clinical systems mentorship and adherence: the icap approach
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USING CLINICAL SYSTEMS MENTORSHIP (CSM) IN ADHERENCE WORKAdherence Workshop
Kigali, 2009
What is mentorship?
Similarities and differences
Supervising Managing Mentoring Advising
The Learner- Centered Model
Mentee role Active partner
Mentor role Facilitator
Learning process Self-directed, responsible for own learning
Relationship Length Goal determined, but has a beginning, middle, end
Focus Process oriented, critical reflection and application
Mutability Dynamic, developmental, changes over time and with
development
So to recap…
Mentorship is relational, an interpersonal process
Mentorship occurs in a context Space: a system Theme: a programme Time: stages of development
Mentorship skills CAN and SHOULD be used by supervisors and advisors
In your work….
Can you name some mentor/mentee pairs?
Adherence advisor and onsite counselor Adherence advisor and onsite MDT Adherence advisor and expert client Adherence advisor and ICAP MDT Adherence advisor and DHT Adherence advisor and patient Adherence advisor and partners (CBO, govt,
NGO, etc)
Moving on to CSM
Clinical Systems Mentorship (CSM)
CSM is the name of an integrated methodology developed by ICAP Broadens the relational principles of clinical
mentorship to the context of public health programming and health systems strengthening.
It adds specific “macro”skills related to implementation, quality, and capacity building
Goals of CSM
The goals of the CSM methodology are to Implement high quality programs Build capacity to sustain these programs
Where did it come from?
Derivative of: Mentorship methodology Communities of practice methodology
(Wenger) Diffusion of innovations methodology
(Rogers) Appreciative inquiry methodology
(Cooperrider) Whole team learning (Engenderhealth) CQI methodology
In short,
It is a way of thinking about things, a strategy for doing them, and ensuring you are doing them effectively.
Continuity Care Model
CSM: Three general principles
Data and data-based problem identification and remediation, with local ownership and team participation, are fundamental (QI,QA)
Specific skillsets are necessary (microskills and macroskills)
Strategies change according to context and stage of development
CSM: First general principle
The foundation of CSM is the process of continuous data-driven assessment, intervention, and re-assessment Measurability is key Using data for problem remediation is key Those involved in service delivery (TEAMS)
lead this process increasingly over time
This is also known as Quality Improvement (QI) or Quality Assurance (QA)
Define measures of quality: SOCs
Measure
Assess measures
Prioritize problem
areas
Design and implement
intervention
Second general principle: Skillsets Microskills (traditional mentorship skills)
Interpersonal, communication, facilitation, teaching
TEAMS are fundamental
Macroskills Specific, content based, task oriented
Third general principle: Stages of Development
Needs at start up are different than they are later, after longer functioning.
Expectations change Indicators for quality may be different Targets for quality may be different
Goal 1: Implement high quality care
Goal 2: Build capacity
Sit
e S
tart
-up
Sit
e M
atu
rity
Assess and
Build Capacity
Time
Assess and improve
implementation
Assess and improve quality
Developing district- and national-level capability
Developing patient-level capability
Are you doing what you think you are doing?
How well?Is it sustainable?
