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Care Partners Training Day 2

September 18th, 2015

Care Partners Training Friday, September 18, 2015

The Westin Long Beach Hotel 333 E. Ocean Blvd.

Long Beach, CA 90802 (562) 436-3000

Time Topic/Activity Presenter(s) 8:00 SIGN-IN 8:15 Archstone Foundation – Grant Management Laura Rath 8:30 Care Manager Skill Development

Rita Haverkamp Theresa Hoeft

10:15 BREAK 10:30 Care Manager Skill Development (continued) Rita Haverkamp 11:30 Partnering with Family in Collaborative Care Ladson Hinton 12:00 LUNCH 1:00 Collaborative Care is Accountable Care Rita Haverkamp 2:00 Big Idea /Goals Sharing Rita Haverkamp

Theresa Hoeft 2:30 BREAK 2:45 Focus Groups Ladson Hinton

Stuart Henderson 4:45 Day 2 Training Feedback Ashley Heald 5:00 ADJOURN

Presenters

Archstone Foundation

Laura Rath, MSG Senior Program Officer

University of Washington

Rita Haverkamp, MSN, PMHCNS-BC, CNS Master Care Manager Trainer, AIMS Center Care Partners Role: Trainer

Theresa Hoeft, PhD Acting Assistant Professor, Department of Psychiatry and Behavioral Sciences Care Partners Role: Investigator

Ashley Heald, MA Senior Project Coordinator, AIMS Center Care Partners Role: Project Manager

University of California, Davis

Ladson Hinton, MD Professor and Director of Geriatric Psychiatry Care Partners Role: UCD Principal Investigator, Psychiatric Consultant (McClellan)

Stuart Henderson, PhD Associate Director of Evaluation, Clinical and Translational Science Center Care Partners Role: Evaluator

1

Care Manager / Therapist Role

Rita Haverkamp

Session Objectives

By the end trainees will be able to:

• Describe the functions of care management• Describe the best use of measures and tracking patient outcomes

• Describe key components of differential diagnosis • Discuss treatment options with a patient• Plan for active follow up and treat to target • Engage patients in activation planning

Session Objectives

• Describe role in supporting medication management

• Have a brief understanding of PST• Be prepared to set therapeutic relationship boundaries

• Understand importance of relapse prevention planning

Clinical Roles: Patient‐Centered Team Care

New Roles

PCP

Psychiatric Consultant

Patient

Care Manager Role

Community Partner

PCC

Shared Care Manager

• Define / Split Care Manager tasks

• Coordinate efforts

• All are involved in care management

• Registry can help

• Clear communication plan

• How will psychiatric consultation be handled?

Care Manager Tasks• Facilitates patient engagement and education

• Works closely with PCP and other team members to manage caseload of all patients engaged in active treatment

• Performs systematic initial and follow‐up contacts

• Assists PCP and Psych Consultant with clinical assessment and differential diagnosis (Therapist)

• Systematically tracks treatment response

• Cues team to change treatment when indicated

2

Care Manager Tasks…• Supports medication management by PCP

• Provides brief, structured evidence‐based therapy (Therapist)

• Provides maximizing activation

• Reviews challenging patients with the psychiatric consultant weekly‐ know how this works for your partnership

• Facilitates referral to other services as needed and available

• Completes relapse prevention with patient. Follows up with patient after RPP

Characteristics of Effective Care Managers and Therapists

• Takes ownership of the quality of care and treatment outcomes for all patients engaged in care

• Persistent

• Flexible

– Open to new ways of practicing

• Adaptable to primary care culture and workflows

• Enjoys working in a collaborative team

• Organized

– Able to track a large group of patients

• Strong advocate for changing treatments until patient improved

Elizabeth Video Care Manager Role

Identify & Engage

Establish a Diagnosis

Initiate Treatment

Follow-up Care & Treat to Target

Complete Treatment & Relapse Prevention

System Level Supports

3 Critical elements of Engagement/ Alliance:

Working

Alliance

Goals?

