Transcript Suffolk County PROS Providers - יספר"א

Introduction to Person Centered Planning
June 2011
Neal Adams MD MPH
California Institute of Mental Health
Learning Pyramid
Warm Up
• List typical goals found on current
service plans
• Write 3 goals/areas of meaning you have
for yourself on a piece of paper
• Hand that paper to the person sitting
next to you
person-centered / directed care
…it’s not a straight path from here to there…
Definition of a Recovery Plan
• A recovery plan is a
document, co-created
by the person
receiving services and
the provider, to
outline the steps
needed to achieve a
particular goal or
outcome.
The Recovery Plan
• It is the work/social
“contract”, created by
the person and
provider.
A Person-Centered Approach to
Service Planning
• Collaboration and
partnership.
• The plan prioritizes the
person’s desires while
including a provider
perspective.
PCP…Don’t we already do this??
 Making progress but… we DON’T “already do
this.”
 Not according to consumer/survivors…
 “old wine…new bottles”
 and not if you take a close look at concrete
implementation strategies
 Review your current records/plans
Treatment Plan
Recovery Plan
The Nature of the Problem
• 24% of sample (N=137) report NEVER having a
treatment plan
• Of those who had experienced a treatment plan, half felt
involved only “a little” or “not at all”.
o Only 21% of participants
report being “very much”
involved
o Only 12% of people invited
someone to their last
treatment planning
meeting
o Over half were not offered
a copy of their plan
o People aren’t even in the
car, let alone the driver’s
seat!
It Works!
• For example, WNYCCP has achieved the
following outcomes:
•
•
•
•
•
55% decrease in ER visits
58% decrease in inpatient days
66% decrease in suicide attempts
52% decrease in harm to others
18% decrease in arrests
• Cost-effective
•
Over a 3 year period, Medicaid costs per
participant decreased 10% compared to an 8%
increase for the general population
The Comprehensive
Person-Centered Plan
Incorporates
Evidence-Based Practices
Encourages Peer-Based
Services
Promotes Cultural
Responsiveness
Focuses on Natural
Supporters/Community
Settings
Maximizes SelfDetermination & Choice
Informed by Stages of
Change & MI Methods
Respects Both Professional &
Personal Wellness Strategies
Consistent w/ Standards of
Fiscal & Regulatory Bodies,
e.g., CMS, JCAHO
PDP is…
• Person Directed Planning is a planning
process that
is controlled by the person receiving services
(family for children)
 results in a recovery plan that details the
issues important to the person

o

managed in all important aspects by that person
with freely chosen support when necessary
spells out what will constitute both quality in
the execution of the plan as well as specific
outcomes
13
Being Person-Centered in Practice
• The consumer as a whole person
• Sharing power and responsibility
• Having a therapeutic
alliance
• The clinician as person
14
Fundamental Principles of PDP
• Adheres to the “person-first” concept
• Applies to ALL people
• Views the recovery process as flexible
and non-linear
• Promotes self-determination to the
maximum extent possible
• Focuses on capitalizing strengths
• Demands transparency and
equal access to information
• Facilitates natural supporter
involvement
The Road to Recovery...
• Person-centered planning



is a collaborative process resulting
in a recovery oriented treatment
plan
is directed by consumers and
produced in partnership with care
providers for treatment and
recovery
supports consumer preferences and
a recovery orientation
Adams/Grieder
Use of Person-first Language
• Not a diagnostic label

Person with schizophrenia, or addiction
•
not “a schizophrenic” or “an addict”
• Not “front-line staff” who are “in the
trenches”

direct care staff providing compassionate care
• Focus on strengths, successes, talents
• Self-determination as a right
• Communicate a consistent message of
hope
17
Serving Two Masters
Understanding
Person-centered





Recovery
Community integration
Core gifts
Partnering
Supports self-direction
Regulation
 Medical necessity
 Diagnosis
 Documentation
 Compliance
 Billing codes
Outcomes and Goals
18
Medical Necessity
• Doing the right thing, at the right time, for
the right reason
• Standard of service and quality
• Five elements


Indicated
Appropriate
o



consider issues of culture
Efficacious
Effective
Efficient
19
Example
• Goal

Decrease depression
• Objectives



Assess medication needs
Improve finances
Develop appropriate vocational goals
20
Example
• Goal