CSM: Summary of general principles
1. Data and data-based problem identification and remediation, with local ownership, are fundamental (QI,QA)
2. Specific skillsets are necessary3. Strategies change according to context
and stage of development
Applying CSM to Adherence
First principle: Data driven QI
Develop a model of care (MOC) with goals and standards (SOC)
Devise strategies for implementation Implement Evaluate
Developing a MOC: Adherence in HIV C&T
Home
Clinic
Clinic
Clinic
Testing
Home
Patient entry into care
Counseling
Adherence happens
Adherence measured/assessed
Adherence monitored
Adherence intervention
Adherence happens
Adherence measured/assessed
Adherence monitored
Counseling
Goals and objectives: Points on adherence support model
To strengthen the continuum of adherence To measure/assess adherence: Shekinah
will discuss this To monitor adherence (use measures): I will
discuss now To intervene in care delivery and receipt of
care: Cross-cutting to working sessions To ensure interventions are effective:
Remeasure/reassess
Five key components of the MOC Appointment systems (priority) Integrated tracking and tracing systems Adherence counseling and
measurement/assessment (priority) Peer education/expert client programs Community linkages and referral
Note: There are two levels
Individual level Assessment of individual adherence and planning
specific interventions Counseling Support for individuals to disclose, how to integrate
adherence into life, etc Program level
Is the program as a whole supporting adherence adequately? SOCs Root cause analysis
Summation of individual level assessments and interventions become the program level SOCs
Creating SOCs
Utilize components of the MOC Set targets
Root cause analysis: Prioritize Key Issues
After measures have been assessed, the team can identify their site priorities:• The most important problems that must be
addressed• Problems that can be easily fixed• Long term issues that need to be addressed but
may take more time
For priority problems…
Brainstorming via asking “Why?” repeatedly
Can then eliminate the root cause, thereby solving the problem
Example: Assessing Measures
Result of measure of SOCPossible actions
Evaluate this month
Prioritize and evaluate next interval
On Target
ICAP Standards of Care for Adherence
Measureof SOC
2007
Patents on ART should be assessed for adherence to treatment at each follow-up clinic visit.
% of patients on ART assessed for adherence to care and treatment at follow-up visit
23/82=
28%
Result: 28% of patients have indication of adherence assessment on record in last interval
Why? Providers ask patients about adherence at every visit, but not in structured way
Why? Adherence questioning is usual patient care but providers do not document results
Why? Providers are in a rush and may only document the most significant non-adherence
Why? Because they don’t think it is necessary to document when patients are adherent
Problem: Providers do not routinely and consistently assess and document patient adherence
Mentorship Considerations: •Sensitize providers to assess patient adherence at every visit and to document both adherent and non-adherent results.•Implement standard adherence assessment questions or medication review for every patient on ART•Observe provider assessments and give feedback
Proposed Analysis
Example: Assessing Measures
Result of measure of SOCPossible actions
Evaluate this month
Prioritize and evaluate next interval
On Target
ICAP Standards of Care for Adherence
Measureof SOC
2008
Patients should be seen for scheduled appointments
% patients seen for scheduled follow-up clinic appointment
220/387
56.8%
Result: 56.8% of patients were seen for scheduled follow-up appointment in qtr.
Why? Attendance is not consistently documented – only appointments
Why? Sometimes patients are ticked or crossed when they come but other times, they are not
Why? There is no column in the attendance book to to indicated kept/missed appointments
Problem: Patient attendance is not routinely and consistently documented and matched with appointments
Mentorship Considerations: •Sensitize MDT on the importance of tracking patient attendance•Support development of appointment system to track patient attendance and missed appointments•Ensure that providers and reception understand appointment system and implement consistently•Plan strategies to create incentive for attendance at scheduled appointments•Develop plan to follow-up on patients who miss appointments
Proposed Analysis
Main idea
Measurement is pointless unless you USE the data for monitoring and intervention planning
Third principle: Context
Adherence challenges change over time and targets and expectations, as well as interventions, need to be flexible
Your role may change as district mentors might be your mentees over time
Social Structural:Patterns of Inequality,
e.g., stigma,gender inequality
Adherencefulfills
responsibility to helpers and
preserverelationshipsas a resource
Relationshipsas resources to
overcome economic
obstacles to adherence
Social Capital
Infrastructural:Few treatment sites
Distance to careCost/Availability of
Transportation
Cultural:Religious Beliefs
Respect for AuthorityImportance of
having children
Individual:HIV knowledge
Med side effectsCognitive function
Mental healthAlcohol Use
ResourceScarcity
ResourceScarcity
Improving Health
A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg PLoS Medicine (in press)
Goal 1: Implement high quality care
Goal 2: Build capacity
Sit
e S
tart
-up
Sit
e M
atu
rity
Assess and
Build Capacity
Time
Assess and improve
implementation
Assess and improve quality
Developing district- and national-level capability
Developing patient-level capability
Are you doing what you think you are doing?
How well?Is it sustainable?