Tasks?

Bond?

Practical tips to grow the bond…

• Be warm up front, to patient and the family

• Have 3 or more contacts within first 2 months

• Get 5‐10 phone numbers of those who are hard to reach or have unstable phone situations

• Have patients call back even if they think they’re doing well

3

Treatment Expectancies

Outcome Expectancy

– Is treatment going to work?

Self‐Efficacy Expectancy

– Can I help myself get better?

Initial assessment video

Initial Assessment – Get Organized!• Orient patient to structure of initial assessment

– Assessment important first step toward getting them the right help

• Start with open‐ended question

• Let patient talk for 3‐5 minutes

• Use registry to help you keep on track and gather what is needed for diagnosis

– History of Present Illness

– Past Psychiatric History

– Social History

– Functional Assessment

– Few sections REQUIRED; use what is clinically useful

Initial Assessment

• Systematic information gathering – presenting complaints, symptoms and relevant history

• Leads to provisional diagnosis (Therapist)

• Essential part of building therapeutic alliance

• Both will do some initial intake‐ know your process

Checkpoint ‐ Elizabeth

• How was she identified?

• What do you think worked for her engagement in this model?

• What would you do to engage her?

• What treatment expectancies did she have?

Care Manager Role

Identify & Engage


Initiate Treatment




4

Diagnosis

• Why do we care about diagnosis?

– Guides treatment and clinical decision making!

– Care partners requirement: Active depressive episode needing treatment

Diagnosis – is it Distress?

• Distress differs from Depression / Anxiety

– External cause(s)

– May be fueled by lack of coping skills

– May look like depression, anxiety

• Intervention not the same!

– Important to differentiate

• Might be Distress AND Depression / Anxiety

– Both can be addressed

Is it Depression?

• How long has patient been feeling this way?– Less than 2 months?

• Did something specific happen?– Grief, bereavement?

– Adjustment reaction?

– Stress?

• Normal reaction to bad situation?– Feeling upset, unhappy, distressed can be normal

Provisional Depression Diagnosis Internal vs. External Causes

Two patients may have same PHQ‐9 score

1. Patient lost job creating stress on marriage, feels overloaded by financial problems

2. Patient depressed most of their life with some periods of worse symptoms

• Can have both types

• May need medication even if environmental factors started cycle


• What would you do about family for her?

• How would you handle

– needs for more information?

– differing input from PCC and CBO

Care Manager Role

Identify & Engage


Initiate Treatment




5

Treatment Planning

Patient, PCP & Care Manager all involved in making the treatment plan

Treatment plans individualized because patients differ in

– Medical comorbidity

– Psychiatric comorbidity

– Prior history of depression and treatment

– Current treatments

– Treatment preferences

– Treatment response

Introducing Treatment

Behavioral Activation

– Discuss how this helps and set a plan today with patient for what they can do before next contact

Medications

– Discuss how they work and results that can be expected, answer questions

Psychotherapy (PST)

– Begin introductory session by briefly describing reasons for doing PST, the structure and how this will help

Treatment Options

• The treatment that WORKS is the best one– Person‐centered care means selecting treatments based 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 of practice• Ask questions and collect information• Support patient being informed and active about all aspects of treatment plan

Cycle of Depression

Discussing Treatment Options

Review all treatment options available

– Psychotherapeutic interventions

• Behavioral Activation, Problem‐Solving Treatment, Cognitive‐Behavioral Treatment, etc.

• Evidence‐based!

– Medications

Discuss pros and cons of each option

Psychotherapy

• Pros:

– No medication side effects

– Alternative for poor response to medications

– Accommodates patient who does not want medication

– Evidence that could work with older adults who have mild cognitive impairments Areán et al., 2010, American Journal of Psychiatry; Alexopoulos et al., 2010, Archives of General Psychiatry

30

6

Psychotherapy

• Cons:– More time consuming (30 min to 1 hr

sessions)

– May take longer to work

– Staff training, mental health professionals

31


• What treatments did she do?

