Transcript Document

A Coordination of Care Quality Impact Project
“Straight from the Heart” : A Client Based Rapid Cycle Intervention
Presented to The NYS AIDS Institute Quality Improvement Learning Network for
Ryan White Case Management Providers
Carla Lewis, Ph.D. & David Pulli, LMSW of Project Hospitality
December 16, 2005
I. Identified Areas for Improvement
Targeted Continuous Quality Impact Goals:

To increase access and coordination with mental health providers for HIV
positive Title I Case Management consumers that present with mental health
symptoms (24/30). Baseline data indicated that one third (8/24) of this
subgroup were not engaged in mental health services in September 2005.

To enhance front line staff’s capacity to identify clinical needs by increasing
awareness, confidence, and ability to identify useful psychosocial variables
related to behavioral health outcomes.

To enhance cross-fertilization between programs, raising the salience of
mental health screening, barriers, and referrals for case managers.
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II. Organize Improvement Team

Dr. Carla Lewis, Agency wide Director of Planning, QI Council, and Evaluation
(conceptualization, instrumentation, design, training, process and outcome evaluation,
report writing)

David Pulli, LMSW Program Director (programmatic/service delivery elements, staff and
client coordination, CQI project oversight and access)

Case management team (Krasimira Dobrinska, Pamela Williamson) Pilot sample
identification, intervention implementation, data collection, evaluation,
documentation, and follow-up)

Peer Volunteers (craft vignettes)

Mental Health Service Providers (special thanks to Dr. Maxine Ain, Staff
Psychiatrist) Peer recruitment, support with vignettes, clinical/creative support
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III. Review of Current Process

Measurement: Quantification/Aggregation of mental health non-

Hypothesized Root Causes of Non-Engagement: Low Outcome

Root Causes: (See empirically derived “Lessons Learned” Section VI)
engagement rate was 33-1/3%; Content Analysis of charts of non-engaged
clients (client factors, length of time since infected, prior mental health
services, circumstances, support networks, activities, change in biomarkers,
housing, cultural influences) revealed contextual and clinical indicators for
mental health services (ranging from supportive counseling through mental
health harm reduction).
Expectancies, Denial, Cultural Myths ,Constraints (“stiff upper lip”, help
seeking perceived as weakness) Unfamiliarity/Awareness, Fear (stigma,
judgment, meds), Adaptation, Self Care, Systemic Attitudes (“Us” vs.
“Them”), Screening Factors/ Acuity
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IV. Select and Test Improvement Strategies
Phase I

Blend elements from Community Identification and Social Cognitive Theory
viz. Bandura’s Social Learning Elements --Role Modeling, Observational
Learning, Outcome Expectancies and create and disseminate peer quotations
e.g., “How Services Changed My Life”.

Volunteer peer testimonials for low literacy and culturally competent flyers
crafted by peer volunteers were used by case managers in one-on–one
intervention with the subset of resistant clients. The flyers, titled by the team
as “Counseling and Me: Straight from the Heart” were also posted on the
walls of the mental health offices, at their request. A byproduct of the
implementation was the cross fertilization of mental health and case
management teams (such as collaboration in collecting peer vignettes,
discussing project mission)

Reactions to the flyer (client feedback survey) and mental health
engagement rate will be evaluated post intervention.
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IV. Select and Test Improvement Strategies (continued)
Phase II
•
Mindfulness/Enrichment Training: Through consciousness raising training
with Project Hospitality’s Social Psychologist/Planner, case managers will be
able to “widen the net” and screen for more nuanced psychosocial
dimensions such as social adequacy, resiliency, and event impact that may
reflect critical variation in need for clinical and supportive mental health
services.
•
Resiliency/attitude scales, Impact of Event Scale, social support, Self
Esteem, psychological maltreatment, and coping style inventories were used
as a point of lively discussion. Items, indicators and correlates were used to
illustrate contextual influences and how they may play out clinically to
inform/enrich service decisions.
•
Formative (iterative) process feedback with case management staff on
training, administration of flyer, evaluation instrumentation, and client
feedback is built into the design.
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V. Measure Results of Improvement Strategies: Phase I
Structured Interview
1. How did you feel when you got to
share your peer’s feelings on the
“Straight from the Heart” Flyer?
2. Does what they wrote make you
feel like you might consider
(reconsider) getting support? If No,
Why Not?
If Yes,
____Wanted to be introduced to
mental health team
___ Expressed interest/intentions
but wanted some time.
Quantitative Results (n=8)
75.0% (6/8) Yes
12.5
62.5
1/8 wanted introduction to MH
5/8 Expressed interest/intentions
25.0% (2/8) No
12.5 1/8 strong support networks
12.5 1/8 client “liked the flyer” and
looked touched but surprised
and frightened by such intimate
sharing. “Not for me”
was relieved
when CM stopped
evaluation.
I am here whenever or whatever you
decide!
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V. Results (Continued)
Phase I Post Intervention Behavioral Outcomes
Figure 1: Pre-Post intervention Engagement Rates in Mental Health Services (N=24)
25