Maintain psychiatric stability
• Objectives


Attend appointments with PCP
Donna will attend psychiatric
appointments
21
Example
• Goal

Life long sobriety and abstinence
• Objectives




Attend all classes and groups on
substance abuse education
Complete 4th step by November 2008
Attend 5 NA/AA meetings per week
Weekly individual therapy
22
Plan Development
• Acquired skill / Art form



Not often taught in professional training
Often viewed as administrative burden and paper
exercise
Requires flexibility
• Opportunity for creative thinking
• Integrates information about person served


Derived from formulation and prioritization
Information transformed to understanding
• Strategy for managing complexity
23
Service Plan Functions
• Specifies intended outcomes / transitions /
discharge criteria

Clearly elaborates expected results of services
o

includes perspective of person served and family
in the context of the person’s culture
Promotes consideration and inclusion of
alternatives and natural supports / community
resources
• Establishes role of person served and family in
their own recovery / rehabilitation


Assures that services are person-centered
Enhances collaboration between person served
and providers
24
Service Plan Functions
continued
• Identifies responsibilities of team members-including person served and family




Increases coordination and collaboration
Decreases fragmentation and duplication
Coordinates multidisciplinary interventions
Prompts analysis of available time and resources
• Provides assurance / documentation of medical
necessity

Anticipates frequency, intensity, duration of
services
• Promotes culturally competent services
25
Service Plan Functions
continued
• Supports utilization management


Services authorization, communication with
payers and payment for services
Allocation of limited resource
• A contract with the people we serve!
26
The Plan…Must it be a heavy burden?
“Apparently, Smith’s desk just couldn’t withstand the
weight of the paperwork we piled on his desk.”
Elements of a Recovery Plan
• The person’s goal: what is the desired outcome of
services?
• Discharge/transition criteria—establishing and end
point
• How to overcome barriers?
• Objectives – what are the steps to reduce barriers
and attain the goal?
• Proposed type(s) of interventions – who is going to
do what to get there?


proposed duration– when will things be accomplished?
Purpose—what’s to be accomplished relative to the
objective?
A Plan is a Road Map
• Provides hope by breaking a seemingly
overwhelming journey into manageable steps for
both the provider and the person served
B
C
D
A
E
“life is a journey…not a destination”
Building a Plan
Outcomes
Services
Objectives
Strengths/Barriers
Goals
Prioritization
Understanding
Assessment
Request for services
Strengths
• Environmental factors that will increase the
likelihood of success: community supports,
family/relationship support/involvement,
work
• Identifying the person’s best
qualities/motivation
• Strategies already utilized to help
• Competencies/accomplishments
• Interests and activities, i.e. sports, art

(Identified by the consumer and/or the provider)
Examples of Strengths
•
•
•
•
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•
•
•
•
•
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Motivated to change
Has a support system –friends, family
Employed/does volunteer work
Has skills/competencies: vocational, relational,
transportation savvy, activities of daily living
Intelligent, artistic, musical, good at sports
Has knowledge of his/her disease
Sees value in taking medications
Has a spiritual program/connected to church
Good physical health
Adaptive coping skills
Capable of independent living
Cultural Factors in Assessment
• Begin with cultural and demographic
factors

Clarify identity
o
o

“how do you see yourself?”
race, ethnicity, sexual orientation, religion,
color, disability reference group
Specify language
o
o
o
fluency
literacy
preference
34
Barriers
• What is keeping the person
from their goals?

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
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


need for skills development
intrusive or burdensome symptoms
lack of resources
need for assistance / supports
problems in behavior
challenges in activities of daily living
threats to basic health and safety
• Challenges / needs as a result of a mental /
alcohol and/or drug disorder
35
Importance of Understanding
• Data collected in assessment is by itself
not sufficient for service planning
• Formulation / understanding is essential




Requires clinical skill and experience
Moves from what to why
Sets the stage for prioritizing needs and goals
The role of culture and ethnicity is critical
to true appreciation of the person served
• Recorded in a chart narrative

