Transcript General Principles of Care MhGAP 2015 File

Field test version-1.00 May 2012
DO NOT UPLOAD ON THE INTERNET
General Principles of
Care
MhGAP 2015
mhGAP-IG base course - field test version 1.00 – May 2012
1
Contents (Introduction)
A. Why train on mental, neurological and substance use
disorders?
B. What is mhGAP?
C. What is the mhGAP Intervention Guide (mhGAP-IG)?
D. Base course
E. Introduction to general principles of care
F. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up
mhGAP-IG base course - field test version 1.00 – May 2012
2
What are mhGAP General Principles of Care?
1.
Communication
2.
Assessment
3.
Treatment and monitoring
4.
Provision of social support
5.
Protection of human rights
6.
Attention to overall well-being
mhGAP-IG base course - field test version 1.00 – May 2012
3
What are the five key actions for establishing care?
Key Action #1: Establish communication and build trust
Key Action #2: Conduct assessment
Key Action #3: Plan and start management
Key Action #4: Link with other services and supports
Key Action #5: Follow up
mhGAP-IG base course - field test version 1.00 – May 2012
4
NOTE:
Throughout this presentation, key questions are emphasized in
red font to enhance your learning.
Key Action #1: Establish communication and build trust
•
What can a clinician do to make a person comfortable when talking about private issues?
•
How does culture influence communication?
•
What are some useful skills for communicating with children?
•
What are some useful skills for communicating with adolescents?
•
How can communication with carers enhance patient progress?
Key Action #2: Conduct assessment
•
How can the mhGAP-IG be used to conduct an assessment?
•
What additional information is necessary in recording patient history?
•
“Do you drink alcohol?”
•
Is there imminent risk of suicide?
•
How can the person’s carer be assessed?
•
What is the impact on the carer?
mhGAP-IG base course - field test version 1.00 – May 2012
5
mhGAP-IG base course - field test version 1.00 – May 2012
6
NOTE:
Throughout this presentation, key questions are emphasized in
red font to enhance your learning.
Key Action #3: Plan and start management
•
What do we communicate in psychoeducation?
•
What is the patient’s psychosocial support system?
•
What is safe prescribing?
Key Action #4: Link with other services and supports
•
What other sectors and services have a role to play in the complete care of the
person?
•
Which individuals in the community may be able to help?
Key Action #5: Follow up
•
In your context, what are the best methods for arranging follow up?
•
What would you do during a follow up visit?
mhGAP-IG base course - field test version 1.00 – May 2012
7
mhGAP-IG base course - field test version 1.00 – May 2012
8
Key Action #1: Establish communication and build trust
•
What can a clinician do to make a person comfortable when talking about
private issues? (E.g. Feelings of depression, Sexual health)
–
Greet the person warmly and with respect
–
Introduce yourself by name and position
–
Listen carefully, notice non-verbal communication
–
Maintain confidentiality and privacy
–
Take time for the interview (especially the 1st interview)
–
Summarize what the person says, show understanding
–
Explain your actions when examining a person, use simple and clear language
–
Be honest - keep promises
mhGAP-IG base course - field test version 1.00 – May 2012
9
Open and Closed Questions
Open Questions
Closed Questions
1. "How are you feeling
today?"
1. "Are you sad?"
2. "How would you describe 2. "Are you having problems
your sleep?"
falling asleep?"
3. "Can you tell me how
3. "Are you still going to
your problem impacts
work?"
your life?“
mhGAP-IG base course - field test version 1.00 – May 2012
10
Culture and communication
How does culture influence communication?
•
Communicating with the opposite gender
•
Eye contact
•
Greeting
•
Distance between two people
•
How to address the person
•
Communicating with a child or adolescent
•
Communicating with a carer
mhGAP-IG base course - field test version 1.00 – May 2012
11
Communicating with children
What are some useful skills for communicating with children?
