Transcript Slide 1

Person-Centered Mental Health Care
Moving Beyond the Rhetoric and
Values of Recovery
in Everyday Practice
Neal Adams MD MPH
Deputy Director
California Institute of Mental Health
Pleonasm
N
O
U
N
:
1a. The use of more words than are required to
express an idea; redundancy. b. An instance of
pleonasm.
2. A superfluous word or phrase.
E
T
Y
M
O
L
O
G
Y
:
Late Latin pleonasmus, from Greek pleonasmos, from pleonazein,
to be excessive, from ple
Kuhn/Paradigm Shift

true paradigm shift
 new model for understanding
and experiencing relationship
between consumer and
provider
 challenges earlier precepts
 can only supplant old model
Neal Adams MD Copyright 2008
Mental health recovery is a journey of healing
and transformation enabling a person with a
mental health problem to live a meaningful life
in a community of his or her choice while
striving to achieve his or her full potential.
Traditional vs. Recovery

Traditional

Recovery-Oriented
 practitioner-based
 person-directed
 problem- based
 strengths-based
 professional
 skill acquisition






dominance
acute treatment
cure/amelioration
facility-based
dependence
episodic
reactive
 collaboration
 quality of life
 community-based
 empowerment/choices
 least restrictive
 preventative/wellness
Managing the Illness…
Focusing on Deficits
Promoting Recovery…
Building Strengths
Decreased symptoms/Clinical stability
Life worth living
Better judgment
A spiritual connection to God/others/self
Increased Insight…accepts illness
A real job, financial independence
Follows team’s recommendations
Being a good mom…dad…daughter
Compliance with treatment
Friends
Decreased hospitalization
Fun
Abstinent
Nature
Motivated
Music
Increased functioning
Pets
Psychiatric Stability
A home to call my own
Healthy relationships/socialization
Love…intimacy…sex
Use services regularly/engagement
Having hope for the future
Cognitive functioning
Joy
Realistic expectations
Giving back…being needed
Attends the job program/clubhouse, etc.
Learning
Treating Acute Illnesses

Professionals as experts diagnosing illnesses
and ordering treatment
 Patient provides history and complies with
treatment
 Life is put on hold while in treatment
 Short term professional-patient relationships
MEDICAL MODEL
symptoms
illness
decrease symptoms
return to life
We Treat Almost Only
Chronic Mental Illnesses

Mission of public mental health to focus on
chronic illnesses
 Because of stigma people don’t come into
treatment until waiting has been ineffective
 Mental illnesses are particularly disabling,
difficult to rehabilitate and adapt to
 Mental illnesses are often associated with
hopelessness
 Mental illnesses impact self image rapidly and
powerfully
REHABILITATION MODEL
illness
functional impairment
improved function
return to life
Harding’s
Schizophrenia Study

Bottom 1/3 considered hopeless
 Degenerating course for rest of life
 Nevertheless 62% recovered or significantly
improved
 Definition of recovered
 having a social life
 holding a job
 being symptom free
 not taking medication
RECOVERY MODEL
worker
illness
father
church
goer
husband
illness
person
Orioles
fan
1.
2.
3.
4.
HOPE
EMPOWERMENT
SELF-RESPONSIBILITY
MEANINGFUL ROLES
Treatment Implications

Emphasize patient education, collaboration, and
self-help
 Focus on hope
 Try to keep people in their lives
 Incorporate rehabilitation and adaptation
 Focus on impact on self image
 Promote long term, more personal doctor-patient
relationships
Mental illness creates
special challenges in all these areas
Recovery Implications

For acute illnesses recovery results from
symptom elimination and cure

For chronic illnesses recovery results from
 achieving self-management of the illness
 maintaining hope and self-image
 carrying on with life through rehabilitation and
adaptation
 replacing professional supports with natural supports
For acute illnesses recovery is illness-based
For chronic illnesses recovery is person-based
ILLNESS CENTERED
friends (social support network)
housing (treatment setting)
illness
vocational class (therapeutic
activity)
family
Person Centered Recovery

Recovery with chronic illnesses must be person
centered not illness centered.
 Illnesses don’t recover, people do.
Recovery is from the crippling, not the injury.
Recovery is from the destruction, not the illness
PERSON CENTERED
employment
housing (home)
illness
(a part of me)
person
friends
family
Person Centered Treatment