• Where did she start?

• Do you think medications would have been enough for her?

Activity ‐ Introducing Treatment Options

We’ll conduct this practice 3 times, allowing each of you to play a different role (Care Manager, Patient and Observer) each time, 3 minutes per role play.

Steps1. Get in groups of three – group less experienced

people with those who have more experience2. Take papers for the role play based on your

experience level. – Blue ‐most – Yellow ‐ least – Green ‐ nervous or in between

3. Start practice, begin with the Care Manager introducing treatment options to the Patient.

• The person playing the Patient has a specific challenge to present. Please do not share about the challenge with the others in your group until done.

• The Observer will use the checklist to assess the Care Manager/Patient exchange and share constructive feedback with the Care Manager.

Activity ‐ Introducing Treatment Options

What went well?

What was challenging?

Activity ‐ Introducing Treatment Options Care Manager Role

Identify & Engage


Initiate Treatment




7

Follow up video Follow‐Up Contacts

Weekly or every other week during acute treatment phase‐ know how CBO and PCC will do this

– 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 of functioning

– Long‐term treatment adherence

Remember: Most Patients Will Need Treatment Adjustments

• Only 30 – 50% of patients will have a complete response to initial treatment

• Remaining 50 – 70% will require at least one change in treatment to get better

Facilitate Consultation

• Establish set schedule for psychiatrist caseload consultations and in person consultations / visits

• Facilitate communication between PCPs and consulting psychiatrists

Seek Consultation with Psychiatrist when Patient…Hasn’t improved in 10 weeks

Is severely depression (PHQ‐9 score ≥20)

Fails to respond to treatment

Has complicating mental health diagnosis, such as personality disorder or substance abuse

Is bipolar or psychotic

Has current substance dependence

Is suicidal or homicidal

Typical Duration of Care Management

6 Months (average)

Best if determined by clinical outcomes, not preset

– 50%‐70% of patients need at least one change in

treatment to improve

– Only 30‐50% patients respond fully to 1st treatment

– Each change of Tx moves an additional ~20% of

patients into response or remission

8

Typical Frequency of Care Management Contact

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

• Monitor for ~3 months to ensure patient stable

• Complete relapse prevention

Using the Telephone

Under utilized tool

– Check up on adherence to medications

– Check in about side effects to medications

– Check in on behavioral activation

– Check in on symptoms after in remission

Client‐centered approach

– Convenient

– Pro‐active

Tracking Clinical Outcomes

Prevents patients from ‘falling through the cracks’

Facilitates treatment planning and adjustment

– Combats clinical inertia: patients staying on ineffective or partially effective treatments

Know when it is time to get consultation and when it is time to change treatment

http://www.jhartfound.org/sif/ 46

Track Measurements Over Time!

Checkpoint

• What are your thoughts about using behavioral health measures?

• What do you think about using them at most contacts to monitor treatment outcomes (not just to screen / identify)?

Role for Care Manager in Medication Treatment

• Time• Different relationship

Opportunity

• Engaging• Assessing / collecting information• Supporting

Skills

9

Collecting Medication Information

History

• Bring in bottles of all current medications• Ask for list of past medications• What is patient’s experience with medications? Helped? Side effects?

Adherence• How are you taking this medication?• Most people miss doses. How many times do you think you missed a dose of

medication in the last week?• How do you remember to take your medications?

Ask about concerns• How is this medication working for you? What has improved? Anything worse?

Quantify.• Any side effects? What, when, how much do they bother you? • Do you think this medication is helping your reach treatment goals?

Supporting Medication Therapy

Become familiar with commonly used antidepressant and other psychotropic medications and medication doses

Provide basic patient education about medications commonly prescribed in primary care

Support medication adherence

Know when treatment is ‘not working’ and alert the rest of the team to facilitate a change

Supporting Medication Therapy

Help patients and providers identify…– Potentially inadequate doses

– Ineffective treatment (e.g., persistent symptoms after adequate duration of medication trial)

– Side effects

Facilitate patient‐provider (e.g., PCP) communication about medications

Consult with team psychiatrist about medication questions

Patient Education About Antidepressants

• Key messagesHow do these medications work?