• Model good interaction
• Carers can learn from you on how to interact with the
child
• Treat the child with dignity
• greet the child
• avoid any negative labels
• Use language that the child can understand
• Never forget that the child is in the room
• Child may listen and understand when adults talk about
them
mhGAP-IG base course - field test version 1.00 – May 2012
12
Communication with adolescents
What are some useful skills for communicating with adolescents?
•
Try to see the adolescent alone
•
Explain that you wish to help
•
Explain that everything will be confidential
•
Show respect
•
Expect several appointments to establish trust
mhGAP-IG base course - field test version 1.00 – May 2012
13
Communicating with carers
How can communication with carers enhance patient progress?
• Carers (eg family) tend to be critical in the lives of people with
mental, neurological and substance use disorders
• Carers are usually key resources for support, but it is
important to remember that carers may need support as well
– In some situations carers are part of the problem (when
they abuse or discriminate)
• You must have the consent of the person before talking to a
carer
• Show understanding for the carer’s emotions
• Explain that they have a major role to play
• Explain that you wish to provide support
mhGAP-IG base course - field test version 1.00 – May 2012
14
Contents (Introduction)
•
Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Discuss and start management
4. Link with other services and supports
5. Follow up
We will discuss these points in general. We will later revisit
them for each condition throughout the base course
mhGAP-IG base course - field test version 1.00 – May 2012
15
Key Action #2: Conduct assessment
(using the Master Chart on page 8 of mhGAP-IG)
mhGAP-IG base course - field test version 1.00 – May 2012
16
Process of assessment in mhGAP-IG
Does the presentation
suggest a priority condition
according to the master chart?
NO
End assessment
Go to relevant module(s)
Conduct assessment according to the module
Identify the condition and treatment
Develop a management plan
mhGAP-IG base course - field test version 1.00 – May 2012
17
If the person is presenting
with multiple possible
conditions, all must be
assessed.
How can the mhGAP-IG be used to conduct an assessment?
Let’s do an example with Depression. Turn to page 10 of mhGAP-IG.
mhGAP-IG base course - field test version 1.00 – May 2012
18
Assess, Decide and Manage
• The assess column guides clinical assessment of the person
• The decide column specifies different clinical scenarios
• The manage column describes how to manage the problem
mhGAP-IG base course - field test version 1.00 – May 2012
19
mhGAP-IG: Assessment column
guides clinical assessment of the person
mhGAP-IG base course - field test version 1.00 – May 2012
20
mhGAP-IG: Decision column
specifies different clinical scenarios
mhGAP-IG base course - field test version 1.00 – May 2012
21
mhGAP-IG: Management column
describes how to manage the problem
mhGAP-IG base course - field test version 1.00 – May 2012
22
* The details of the interventions for each module are found
after the assessment, decision and management columns. *
mhGAP-IG base course - field test version 1.00 – May 2012
23
What additional information is necessary in
recording patient history?
•
•
•
•
•
History of presenting
complaint
Other symptoms
Medical history
Medication
Impact on function
mhGAP-IG base course - field test version 1.00 – May 2012
Family history
• Social stressors
• Available resources and
sources for social support
• Alcohol use
• Self harm/suicide
•
24
Assess for alcohol use in anybody
• Ask at least one question about alcohol use!
• “Do you drink alcohol?”
• If yes, ask more questions :
You will learn about this in the alcohol module session.
mhGAP-IG base course - field test version 1.00 – May 2012
25
Is there imminent risk of suicide?
mhGAP-IG base course - field test version 1.00 – May 2012
26
General physical examination
•
•
•
•
A proper general physical examination is necessary
Need to rule out other medical conditions or an underlying
medical cause for the mental, neurological and substance use
disorder
Need to assess for the physical effects of the condition, e.g.
• alcohol use
• suicide attempt
• self-neglect
Do not forget that people with mental, neurological and
substance use disorders also need to be assessed for their
general physical health
mhGAP-IG base course - field test version 1.00 – May 2012
27
How can the person's carers be assessed?