The foundation of a good treatment is a good
relationship, not a good diagnosis.
 The purpose of mental health treatment,
including medication, is not just to treat mental
illnesses. It’s to help people with mental
illnesses have better lives.
 Medications should be quality of life goal
directed instead of symptom relief directed
Person-Centered
…a fuzzy concept

everyone recognizes overall
meaning
 different
connotation for different
people

core elements of concept is
clear
 but

unclear on the periphery
difficult to operationalize in
measurable elements
Neal Adams MD Copyright 2008
Patient-Centeredness
The concept of a medical home
(practice team that coordinates a
person’s care across episodes and
specialties) is now reaching center
stage in proposal for redesign of
the US health care system.
The question remains open, however, about the degree to which
medical homes will shift power and control into the hands of
patients, families and communities. In this paper I argue for a
radical transfer of power and bolder meaning of ‘patientcentered care, whether in a medical home or in the current
cathedral of care, the hospital.”
“What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist”
Don Berwick, MD, Health Affairs, May 2009
Berwick’s Three Maxim’s
 The
needs of the patient come first
 Nothing about me without me
 Every patient is the only patient
The experience (to the extent the informed,
individual patient desires it) of transparency,
individualization, recognition, respect, dignity,
and choice in all matters, without exception,
related to one’s person, circumstances, and
relationships in health care.
Nothing About Me…
Without Me
quality
 right care
 right way
 right time
Neal Adams MD Copyright 2008
Nothing About Me…
Without Me
quality
person-centered
 right care
 care person needs
 right way
 manner person desires
 right time
 time person desires
Neal Adams MD Copyright 2008
Surgeon General




Established the scientific case for effective mental
health practice
Identifies gaps between current practice and potential
Highlights inequities based on race and culture
Lays the groundwork for President’s
New Freedom Mental Health
Commission

…America's mental
health service delivery
system is in shambles

…we have found that
the system needs
dramatic reform….

…a dysfunctional
service system that
cannot deliver the
treatments that work so
well.
Michael Hogan, PhD
Chair
President’s New Freedom
Commission
Interim Report
2002
President's MH Commission

in a transformed system…
“Consumers of mental health
services must stand at the center
of the system of care.
Consumers needs must drive the
care and services provided.”
President's MH Commission

Goal 2
 Mental Health Care is Consumer and Family Driven

Recommendation 2.1
 the plan of care will be at the core of the consumer-
centered, recovery-oriented mental health system
 providers should develop customized plans in full
partnership with consumers
IOM quality chasm report

Health care system is failing
 needs more than incremental change

Problems are structural and systemic
 views healthcare as a complex adaptive system

Proposes new paradigm
 6 aims that define quality
 10 operational rules
 4 domains of change
 4 levels within a system
IOM six aims
 Healthcare should be
 safe
 effective
 timely
 efficient
 equitable
 person-centered
IOM quality chasm report

Health care system is failing
 needs more than incremental change

Problems are structural and systemic
 views healthcare as a complex adaptive system

Proposes new paradigm
 6 aims that define quality
 10 operational rules
 4 domains of change
 4 levels within a system
Improving the Quality of Health Care
for M/SU Conditions

Six Key problem areas
 assuring that the system is patient-centered
 enhancing the measurement and quality improvement
infrastructures that support care
 improving linkages across all systems of health care
 promoting active participation by representatives of
both the mental and substance use field in the national
health information infrastructure
 building workforce competency and capacity
 the need to adapt to the unique marketplace for the
care of M/SU conditions
International Pathways






making mental health a public priority, promoting mental
well-being and diminishing the stigma and discrimination
associated with mental illness
improving access and enhancing the range of available
services
assuring an adequate, competent, and skilled mental
health workforce
making consumer involvement, a response to
individual needs, and recovery and wellness the
focus of mental healthcare
integrating and linking mental healthcare with general
healthcare and other sectors and services
promoting evidence-based, measurable, and accountable
mental healthcare
People who rely on public mental health
services should be directly involved in designing
their own care plan. Even though state and local
agencies often include consumers and other
advocates in care planning, they often allow
them to have only a marginal
role and fail to provide
important information that
could enable them to
participate fully and effectively.
Bazelon Center 2008
In Other Words...
“You keep talking about getting
me in the ‘driver’s seat’ of my
treatment and my life… when
half the time I am not even in
the damn car!”
Person in Recovery as Quoted in CT DMHAS
Recovery Practice Guidelines, 2005
Neal Adams MD Copyright 2008
Carl Rogers