By restoring a chemical imbalance in the brain

There are many options (over 20 available medications)

• AnticipatePatient concerns about medications

Side effects (these can be managed)

Problems with adherence

• ReinforceNeed for continuation or maintenance treatment to prevent relapse

even after the patient feels better

Antidepressant Adherence

Key messages:

Take medication daily

Wait 2-4 weeks for effect

Side effects can occur, but often resolve in 1-2 weeks

Keep taking medication even if better

Check with MD before stopping

Not addictingLin EH. Med Care 1995;33:67

• How do you think families can help or hurt with medications?

Checkpoint

10

Maximizing Activation: Simple but Powerful

Goals

– Re‐establish routines

– Distract from problems or unpleasant events

– Increase positively reinforcing experiences

– Reduce avoidant patterns

– Increase critical thinking

– Decrease negative emotional response

Typically we think of acting from the “inside out”

(e.g., we wait to feel motivated before completing tasks)

In BA, we ask people to act according to a plan or goal rather than a

feeling or internal state

Approach: Outside In

Types of Activity

Physical Activity

Social Interaction

Pleasant Events

Household Activities / Projects

Complex tasks

Simple tasks

Assign increasingly more difficult tasks to move toward full participation in

activities

• Help break tasks down into manageable tasks• Mastery and success of one small

task will increase likelihood of completing other tasks

• Have them tell you what and how they’ll do the task (Details! Details! Details! Have them walk you through it)• Help problem solve and ask how

likely it is they will do it.• If it seems too challenging, it is! Break

it down further.

Avoiding Mount Everest:Selecting the BA Targets


• What activation did she do?

• Where would you have started with her?

Activity – Maximizing Activation

We’ll conduct this practice 3 times, allowing each of you to play a different role (Care Manager, Patient and Observer), 3 minutes each role play.

Steps

1. Get in groups of three – have less experienced people with those who have more experience

2. Take papers for the role play based on experience. – Blue‐most

– Yellow‐ least

– Green‐ nervous or in between

11

3. Start practice, begin with the Care Manager discussing activation and then make a clear plan with the Patient.

• The person playing the Patient has a specific challenge to present. Please do not share about the challenge with the others in your group until done.

• The Observer will use the checklist to assess the Care Manager/Patient exchange and share constructive feedback with the Care Manager.


What went well?

What was challenging?


Key Messages

• Collaborative Care and PST are not the same thing

– Collaborative Care is a WAY of delivering treatment

– Medications

– Psychotherapy (including PST)

– PST is one specific treatment modality

Key Messages

• Most Collaborative Care patients never get PST or any other form of psychotherapy

– Most primary care patients prefer medication therapy

• That’s OK

• These patients need IMPACT just as much

– Only 30% of IMPACT study patients EVER got psychotherapy as part of treatment plan

– In real world settings 30‐60% of patients get psychotherapy at any time during treatment

Key Messages

• Teach patients a skill / technique

– Patient empowerment

– NOT ongoing, open‐ended therapy

– Helps prevent relapse

• 6‐10 sessions maximum

– If not learned by then, it won’t be

• Can be done by phone

– Best if initial session in‐person

PST: a patient-directed process

• Patient identified problems

• Teach patient structured technique for solving problems

• Help patients understand connection between depression, problems and solving problems

12

What PST is not…

67

PST for Depression

• Brief

• Common sense

• Evidence-based

• Practical to apply

• Easily learned by therapist and patient

• High patient receptiveness and satisfaction

68

Depression, Problems, andProblem-Solving Skills• Rationale for relationship of depression and problems

– Life problems can be precipitants of depression

– Once depressed, problems become more difficult to solve

– Weak problem-solving skills make a person vulnerable to depression

• Rationale for treatment effectiveness– Problem-solving helps patients exert control over problems

– Fewer problems, increased self-efficacy & hope improve mood

Once learned, problem-solving skills can help prevent relapse

69D’Zurilla T, Nezu A, et al.

