared goals

• Self Efficacy Expectancy– What am I doing to help myself get better?

• Shared tasks

Tracking Clinical Outcomes

• Prevents patients from “falling through thecracks”

• Facilitates treatment planning andadjustment– Combats clinical inertia: patients staying onineffective or partially effective treatments

• Know when it is time to get consultation andwhen it is time to change treatment

IDENTIFY A PROBLEM IN THEFOLLOWING CASELOADS OR

PATIENT REPORTS:

http://www.jhartfound.org/sif/ 40

Track Measurements Over Time!

http://www.jhartfound.org/sif/ 42


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3. Seek Consultation Early and Often

• Too much consultation is better than notenough

• Major factor in improvement rates is the useof consultation

• Ask consultant when they like to increase amed that has some effectiveness but not full

• Any person you think maybe “I should”consult, then “do” consult


Where and how are you deciding about casesto be discussed in consultation?

Priorities for Consultation1. All patients who have 8 10 weeks of treatment with no

improvement/not in remission2. Patients you or consultant have flagged3. Patients where there is a diagnostic question and/or

concern if they need behavioral health program– Severely depressed (PHQ 9 score 20)– Fails to respond to treatment– Has side effects from medication– Has complicating mental health diagnosis, such as personality

disorder or substance abuse– Is bipolar or psychotic– Has current substance dependence– Is suicidal or homicidal

Priorities for Consultation (cont’d)

4. Patients who aren't engaged or have otherdifficulties in their care

5. Patients who are on a low dose of anantidepressant for 4 weeks or longer withonly little or no improvement

6. New patients, especially those who aremore complex


Identify & Engage


Initiate Treatment




Complete Treatment and RelapsePreventionInclude asking the patient to make time toreview their own PHQ 9 score on a regularbasis so they can keep track of how they aredoing.


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Any questions/ comments?

Case Call Next Month – Feb. 17, 2016

Care Managers should come prepared todiscuss a specific case involving follow up andtreatment to target

Selecting a Case1. Review your caseload and find a case that isn’t improving or

process of follow up that can be improved2. Implement a change before the next call

For example:– Find a pattern of a problem by looking at your registry and think

about what barriers there are.– Find a patient with few consults and think about why? Do a consult

and see what changes can occur.– Use scheduled telephone contacts with someone you haven’t before

and report what happened.– Think about whether you are holding on to a therapy model with a

patient when another treatment might be needed. Change thetreatment.

– Change how you describe the treatment options to the patient andsee what happens.


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