congruence


genuineness, honesty with the
client
empathy
 the
ability to feel what the client
feels

respect
 acceptance,
unconditional
positive regard
Neal Adams MD Copyright 2008
Chronic Care Model
Community
Health System
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Outcomes
Improved Outcomes
Mental Health Care Model
The (written) treatment plan
makes EXPLICIT the shared
understanding and the course of
action agreed upon by the patient
and provider
The plan is social contract
Shared Decision Making is an
opportunity to make recovery real.
By developing and promoting
shared decision-making in mental
healthcare, we can advance
consumer-centered care and
recovery.
Kathryn Powers
July 10, 2007
Shared decision-making is an interactive and
collaborative process between individuals and their
health care practitioners about decisions pertinent to the
individual ’ s treatment, services, and ultimately their
personal recovery.
An optimal decision is one that is informed, consistent
with personal values, and acted upon. Participants are
satisfied with the process used to make the decision.
 Shared
decision-making is particularly
relevant when there is uncertainty about a
particular decision
 Uncertainty may stem from multiple or
competing options each with advantages and
disadvantages, incomplete or inconclusive
scientific outcome evidence or individual
factors such as personal values and beliefs, a
limited knowledge about the options,
or lack of support to make
a clear choice.
 Effective
shared decision-making requires
both informed and involved consumers,
and practitioners who are willing to enter
into meaningful dialogue with the person
about the decision to be made.
Advantages of SDM



Clients can best make decisions because of the
unique values they place on outcomes and the
necessary trade-offs based on preferences and
needs (Charles and Demaio, 1993).
Surveys demonstrate near universal client desire to
receive health care information and to participate in
treatment decision-making (Benbassat, Pilpel &
Tidhar, 1998).
Shared decision-making leads to improvements in
the provider-client relationship and health outcomes,
such as treatment adherence, treatment
satisfaction, and biomedical outcomes (Stewart,
1995).
SDM in Mental Health
 The
critical first step to productive
interactions and shared decision-making in
mental health is shared understanding of
consumer’s personal hopes and dreams,
as well as the barriers that may lie in the
way of success.
 Without this understanding, there is no
real basis for shared decision
SDM in Mental Health
 In
most service delivery systems today,
this essential step is all too often
overlooked and neglected—or at minimum
done poorly.
 Even when such understanding is
considered, disagreements that become
barriers to true mutuality in decision–
making are avoided and go unrecognized
rather than acknowledged and resolved.
Common Ground

The critical first step to “productive interactions” and
shared decision-making is shared understanding of
 the patients personal hopes and dreams and wellness vision
 the barriers that may lie in the way of success
 appreciation of the patient’s experience and life context

Common Ground / Shared Understanding / Formulation
 must be an explicit step in the process
 supports phenomenological / integrative rather than nosological
approach to diagnosis
Common Ground

Without this understanding, there is no real basis
for shared decision making and personcentered care.
 In most service delivery systems today, this
essential step is all too often overlooked and
neglected—or at minimum done poorly.
 Even when such understanding is considered,
disagreements that become barriers to true
mutuality in decision–making are avoided and
go unrecognized rather than acknowledged and
resolved.
Decisional Conflict

The uncertainty about which course of action to
take when choice among competing actions
involves risk, loss, regret or challenge to personal
life values
 Every day, people are faced with options affecting
their health
 Surgery or medical management
 Condoms or the Pill?
 More aggressive options when simpler strategies are
not controlling acne, depression, cholesterol, blood
sugar, menopause symptoms, insomnia, or attention
deficit disorder?
 Care at home or in a nursing home?
Decisional Conflict
 Decision
making is the process of choosing
between alternatives, which may include
doing nothing.
 Competent decision makers need to understand
and consider
• the courses of action open to them
• the chances of positive and negative effects
• the desirability or value of these effects.