Problem DefinitionA problem well‐stated is a problem half solved. –Kettering

• Behavioral description

Goal SettingGoals are dreams we convert to plans and take action to fulfill. –Zig Ziglar

• SMART goal

BrainstormingDon’t put all your eggs in one basket –anon.

• All ideas that come to mind

• Withhold judgment

13

Decision MakingAgain and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. –Robert H. Schuller

Weighing the pros and cons

Selecting the SolutionYou are the sum total of all your choices up to now. – Dr. Wayne Dyer

• Most feasible

Solution ImplementationEven if you are on the right track, you’ll get run over if you just sit there. –Will Rogers

• Steps to implementation

Solution EvaluationWhen you lose, do not lose the lesson. –The 14th Dalai Lama

• Did it work?

– If so, why?

• If not why?

Rewards and ActivitiesOne joy scatters a hundred griefs. – Chinese proverb

• Reinforce patient efforts at change

Role of all in PST

• Supporting plans and knowing plans

• How do you plan to communicate this?

14

Care Manager Role


Identify & Engage


Initiate Treatment


Complete Treatment &

Relapse Prevention


Knowing when a patient is ready to graduate from care

Do you have guidelines for ending treatment now?

How is having a guideline different from usual behavioral health care ?

Checkpoint

Maintenance Treatment & Relapse Prevention

Patient in remission from acute episode

– Make a relapse prevention plan

Follow the patient with monthly contacts

– Usually by telephone

– Individual OR in a maintenance group

Bring patient back in for further evaluation if symptoms recur

Purpose of Relapse Prevention

Helps patients identify:– Their own symptoms of depression or anxiety

• Look at first few symptom measurements if cannot remember

• Intervene earlier if symptoms return

– What worked to get better• Keep doing these things

– A plan if symptoms return

Relapse Prevention Plan

• What would need to go in her RPP

Checkpoint- Elizabeth

15

Safe therapeutic relationships

• Boundaries – professional but warm, friendly but not friends

• Discuss these issues as a team ongoing

Care Manager Role

Identify & Engage


Initiate Treatment




Ongoing Training for Care Managers & Therapists

Insrt plan here

1

Care Manager / Therapist Role:Strategies for Involving Family in Collaborative Care

Ladson Hinton, MD

University of California Davis

Overview of presentation

• Assessment and treatment planning– Engaging patients and family members

– Family contributions to assessment

– Developing a joint treatment plan

• Treatment phase– Family participation in behavioral activation

– Family support of medication management

• Relapse and prevention phase

• Caveats and challenges

Partnering with a CBO and Family

PCP

Psychiatric Consultant

Patient (Family)

Care Manager Role

Community Partner

PCC

2

Care Manager Role

Identify & Engage


Initiate Treatment

Follow‐up Care & Treat to Target

Complete Treatment & Relapse

Prevention


How to Engage Patients in Family‐Centered Care

• Explain how family/caregivers (i.e. kin, non‐kin) can help

• Describe what family‐centered care is and isn’t (e.g. not family therapy)

• Identify potential family helpers

• Address any concerns patient may have

– e.g. being a burden, privacy, autonomy

• Consider re‐approaching patients who are initially hesitant or ambivalent

How to Engage Family Members

• Identify opportunities to engage family in your workflow

– May occur in first or second visit

– Or later in treatment

• Get to know family member

• Explain what depression is and how family can help

• Address family concerns and questions

3

Care Manager Role

Identify & Engage


Initiate Treatment



Prevention


Family Role in Assessment

• Patient is usually primary source of information

• Family provides additional collateral history to assist in assessment process

– Fills in gaps in history

– Family perspective on symptoms may be helpful (e.g. PHQ‐9)