Shared with person served
36
Interpretive Summary Bridge
• Informative findings based on assessment data
and the subsequent recommendations
• Perception of the individual on his/her SNAP
(strengths, needs, abilities and preferences)
• Perception of the provider on individual’s
SNARF (strengths, needs, abilities, risk and
functional status)
• Provider insight into contribution and impact of
individual’s psychodynamic, cognitive, familial,
environmental and personality traits on current
status, service goals and treatment outcomes
Interpretive Summary, cont.
• Provider & individual’s understanding of
how illness/condition impacts function
• Provider and individual’s speculation and
understanding of previous treatment
outcomes
• Groundwork for recovery vision and future
goals
• Prioritization of needs for service planning
• Individual’s readiness and motivation for
change
The 10 Ps
•
•
•
•
•
•
•
•
•
•
P ertinent history (brief)
P redisposing factors
P recipitating factors
P erpetuating factors
P resent condition / presenting problem
P revious treatment and response
P rioritization by person served
P references of person served
P rognosis
P ossibilites
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Stages of Recovery and Treatment
Ohio
Village
Prochaska &
DiClemente
Stage of
Treatment
Treatment
Focus
Engagement
• outreach
• practical help
• crisis
intervention
• relationship
building
Dependent
unaware
High risk/
Unidentified or
Unengaged
Dependent
aware
Poorly
coping/Engage Contemplation/p
Persuasion
d/not selfreparation
directed
Independent
aware
Coping/Self
responsible
Interdependent
aware
Graduated or
Discharged
Precontemplation
Action
Maintenance
Active
Treatment
Relapse
Prevention
• psychoeducation
• set goals
• build
awareness
• counseling
• skills training
• self-help groups
• prevention plan
• skills training
• expand
recovery
The person
is…
moving
beyond…
challenging…
overwhelmed
by…
…the
disabling
power of
the illness
giving in
to…
questioning
Vignette--Carmen
• 18 year old Latina
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

High school senior
o preparing for graduation
First generation
o parents monolingual Spanish speaking
o client bilingual
o observant Catholic family
Lives in predominantly Anglo-American
community
43
Vignette continued
• Excellent student



Active in school and social activities
Recently unable to attend school because of
distress
Graduation from high school and college
attendance is core value for Carmen and family
• Recent physical problems

Nausea, vomiting, dizziness, headaches
• Parents believe she is suffering from susto

Treatment from curandero
44
Vignette continued
• Recent crisis



Acute physical distress
Admitted to hearing a baby cry while at
school
Reported feeling sad and blue
• Referred to mental health


Embarrassed and resistant
First family member to seek MH services
45
Vignette continued
• Assessment with Latina provider in
Spanish




Revealed she had a miscarriage a year
ago
Feeling increasingly guilty and troubled
Wants to die and join her baby
Relationship with parents has become
distant and full of conflict
o
father refusing to speak with her
46
Vignette Formulation
• Identity


First generation Latina
Bilingual
• Explanation of Illness

What appeared to be a physical problem is a
mental health problem
o
o
somatization is idiom of distress
shame, guilt and embarrassment are key themes
• Provider relationship


Spanish preferred
More open with Latina clinician
47
Vignette Formulation
continued
• Psychosocial environment


Lives with family, first generation
Some degree of acculturation and distance
from parents
o
difficult and painful
• Diagnosis

Consider possibility of culture bound syndrome
o


susto
Possible depression with psychotic features
Understanding her beliefs may be key to
treatment
48
Vignette Formulation
continued
• Hypothesis

Intergenerational issues of acculturation are a
major factor
o



Age appropriate issues of individuation and
separation
She is between contemplative and active
stage—some ambivalence about help-seeking
School completion and education opportunity
and advancement are shared values /strengths
to build upon
Need to help her reconcile feelings of guilt and
remorse
o
Religious and spiritual factors may be significant49
Definition of a Goal
“The goal is a broad, general statement that
expresses the individual’s and family’s desires
for change and improvement in their lives,
ideally captured in their own words.”
Source: Adams, N. and Grieder, D. (2005)
Treatment Planning for Person-Centered Care.
Elsevier Academic Press.
Definition of a Goal
• Goals express the hopes
and dreams of the client.
• Goals identify the hopedfor destination to be
arrived at through the
services provided.
The Essential Features of Goals
• They are BIG


Long term, global, and broadly
stated
They are not necessarily measurable
• Written in positive terms


built upon abilities / strengths,
preferences and needs
embody hope/alternative to current
circumstances
Key Points about Goals
• A good goal inspires the individual to
reconnect to their dreams.
• Goal development is an essential
part of engagement and creating a
collaborative working relationship.
Collaboration and Goals
• Reaching agreement on the goal is
essential