People are more likely to choose an option
they think is likely to achieve valued
outcomes and to avoid undesirable
outcomes.
Decisional Conflict
 Unfortunately,
many health care decisions
have alternatives that
have both desirable and undesirable
outcomes
have desirable outcomes occurring partly with
one option and partly with another
 No
alternative will satisfy all our personal
objectives and no alternative is without its
risk of undesirable outcomes
Preference-Sensitive Care
 comprises
treatments that involve significant
tradeoffs affecting the patient’s quality and/or
length of life
 decisions about these interventions –
whether to have them or not, which ones to
have – ought to reflect patients’ personal
values and preferences
 ought to be made only after patients have
enough information to make an informed
choice
Preference-Sensitive Care
 Treatments
for conditions where legitimate
treatment options exist
options involving significant tradeoffs among
different possible outcomes of each treatment
• some people will prefer to accept a small risk of
death to improve their function
• others won’t
decisions about these interventions should
• reflect patients’ personal values and preferences
• should be made only after patients have enough
information to make an informed choice, in
partnership with the physician
Variations in Rates of
Preference-Sensitive Care
 Extreme
variation arises because patients
commonly delegate decision-making to
physicians
under the assumption that doctors can
accurately understand patients’ values and
recommend the correct treatment for them
 Yet
studies show that when patients are
fully informed about their options, they
often choose very differently from their
physicians
Research on Decision-Making Capability
Involving Individuals With Psychotic
Symptoms
 IOM
findings
 Although as a group, persons with psychotic
symptoms exhibit impaired decision-making
capability to a greater extent than non–mentally ill
individuals, there is considerable heterogeneity
within the group.
 Psychotic symptoms have less influence on
decision-making capability than do cognitive
abilities (i.e., the ability to remember, learn,
under- stand, and reason).
Research on Decision-Making Capability
Involving Individuals With Psychotic
Symptoms
 IOM
findings
 Individuals with severe mental illnesses, such as
schizophrenia, that can affect cognition may have
much in common with those having other chronic
general medical conditions, that can impair brain
functioning, memory, and cognition
 There is substantial evidence that understanding
of factual information--even among persons with
psychotic symptoms-- can be improved through
interventions
Hypothesis
 Person-centered
treatment plans are a key
lever of personal and systems
transformative change at all levels:




Individual and family
Provider
Administrator
Policy and oversight
66
essential role
of treatment planning

key lever for systems
changes at all levels
 making
it real

opportunity to assure that
individual recovery-oriented life goals direct
services
 not about documentation
 all

Neal Adams MD Copyright 2008
about the process
frequent point of failure
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”
Neal Adams MD Copyright 2008
68
What Do People Want?

Commonly expressed goals of persons served
 Manage their own lives
 Social opportunity
 Activity / Accomplishment
 Transportation
 Spiritual fulfillment
Quality of life
 Education
 Work
 Housing
 Health / Well-being

 Satisfying relationships
... to be part of the life of the community
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Building a Plan
Outcomes
Services
Objectives
Strengths/Barriers
Goals
Prioritization
Understanding
Assessment
Request for services
Neal Adams MD Copyright 2008
70
The Problem is, However…

Many/most clinician’s have little training in writing
plans
 The focus tends to be on filling out forms and
meeting paperwork requirement
 The plan is viewed as an administrative
requirement with little relevance to patient care
 Because clinician's don’t know how to plan well,
they don’t see it as useful for themselves or
patients
 Rather than using the plan as a point of
engagement, it is a burden outside their “real work”
Neal Adams MD Copyright 2008
Creating The Solution

the treatment / recovery management plan
can be the bridge between the system as it
exists now and where we need to go in the
future
Neal Adams MD Copyright 2008
Change Model
Competency
knowledge, skills and abilities
Change
Management
behavior and
attitude
Neal Adams MD Copyright 2008
Project
Management
work / business
flow
In Conclusion…
We must move beyond endorsing the values of
person-centered medicine shared decisionmaking and make it the everyday norm—for
patients and providers
 Treatment planning based on common ground
and shred decision-making can be an effective
strategy for making practice more personcentered and recovery oriented