20
15
No MHS
MHS
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
5
0
Pre
Post
Non-engagement rate of clients
presenting with mental health
needs decreased from 33-1/3%
(8/24) to 12.5% (3/24) at one
month follow-up.
Engagement of those
presenting with mental health
needs increased from 66-2/3%
(16/24) to 87.5%.( 21/24) at
one month follow-up.
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V. Results of Improvement Strategies
Phase II
(continued)
Case Managers Evaluation
1. Since our training are you:
(always, much more likely, more
likely, about the same, less
likely)
to discuss/or screen for mental
health issues?
Quantitative Results
Two Ryan White Case Managers
reported that they were “50% more
likely” and “always conscious of
mental health issues” since the
project.
2. Can you estimate the percent
of time you are mindful/screen
for mental health needs since
the intervention?
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V. Results (continued)
Mindfulness, Coordination and Social Contagion

There is strong evidence that the salience of the project has diffused
to neighboring COBRA staff which shares the same Project Director.

Since the start of this project, Harm Reduction Mental Health Services
received twice as many referrals in October than usual. Supportive
Counseling has admitted 6 new clients over October/November—20%
of its most current caseload!

All Mental Health Staff including the Area Director, our Psychiatrist,
Harm Reduction Mental Health, DOH AI Mental Health, and Supportive
Counseling staff requested that the “Straight from the Heart” Flyer be
posted on their walls.

Case Management staff have “enjoyed” more informal visits with
Mental Health Staff since the project and the CM QI Team has decided
to use the community identification tool for future clients as indicated.
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VI. Lessons Learned
Grassroots Gems

The flyer served as a window from which to explore underlying ambivalence.
Our follow up results show that clients may be “sitting on the fence” initially but
the opportunity to process concerns, coupled with case manager’s gentle
support appears to be a catalyst for positive change. As indicated below,
immediate reactions to “Straight from the Heart” peer quotes differed
significantly from ultimate behavioral outcomes.

My first thought is ….identification. Yes, I can identify with the quotes…I
feel it. It is touchy. I cannot say anything else at the moment. [Expressed
interest/intentions but wanted some time]

They remind me that I need help. [Wanted to be introduced to Mental

Yes I will think about it but have no time. Tell me when I will have a kitchen
table…. [Expressed interest/intentions but wanted time]

They are right…but I am not like them. I am a strong man. I do not want to
discuss my feelings. With you, it is enough. You are my case manager .I do
not want to cry next door. ….Does what they wrote make you feel like you
might reconsider getting support? …If you insist….[Expressed
Health Team]
interest/intentions but wanted some time]
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VI. Lessons Learned (continued)

The psychology of the environment, especially sharing space with COBRA staff
and sharing an adjoining building with Mental Health staff was not fully utilized
before the project. There is an exciting ripple effect on organizational culture
when teams are committed to QI initiatives.

Hypothesized root causes of resistance or non-engagement require empirical
validation so interventions can be crafted to penetrate actual barriers such as
those generated through intervention using peer quotes as a stimulus.
 Logistical Interference (time pressures, “taking care of business”
housing appointments, insurance, getting the lights turned on, MHS
engagement viewed as a luxury)
 Privacy, Shyness, Embarrassment, cultural constraints about sharing
feelings
 Pseudo independence, machismo, views help seeking as a weakness,
“me” vs. “them”
 Strong social/alternate support networks
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VII. Next Steps
1. Debrief results, disseminate, and acknowledge team success!
2.Level the Divide/Normalize by continuing to work strategically with social
influence flyer to penetrate client isolation (“me vs. “them”) and fears about
becoming a consumer of mental health services.
3. Screening Acuity: Continue to increase knowledge and awareness of
psychosocial influences on well-being through “brown bag” rap sessions with staff
social psychologist/Planner.
4. Keep track of resistant clients using a Stages of Change/readiness
consciousness. Document where client fell on the continuum ( no interest, some
interest, maybe later, after detox, refer now) on post-intervention treatment
orientation questionnaire.
5. “Connecting the Dots” by leveraging client strengths, health efficacy
beliefs, self care, and help-seeking more explicitly and interactively. Crafting mini
treatment planning interventions, highly specific per client with quantifiable goals.
6. Diffuse culturally competent QI initiatives/interventions like this to
identify/penetrate other service/behavioral barriers through ongoing collaboration
with the Director of Planning/Evaluation.
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