The provider understands and
appreciates the importance of the goal.
The goal has immediate meaning and
relevance for the consumer.
The goal becomes a shared vision of
success.
The Right Balance
Let client do what
he/she wants
Get client to do
what I want
Recovery Zone
Neglect
Control
55
Common Ground
• Clients should have the dignity of risk and
right of failure
• Providers are advocates of client choice
• Clients are not abandoned to suffer “the
natural consequences” of their choices
• Provider or client not a failure if choice
results in failure
• Use reinforcers to support client choice
• Assure true choice over a wide range of
options
Pat Deegan
56
Carmen’s Plan/Action Stage
• Goal
 “I want to graduate from high school”
57
Barriers
• What is getting in the way of the person
achieving their goal


Why can’t they do it tomorrow
Why can’t they do it themselves
• Our focus is removing/reducing/resolving
barriers that are a result of the mental illness
Recovery Happens In Small Steps
• To be an effective road-map,
plans need to clearly identify the
smaller steps that get you to
your destination.
• These markers along the way
also offer opportunity to
celebrate and acknowledge
progress.
• Every gain made is additional
fuel for the journey!
Defining Objectives
• Objectives describe a significant and
meaningful change that the individual can see
or experience.
• Objectives are milestones – they designate the
mini-goals along the way.
• Well-written objectives create opportunity for
success, for seeing that the dream is really
possible.
What Do Objectives Do?
• Take into account the culture of person
served
• Divide larger goals into manageable tasks
• Provide time frames for assessing progress
• These are the action steps the person
takes toward their goal
Objectives and Medical Necessity
• Objectives address barriers to the goal.
• They also describe changes in behavior,
function, or status.
 relate back to functional impairments
o

how the work we are doing will reduce these
barriers
identify key changes that the consumer
wishes to accomplish
Keep it Focused!
• A maximum of two or three objectives per
goal is recommended to create focus and
reduce the chances of feeling overwhelmed.
Objectives Should Be SMART
•
•
•
•
•
Simple or Straightforward
Measurable
Attainable
Realistic
Time-framed
How to Write an Objective
• Subject
• Person receiving services
• Verb/Action Word
• Will demonstrate
• What
• Ability to use three coping
techniques to address
anger
• When will it be
done/timeframe?
• Within one month
• How will it be measured?
• As measured by therapist
observation
Objectives Are Not Interventions
• Objectives are the WHAT
 What is the next step towards the goal?
 What is the next significant milestone?
• Interventions are the HOW
 How are we going to get there?
 Interventions are the action steps taken to
achieve the objective.
Carmen’s Plan/Action Stage
• Goal
 “I want to graduate from high school”
• Objective
 Carmen will return to class attendance
for 5 consecutive full days within a
month as reported by Carmen / or
support worker
67
Interventions
• Actions by staff, family, peers, natural
supports
• Specific to an objective
• Respect consumer choice and
preference
• Specific to the stage of
change/recovery
• Availability and accessibility
of services may be impacted
by cultural factors
68
Five Critical Elements
• Interventions must specify





provider and clinical discipline
staff member’s name
modality
frequency /intensity / duration
purpose / intent / impact
• Clarifies who does what
• Include a task for the family, or other
component of natural support system to
accomplish
69
The 5 W’s of Interventions
• Who

Which member of the team or support system will
provide it
• What

specifically what service will be provided.
• When

How often, how much time and duration
• Where

Identify the location of service delivery
• Why

Link the intervention back to the desired outcome
Carmen’s Plan/Action Stage
• Interventions

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Psychiatrist to provide weekly to monthly
pharmacotherapy management visits for 3 months to
relieve acute symptoms of anxiety and depression
Social worker to provide one hour of cognitivebehavioral psychotherapy twice a week for 4 weeks
to help Carmen resolve feelings of guilt and loss
Support worker to meet with Carmen up to 3 hours /
week for 4 weeks as required to coordinate / facilitate
return to school with school counselors and mental
health team
Carmen and family to attend weekly sessions with
their parish priest to bring about forgiveness and
71
family reconciliation.
Common Mistakes
• Assessment