•
Help carers cope because they ensure the well-being of the
person with the condition
mhGAP-IG base course - field test version 1.00 – May 2012
28
What is the impact on the carer?
•
There are a number of potential strains on the carer
– Psychological
• Stress and feelings of hopelessness
• Depression – needs management as appropriate
– Physical
• Poorer physical health
• More visits to the doctor
– Social:
• Friends and families embarrassed
• Social isolation and exclusion
– Financial
• Loss of earning from time away from work
• Medical bills
mhGAP-IG base course - field test version 1.00 – May 2012
29
Key Action #3: Plan and start management
Explain results and likely diagnosis while keeping a realistic
and positive outlook
• Explain and discuss all treatment options including benefits
and risks
• Provide psychoeducation and other psychosocial support
• Explain any possible medications before prescribing
• Make sure that everyone understands the plan
•
mhGAP-IG base course - field test version 1.00 – May 2012
30
What do we communicate in psychoeducation?
I. Empowerment
– Focus on what the person and family can do now to
improve their situation
– Emphasize the importance of involving the person with the
disorder in all decisions
II. Facts
– Take time to explain the prognosis. Be realistic but
emphasize that with proper management, many people
improve
mhGAP-IG base course - field test version 1.00 – May 2012
31
What do we communicate in psychoeducation?
III. Coping strategies
– Recognize and encourage things people are doing well
– Discuss actions that have helped in the past
– Discuss local options for community resources
IV. Advice on overall wellbeing
– Encourage a healthy lifestyle including a good diet, regular
physical exercise and routine health checks at the doctor
– Advise the person and the carers to seek help when
needed
mhGAP-IG base course - field test version 1.00 – May 2012
32
What is the patient’s psychosocial support system?
•
•
•
•
•
•
Offer an opportunity to talk, preferably in a private space
Ask about current stressors
Assess for any maltreatment or abuse
Brain storm together for solutions or for ways of coping
Identify and involve supportive family members
Encourage involvement in self-help and family support
groups
mhGAP-IG base course - field test version 1.00 – May 2012
33
Prescribing principles – What is safe prescribing?
• Medication treatment depends on the condition.
– Worldwide more than 50% of all medicines are
prescribed, dispensed, or sold inappropriately, while 50%
of patients fail to take them correctly (WHO, 2002)
• Safe prescribing
– Explain effects, time of onset, side effects
– Obtain consent
– Start low, go slow
– Follow up on a regular basis with thorough assessment
mhGAP-IG base course - field test version 1.00 – May 2012
34
Key Action #4: Link with other services and supports
What other sectors and services have a role to play in the
complete care of the person?
• Housing
• Employment
• Education
• Child protection and social services
• Which individuals in the community may be able to help?
• Community leaders
• Women's groups
• Self-help and family support groups
•
mhGAP-IG base course - field test version 1.00 – May 2012
35
Key Action #5: Follow Up.
•
Make a clear follow up plan (e.g., date, person)
•
The frequency of follow up depends on the condition and
resources available
•
In your context, what are the best methods for arranging
follow up?
mhGAP-IG base course - field test version 1.00 – May 2012
36
What would you do during a follow up visit
• Assess progress in a number of areas
– Symptoms and well-being of both the person and carer
– Check for new symptoms
– Ongoing stressors
– Medication effectiveness, adherence, side effects
– Links to community resources
• Make changes to the management plan as necessary.
• Refer to the mhGAP-IG if needed
mhGAP-IG base course - field test version 1.00 – May 2012
37
Conclusion
• The burden of mental, neurological and substance abuse
disorders is large and growing
• Stigma and discrimination is common
• You can effectively manage these conditions in nonspecialized health care and reduce stigma and discrimination
• The base course provides the basic skills to identify and
manage these conditions (in consultation with specialists if
needed)
mhGAP-IG base course - field test version 1.00 – May 2012
38
mhGAP-IG base course - field test version 1.00 – May 2012
39