Care Manager Role

Identify & Engage


Initiate Treatment



Prevention


4

Joint psychoeducation

• Occurs in 1st or 2nd session with family

• Critical to lay a “shared foundation” for depression treatment

• Addresses nature of depression and how treatment works

• PHQ‐9 to track symptoms

• Can reduce stress and improve communication

Developing a Joint Treatment Plan and Initiating Treatment

• Describe possible roles for family in collaborative care– Facilitating connection with CBO

– Behavioral activation

– Medication management

– Participation in primary care visits

• Identify and negotiate specific family role in patient’s treatment

• Incorporate family task‐sharing as part of the treatment plan

Care Manager Role

Identify & Engage


Initiate Treatment



Prevention


5

Family Role in Supporting Evidence‐Based Treatment

• Participate in sessions with care manager

• Behavioral activation

– Can support patient in achieving behavioral goals

– Participate in problem‐solving when goals are not achieved

• Medication management

– Help with adherence to medication

– Help with monitoring side effects and symptoms

Family Role in Relapse Prevention

• Family members can partner with patients to continue activities/meds, manage symptoms, watch for warning signs, encourage help‐seeking

• Include family in education about relapse prevention

• Relapse prevention plan can be modified to incorporate family caregivers

Caveats and Challenges

• Confidentiality / privacy issues

• Family impedes treatment

• Elder abuse situations

• Provider lack of skills/training

• Multiple family members involved

• Cultural aspects of family caregiving

• Family unavailable (time, interest etc..)

6

Resources

• All of us!

– Discussion of family involvement on calls

– VA workflow document

• Consultation with UC Davis team

– Ongoing NIMH funded study on depression and family engagement

• References

9/15/2015

1

Overcoming Common Implementation Challenges

Using Accountability

Principle 5: Accountable Care

Monthly calls

Process of care data is used internally and during monthly calls between each clinic and the AIMS Center to help them identify and resolve implementation challenges

9/15/2015

2

Evaluating Progress and Continuous Quality Improvement

• No shame or judgment — just information from which to learn

• Know your goals/targets

– Which numbers are on target for goals?

– Which numbers fall below target for goals?

• Is there information that might be helpful to understand current numbers?

Clinical outcomes: • 5+ Point decrease in PHQ‐9 score

Goal: 50% of active caseload• 50% decrease in PHQ‐9 score after at least 10 weeks

Goal: 40% of active caseload

Processes of care: • Active Caseload % of Minimum

Goal: Caseload based on CM type• % of active patients with psychiatric consultation note

Goal: 75% of active patients with note

Implementation Overview

9/15/2015

3

Too many patients and low rates of improvement

Not enough patients enrolled

9/15/2015

4

Caseload Statistics

Processes of care: • Initial assessment‐ Goal 90% most will be 100%• Follow‐up Contacts

Goal: The minimum target for this is 80%• % of active patients with psychiatric consultation note

Goal: 75% of active patients with notePreferably very low numbers in need of consult without improvement

Caseload Statistics

Clinical outcomes: • 5+ Point decrease

Goal: 50% of active caseload• 50% decrease after at least 10 weeks

Goal: 40% of active caseload

Processes of care: • Clinical Assessment

Goal: Completed • Follow‐up Contacts

Goal: Contact 2X per month• active patients with psychiatric consultation note

Goal: patients without improvement every 2 months

Current Caseload Patient View

9/15/2015

5

Processes of care: • Clinical Assessment

Goal: Completed • Follow‐up Contacts

Goal: Contact 2X per month• active patients with psychiatric consultation note

Goal: patients without improvement every 2 months

Current Caseload Patient View

Clinical outcomes: • Green numbers 50% decrease after at least 10 weeks• Yellow numbers 5 point decrease • Red numbers: Not improved, consider consultation

Current Patient View


9/15/2015

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Current Patient View Patients Not Engaged


Patients Not Improving

Can I get someone else to put things in the registry?

• Registry is more than just data for sake of data

• Knowing the data helps you do a better job

• Patients get better care and don’t get lost to care

• PCC and CBO will know what is going on at each area

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