Do not use all available information resources
Not culturally appropriate / sensitive
Not sufficiently comprehensive
Lack adequate integration / understanding of the
person
Common Mistakes
• Goals





Not global
Not directed towards recovery
Not responsive to need
Not strengths based
Too many
Common Mistakes
• Objectives


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

Don’t support the goal
Not measurable or behavioral
Interventions become objectives
Not time framed
Too many simultaneous objectives
Common Mistakes
• Interventions
 Purpose not included
 Frequency, intensity, and duration not
documented
 Too few
 Don’t reflect multidisciplinary activity
Jane
• Jane comes in to the mental health clinic for
medications that help her with her depression
and anxiety. In the past, she has been
overwhelmed by sadness and would drink to
“numb-out” and her drinking made it impossible
for her to function at home or work. Feeling
much better, Jane wants to get back into the
workforce. She occasionally experiences
relapses, but finds that she gets back on her feet
more quickly now.
Jane’s Goal
•
Goal: I want to work full-time.
Addressing Jane’s Barriers
• Objective 1

Jane will be clean and sober for 30 consecutive
days as measured by self-report.
• Interventions:



Sam Smith, LCSW, will provide dual recovery
groups once per week for one year to Jane so she
can learn the tools to stay clean.
CM will discuss how meetings went with Jane once
per week in the community, and reinforce active
participation in the group to assist her in achieving
sobriety for 3 months.
Jane will attend AA meetings 3 x per week for 3
months in order to develop a sober support
system
Addressing Jane’s Barriers
• Objective 2

Jane will master two stress reduction skills
within the next 60 days as measured by her self
report of successfully resolving
conflicts/problems without self-defeating
behavior .
• Interventions


Peer specialist will meet with Jane every other
week in the community to practice stress
reduction skills for 2 months
CM will provide skills training on stress
management one hour/once per week for 60
Barriers / Excuses / Rationales
• Medicaid won’t let us do this!

•
•
•
•
OIG audits
the forms don’t have the right fields
regulations prohibit it
consumers aren’t interested/motivated
recovery isn’t real

stigma among professionals
• lack of time/caseloads
too high
• “my clients are sicker”
Barriers / Excuses / Rationales
• social control is our “true” mission
• professional boundaries
• funding issues
 getting paid for services
 no Medicaid
reimbursement
 dis-incentives
 lack of Medicaid funding for EBP’s
• “we’re already doing this”
Provider Role And Contribution
• Perception

There isn’t much of a role for providers in the
person-centered world
• Reality

There is a large but changed role for providers
• providers of hope
• assessment / formulation
• knowledge of the system of care/community
• knowledge of the disease and possible solutions
• teachers/trainers/coaches
It’s Not Permitted / Reimbursable
• Perception

Medicaid regulations and state plans won’t allow for
person-centered planning
• Reality

Most state plans for Medicaid reimbursement, be they
option, clinic option or waiver, speak the language of
individualized planning
 the person directing the planning, and a strengths
based approach to assessment and planning
Violates Professional Boundaries
• Perception




This isn’t how I was trained
I’m not comfortable with this
I know better
My licensing board won’t let me do that
• Reality


Providers have not received necessary training and
support
Established appropriate professional model
Linking Planning With EBP
• Perception

EBPs are not person-centered nor Medicaid reimbursable
• Reality




Most evidence based practices / programs are
constructed from smaller specific service
interventions that can be individualized
“De-constructing” EBPs into specific billable services
demonstrates medical necessity of each element
EBPs provide decision-support point in shareddecision making
IMR/IDDT/SE all closely related to PDP
Services Are Not Aligned With PCP
• Perception

“programs” are not individualized
treatment/services and PCP doesn’t fit
• Reality

There are opportunities within program structures
to provide consumer-centered services
o phases/stages of change approach
o employing peers as facilitators
o budgeting needs to consider moving from
services to supports
Consumers Are Too Sick
• Perception

Consumers aren’t interested in
participating (“old timers”),
are “delusional”, have
no goals, etc.
• Reality


Need to communicate a message of hope and a
belief that their life can be different, or
education/training/tools on person-centered
planning
Need to assess and plan for stage of change
“If you don’t know where you are going,
you will probably end up somewhere else.”
Lawrence J. Peter